Uterine arteriolar injuries in chronic hypertension

Abstract

Dr Nzelu et al1Nzelu D. Dumitrascu-Biris D. Nicolaides K.H. Kametas N.A. Chronic hypertension: first trimester blood pressure control and likelihood of severe hypertension, preeclampsia and small-for-gestational-age.Am J Obstet Gynecol. 2018; 218: 331-337Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar quantify the effects of chronic hypertension on subsequent pregnancies; the more severe hypertension, the worse the pregnancy outcomes. They explain their findings in terms of events that take place during pregnancy, which includes continuing endothelial dysfunction. However, recent histologic observations (Figure) suggest that some of the injuries take place before pregnancy. Fetal outcomes that include severe preeclampsia and the small-for-gestational-age fetus reflect previous denervatory injuries to the uterus. 2Wu X.Q. Cai Y.Y. Xia W.T. Quinn M.J. The aetiology of pre-eclampsia, 1945-1953.BJOG. 2016; 123: 2130Crossref PubMed Scopus (8) Google Scholar, 3Li Y.Y. Gu Q.R. Chen G.R. Quinn M.J. Arteriolar injury in hypertension.Am J Med. 2018; 131: e133-e134Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar In these studies, there is evidence of coexistent neurovascular injuries (ie, narrowed uterine arterioles surrounded by layers of regenerating nerves) in the isthmic regions of postpartum hysterectomy specimens (Figure, A). The histologic consequences of progressive maternal hypertension during pregnancy show disruption of the circumferential hyalinization of uterine arterioles (“woven basket” appearances; Figure, C–D) that are best seen in smaller arterioles (Figure, D).3Li Y.Y. Gu Q.R. Chen G.R. Quinn M.J. Arteriolar injury in hypertension.Am J Med. 2018; 131: e133-e134Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar All forms of pregnancy hypertension require appropriate treatment during and beyond, pregnancy to prevent continuing neuroarteriolar injury in the kidney, uterus, and other visceral arteriolar beds.3Li Y.Y. Gu Q.R. Chen G.R. Quinn M.J. Arteriolar injury in hypertension.Am J Med. 2018; 131: e133-e134Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar There may be no change in the measureable fetal consequences,4Magee L.A. von Dadelszen Rey E. et al.Less tight v tight control of hypertension in pregnancy.N Engl J Med. 2015; 372: 407-417Crossref PubMed Scopus (295) Google Scholar but it is likely that there are significant consequences in terms of later maternal cardiovascular morbidity?5Cain M.A. Salemi J.L. Tanner J.P. Kirby R.S. Salihu H.M. Louis J.M. Pregnancy as a window to future health: maternal placental syndromes and short-term cardiovascular outcomes.Am J Obstet Gynecol. 2016; 215: 484.e1-484.e14Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar Chronic hypertension: first-trimester blood pressure control and likelihood of severe hypertension, preeclampsia, and small for gestational ageAmerican Journal of Obstetrics & GynecologyVol. 218Issue 3PreviewThere is extensive evidence that prepregnancy chronic hypertension is associated with a high risk of development of severe hypertension and preeclampsia and birth of small-for-gestational-age neonates. However, previous studies have not reported whether antihypertensive use, blood pressure control, or normalization of blood pressure during early pregnancy influences the rates of these pregnancy complications. Full-Text PDF Chronic hypertension in pregnancy: an unique opportunityAmerican Journal of Obstetrics & GynecologyVol. 219Issue 5PreviewWith great interest we read the article of Nzelu et al1 that investigated the association between first-trimester blood pressure control in pregnant women with chronic hypertension and pregnancy complications. The authors present a unique cohort with a large size for this specific population. An association with the risk of severe hypertension, preeclampsia, and small-for-gestational-age children was demonstrated with a stratified analysis based on first-trimester blood pressure and the use of blood pressure–lowering medication, which resembles stages of increasing severity of vascular vulnerability. Full-Text PDF