Department of Obstetrics, Gynecology, and Reproductive Science, Yale New Haven Hospital, New Haven, CT.
Department of Gynecology and Obstetrics, Emory University, Atlanta, GA.
Am J Obstet Gynecol. 2019 Jun;220(6):582.e1-582.e11. doi: 10.1016/j.ajog.2019.02.010. Epub 2019 Feb 8.
Cardiovascular disease is the leading cause of pregnancy-related death in the United States. Identification of short-term indicators of cardiovascular morbidity has the potential to alter the course of this devastating disease among women. It has been established that hypertensive disorders of pregnancy are associated with increased risk of cardiovascular disease 10-30 years after delivery; however, little is known about the association of hypertensive disorders of pregnancy with cardiovascular morbidity during the delivery hospitalization.
We aimed to identify the immediate risk of cardiovascular morbidity during the delivery hospitalization among women who experienced a hypertensive disorder of pregnancy.
This retrospective cohort study of women, 15-55 years old with a singleton gestation between 2008 and 2012 in New York City, examined the risk of severe cardiovascular morbidity in women with hypertensive disorders of pregnancy compared with normotensive women during their delivery hospitalization. Women with a history of chronic hypertension, diabetes mellitus, or cardiovascular disease were excluded. Mortality and severe cardiovascular morbidity (myocardial infarction, cerebrovascular disease, acute heart failure, heart failure or arrest during labor or procedure, cardiomyopathy, cardiac arrest and ventricular fibrillation, or conversion of cardiac rhythm) during the delivery hospitalization were identified using birth certificates and discharge record coding. Using multivariable logistic regression, we assessed the association between hypertensive disorders of pregnancy and severe cardiovascular morbidity, adjusting for relevant sociodemographic and pregnancy-specific clinical risk factors.
A total of 569,900 women met inclusion criteria. Of those women, 39,624 (6.9%) had a hypertensive disorder of pregnancy: 11,301 (1.9%) gestational hypertension; 16,117 (2.8%) preeclampsia without severe features; and 12,206 (2.1%) preeclampsia with severe features, of whom 319 (0.06%) had eclampsia. Among women with a hypertensive disorder of pregnancy, 431 experienced severe cardiovascular morbidity (10.9 per 1000 deliveries; 95% confidence interval, 9.9-11.9). Among normotensive women, 1780 women experienced severe cardiovascular morbidity (3.4 per 1000 deliveries; 95% confidence interval, 3.2-3.5). Compared with normotensive women, there was a progressively increased risk of cardiovascular morbidity with gestational hypertension (adjusted odds ratio, 1.18; 95% confidence interval, 0.92-1.52), preeclampsia without severe features (adjusted odds ratio, 1.96; 95% confidence interval, 1.66-2.32), preeclampsia with severe features (adjusted odds ratio, 3.46; 95% confidence interval, 2.99-4.00), and eclampsia (adjusted odds ratio, 12.46; 95% confidence interval, 7.69-20.22). Of the 39,624 women with hypertensive disorders of pregnancy, there were 15 maternal deaths, 14 of which involved 1 or more cases of severe cardiovascular morbidity.
Hypertensive disorders of pregnancy, particularly preeclampsia with severe features and eclampsia, are significantly associated with cardiovascular morbidity during the delivery hospitalization. Increased vigilance, including diligent screening for cardiac pathology in patients with hypertensive disorders of pregnancy, may lead to decreased morbidity for mothers.
心血管疾病是美国导致妊娠相关死亡的主要原因。识别心血管发病率的短期指标有可能改变女性在这种毁灭性疾病中的病程。已经确定，妊娠高血压疾病与分娩后 10-30 年内发生心血管疾病的风险增加有关；然而，对于妊娠高血压疾病与分娩住院期间心血管发病率的关联，人们知之甚少。
我们旨在确定患有妊娠高血压疾病的女性在分娩住院期间发生心血管发病率的即时风险。
这项针对 2008 年至 2012 年期间在纽约市 15-55 岁单胎妊娠的女性的回顾性队列研究，检查了患有妊娠高血压疾病的女性与正常血压女性在分娩住院期间发生严重心血管发病率的风险。患有慢性高血压、糖尿病或心血管疾病病史的女性被排除在外。使用出生证明和出院记录编码，确定分娩住院期间的死亡率和严重心血管发病率（心肌梗死、脑血管疾病、急性心力衰竭、分娩或手术期间心力衰竭或骤停、心肌病、心搏骤停和心室颤动、或心脏节律转换）。使用多变量逻辑回归，我们调整了相关的社会人口学和妊娠特定临床风险因素后，评估了妊娠高血压疾病与严重心血管发病率之间的关联。
共有 569,900 名女性符合纳入标准。其中 39,624 名（6.9%）患有妊娠高血压疾病：11,301 名（1.9%）妊娠期高血压；16,117 名（2.8%）无严重特征的子痫前期；和 12,206 名（2.1%）有严重特征的子痫前期，其中 319 名（0.06%）发生子痫。在患有妊娠高血压疾病的女性中，有 431 名出现严重心血管发病率（每 1000 次分娩中发病率为 10.9%；95%置信区间，9.9-11.9）。在正常血压的女性中，有 1780 名女性出现严重心血管发病率（每 1000 次分娩中发病率为 3.4%；95%置信区间，3.2-3.5）。与正常血压的女性相比，妊娠期高血压（调整后的优势比，1.18；95%置信区间，0.92-1.52）、无严重特征的子痫前期（调整后的优势比，1.96；95%置信区间，1.66-2.32）、有严重特征的子痫前期（调整后的优势比，3.46；95%置信区间，2.99-4.00）和子痫（调整后的优势比，12.46；95%置信区间，7.69-20.22）的心血管发病率风险呈逐渐增加趋势。在 39,624 名患有妊娠高血压疾病的女性中，有 15 例产妇死亡，其中 14 例与 1 例或多例严重心血管发病率有关。
妊娠高血压疾病，特别是有严重特征的子痫前期和子痫，与分娩住院期间的心血管发病率显著相关。增加警惕，包括在患有妊娠高血压疾病的患者中进行心脏病理学的认真筛查，可能会降低母亲的发病率。
