轻度慢性高血压孕妇的最佳分娩时机。
Optimal Timing of Delivery for Pregnant Individuals With Mild Chronic Hypertension.
机构信息
Departments of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, University of Texas at Houston, Houston, and University of Texas Medical Branch, Galveston, Texas, University of Pennsylvania and Drexel University College of Medicine, Philadelphia, and Magee Women's Hospital and University of Pittsburgh, Pittsburgh, Pennsylvania, University of North Carolina at Chapel Hill, Chapel Hill, and Duke University, Durham, North Carolina, Columbia University and Weill Cornell University, New York, and NYU Langone Hospital-Long Island, Long Island, and NewYork-Presbyterian Queens Hospital, Flushing, New York, University of Oklahoma Health Sciences, Oklahoma City, Oklahoma, Indiana University, Indianapolis, Indiana, University of Alabama at Birmingham, Birmingham, and University of South Alabama at Mobile, Mobile, Alabama, UnityPoint Health-Meriter Hospital/Marshfield Clinic, Madison, and Medical College of Wisconsin, Milwaukee, Wisconsin, Washington University, St. Louis, Missouri, University of Mississippi Medical Center, Jackson, Mississippi, The Ohio State University, Columbus, and Wright State University and Miami Valley Hospital, Dayton, Ohio, Rutgers University-Robert Wood Johnson Medical School, New Brunswick, New Jersey, Yale University, New Haven, Connecticut, University of Colorado, Aurora, and Denver Health, Denver, Colorado, Emory University, Atlanta, Georgia, University of California, San Francisco, San Francisco, Stanford University, Stanford, and Arrowhead Regional Medical Center, Colton, California, Beaumont Hospital, Michigan, Grosse Pointe, Michigan, Oregon Health & Science University, Portland, Oregon, Tulane University, New Orleans, Louisiana, and University of Kansas Medical Center, Kansas City, Kansas; the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, and the Department of Women's Health, University of Texas at Austin, Austin, Texas; the Department of Biostatistics, the Division of Neonatology, Department of Pediatrics, and the Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama; Ochsner Baptist Medical Center, New Orleans, Louisiana; St. Luke's University Health Network, Fountain Hill, and the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, Pennsylvania; MetroHealth System, Cleveland, and the Fetal Care Center of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Intermountain Healthcare, Ogden, Utah; Christiana Care Health Services, Newark, Delaware; St. Peters University Hospital, New Brunswick, Virtua Health, Marlton, and the Department of Obstetrics, Gynecology and Women's Health, New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, New Jersey; Zuckerberg San Francisco General Hospital, San Francisco, California; the Department of Obstetrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Obstetrics and Gynecology/Maternal-Fetal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee; Medical University of South Carolina, Charleston, South Carolina; and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland.
出版信息
Obstet Gynecol. 2024 Sep 1;144(3):386-393. doi: 10.1097/AOG.0000000000005676. Epub 2024 Jul 17.
OBJECTIVE
To investigate the optimal gestational age to deliver pregnant people with chronic hypertension to improve perinatal outcomes.
METHODS
We conducted a planned secondary analysis of a randomized controlled trial of chronic hypertension treatment to different blood pressure goals. Participants with term, singleton gestations were included. Those with fetal anomalies and those with a diagnosis of preeclampsia before 37 weeks of gestation were excluded. The primary maternal composite outcome included death, serious morbidity (heart failure, stroke, encephalopathy, myocardial infarction, pulmonary edema, intensive care unit admission, intubation, renal failure), preeclampsia with severe features, hemorrhage requiring blood transfusion, or abruption. The primary neonatal outcome included fetal or neonatal death, respiratory support beyond oxygen mask, Apgar score less than 3 at 5 minutes, neonatal seizures, or suspected sepsis. Secondary outcomes included intrapartum cesarean birth, length of stay, neonatal intensive care unit admission, respiratory distress syndrome (RDS), transient tachypnea of the newborn, and hypoglycemia. Those with a planned delivery were compared with those expectantly managed at each gestational week. Adjusted odds ratios (aORs) with 95% CIs are reported.
RESULTS
We included 1,417 participants with mild chronic hypertension; 305 (21.5%) with a new diagnosis in pregnancy and 1,112 (78.5%) with known preexisting hypertension. Groups differed by body mass index (BMI) and preexisting diabetes. In adjusted models, there was no association between planned delivery and the primary maternal or neonatal composite outcome in any gestational age week compared with expectant management. Planned delivery at 37 weeks of gestation was associated with RDS (7.9% vs 3.0%, aOR 2.70, 95% CI, 1.40-5.22), and planned delivery at 37 and 38 weeks was associated with neonatal hypoglycemia (19.4% vs 10.7%, aOR 1.97, 95% CI, 1.27-3.08 in week 37; 14.4% vs 7.7%, aOR 1.82, 95% CI, 1.06-3.10 in week 38).
CONCLUSION
Planned delivery in the early-term period compared with expectant management was not associated with a reduction in adverse maternal outcomes. However, it was associated with increased odds of some neonatal complications. Delivery timing for individuals with mild chronic hypertension should weigh maternal and neonatal outcomes in each gestational week but may be optimized by delivery at 39 weeks.
目的
探讨为慢性高血压孕妇分娩的最佳孕龄，以改善围产期结局。
方法
我们对慢性高血压治疗的随机对照试验进行了计划的二次分析，以不同的血压目标为研究对象。纳入的研究对象为足月、单胎妊娠。排除了胎儿畸形和 37 周前诊断为子痫前期的患者。主要的母体复合结局包括死亡、严重并发症（心力衰竭、中风、脑病、心肌梗死、肺水肿、重症监护病房入院、插管、肾衰竭）、重度特征性子痫前期、需要输血的出血或胎盘早剥。主要新生儿结局包括胎儿或新生儿死亡、需要氧面罩以外的呼吸支持、5 分钟时 Apgar 评分<3 分、新生儿癫痫发作或疑似败血症。次要结局包括产时剖宫产、住院时间、新生儿重症监护病房入院、呼吸窘迫综合征（RDS）、新生儿暂时性呼吸急促和低血糖。与期待管理相比，对计划分娩者和期待管理者在每个孕周进行比较。报告调整后的优势比（aOR）和 95%置信区间（CI）。
结果
我们纳入了 1417 名轻度慢性高血压孕妇；305 名（21.5%）为妊娠新诊断，1112 名（78.5%）为已知的既往高血压。两组在体重指数（BMI）和既往糖尿病方面存在差异。在调整后的模型中，与期待管理相比，在任何孕周，计划分娩与主要的母体或新生儿复合结局之间均无关联。与期待管理相比，37 孕周的计划分娩与 RDS（7.9%vs.3.0%，aOR 2.70，95%CI，1.40-5.22）相关，37 周和 38 孕周的计划分娩与新生儿低血糖（19.4%vs.10.7%，aOR 1.97，95%CI，1.27-3.08 周；14.4%vs.7.7%，aOR 1.82，95%CI，1.06-3.10 周）相关。
结论
与期待管理相比，在早期分娩期进行计划分娩与降低不良母体结局无关。然而，它与一些新生儿并发症的发生几率增加有关。对于轻度慢性高血压的个体，分娩时机应在每个孕龄权衡母婴结局，但在 39 孕周分娩可能会使结局得到优化。
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