Blood pressure control in pregnant patients with chronic hypertension and diabetes: should <130/80 be the target? - 31/10/24

Doi : 10.1016/j.ajog.2024.09.006

Lorie M. Harper, MD, MSCI ^a,^⁎ , Hui-Chien Kuo, MPH ^b, Kim Boggess, MD ^c, Lorraine Dugoff, MD ^d, Baha Sibai, MD ^e, Kirsten Lawrence, MD ^f, Brenna L. Hughes, MD ^g, Joseph Bell, MD ^h, Kjersti Aagaard, MD, PhD ^i,^j, Rodney K. Edwards, MD ^k, Kelly S. Gibson, MD ^l, David M. Haas, MD ^m, Lauren Plante, MD ⁿ, Torri D. Metz, MD ^o, Brian M. Casey, MD ^p, Sean Esplin, MD ^q, Sherri Longo, MD ^r, Matthew Hoffman, MD ^s, George R. Saade, MD ^t, Kara Hoppe, MD ^u, Janelle Foroutan, MD ^v, Methodius G. Tuuli, MD ^w, Michelle Y. Owens, MD ^x, Hyagriv N. Simhan, MD ^y, Heather A. Frey, MD ^z, Todd Rosen, MD ^aa, Anna Palatnik, MD ^ab, Phyllis August, MD ^ac, Uma M. Reddy, MD ^ad, Wendy Kinzler, MD ^ae, Emily J. Su, MD ^af, Iris Krishna, MD ^ag, Nguyet A. Nguyen, MD ^ah, Mary E. Norton, MD ^ai, Daniel Skupski, MD ^aj, Yasser Y. El-Sayed, MD ^ak, Zorina S. Galis, PhD ^al, Namasivayam Ambalavanan, MD ^am, Suzanne Oparil, MD ^an, Jeff M. Szychowski, PhD ^ao, Alan T.N. Tita, MD ^ap
^a Department of Women’s Health, University of Texas at Austin, Austin, TX
^b Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL
^c Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, Chapel Hill, NC
^d Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA
^e Department of Obstetrics and Gynecology, University of Texas at Houston, Houston, TX
^f Department of Obstetrics and Gynecology, Columbia University, New York, NY
^g Department of Obstetrics and Gynecology, Duke University, Durham, NC
^h Department of Obstetrics and Gynecology, St. Luke’s University Health Network, Bethlehem, PA
ⁱ Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children’s Hospital and HCA Healthcare and HCA Healthcare Research Institute, Nashville, TN
^j HCA Texas Maternal Fetal Medicine, Houston, TX
^k Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences, Oklahoma City, OK
^l MetroHealth System, Cleveland, OH
^m Department of Obstetrics and Gynecology, Indiana University, Bloomington, IN
ⁿ Department of Obstetrics and Gynecology, Pennsylvania State College of Medicine, Hershey, PA
^o Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT
^p Department of Obstetrics and Gynecology, University of Texas Southwestern, Dallas, TX
^q Department of Obstetrics & Gynecology, Intermountain Healthcare, Salt Lake City, UT
^r Department of Obstetrics and Gynecology, Ochsner Baptist Medical Center, New Orleans, LA
^s Department of Obstetrics and Gynecology, Christiana Care Health Services, Newark, DE
^t Department of Obstetrics and Gynecology, Eastern Virginia Medical Center, Norfolk, VA
^u Department of Obstetrics and Gynecology, University of Wisconsin, Madison, WI
^v Department of Obstetrics and Gynecology, St. Peters University Hospital, New Brunswick, NJ
^w Department of Obstetrics and Gynecology, Washington University, St. Louis, MO
^x Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS
^y Department of Obstetrics and Gynecology, Magee Women's Hospital and University of Pittsburgh, Pittsburgh, PA
^z Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH
^aa Department of Obstetrics and Gynecology, Rutgers University-Robert Wood Johnson Medical School, New Brunswick, NJ
^ab Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI
^ac Department of Medicine, Weill Cornell University, New York, NY
^ad Department of Obstetrics and Gynecology, Yale University, New Haven, CT
^ae Department of Obstetrics and Gynecology, Winthrop University Hospital, Mineola, NY
^af Department of Obstetrics and Gynecology, University of Colorado, Boulder, CO
^ag Department of Obstetrics and Gynecology, Emory University, Atlanta, GA
^ah Department of Obstetrics and Gynecology, Denver Health, Denver, CO
^ai Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
^aj Department of Obstetrics and Gynecology, New York Presbyterian Queens Hospital, Flushing, NY
^ak Department of Obstetrics and Gynecology, Stanford University, Stanford, CA
^al Division of Cardiovascular Sciences, NHLBI, Bethesda, MD
^am Division of Neonatology, Department of Pediatrics, Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, AL
^an Division of Cardiovascular Disease, Department of Medicine, Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, AL
^ao Department of Biostatistics, Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, AL
^ap Department of Obstetrics and Gynecology, Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, AL

^∗Corresponding author: Lorie M. Harper, MD, MSCI.

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Thursday 31 October 2024

Abstract

Background

The Chronic Hypertension and Pregnancy Study demonstrated that a target blood pressure of <140/90 mm Hg during pregnancy is associated with improved perinatal outcomes. Outside of pregnancy, pharmacologic therapy for patients with diabetes and hypertension is adjusted to a target blood pressure of <130/80 mm Hg. During pregnancy, patients with both diabetes and chronic hypertension may also benefit from tighter control with a target blood pressure <130/80 mm Hg.

Objective

We compared perinatal outcomes in patients with hypertension and diabetes who achieved blood pressure <130/80 vs 130 to 139/80 to 89 mm Hg.

Study Design

This was a secondary analysis of a multcenter randomized controlled trial. Participants were included in this secondary analysis if they had diabetes diagnosed prior to pregnancy or at <20 weeks of gestation and at least 2 recorded blood pressure measurements prior to delivery. Average systolic and diastolic blood pressure were calculated using ambulatory antenatal blood pressures. The primary composite outcome was preeclampsia with severe features, indicated preterm birth <35 weeks, or placental abruption. Secondary outcomes were components of the primary outcome, cesarean delivery, fetal or neonatal death, neonatal intensive care unit admission, and small for gestational age. Comparisons were made between those with an average systolic blood pressure <130 mm Hg and average diastolic blood pressure <80 mm Hg and those with an average systolic blood pressure 130 to 139 mm Hg or diastolic blood pressure 80 to 89 mm Hg using Student’s t test and chi-squared tests. Multivariable log-binomial regression models were used to evaluate risk ratios between blood pressure groups for dichotomous outcomes while accounting for baseline covariates.

Results

Of 434 participants included, 150 (34.6%) had an average blood pressure less than 130/80 mm Hg. Participants with an average blood pressure less than 130/80 were more likely to be on antihypertensive medications at the start of pregnancy and more likely to have newly diagnosed diabetes mellitus prior to 20 weeks. Participants with an average blood pressure less than 130/80 mm Hg were less likely to have the primary adverse perinatal outcome (19.3% vs 46.5%, adjusted relative risk 0.43, 95% confidence interval 0.30–0.61, P<.01), with decreased risks specifically of preeclampsia with severe features (adjusted relative risk 0.35, 95% confidence interval 0.23–0.54) and indicated preterm birth prior to 35 weeks (adjusted relative risk 0.44, 95% confidence interval 0.24–0.79). The risk of neonatal intensive care unit admission was lower in the lower blood pressure group (adjusted relative risk 0.74, 95% confidence interval 0.59–0.94). No differences were noted in cesarean delivery (adjusted relative risk 1.04, 95% confidence interval 0.90–1.20), fetal or neonatal death (adjusted relative risk 0.59, 95% confidence interval 0.12–2.92). Small for gestational age less than the 10th percentile was lower in the lower blood pressure group (adjusted relative risk 0.37, 95% confidence interval 0.14–0.96).

Conclusion

In those with chronic hypertension and diabetes prior to 20 weeks, achieving an average goal blood pressure of <130/80 mm Hg may be associated with improved perinatal outcomes.

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Key words : antihypertensives, chronic hypertension, diabetes

Plan

Introduction

Materials and methods

Results

Comments

Principal findings

Results in the context of what is known

Clinical implications

Research implications

Strengths and limitations

Conclusions

Patients, faculty, fellows and residents, and staff at the participating sites

Investigators and study personnel

Clinical Coordinating Center

Data Coordinating Center

Clinical centers/sites

Drug Distribution Center

National Heart Lung and Blood Institute

CRediT authorship contribution statement

	The authors report no conflict of interest.
	Funding was provided by NHLBI U01HL120338, PI Tita.
	Presented as an oral abstract at the 43rd Pregnancy Meeting, Society for Maternal-Fetal Medicine, February 10, 2023, San Francisco, CA, US.
	Cite this article as: Harper LM, Kuo H-C, Boggess K, et al. Blood pressure control in pregnant patients with chronic hypertension and diabetes: should <130/80 be the target?. Am J Obstet Gynecol 2024;XXX:XX–XX.
	The views expressed in this manuscript are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; the National Institutes of Health; or the U.S. Department of Health and Human Services.
	Condensation: In pregnancies complicated by coexisting chronic hypertension and diabetes, achieving a blood pressure <130/80 mm Hg was associated with decreased occurrence preeclampsia with severe features, reduced incidence of preterm birth, and fewer NICU admissions without increasing fetal growth restriction.