Severe Gestational Hypertension Research Articles

Blinding lights: Acute persistent vision loss in pregnancy

Acute persistent vision loss in pregnancy is an emergent presentation with a broad differential and should prompt rapid assessment and treatment of the underlying etiology. In pregnancy, causes can include preeclampsia, severe gestational hypertension, and hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome. Nonobstetrically related etiologies that can exacerbate in pregnancy include optic neuritis, giant cell arteritis, central retinal artery occlusion, or retinal detachment. In this case report, we describe a case of acute vision loss due to Purtscher's-like retinopathy, a rare but serious complication of pancreatitis in pregnancy. To our knowledge, this is the first published case of Purtscher's-like retinopathy in pregnancy unrelated to preeclampsia. Given the impact of permanent visual loss associated with Purtscher's-like retinopathy, more research is needed to determine treatments to substantively improve outcomes.

Comparing Intravenous Labetalol and Intravenous Hydralazine for Managing Severe Gestational Hypertension.

Background Hypertensive disorders of pregnancy are the leading causes of both maternal morbidity and maternal mortality. Hypertensive disorders are acute obstetric emergencies, which refer to various life-threatening medical challenges known to develop during pregnancy, labor, and delivery,requiring urgent attention to reduce blood pressure (BP) for the benefit ofthe affected mothers and infants. Hydralazine and labetalol have been widely used as the first-line medications in themanagement of severe hypertension during pregnancy. However, the choice between these two drugs lacks clear evidence regarding their safety and superiority. Several studies have attempted to study intravenous (IV) labetalol versus hydralazine, but very fewsuch comparison studies havebeen conducted in Africa. Objective To compare the effectiveness of IV labetalol and IV hydralazine in reducing systolic and diastolic BP in pregnant women with severe hypertension. Also, to determine thetime required for hydralazine and labetalol to lower BP to ≤150/100 mmHg, the number of doses needed for each drug, and evaluating maternal and perinatal outcomes. Study design This study employed an open-label randomized clinical trial design conducted in the labor, delivery, and antenatal ward of the Central and Stella Obasanjo Hospital in Benin City. A total of 120 women with severe pregnancy-induced hypertension were randomly assigned to two groups: Group X, consisting of 60 pregnant women, received IV hydralazine at a slow rate of 5 mg for five minutes, repeated every 20 minutes (maximum of five doses) until a blood pressure of ≤150/100 mmHg was achieved. Group Y, also consisting of 60 pregnant women, received IV labetalol in escalating doses of 25, 50, 75, 75, and 75 mg (maximum of 300 mg) every 20 minutes until the blood pressure reached ≤150/100 mmHg. Statistical analysis was performed using SPSS version 23(IBMInc., Armonk, New York). Result IV hydralazine achieved the target BP in an average time of 45.80 +/- 25.17 minutes, while IV labetalol took an average of 72.67 +/- 41.80 minutes (p=0.001). The number of doses required to reach the target BP differed significantly between the two drugs. Hydralazine required an average of 1.72 +/- 0.904 doses, whereas labetalol required an average of 3.72 +/- 1.782 doses (p=0.0001). While 45% of women in the hydralazine group attained the target BP with a single dose of hydralazine, only 31.1% of women in the labetalol group were able to attain the target BP with asingle doseof labetalol(p=0.02). Overall, target BP was achieved in 55 out of 60 women (91.7%) who were randomized to receive IV hydralazine, whereas 45 out of 60 women (75%) who received IV labetalol achieved the target blood pressure. While hydralazine demonstrated more favorable results in terms of achieving target blood pressure, there were higher incidences of maternal adverse effects in the hydralazine group compared to the labetalol group. However, these adverse effects were not severe enough to warrant discontinuation of the medication. Conclusion IV hydralazine showed faster achievement of the target BP and a lower number of doses required compared to IV labetalol. Additionally, a higher percentage of women in the hydralazine group achieved the target BP with a single dose. However, there were more maternal adverse effects associated with hydralazine, although they were not severe. Perinatal outcomes did not differ significantly between the two groups.

Association of the Severity of Hypertensive Disorders in Pregnancy with Birthweight, Childhood Obesity, and Blood Pressure at Age 7.

We aimed to examine the effects of various severities of hypertensive disorders in pregnancy on birthweight, blood pressure (BP), and body mass index in offspring at age 7. In the China Labor and Delivery Survey and the United States Collaborative Perinatal Project (CPP), the relationship of the severity of hypertensive disorders and nutritional and cardiovascular outcomes in offspring was assessed using a multivariable logistic and general linear regression model. In both datasets, those with gestational hypertension were more likely to deliver large for gestational age (LGA) and macrosomia (adjusted odds ratios (aOR) ranged from 1.29 to 1.91), as well as low birth weight (LBW) neonates (aOR ranged from 1.23 to 3.56), compared with normotensive mothers. In the CPP, when gestational hypertension was further stratified into mild and severe, only those with mild gestational hypertension (the mild group) were more likely to deliver macrosomia and LGA (aOR ranged from 1.25 to 1.32). Others (severe gestational hypertension and preeclampsia/eclampsia) were closely related to LBW and small for gestational age (aOR ranged from 1.27 to 2.77). Moreover, children of mothers in the mild group tended to be overweight/obese and had elevated diastolic BP. We concluded that the severity of hypertensive disorders had different effects on birthweight, childhood overweight, and BP.

Pregnancy outcomes after living kidney donation from a nationwide population-based cohort study from Korea

While most living kidney donors experience good outcomes and high rates of satisfaction, kidney donation can increase the risk of gestational hypertension or preeclampsia. However, pregnancy outcomes in non-white donors are limited. We conducted a nationwide cohort study of 112 living kidney donors and 672 matched healthy non-donors using the Korean National Health Insurance Claims Database. Donors and healthy non-donors were matched according to age, year of cohort entry, residency, income, number of pregnancies, and the time to the first pregnancy after cohort entry. We assessed pregnancy outcomes of live kidney donors compared with matched healthy non-donors using the nationwide database. Gestational hypertension or preeclampsia was more common in kidney donors than in non-donors (8.9% vs. 1.8%; adjusted odds ratio, 2.68; 95% confidence interval, 1.11–6.50). However, the incidence of severe gestational hypertension or preeclampsia that required antihypertensive medication was comparable (2.7% vs. 0.9%; P = 0.121). The time from donation to delivery within 5 years and primiparity were risk factors for preeclampsia in donors. Low birth weight, stillbirth, and ectopic pregnancy were not significantly different between the two groups. Maternal death occurred in two non-donor cases, but none occurred in donors compared to non-donors. Our findings indicate that kidney donors are associated with an increased risk of gestational hypertension or preeclampsia than matched healthy non-donors. However, the probabilities of serious maternal and fetal outcomes remained low and are not increased significantly after kidney donation.

A Comparative Study of Local Dietary Intake Among Subjects with Hypertensive Disorders of Pregnancy Attending Antenatal Care

Background: Hypertensive disorders of pregnancy remain among the most significant causes of pregnancy-related complications. The research by the Dietary Approaches to Stop Hypertension (DASH) group revealed that non-pharmacological measures and intervention such as diet can be used to control blood pressure. Objective: This study was completed to determine the frequency of consumption of local food among females who were pregnant and their relationship with pregnancy-related hypertensive disorders. Methods: This was a descriptive research study of females who were pregnant with pre-eclampsia (PE) and gestational hypertension (GH) who presented at the Federal Medical Centre (FMC), Abeokuta, Nigeria. During the study period (September–October 2019) at the tertiary healthcare centre, 45 subjects who were pregnant were select from a PE and GH group, and matched with 45 patients with normotension. Comparison of bean meal onsumption (gbegiri) and bone meal (gbure-oloboro) consumption in subjects who were pregnant did not reveal statistically significant differences in those with PE and GH. Results: The findings reveal a statistically significant difference in milk consumption between females who were pregnant with mild and severe PE (p=0.019). There was also a statistically significant difference in subjects with mild and severe GH who consumed milk (p=0.003).

Study of coagulation profile and platelet count in pregnancy induced hypertension, preeclamptic and eclamptic patients

Introduction: Hypertensive disorders in pregnancy is one of the major causes of maternal & perinatal morbidity and mortality. Pregnancy induced hypertention (PIH) is defined as hypertension that develops as the direct result of the gravid state. Profound changes in coagulation and fibrinolytic system occur during normal pregnancy causing hypercoagulable state. Preeclampsia and eclampsia is a highly thrombotic and pro-coagulant state with platelet activation and thrombin and fibrin formation. Methodology: A prospective study carried out in department of pathology B. J. medical college during March 2021 to August 2021. Coagulation profile (PT, aPTT, and D-dimer) and platelet count was done in cases and values were correlated with the severity of PIH. Results: Total of 100 cases were included in the study. 26 were mild gestational hypertension, 13 cases were severe gestational hypertension, 36 cases were mild pre-eclampsia and 14 cases were in severe pre-eclampsia group and 11 patients in eclampsia group. Prolonged PT, aPTT, D-Dimer and thrombocytopenia was seen in 9 cases, 29 cases, 32 cases and 17 cases respectively. In our study we observed increased aPTT, D-dimer and thrombocytopenia in severe pre-eclampsia and eclampsia patients. Conclusion: Estimation of the coagulation parameters and platelet count play an important role in the evaluation of risk factors, early detection, and effective antenatal services. Which can help to reduce the maternal and fetal morbidity and mortality associated with pregnancy induced hypertension.

A retrospective study of coagulation parametres in patients of pregnancy induced hypertension

Introduction: Human pregnancy also known as gestation, is the time between fertilization of ovum to delivery of a baby. It is approcximately a process of 9 months during which new baby develops inside a womb. Physiologically, pregnancy is a hypercoagulative state. Hypercoagulable state in pregnancy is a naturally occuring preventive response to prevent excess loss of blood during delivery. It is essential to know the range of variations of the coagulation factors during normal pregnancy, if any specific component has to be incriminated as a causative agent for the vascular disorder. Preeclampsia is a serious and life threatening complication in pregnant women. It is a pregnancy specific disorder which rates among one of the major causes of maternal and foetal morbidity and mortality. Aims and Objectives: To evaluate severity of eclampsia by estimating coagulation profile tests in pregnancy induced hypertensive patients. To compare these biochemical parameters between the test group and control group. To correlate the outcome of pregnancy with these biochemical parameters. Materials and Methods: This retrospective study includes 120 females of uncomplicated pregnancy of age group 16-35 years as a control group and 120 females of same age group with pregnancy with hypertension (PIH) attending obstetric outdoor patient department (OPD) of the institute in the year of 2015. Blood samples are withdrawn from all participants for biochemical markers of coagulation study that includes total platelet count (PC), prothrombin time (PT) and activated partial thromboplastin time (APTT). Results: Among total 120 PIH participants, 44 (36.67%) cases were having mild gestational hypertension, 11 (9.17%) cases were having severe gestational hypertension, 34 (28.33%) cases were having mild preeclampsia and 31 (25.83%) cases were having severe preeclampsia. The mean value of PT and APTT is found to be high in PIH cases as compared to control group participants. Conclusion: Parameters

Study protocol for the randomized controlled EVA (early vascular adjustments) trial: tailored treatment of mild hypertension in pregnancy to prevent severe hypertension and preeclampsia

BackgroundIn contrast to severe gestational hypertension, it is questioned whether antihypertensive medication for mild to moderate gestational hypertension prevents adverse maternal and offspring outcomes. Hypertensive drugs halve the risk of severe hypertension, but do not seem to prevent progression to preeclampsia or reduce the risk of complications in offspring. In fact, beta-blockers, a first line therapy option, are suspected to impair foetal growth. Disappointing effects of antihypertensive medication can be anticipated when the pharmacological mode of action does not match the underlying haemodynamic imbalance. Hypertension may result from 1) high cardiac output, low vascular resistance state, in which beta blockade is expected to be most effective, or 2) low cardiac output, high vascular resistance state where dihydropyridine calcium channel blockers or central-acting alpha agonists might be the best corrective medication. In the latter, beta-blockade might be maternally ineffective and even contribute to impaired foetal growth by keeping cardiac output low. We propose a randomized controlled trial to determine whether correcting the haemodynamic imbalance in women with mild to moderate hypertension reduces the development of severe hypertension and/or preeclampsia more than non-pharmacological treatment does, without alleged negative effects on foetal growth.MethodsWomen diagnosed with mild to moderate hypertension without proteinuria or signs of other organ damage before 37 weeks of pregnancy are invited to participate in this randomized controlled trial. Women randomized to the intervention group will be prescribed tailored antihypertensive medication, using a simple diagnostic and treatment algorithm based on the mean arterial pressure/heart rate ratio, which serves as an easy-to-determine proxy for maternal circulatory state. Women randomized to the control group will receive non-pharmacological standard care according to national and international guidelines. In total, 208 women will be randomized in a 1:1 ratio. The primary outcome is progression to severe hypertension and preeclampsia and the secondary outcomes are adverse maternal and neonatal outcomes.DiscussionThis trial will provide evidence of whether tailoring treatment of mild to moderate gestational hypertension to the individual haemodynamic profile prevents maternal disease progression.Trial registrationNCT02531490, registered on 24 August 2015.

Evaluating the maternal and perinatal sequelae of severe gestational hypertension

Hypertensive disorders of pregnancy are widespread and have long-standing implications for women's health. Historically, the management of "severe gestational hypertension," or the presence of severely elevated blood pressures without any other signs or symptoms of end-organ damage meeting the criteria for preeclampsia, has been unclear. The new American College of Obstetricians and Gynecologists guidelines based on expert opinion recommend that severe gestational hypertension be treated similarly to preeclampsia with severe features, but data regarding outcomes for women with this diagnosis have been limited. This study aimed to compare the maternal and perinatal sequelae of severe gestational hypertension with that of other types of hypertensive disorders of pregnancy. This is a retrospective cohort study of women with hypertensive disease of pregnancy who delivered at a single tertiary care center between February and December 2018. Women with chronic hypertension; hemolysis, elevated liver enzymes, and low platelet count syndrome; preexisting kidney, liver, rheumatologic, or hematologic disorders; or multifetal pregnancies were excluded. Women were categorized as having severe gestational hypertension if they had a sustained systolic blood pressure of >160 mm Hg or a diastolic blood pressure of >110 mm Hg without other criteria for preeclampsia. The primary comparison was between women with severe gestational hypertension and women with preeclampsia without severe features. Secondary comparisons included women with severe gestational hypertension vs women with other types of hypertensive disease of pregnancy. The primary outcome for this analysis was small-for-gestational-age birth. We also evaluated other maternal and neonatal morbidities including but not limited to pulmonary embolism, stroke, eclampsia, blood transfusion, mechanical ventilation, intensive care unit admission, death, 5-minute Apgar score of ≤4, umbilical cord pH, neonatal intensive care unit admission of >2 days, respiratory distress syndrome, and neonatal death. Bivariate analyses using chi-square tests and logistic regressions adjusting for race, ethnicity, age, body mass index, parity, and insurance status were performed to compare frequencies of outcomes for each type of hypertensive disease of pregnancy with those of severe gestational hypertension. Of 2076 women eligible for inclusion, 12.2% (n=254) had severe gestational hypertension and 379 (18.2%) had preeclampsia without severe features. Although there was no difference in the odds of small-for-gestational-age birth between women with severe gestational hypertension and women with preeclampsia without severe features(14.7% vs 9.8%; adjusted odds ratio, 0.72; 95% confidence interval, 0.44-1.21), the latter were significantly less likely to receive a prescription for antihypertensive medication at discharge (OR 0.11, 95% CI 0.06-0.22) or to be readmitted postpartum (OR 0.14, 95% CI 0.04-0.50). There was no difference in the primary outcome, that is, rate of small-for-gestational-age birth, between women with severe gestational hypertension and women with preeclampsia without severe features. However, women with severe gestational hypertension had greater odds of other maternal and neonatal morbidities than women with preeclampsia without severe features or mild gestational hypertension. These findings support recent recommendations regarding the management of women with severe gestational hypertension.

BRAzil magnesium (BRAMAG) trial: a double-masked randomized clinical trial of oral magnesium supplementation in pregnancy

BackgroundThere is conflicting evidence about the role of oral magnesium supplementation in the prevention of preterm birth and related adverse outcomes. The objective of this study was to compare magnesium citrate with placebo in the prevention of adverse perinatal and maternal outcomes among women at higher risk.MethodsThis multicenter, double-masked, placebo-controlled randomized superiority clinical trial compared oral magnesium citrate 300 mg to matched placebo, from 12 to 20 weeks’ gestation until delivery. This trial was completed in three centers in northeastern Brazil. Eligible women were those with a singleton pregnancy and ≥ 1 risk factor, such as prior preterm birth or preeclampsia, or current chronic hypertension or pre-pregnancy diabetes mellitus, age > 35 years or elevated body mass index. The primary perinatal composite outcome comprised preterm birth < 37 weeks’ gestation, stillbirth > 20 weeks, neonatal death or NICU admission < 28 days after birth, or small for gestational age birthweight < 3rd percentile. The co-primary maternal composite outcome comprised preeclampsia or eclampsia < 37 weeks, severe gestational hypertension < 37 weeks, placental abruption, or maternal stroke or death during pregnancy or ≤ 7 days after delivery.ResultsAnalyses comprised 407 women who received magnesium citrate and 422 who received placebo. The perinatal composite outcome occurred among 75 (18.4%) in the magnesium arm and 76 (18.0%) in the placebo group – an adjusted odds ratio (aOR) of 1.10 (95% CI 0.72–1.68). The maternal composite outcome occurred among 49 (12.0%) women in the magnesium arm and 41 women (9.7%) in the placebo group – an aOR of 1.29 (95% CI 0.83–2.00).ConclusionsOral magnesium citrate supplementation did not appear to reduce adverse perinatal or maternal outcomes in high-risk singleton pregnancies.Trial registrationClinicalTrials.gov NCT02032186, registered January 9, 2014.

Effects of blood pressure level management on maternal and perinatal outcomes in pregnant women with mild to moderate gestational hypertension.

This study aims to investigate the effects of blood pressure control level on maternal and perinatal outcomes in pregnant women with mild to moderate gestational hypertension (GHp). A total of 344 pregnant women who initially diagnosed as mild to moderate gestational hypertension were recruited in this study. They were divided into 4 groups according to the stabilized blood pressure level (BPL) during pregnancy. The clinical parameters and the incidence of adverse pregnancy outcomes were compared among the four groups. The association between blood pressure levels and relative factors were analyzed using the χ2 test. Multivariate logistic regression analysis was adopted for risk factors associated with adverse pregnancy outcomes. The results showed the prevalence of obesity was significantly associated with blood pressure levels of mild-moderate GHp pregnant women (p = 0.029). The incidence of severe GHp, SPE in group A, group B, and group C were statistically significant (p < 0.001, p = 0.041, respectively). In the patients who used drugs to control BPL, the incidence of severe GHp has a significant association with the initial blood pressure levels (p = 0.004). However, no significant difference was found in the incidence of sPE, PE + Upro, and SGA (all p > 0.05). Multivariate logistic regression analyses results showed that the gestational factor BPL was an independent risk factor for the incidence of sGHp. The AMA, primigravida, gestational BPL, and edema were risk factors for the incidence of preeclampsia with proteinuria. To the incidence of sPE, gestational BPL is the independent risk factor. Finally, preeclampsia anamnesis and FGR trend are the high-risk parameters to the incidence of SGA. Timely management and control of blood pressure in pregnant women with mild to moderate GHp were beneficial to reduce the occurrence of severe GHp and sPE, but the incidence of SGA does not affected.

The effect of folic acid throughout pregnancy among pregnant women at high risk of pre-eclampsia: A randomized clinical trial.

Pre-eclampsia is a serious hypertension disease that occurs during pregnancy. Folic acid (FA) supplementation has been reported to reduce pre-eclampsia risk in pregnant women. Here, we aimed to assess whether treatment of high doses of FA in pregnant women with high pre-eclampsia risk could prevent the onset of pre-eclampsia. We conducted a randomized clinical trial in 1576 women who had pre-eclampsia or eclampsia in their last pregnancy and had a pregnancy plan. Subjects were randomized into two groups. The low dose (LD) group (n=788) received 0.4mg of FA daily from the first 3months of pregnancy until the entire pregnancy, and the high dose (HD) group (n=788) received 4mg of FA per day. We followed up the subjects until production. The plasma homocysteine (homocysteine) and FA levels were significantly higher in the HD group that in the LD group. Severe gestational hypertension, early onset pre-eclampsia (<32weeks' gestation), severe pre-eclampsia, and newborns' Apgar score <7 at 5min were remarkably decreased in the HD group compared with the LD group. Further, the incidence of pre-eclampsia was reduced in the HD group with compliance >50%. This study has provided evidence that a high dosage of FA supplement from 3months before pregnancy until the entire pregnancy reduces the recurrent pre-eclampsia.

1030: Evaluating the maternal and perinatal sequelae of severe gestational hypertension

1030: Evaluating the maternal and perinatal sequelae of severe gestational hypertension

Medical and surgical complications in pregnancy and obstetric labour complications in the Japan Environment and Children’s Study (JECS) cohort: a birth cohort study

This study aimed to describe the distribution of pregnancies with medical and obstetric complications based on the Japan Environment and Children’s Study (JECS). We evaluated the distribution of the history of obstetric/gynaecological diseases, the history of obstetric labour complications, pregnancy with medical and surgical complications, and obstetric labour complications in participants in the JECS. Of 100,818 pregnant women with medical record entries after delivery, 15,305 (15.2%) had medical and surgical complications in pregnancy and 46,756 (46.4%) experienced obstetric labour complications. The proportion of pregnancies with heart disease, kidney disease and hepatitis was 0.3%, 0.3% and 0.1%, respectively. Gestational diabetes was diagnosed in 2715 (2.7%) women. The proportion of women with mild and severe gestational hypertension was 2.3% and 1%, respectively. The JECS is the largest birth cohort in Japan. These data will provide useful, basic information for perinatal care in Japan. IMPACT STATEMENT What is already known on this subject? Epidemiological studies have suggested that pre-existing diseases and complications of pregnancy, such as heart disease in pregnancy, gestational hypertension and gestational diabetes, may have implications for pregnancy outcomes, as well as for children’s health and development. What the results of this study add? We evaluated the distribution of the history of obstetric/gynaecological diseases, the history of obstetric labour complications, medical and surgical complications in pregnancy, and obstetric labour complications using data from the Japan Environment and Children’s Study (JECS). What the implications are of these findings for clinical practice and/or further research? The JECS is the largest birth cohort in Japan. Our data will provide useful, basic information for perinatal care in Japan.

Calcium supplementation commencing before or early in pregnancy, for preventing hypertensive disorders of pregnancy.

Background The hypertensive disorders of pregnancy include pre-eclampsia, gestational hypertension, chronic hypertension, and undefined hypertension. Pre-eclampsia is considerably more prevalent in low-income than in high-income countries. One possible explanation for this discrepancy is dietary differences, particularly calcium deficiency. Calcium supplementation in the second half of pregnancy reduces the serious consequences of pre-eclampsia, but has limited effect on the overall risk of pre-eclampsia. It is important to establish whether calcium supplementation before, and in early pregnancy (before 20 weeks' gestation) has added benefit. Such evidence could count towards justification of population-level interventions to improve dietary calcium intake, including fortification of staple foods with calcium, especially in contexts where dietary calcium intake is known to be inadequate. This is an update of a review first published in 2017. Objectives To determine the effect of calcium supplementation, given before or early in pregnancy and for at least the first half of pregnancy, on pre-eclampsia and other hypertensive disorders, maternal morbidity and mortality, and fetal and neonatal outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Trials Register (31 July 2018), PubMed (13 July 2018), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP; 31 July 2018), and reference lists of retrieved studies. Selection criteria Eligible studies were randomised controlled trials (RCT) of calcium supplementation, including women not yet pregnant, or women in early pregnancy. Cluster-RCTs, quasi-RCTs, and trials published as abstracts were eligible, but we did not identify any. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked them for accuracy. They assessed the quality of the evidence for key outcomes using the GRADE approach. Main results Calcium versus placeboWe included one study (1355 women), which took place across multiple hospital sites in Argentina, South Africa, and Zimbabwe. Most analyses were conducted only on 633 women from this group who were known to have conceived, or on 579 who reached 20 weeks' gestation; the trial was at moderate risk of bias due to high attrition rates pre-conception. Non-pregnant women with previous pre-eclampsia received either calcium 500 mg daily or placebo, from enrolment until 20 weeks' gestation. All participants received calcium 1.5 g daily from 20 weeks until birth.Primary outcomes: calcium supplementation commencing before conception may make little or no difference to the risk of pre-eclampsia (69/296 versus 82/283, risk ratio (RR) 0.80, 95% confidence interval (CI) 0.61 to 1.06; low-quality evidence). For pre-eclampsia or pregnancy loss or stillbirth (or both) at any gestational age, calcium may slightly reduce the risk of this composite outcome, however the 95% CI met the line of no effect (RR 0.82, 95% CI 0.66 to 1.00; low-quality evidence). Supplementation may make little or no difference to the severe maternal morbidity and mortality index (RR 0.93, 95% CI 0.68 to 1.26; low-quality evidence), pregnancy loss or stillbirth at any gestational age (RR 0.83, 95% CI 0.61 to 1,14; low-quality evidence), or caesarean section (RR 1.11, 95% CI 0.96 to 1,28; low-quality evidence).Calcium supplementation may make little or no difference to the following secondary outcomes: birthweight 24h, or both (RR 1.11, 95% CI 0.77 to 1.60; low-quality evidence).It is unclear what impact calcium supplementation has on Apgar score 24 hours, maternal death, hospital stay > 7 days from birth, and pregnancy loss before 20 weeks' gestation. Authors' conclusions The single included study suggested that calcium supplementation before and early in pregnancy may reduce the risk of women experiencing the composite outcome pre-eclampsia or pregnancy loss at any gestational age, but the results are inconclusive for all other outcomes for women and babies. Therefore, current evidence neither supports nor refutes the routine use of calcium supplementation before conception and in early pregnancy.To determine the overall benefit of calcium supplementation commenced before or in early pregnancy, the effects found in the study of calcium supplementation limited to the first half of pregnancy need to be added to the known benefits of calcium supplementation in the second half of pregnancy.Further research is needed to confirm whether initiating calcium supplementation pre- or in early pregnancy is associated with a reduction in adverse pregnancy outcomes for mother and baby. Research could also address the acceptability of the intervention to women, which was not covered by this review update.

Creatine kinase is associated with blood pressure during pregnancy

Hypertensive disorders in pregnancy pose a major burden during pregnancy and are also associated with an increased risk for hypertension later in life. Plasma creatine kinase activity is identified in the general population as an independent risk factor for hypertension. We hypothesize that plasma creatine kinase activity is similarly associated with blood pressure during pregnancy. Women who participated in the 'Amsterdam Born Children and their Development-study' were eligible for the current study. The associations between plasma creatine kinase activity and blood pressure measurements during pregnancy, and between plasma creatine kinase activity and hypertensive disorders in pregnancy (gestational hypertension, HELLP, preeclampsia and eclampsia) were evaluated using multiple linear regression and logistic regression models. In 3619 pregnant women, plasma creatine kinase activity was significantly associated with all blood pressure outcomes. This was most pronounced for the mean SBP throughout pregnancy, with a regression coefficient of 3.48 mmHg (CI 1.67-5.28, P < 0.001) per 1-unit logCK. With respect to the hypertensive disorders in pregnancy, we found a significant association between severe gestational hypertension diagnosed before 34 weeks of gestation (OR 9.16, CI 1.32-63.86, P = 0.025) per 1-unit logCK activity. HELLP and preeclampsia were not significantly associated. Our data show that plasma creatine kinase activity measured in early pregnancy is associated with blood pressure during pregnancy and associated with severe gestational hypertension diagnosed before 34 weeks of gestation, whereas no significant association was found between creatine kinase and other hypertensive disorders in pregnancy.

Fetal growth patterns in pregnancy-associated hypertensive disorders: NICHD Fetal Growth Studies

Fetal growth patterns in pregnancy-associated hypertensive disorders is poorly understood because prospective longitudinal data are lacking. The objective of the study was to compare longitudinal fetal growth trajectories between normotensive women and those with pregnancy-associated hypertensive disorders. This is a study based on data from a prospective longitudinal cohort study of fetal growth performed at 12 US sites (2009-2013). Project gestational age was confirmed by ultrasound between 8 weeks 0 days and 13 weels 6 days, and up to 6 ultrasounds were performed across gestation. Hypertensive disorders were diagnosed based on 2002 American College of Obstetricians and Gynecologists guidelines and grouped hierarchically as severe preeclampsia (including eclampsia or HELLP [hemolysis, elevated liver enzymes, and low platelet count] syndrome), mild preeclampsia, severe gestational hypertension, mild gestational hypertension, or unspecified hypertension. Women without any hypertensive disorder constituted the normotensive group. Growth curves for estimated fetal weight and individual biometric parameters including biparietal diameter, head circumference, abdominal circumference, and femur and humerus length were calculated for each group using linear mixed models with cubic splines. Global and weekly pairwise comparisons were performed between women with a hypertensive disorder compared with normotensive women to analyze differences while adjusting for confounding variables. Delivery gestational age and birthweights were compared among groups. Of 2462 women analyzed, 2296 (93.3%) were normotensive, 63 (2.6%) had mild gestational hypertension, 54 (2.2%) mild preeclampsia, 32 (1.3%) severe preeclampsia, and 17 (0.7%) unspecified hypertension. Compared with normotensive women, those with severe preeclampsia had estimated fetal weights that were reduced between 22 and 38 weeks (all weekly pairwise values of P < .008). Women with severe preeclampsia compared with those without hypertension also had significantly smaller fetal abdominal circumference between 23-31 and 33-37 weeks' gestation (weekly pairwise values of P < .04). Scattered weekly growth differences were noted on other biometric parameters between these 2 groups. The consistent differences in estimated fetal weight and abdominal circumference were not observed between women with other hypertensive disorders and those who were normotensive. Women with severe preeclampsia delivered significantly earlier (mean gestational age 35.9 ± 3.2 weeks) than the other groups (global P < .0001). Birthweights in the severe preeclampsia group were also significantly lower (mean -949.5 g [95% confidence interval, -1117.7 to -781.2 g]; P < .0001) than in the normotensive group. Among women with pregnancy-associated hypertensive disorders, only those destined to develop severe preeclampsia demonstrated a significant and consistent difference in fetal growth (ie, smaller estimated fetal weight and abdominal circumference) when compared with normotensive women.

300. Creatine kinase: An independent risk factor for high blood pressure during pregnancy

Hypertensive disorders in pregnancy not only pose a major burden during pregnancy, but are also associated with an increased risk for hypertension later in life. Plasma creatine kinase (CK) activity is identified in the general population as an independent risk factor for hypertension. We hypothesize that plasma CK activity is similarly associated with blood pressure during pregnancy. Women who participated in the Amsterdam Born Children and their Development-study were eligible for the current study. The associations between plasma CK activity and blood pressure measurements during pregnancy, and between plasma CK activity and hypertensive disorders in pregnancy (gestational hypertension, HELLP, preeclampsia and eclampsia) were evaluated using multiple linear- and logistic regression models, respectively. In 3.619 pregnant women, plasma CK activity was significantly associated with all blood pressure outcomes. This was most pronounced for the mean systolic blood pressure with a regression coefficient of 3.48 mmHg (CI 1.67 to 5.28, p Our data show that high plasma CK activity measured in early pregnancy is an independent risk factor for high blood pressure during pregnancy and is associated with severe gestational hypertension diagnosed before 34 weeks of gestation, while no significant association was found between CK and other hypertensive disorders in pregnancy.

Delayed Lactogenesis II and potential utility of antenatal milk expression in women developing late-onset preeclampsia: a case series

BackgroundPreeclampsia is a multi-system, hypertensive disorder of pregnancy that increases a woman’s risk of later-life cardiovascular disease. Breastfeeding may counteract the negative cardiovascular sequela associated with preeclampsia; however, women who develop preeclampsia may be at-risk for suboptimal breastfeeding rates. In this case series, we present three cases of late-onset preeclampsia and one case of severe gestational hypertension that illustrate a potential association between hypertensive disorders of pregnancy and suboptimal breastfeeding outcomes, including delayed onset of lactogenesis II and in-hospital formula supplementation.Case presentationAll cases were drawn from an ongoing pilot randomized controlled trial investigating the impact of antenatal milk expression versus an education control on breastfeeding outcomes. All study participants were healthy nulliparous women recruited at 34–366/7 gestational weeks from a hospital-based midwife practice. The variability in clinical presentation among the four cases suggests that any effect of hypertensive disorders on breastfeeding outcomes is likely multifactorial in nature, and may include both primary (e.g., preeclampsia disease course itself) and secondary (e.g., magnesium sulfate therapy, delayed at-breast feeding due to maternal-infant separation) etiologies. We further describe the use of antenatal milk expression (AME), or milk expression and storage beginning around 37 weeks of gestation, as a potential intervention to mitigate suboptimal breastfeeding outcomes in women at risk for preeclampsia and other hypertensive disorders of pregnancy.ConclusionsAdditional research is needed to address incidence, etiology, and interventions, including AME, for breastfeeding issues among a larger sample of women who develop hypertensive disorders of pregnancy.

Effect of blood pressure control level on perinatal outcomes in women with mild-moderate gestational hypertension

Objective: To investigate the effect of blood pressure (BP) control level on perinatal outcomes in women with mild-moderate gestational hypertension (GHp). Methods: Totally, 344 women diagnosed initially as mild-moderate GHp who delivered in Peking University Third Hospital from January 2012 to December 2016 were recruited. They were divided into four groups according to the stabilized level of BP during pregnancy. (1) Group A: BP<130/80 mmHg (1 mmHg=0.133 kPa) ; (2) Group B: BP (130-139) / (80-89) mmHg; (3) Group C: BP (140-149) / (90-99) mmHg; (4) Group D: BP (150-159) / (100-109) mmHg. The clinical profile and incidence of severe GHp, pre-eclampsia with proteinuria (PE+Upro), severe pre-eclampsia (sPE), small-for-gestational age (SGA) were compared among the four groups. Student t-test was preformed to normal distributive data and Kruskal-Wallis test was used to non-normally distributed variables. Chi-square test was used in count data. Logistic regression analysis was adopted for multiple-factor analysis. Results: (1) The incidence of severe GHp in group A was lower than group B (P<0.05). The incidences of severe GHp and sPE in the group B was lower than those in group C (P<0.05). While there was no difference in the incidence of PE+Upro and SGA among the four groups (P>0.05). And the incidence of severe GHp in group D had no difference with group A, B, C (P>0.05). (2) In the 48 patients who used medications to control BP, the occurence of severe GHp in those whose initial BP was (140-149) / (90-99) mmHg was lower than those of ≥160/110 mmHg (P<0.05). But the incidence of severe GHp had no significant difference between patients whose initial BP was (140-149) / (90-99) mmHg and patients whose initial BP was (150-159) / (100-109) mmHg (P>0.05). The initial BP level had no impact on the incidence of PE+Upro, sPE and SGA (P>0.05). (3) Multivariate logistic regression analysis showed that the BP level before using medications (OR=3.566, 95%CI: 1.080-11.771, P=0.037) and the BP level maintained (OR=4.787, 95%CI: 1.115-20.551, P=0.035) were independent factor that affected the incidence of severe GHp. Edema (OR=2.651, 95% CI: 1.628-4.316 P=0.000), fetal growth restriction (FGR; OR=1.103, 95% CI: 1.427-5.914, P=0.002) and the onset gestational age of GHp (OR=0.755, 95%CI: 0.578-0.985, P=0.038) were independent factors that affected the incidence of PE+Upro. The tendency of FGR (OR=17.787, 95%CI: 1.833-40.396 P=0.000), history of PE (OR=5.294, 95%CI: 1.086-25.800, P=0.039) and the BP level during pregnancy (OR=2.109, 95%CI: 1.274-3.491, P=0.004) were independent factors affecting the incidence of sPE. FGR tendency was independent factor affecting the incidence of SGA (OR=25.622, 95%CI: 2.596-252.864, P=0.005). Conclusion: A satisfied control of BP is helpful to reduce severe GHp and sPE, but the incidence of SGA does not affected.