Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada.
Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.
JAMA Netw Open. 2024 Oct 1;7(10):e2436478. doi: 10.1001/jamanetworkopen.2024.36478.
The incidence of severe maternal morbidity (SMM)-and particularly cardiovascular SMM (cvSMM), the first cause of pregnancy-related mortality-has been rising in North America. Although hypertensive disorders of pregnancy (HDP) are common, their association with cvSMM specifically remains unclear.
To assess the association between individual subtypes of HDP and cvSMM, in addition to overall SMM, in a large, nationally representative sample.
DESIGN, SETTING, AND PARTICIPANTS: A population-based cohort study using the United States National Inpatient Sample was conducted. Individuals with obstetric deliveries between 2015 and 2019 were included. Data analysis was performed from October 2023 to February 2024.
HDP subtypes included gestational hypertension, chronic hypertension, preeclampsia without severe features, severe preeclampsia, and HELLP (hemolysis, elevated liver enzymes, and low platelet) syndrome.
The primary outcome was a composite of cvSMM (including conditions such as pulmonary edema, stroke, and acute myocardial infarction) and the secondary outcome was a composite of overall SMM (including cvSMM and other conditions such as respiratory failure, severe postpartum hemorrhage, and sepsis). Adjusted risk ratios (aRRs) for the association between HDP subtypes and the outcomes were estimated using modified Poisson regression models adjusted for demographic and clinical characteristics.
Among 15 714 940 obstetric deliveries, 2 045 089 (13.02%) had HDP, 23 445 (0.15%) were affected by cvSMM, and 282 160 (1.80%) were affected by SMM. The mean (SD) age of the cohort was of 29 (6) years. The incidence of cvSMM was higher in participants with HDP than those without HDP (0.48% [9770 of 2 045 089] vs 0.10% [13 680 of 13 669 851]; P < .001). Participants with HELLP syndrome had the highest risk for cvSMM (aRR, 17.55 [95% CI, 14.67-21.01]), followed by severe preeclampsia (aRR, 9.11 [95% CI, 8.26-10.04]), and chronic hypertension (aRR, 3.57 [95% CI, 3.15-4.05]). Although HDP subtypes were also associated with overall SMM, the association with HELLP syndrome (aRR, 9.94 [95% CI, 9.44-10.45]), severe preeclampsia (aRR, 3.66 [95% CI, 3.55-3.78]), and chronic hypertension (aRR, 1.96 [95% CI, 1.88-2.03]) was attenuated compared with cvSMM.
In this cohort study, a graded relationship by severity characterized the association between HDP and cvSMM. Although all HDP subtypes were associated with an increased risk of overall SMM, the risk was more pronounced for cvSMM.
在北美，严重产妇发病率（SMM）-尤其是心血管 SMM（cvSMM），妊娠相关死亡的首要原因-呈上升趋势。虽然妊娠高血压疾病（HDP）很常见，但它们与 cvSMM 的具体关联仍不清楚。
在一个大型的、具有全国代表性的样本中，评估 HDP 的各个亚型与 cvSMM 以及总体 SMM 的关联。
设计、地点和参与者：使用美国国家住院患者样本进行了一项基于人群的队列研究。纳入了 2015 年至 2019 年期间分娩的个体。数据分析于 2023 年 10 月至 2024 年 2 月进行。
HDP 亚型包括妊娠期高血压、慢性高血压、无严重特征的子痫前期、严重子痫前期和 HELLP（溶血、肝酶升高和血小板减少）综合征。
主要结局是 cvSMM 的复合结局（包括肺水肿、中风和急性心肌梗死等情况），次要结局是总体 SMM 的复合结局（包括 cvSMM 和呼吸衰竭、严重产后出血和败血症等其他情况）。使用调整后的泊松回归模型，根据人口统计学和临床特征，对 HDP 亚型与结局之间的关联进行调整风险比（aRR）估计。
在 15714940 例产科分娩中，2045089 例（13.02%）患有 HDP，23445 例（0.15%）患有 cvSMM，282160 例（1.80%）患有 SMM。队列的平均（SD）年龄为 29（6）岁。患有 HDP 的参与者中 cvSMM 的发生率高于未患有 HDP 的参与者（0.48%[2045089 例中的 9770 例]与 0.10%[13669851 例中的 13680 例]；P<0.001）。患有 HELLP 综合征的参与者发生 cvSMM 的风险最高（aRR，17.55[95%CI，14.67-21.01]），其次是严重子痫前期（aRR，9.11[95%CI，8.26-10.04]）和慢性高血压（aRR，3.57[95%CI，3.15-4.05]）。尽管 HDP 亚型也与总体 SMM 相关，但与 HELLP 综合征（aRR，9.94[95%CI，9.44-10.45]）、严重子痫前期（aRR，3.66[95%CI，3.55-3.78]）和慢性高血压（aRR，1.96[95%CI，1.88-2.03]）的关联比 cvSMM 有所减弱。
在这项队列研究中，严重程度的分级关系描述了 HDP 与 cvSMM 之间的关联。虽然所有 HDP 亚型都与总体 SMM 的风险增加相关，但与 cvSMM 的风险增加更为明显。
