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De Novo Postpartum Hypertension: Is Pregnancy a Stress Test or Risk Factor?

2023; Lippincott Williams & Wilkins; Volume: 80; Issue: 2 Linguagem: Inglês

10.1161/hypertensionaha.122.20155

1524-4563

Ayodeji Sanusi, Rachel Sinkey,

Maternal and fetal healthcare

HomeHypertensionVol. 80, No. 2De Novo Postpartum Hypertension: Is Pregnancy a Stress Test or Risk Factor? Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBDe Novo Postpartum Hypertension: Is Pregnancy a Stress Test or Risk Factor? Ayodeji A. Sanusi and Rachel G. Sinkey Ayodeji A. SanusiAyodeji A. Sanusi Correspondence to: Ayodeji Sanusi, MD, MPH, 1700 6th Ave South, WIC 10274, Birmingham, AL, 35233. Email E-mail Address: [email protected] https://orcid.org/0000-0002-8263-5776 Center for Women's Reproductive Health, University of Alabama at Birmingham (A.A.S., R.G.S.). Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham (A.A.S., R.G.S.). and Rachel G. SinkeyRachel G. Sinkey https://orcid.org/0000-0001-7674-9796 Center for Women's Reproductive Health, University of Alabama at Birmingham (A.A.S., R.G.S.). Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham (A.A.S., R.G.S.). Originally published18 Jan 2023https://doi.org/10.1161/HYPERTENSIONAHA.122.20155Hypertension. 2023;80:288–290This article is a commentary on the followingDe Novo Postpartum Hypertension: Incidence and Risk Factors at a Safety-Net HospitalSee related article, pp 279–287In this edition of Hypertension, Parker et al1 present intriguing data on the risk of de novo postpartum hypertension in the year following pregnancy among patients without a prior diagnosis of chronic or pregnancy-related hypertension. They performed an observational cohort study of racially diverse patients receiving prenatal care and delivering at Boston Medical Center, Boston, United States from 2016 to 2018 to estimate the incidence of de novo postpartum hypertension through the first year postpartum. Two blood pressure (BP) readings with systolic BP ≥140 mmHg or diastolic BP≥90 mmHg ≥48 hours following delivery were required for de novo postpartum hypertension diagnosis. The observed rate of de novo postpartum hypertension in the total cohort was 12.1% (n=298/2465); the rate was as high as 1 in 3 for patients with advanced maternal age (≥35 years), tobacco use history, and cesarean delivery. The authors conclude that certain patient characteristics (body mass index ≥30 kg/m2, current tobacco use, substance use, diabetes and cesarean delivery) may help prenatally identify pregnant people at risk of developing de novo postpartum hypertension.1A concern exists whether the authors are capturing patients with a missed pre-pregnancy diagnosis of chronic hypertension. Systemic vascular resistance decreases in the first trimester of pregnancy and BPs may be up to 30% lower than baseline in the second trimester.2 However, when the study population was restricted to the 1392 patients who entered prenatal care at ≤13 weeks' gestation, the de novo postpartum hypertension rate was similar at 13.3%, strengthening the credibility of the authors' findings.Figure depicts rates of hypertensive disorders across various stages of a reproductive-aged female. Approximately 8% of reproductive-aged females have chronic hypertension, and 2% to 8% of pregnancies are complicated by gestational hypertension or preeclampsia.3,4 Excluding de novo postpartum hypertension, nearly one in 10 pregnancies is complicated by hypertension. Once de novo postpartum hypertension is included, up to 1 in 5 pregnant people experience a hypertensive disorder. Pregnancy-associated hypertension should thus be viewed as a top public health priority.Download figureDownload PowerPointFigure. Frequency of hypertensive disorders across the pregnancy spectrum. HTN indicates hypertension.A prior randomized trial in non-pregnant adults without diabetes comparing intensive to standard BP control (systolic BP ≤120 vs ≤140 mmHg) found a lower incidence of an adverse cardiovascular composite in participants assigned to intensive BP treatment (HR, 0.75 [95% CI, 0.64–0.89]).5 Further, the results of the recent Chronic Hypertension and Pregnancy trial showed an 18% reduced risk (RR, 0.82 [95% CI, 0.74–0.92]) of a composite of severe preeclampsia, preterm delivery <35weeks, placental abruption or fetal or neonatal death, following treatment of mild chronic hypertension to BPs <140/90 mmHg in pregnancy.6 Maternal follow up from this cohort is ongoing. Taken together with the findings from Parker et al, the first year following delivery may provide a window of opportunity for lifestyle interventions, and when applicable, antihypertensive initiation, to attain lower BP in a group at high-risk of developing chronic hypertension.The US Preventive Services Taskforce currently recommends office blood pressure measurements for adults ≥18 years at routine preventive yearly visits. Postpartum de novo hypertension screening is widely available, associated with minimal risk, and can identify early chronic hypertension, which has been shown to reduce cardiovascular risk. Screening strategies that can overcome numerous social determinants of health barriers are critical. In the United States, only 23 states have implemented expanded Medicaid coverage for up to 1 year postpartum.7 Nationally, Medicaid remains the largest health care insurer (42%) in pregnancy and loss of postpartum insurance coverage is often an insurmountable barrier to preventive health care.8–10 Since more than 1 in 5 participants (22.5%) in the study by Parker et al developed de novo postpartum hypertension after 6 weeks postpartum, insurance coverage expansion may improve postpartum identification and treatment of patients with de novo postpartum hypertension. Further, Black patients in this cohort had the highest risk of de novo postpartum hypertension at 14%, highlighting opportunities to reduce marked racial disparities in the year after delivery.Importantly, the threshold for the diagnosis of de novo postpartum hypertension used in the study by Parker et al was systolic or diastolic BP ≥140/90 mmHg, respectively. In 2017, the ACC/AHA recommended BP ≥130/80 mmHg for the diagnosis of stage 1 hypertension, which has been estimated to increase the prevalence of chronic hypertension in pregnancy from 4.2% to 25.0%, in one study.11 If applied to the study by Parker et al, the prevalence of de novo postpartum hypertension would likely be even higher, broadening the number of people who may benefit from risk reducing interventions. Although prospective studies are needed to investigate the prevalence of de novo postpartum hypertension in other populations, these findings challenge the traditional views of pregnancy only as a stress-test that unmasks underlying susceptibility to hypertension.12 The increased risk of chronic hypertension and cardiovascular morbidity following a hypertensive disorder of pregnancy have been well described.13 Further, it is accepted that pregnancy-associated factors—such as gestational weight gain, a risk factor for obesity—may contribute to the future development of chronic hypertension. However, elucidation of the role of pregnancy-related cardiovascular remodeling in the causal pathway to chronic hypertension is needed. The findings by Parker et al turns the spotlight on the significant burden of hypertension across the reproductive spectrum, highlight the need for policy and interventions to improve cardiovascular health, and beg the question: is pregnancy a stress test, a risk factor or both?Article InformationSources of FundingR.G. Sinkey is supported by K23HL159331.Disclosures None.FootnotesThe opinions expressed in this article are not necessarily those of the editors nor the American Heart Association.For Sources of Funding and Disclosures, see page 289.Correspondence to: Ayodeji Sanusi, MD, MPH, 1700 6th Ave South, WIC 10274, Birmingham, AL, 35233. Email aasanusi@uabmc.eduReferences1. Parker SE, Ajayi A, Yarrington CD. De Novo postpartum hypertension: incidence and risk factors at a safety-net hospital.Hypertension. 2023; 80:279–287. doi: 10.1161/HYPERTENSIONAHA.122.19275LinkGoogle Scholar2. Battarbee AN, Sinkey RG, Harper LM, Oparil S, Tita ATN. Chronic hypertension in pregnancy.Am J Obstet Gynecol. 2020; 222:532–541. doi: 10.1016/j.ajog.2019.11.1243CrossrefMedlineGoogle Scholar3. Chen HY, Chauhan SP. Hypertension among women of reproductive age: impact of 2017 American College of Cardiology/American heart association high blood pressure guideline.Int J Cardiol Hypertens. 2019; 1:100007. doi: 10.1016/j.ijchy.2019.100007CrossrefMedlineGoogle Scholar4. Gestational hypertension and preeclampsia: ACOG practice bulletin, number 222.Obstet Gynecol. 2020; 135:e237–e260. doi: 10.1097/AOG.0000000000003891CrossrefMedlineGoogle Scholar5. WrightWilliamson JTJD, Whelton PK, Snyder JK, Sink KM, Rocco MV, Reboussin DM, Rahman M, Oparil S, Lewis CE, Kimmel PL., et al; SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control.N Engl J Med. 2015; 373:2103–2116. doi: 10.1056/NEJMoa1511939CrossrefMedlineGoogle Scholar6. Tita AT, Szychowski JM, Boggess K, Dugoff L, Sibai B, Lawrence K, Hughes BL, Bell J, Aagaard K, Edwards RK., et al; Chronic Hypertension and Pregnancy (CHAP) Trial Consortium. Treatment for mild chronic hypertension during pregnancy.N Engl J Med. 2022; 386:1781–1792. doi: 10.1056/NEJMoa2201295CrossrefMedlineGoogle Scholar7. Shah S, Friedman H. Medicaid and moms: the potential impact of extending medicaid coverage to mothers for 1 year after delivery.J Perinatol. 2022; 42:819–824. doi: 10.1038/s41372-021-01299-wCrossrefMedlineGoogle Scholar8. Dunlop AL, Joski P, Strahan AE, Sierra E, Adams EK. Postpartum medicaid coverage and contraceptive use before and after Ohio's medicaid expansion under the affordable care act.Womens Health Issues. 2020; 30:426–435. doi: 10.1016/j.whi.2020.08.006CrossrefMedlineGoogle Scholar9. Steenland MW, Wilson IB, Matteson KA, Trivedi AN. Association of medicaid expansion in arkansas with postpartum coverage, outpatient care, and racial disparities.JAMA Health Forum. 2021; 2:e214167. doi: 10.1001/jamahealthforum.2021.4167CrossrefMedlineGoogle Scholar10. Rodriguez MI, Skye M, Lindner S, Caughey AB, Lopez-DeFede A, Darney BG, McConnell KJ. Analysis of contraceptive use among immigrant women following expansion of medicaid coverage for postpartum care.JAMA Netw Open. 2021; 4:e2138983. doi: 10.1001/jamanetworkopen.2021.38983CrossrefMedlineGoogle Scholar11. Hu J, Li Y, Zhang B, Zheng T, Li J, Peng Y, Zhou A, Buka SL, Liu S, Zhang Y., et al. Impact of the 2017 ACC/AHA guideline for high blood pressure on evaluating gestational hypertension–associated risks for newborns and mothers: a retrospective birth cohort study.Circ Res. 2019; 125:184–194. doi: 10.1161/CIRCRESAHA.119.314682LinkGoogle Scholar12. Burger RJ, Delagrange H, van Valkengoed IGM, de Groot CJM, van den Born BH, Gordijn SJ, Ganzevoort W. Hypertensive disorders of pregnancy and cardiovascular disease risk across races and ethnicities: a review.Front Cardiovasc Med. 2022; 9:933822. doi: 10.3389/fcvm.2022.933822CrossrefMedlineGoogle Scholar13. Xu J, Li T, Wang Y, Xue L, Miao Z, Long W, et al. The association between hypertensive disorders in pregnancy and the risk of developing chronic hypertension.Front Cardiovasc Med. 2022; 9:897771. doi: 10.3389/FCVM.2022.897771CrossrefGoogle Scholar eLetters(0) eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate. Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page. Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesDe Novo Postpartum Hypertension: Incidence and Risk Factors at a Safety-Net HospitalSamantha E. Parker, et al. Hypertension. 2023;80:279-287 February 2023Vol 80, Issue 2 Advertisement Article Information Metrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/HYPERTENSIONAHA.122.20155PMID: 36652531 Originally publishedJanuary 18, 2023 PDF download Advertisement Subjects Hypertension Preeclampsia