Antenatal Hypertension Clinic, Fetal Medicine Research Institute, King's College Hospital, London, UK.
Antenatal Hypertension Clinic, Fetal Medicine Research Institute, King's College Hospital, London, UK.
Am J Obstet Gynecol. 2018 Mar;218(3):337.e1-337.e7. doi: 10.1016/j.ajog.2017.12.235. Epub 2018 Jan 2.
There 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.
The purpose of this study was to stratify women with prepregnancy chronic hypertension according to the use of antihypertensive medications and level of blood pressure control at the first hospital visit during the first trimester of pregnancy and to examine the rates of severe hypertension, preeclampsia, and birth of small-for-gestational-age neonates according to such stratification.
We conducted a prospective study of 586 women with prepregnancy chronic hypertension, in the absence of renal or liver disease, that was booked at a dedicated clinic for the management of hypertension in pregnancy. The patients had singleton pregnancies and were subdivided according to findings in their first visit: group 1 (n=199), blood pressure <140/90 mm Hg without antihypertensive medication; group 2 (n=220), blood pressure <140/90 mm Hg with antihypertensive medication; and group 3 (n=167), systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg, despite antihypertensive medication. In the subsequent management of these pregnancies, our policy was to maintain the blood pressure at 130-140/80-90 mm Hg with the use of antihypertensive medication; antihypertensive drugs were stopped if the blood pressure was persistently <130/80 mm Hg. The outcome measures were severe hypertension (systolic blood pressure ≥160 mm Hg and/or diastolic blood pressure ≥110 mm Hg), preterm and term preeclampsia (in addition to hypertension at least 1 of renal involvement, liver impairment, neurologic complications, or thrombocytopenia), and birth of small-for-gestational-age neonates (birthweight <5th percentile for gestational age). The incidence of these complications was compared in the 3 strata.
The median gestational age at presentation was 10.0 weeks (interquartile range, 9.1-11.0 weeks). In groups 2 and 3, compared with group 1, there was a significantly higher body mass index, incidence of black racial origin, and history of preeclampsia in a previous pregnancy. There was a significant increase from group 1 to group 3 in the incidence of severe hypertension (10.6%, 22.2%, and 52.1%), preterm preeclampsia with onset at <37 weeks of gestation (7.0%, 15.9%, and 20.4%), and small for gestational age (13.1%, 17.7%, and 21.1%), but not term preeclampsia with onset at ≥37 weeks of gestation (9.5%, 9.1%, and 6.6%).
In women with prepregnancy chronic hypertension, the rates of development of severe hypertension, preterm preeclampsia, and small for gestational age are related to the use of antihypertensive medications and the level of blood pressure control at the first hospital visit during the first trimester of pregnancy.
有大量证据表明，孕前慢性高血压与发生严重高血压和子痫前期以及胎儿出生体重小于胎龄儿的风险增加有关。然而，之前的研究并未报告抗高血压药物的使用、血压控制或孕早期血压正常化是否会影响这些妊娠并发症的发生率。
本研究旨在根据孕早期首次就诊时抗高血压药物的使用和血压控制水平，对患有孕前慢性高血压的女性进行分层，并根据分层情况检查严重高血压、子痫前期和胎儿出生体重小于胎龄儿的发生率。
我们对 586 名患有孕前慢性高血压且无肾脏或肝脏疾病的女性进行了前瞻性研究，这些女性在专门的妊娠高血压管理诊所就诊。这些患者均怀有单胎妊娠，并根据首次就诊时的检查结果进行了细分：第 1 组（n=199），血压<140/90mmHg，未使用降压药物；第 2 组（n=220），血压<140/90mmHg，使用降压药物；第 3 组（n=167），收缩压≥140mmHg 和/或舒张压≥90mmHg，尽管使用了降压药物。在这些妊娠的后续管理中，我们的策略是使用降压药物将血压维持在 130-140/80-90mmHg；如果血压持续<130/80mmHg，则停止使用降压药物。主要结局为严重高血压（收缩压≥160mmHg 和/或舒张压≥110mmHg）、早产和足月子痫前期（除高血压外，还至少有 1 项肾损伤、肝损害、神经并发症或血小板减少症）以及胎儿出生体重小于胎龄儿（出生体重<胎龄第 5 百分位）。在这 3 个分层中比较了这些并发症的发生率。
中位就诊时的孕龄为 10.0 周（四分位间距，9.1-11.0 周）。与第 1 组相比，第 2 组和第 3 组的体重指数、黑人种族比例和既往妊娠子痫前期史显著更高。第 1 组到第 3 组严重高血压（10.6%、22.2%和 52.1%）、早产子痫前期（<37 孕周时发生）（7.0%、15.9%和 20.4%）和胎儿出生体重小于胎龄儿（13.1%、17.7%和 21.1%）的发生率显著增加，但足月子痫前期（≥37 孕周时发生）的发生率无显著差异（9.5%、9.1%和 6.6%）。
在患有孕前慢性高血压的女性中，严重高血压、早产子痫前期和胎儿出生体重小于胎龄儿的发生与孕早期首次就诊时抗高血压药物的使用和血压控制水平有关。
