Gunderson Erica P, Greenberg Mara, Najem Michael, Sun Baiyang, Alexeeff Stacey E, Alexander Janet, Nguyen-Huynh Mai N, Roberts James M
Division of Research, Kaiser Permanente Northern California, Pleasanton.
Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California.
JAMA Netw Open. 2025 Jan 2;8(1):e2451406. doi: 10.1001/jamanetworkopen.2024.51406.
Chronic hypertension and preeclampsia are leading risk enhancers for maternal-neonatal morbidity and mortality. Severe maternal morbidity (SMM) indicators include heart, kidney, and liver disease, but studies have not excluded patients with preexisting diseases that define SMM. Thus, SMM risks for uncomplicated chronic hypertension specific to preeclampsia remain unclear.
To determine SMM rates and estimate relative risks associated with hypertensive disorders of pregnancy among patients with and without chronic hypertension unencumbered by preexisting vascular or end organ diseases.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used longitudinal health data from electronic health records from patients within a community-based, integrated health care system in northern California. The study cohort selected 263 518 pregnant patients without pregestational heart, kidney, or liver disease entering prenatal care at 14 weeks' gestation or earlier and delivering a singleton stillbirth or live birth in 2009 to 2019. The data were analyzed between February 2022 and March 2024.
Five joint subgroups combining chronic hypertension status and the hypertensive disorders developing during pregnancy, defined as follows: (1) chronic hypertension with superimposed preeclampsia, (2) chronic hypertension and no preeclampsia, (3) no chronic hypertension with preeclampsia, (4) gestational hypertension, and (5) no chronic hypertension and no preeclampsia or gestational hypertension (reference group).
The main outcome was SMM rates at delivery hospitalization (cases per 10 000 births) using the Centers for Disease Control and Prevention criteria (≥1 of 21 indicators to define SMM) obtained from electronic health records. Modified Poisson regression models estimated crude and adjusted relative risks (aRRs) and 95% CIs of SMM associated with the chronic hypertension and developing hypertensive disorders of pregnancy groups vs the reference group (no chronic hypertension and no preeclampsia or gestational hypertension) adjusted for clinical, sociodemographic, social, and behavioral covariates.
The analysis included a total of 263 518 pregnant patients (mean [SD] age at delivery, 31.0 [5.3] years), including 249 892 patients without chronic hypertension (4.7% developed preeclampsia) and 13 626 patients with chronic hypertension (31.5% developed superimposed preeclampsia). The highest SMM rates occurred in the no chronic hypertension with preeclampsia (934.3 [95% CI, 882.3-988.3] cases per 10 000 births) and the chronic hypertension with superimposed preeclampsia (898.3 [95% CI, 814.5-987.8] cases per 10,000 births) groups. Lower SMM rates occurred in the chronic hypertension and no preeclampsia (195.1 [95% CI, 168.0-225.2] cases per 10,000 births), gestational hypertension (312.7 [95% CI, 281.6-346.1] cases per 10,000 births), and no chronic hypertension and no preeclampsia or gestational hypertension (165.8 [95% CI, 160.6-171.2] cases per 10,000 births) groups (P < .001). Compared with the no chronic hypertension and no preeclampsia or gestational hypertension group, risks of SMM were significantly higher for the chronic hypertension with superimposed preeclampsia group (aRR, 4.97 [95% CI, 4.46-5.54]), no chronic hypertension with preeclampsia group (aRR, 5.12 [95% CI, 4.79-5.48]), chronic hypertension and no preeclampsia group (aRR, 1.17 [95% CI, 1.003-1.36]; P = .046), and the gestational hypertension group (aRR, 1.78 [95% CI 1.60-1.99]).
This cohort study found that the highest SMM rates at delivery hospitalization occurred for preeclampsia superimposed on chronic hypertension and preeclampsia without chronic hypertension, while gestational hypertension had intermediate rates of SMM. The patients with chronic hypertension who did not develop preeclampsia had SMM rates that were nearly the same as the lowest-risk patients without chronic hypertension who did not develop preeclampsia or gestational hypertension. These findings provide evidence that prevention of preeclampsia among patients with uncomplicated chronic hypertension is paramount to mitigating maternal morbidity.
慢性高血压和子痫前期是孕产妇-新生儿发病和死亡的主要风险增强因素。严重孕产妇发病（SMM）指标包括心脏、肾脏和肝脏疾病，但研究并未排除那些已存在定义SMM疾病的患者。因此，子痫前期特有的单纯慢性高血压的SMM风险仍不明确。
确定分娩住院时的SMM发生率，并估计有无慢性高血压且无既往血管或终末器官疾病的妊娠高血压疾病患者的相对风险。
设计、设置和参与者：这项回顾性队列研究使用了来自加利福尼亚北部一个基于社区的综合医疗系统中患者电子健康记录的纵向健康数据。研究队列选取了263518例妊娠14周及更早开始产前检查且在2009年至2019年分娩单胎死产或活产、孕前无心脏、肾脏或肝脏疾病的孕妇。数据在2022年2月至2024年3月期间进行分析。
五个联合亚组，结合慢性高血压状态和孕期发生的高血压疾病，定义如下：（1）慢性高血压合并子痫前期；（2）慢性高血压且无子痫前期；（3）无慢性高血压合并子痫前期；（4）妊娠期高血压；（5）无慢性高血压且无子痫前期或妊娠期高血压（参照组）。
主要结局是根据从电子健康记录中获取的疾病控制和预防中心标准（21项指标中≥1项定义SMM）计算的分娩住院时的SMM发生率（每10000例分娩的病例数）。修正泊松回归模型估计了与慢性高血压和孕期发生的高血压疾病组相比，参照组（无慢性高血压且无子痫前期或妊娠期高血压）经临床、社会人口统计学、社会和行为协变量调整后的SMM的粗相对风险和调整相对风险（aRRs）及95%置信区间。
分析共纳入263518例孕妇（分娩时平均[标准差]年龄为31.0[5.3]岁），其中249892例无慢性高血压（4.7%发生子痫前期），13626例有慢性高血压（31.5%发生合并子痫前期）。SMM发生率最高的是无慢性高血压合并子痫前期组（每10000例分娩934.3[95%置信区间，882.3 - 988.3]例）和慢性高血压合并子痫前期组（每10000例分娩898.3[95%置信区间，814.5 - 987.8]例）。慢性高血压且无子痫前期组（每10000例分娩195.1[95%置信区间，168.0 - 225.2]例）、妊娠期高血压组（每10000例分娩312.7[95%置信区间，281.6 - 346.1]例）和无慢性高血压且无子痫前期或妊娠期高血压组（每10000例分娩165.8[95%置信区间，160.6 - 171.2]例）的SMM发生率较低（P <.001）。与无慢性高血压且无子痫前期或妊娠期高血压组相比，慢性高血压合并子痫前期组（aRR，4.97[95%置信区间，4.46 - 5.54]）、无慢性高血压合并子痫前期组（aRR，5.12[95%置信区间，4.79 - 5.48]）、慢性高血压且无子痫前期组（aRR，1.17[95%置信区间，1.003 - 1.36]；P = 0.046）和妊娠期高血压组（aRR，1.78[95%置信区间1.60 - 1.99]）的SMM风险显著更高。
这项队列研究发现，分娩住院时SMM发生率最高的是慢性高血压合并子痫前期和无慢性高血压合并子痫前期，而妊娠期高血压的SMM发生率处于中等水平。未发生子痫前期的慢性高血压患者的SMM发生率与未发生子痫前期或妊娠期高血压的最低风险无慢性高血压患者几乎相同。这些发现提供了证据，表明在单纯慢性高血压患者中预防子痫前期对于减轻孕产妇发病至关重要。
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