Trends in Chronic Hypertension in Pregnancy Highlight Racial Disparities in Maternal Health
2019; Lippincott Williams & Wilkins; Volume: 74; Issue: 5 Linguagem: Inglês
10.1161/hypertensionaha.119.13480
ISSN1524-4563
AutoresDana Larsen, Jessica Sheehan Tangren,
Tópico(s)Maternal and Perinatal Health Interventions
ResumoHomeHypertensionVol. 74, No. 5Trends in Chronic Hypertension in Pregnancy Highlight Racial Disparities in Maternal Health Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBTrends in Chronic Hypertension in Pregnancy Highlight Racial Disparities in Maternal Health Dana M. Larsen and Jessica Sheehan Tangren Dana M. LarsenDana M. Larsen From the Renal Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School. and Jessica Sheehan TangrenJessica Sheehan Tangren Correspondence to Jessica Sheehan Tangren, 165 Cambridge St Suite 302, Boston, MA 02114. Email E-mail Address: [email protected]617-726-4367 From the Renal Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School. Originally published9 Sep 2019https://doi.org/10.1161/HYPERTENSIONAHA.119.13480Hypertension. 2019;74:1087–1088This article is a commentary on the followingChanges in the Prevalence of Chronic Hypertension in Pregnancy, United States, 1970 to 2010Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: September 9, 2019: Ahead of Print See related article, pp 1089–1095Rates of maternal mortality across the globe are on the decline, but maternal death rates in the United States are increasing.1 Hypertension complicates up to 10% to 15% of pregnancies and is a leading cause of maternal morbidity and mortality. Although hypertension can arise de novo in pregnancy, women with chronic hypertension (ie, hypertension diagnosed before conception) are at especially high risk for pregnancy complications including preeclampsia, intrauterine growth restriction, and perinatal mortality compared with the general population.2In this issue of Hypertension, Ananth et al3 report on the rate of maternal chronic hypertension in United States in a large cross-sectional analysis of over 150 million women using the National Hospital Discharge Survey database. Although studies on the relationship of maternal chronic hypertension and maternal age have been previously reported, Ananth et al3 present an age-period-cohort analysis to investigate this relationship. As the name suggests, an age-period-cohort analysis is used to assess the independent contributions of age, period, and cohort on disease rates. The age effect describes the risk of an outcome associated with different ages; the period effect describes changes in disease prevalence over time that influence all age groups; the cohort effect is associated with changes in disease prevalence in individuals born at the same time, most often related to exposures.Using age-period-cohort modeling, Ananth et al3 identify a strong correlation between advancing maternal age and maternal chronic hypertension among all women. Mostly notably, they identified a nearly a 6% increase in rates of maternal chronic hypertension each year. Furthermore, chronic hypertension prevalence was 2-fold higher in black (1.24%) compared with white (0.53%) women. Modeling secular trends in obesity and smoking did not impact rates of chronic maternal hypertension independently or by racial category.A strong positive for this study relies on its large and diverse sample size consisting of over 151 million births over a geographically diverse US landscape. This is of particular importance given the relatively low overall prevalence of maternal chronic hypertension. Working with a sample of this size and longitudinal breadth has its own set of consequences. Two independent International Classification of Diseases codes and varying definitions of hypertension exist in the dataset. Severity of hypertension and the effects of pharmacological or lifestyle interventions could not be assessed, and analysis of the effect of smoking and obesity were modeled on a population level using trends from the National Health and Nutrition Examination Survey, which may not be representative of the specific population studied in the National Hospital Discharge Survey database. Furthermore, it should be highlighted that 19% of records were missing racial data, which is significant given that 13% of the analyzed population was black.The analysis by Ananth et al3 is nonetheless important in connecting the previously observed profound racial disparities in maternal health and cardiovascular disease. In a study of pregnancy-related deaths in the United States from 2006 to 2010, non-Hispanic black women had higher rates of pregnancy-related death compared with non-Hispanic white women.4 Increasing age was associated with increased risk of pregnancy-related death in all racial/ethnic groups; however, it was most pronounced in black women. The pregnancy-related mortality ratio for black women aged ≥40 years in this cohort was nearly 150 deaths per 100 000 live births versus 40 deaths per 100 000 live births among white women of this age. Cardiovascular disease is now the leading cause of pregnancy-related death.5 Black women in the United States have higher rates of hypertension with earlier disease onset and poorer control compared with white Americans.6In summary, the study by Ananth et al3 provides a large sample of diverse, both racially and geographically, data suggesting a correlation between increasing maternal age and increasing maternal chronic hypertension within the United States and highlights prominent racial disparities between white and black women. Many limitations exist in interpreting the outcomes of administrative data analyses used in this study. However, this study is an important step in trying to dissect the causes of this disparity. Trends in maternal age are likely to remain. Large randomized control trials on hypertension targets include few women in their reproductive years.7 Similarly, the largest randomized trial on treatment of chronic hypertension during pregnancy did not include US patients.8 Identifying the optimal treatment strategy for hypertension in reproductive-age women is needed in conjunction with expanded efforts at reducing disparities in the treatment of hypertension across a woman's lifespan.Sources of FundingNone.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to Jessica Sheehan Tangren, 165 Cambridge St Suite 302, Boston, MA 02114. Email [email protected]org617-726-4367References1. GBD 2015 Maternal Mortality Collaborators. Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388:1775–1812. doi: 10.1016/S0140-6736(16)31470-2CrossrefMedlineGoogle Scholar2. ACOG practice bulletin no. 203: chronic hypertension in pregnancy.Obstet Gynecol. 2019; 133:e26–e50.CrossrefMedlineGoogle Scholar3. Ananth CV, Duzyj CM, Yadava S, Schwebel M, Tita ATN, Joseph KS. Changes in the prevalence of chronic hypertension in pregnancy, United States, 1970 to 2010.Hypertension. 2019; 74:1089–1095.LinkGoogle Scholar4. Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006–2010.Obstet Gynecol. 2015; 125:5–12.CrossrefMedlineGoogle Scholar5. Centers for Disease Control and Prevention. Pregnancy mortality surveillance system.Google Scholar6. Carnethon MR, Pu J, Howard G, Albert MA, Anderson CAM, Bertoni AG, Mujahid MS, Palaniappan L, Taylor HA, Willis M, Yancy CW; American Heart Association Council on Epidemiology and Prevention; Council on Cardiovascular Disease in the Young; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Functional Genomics and Translational Biology; and Stroke Council. Cardiovascular health in African Americans: a scientific statement from the American Heart Association.Circulation. 2017; 136:e393–e423. doi: 10.1161/CIR.0000000000000534LinkGoogle Scholar7. A randomized trial of intensive versus standard blood-pressure control.N Engl J Med. 2015; 373:2103–2116.CrossrefMedlineGoogle Scholar8. Magee LA, von Dadelszen P, Rey E, et al. Less-tight versus tight control of hypertension in pregnancy.N Engl J Med. 2015; 372:407–417. doi: 10.1056/NEJMoa1404595CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Barnes K and Guthrie K (2017) Hypertension in Pregnancy PharmacotherapyFirst: A Multimedia Learning Resource, 10.21019/pharmacotherapyfirst.hp_overview, Online publication date: 1-May-2017. Related articlesChanges in the Prevalence of Chronic Hypertension in Pregnancy, United States, 1970 to 2010Cande V. Ananth, et al. Hypertension. 2019;74:1089-1095 November 2019Vol 74, Issue 5 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/HYPERTENSIONAHA.119.13480PMID: 31495280 Originally publishedSeptember 9, 2019 PDF download Advertisement SubjectsHypertension
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