Advertisement

Blood pressure trajectory and category and risk of hypertensive disorders of pregnancy in nulliparous women

      Background

      Recently updated American College of Cardiology/ American Heart Association (ACC/AHA) guidelines redefine blood pressure categories as stage 1 hypertension (systolic, 130–139 mm Hg or diastolic, 80–89 mm Hg), elevated (systolic, 120–129 mm Hg and diastolic, <80 mm Hg), and normal (<120/<80 mm Hg), but their relevance to an obstetric population is uncertain.

      Objective

      We sought to evaluate the risk of gestational hypertension or preeclampsia based on early pregnancy blood pressure category and trajectory.

      Study Design

      We utilized data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be cohort, a prospective observational study of nulliparous women with singleton pregnancies conducted at 8 clinical sites between 2010 and 2014. Women included in this analysis had no known history of prepregnancy hypertension (blood pressure, ≥140/90 mm Hg) or diabetes. We compared the frequency of hypertensive disorders of pregnancy, including preeclampsia and gestational hypertension, among women based on ACC/AHA blood pressure category at a first-trimester study visit and blood pressure trajectory between study visits in the first and second trimesters. Blood pressure trajectories were categorized based on blood pressure difference between visits 1 and 2 as stable (<5 mm Hg difference), upward (≥5 mm Hg), or downward (≤-5 mm Hg). Associations of blood pressure category and trajectory with preeclampsia and gestational hypertension were assessed via univariate analysis and multinomial logistic regression analysis with covariates identified a priori.

      Results

      A total of 8899 women were included in the analysis. Study visit 1 occurred at a mean gestational age of 11.6 ± 1.5 weeks and study visit 2 at a mean gestational age of 19.0 ± 1.6 weeks. First-trimester blood pressure category was significantly associated with both preeclampsia and gestational hypertension, with increasing blood pressure category associated with a higher risk of all hypertensive disorders of pregnancy. Elevated blood pressure was associated with an adjusted relative risk of 1.54 (95% confidence interval, 1.18–2.02) and stage 1 hypertension was associated with adjusted relative risk of 2.16 (95% confidence interval, 1.31–3.57) of any hypertensive disorder of pregnancy. Stage 1 hypertension was associated with the highest risk of preeclampsia with severe features, with an adjusted relative risk of 2.48 (95% confidence interval, 1.38–8.74). Both systolic and diastolic blood pressure trajectories were also significantly associated with the risk of hypertensive disorders of pregnancy independent of blood pressure category (P < .001). Women with a blood pressure categorized as normal and with an upward systolic trajectory had a 41% increased risk of any hypertensive disorder of pregnancy (adjusted relative risk, 1.41; 95% confidence interval, 1.20–1.65) compared to women with a downward systolic trajectory.

      Conclusion

      In nulliparous women, blood pressure category and trajectory in early pregnancy are independently associated with risk of preeclampsia and gestational hypertension. Our study demonstrates that blood pressure categories with lower thresholds than those traditionally used to identify individuals as hypertensive may identify more women at risk for preeclampsia and gestational hypertension.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Whelton P.K.
        • Carey R.M.
        • Aronow W.S.
        • et al.
        2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
        Hypertension. 2018; 71: e13-e15
        • Lewington S.
        • Clarke R.
        • Qizilbash N.
        • Peto R.
        • Collins R.
        • Prospective Studies Collaboration
        Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies.
        Lancet. 2002; 360: 1903-1913
        • Ankumah N.-A.
        • Cantu J.
        • Jauk V.
        • et al.
        Risk of adverse pregnancy outcomes in women with mild chronic hypertension before 20 weeks of gestation.
        Obstet Gynecol. 2014; 123: 966-972
        • Bramham K.
        • Parnell B.
        • Nelson-Piercy C.
        • Seed P.T.
        • Poston L.
        • Chappell L.C.
        Chronic hypertension and pregnancy outcomes: systematic review and meta-analysis.
        BMJ. 2014; 348: g2301
        • Rolnik D.L.
        • Wright D.
        • Poon L.C.
        • et al.
        Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia.
        N Engl J Med. 2017; 377: 613-622
        • Hermida R.C.
        • Ayala D.E.
        • Iglesias M.
        Predictable blood pressure variability in healthy and complicated pregnancies.
        Hypertension. 2001; 38: 736-741
        • Ayala D.E.
        • Hermida R.C.
        • Mojón A.
        • et al.
        Blood pressure variability during gestation in healthy and complicated pregnancies.
        Hypertension. 1997; 30: 611-618
        • Hauspurg A.
        • Sutton E.F.
        • Catov J.M.
        • Caritis S.N.
        Aspirin effect on adverse pregnancy outcomes associated with stage 1 hypertension in a high-risk cohort.
        Hypertension. 2018; 72: 202-207
        • Sutton E.F.
        • Hauspurg A.
        • Caritis S.N.
        • Powers R.W.
        • Catov J.M.
        Maternal outcomes associated with lower range stage 1 hypertension.
        Obstet Gynecol. 2018; 132: 843-849
        • Haas D.M.
        • Parker C.B.
        • Wing D.A.
        • et al.
        A description of the methods of the Nulliparous Pregnancy Outcomes Study: monitoring mothers-to-be (nuMoM2b).
        Am J Obstet Gynecol. 2015; 212: 539.e1-539.e4
        • Pickering T.G.
        • Hall J.E.
        • Appel L.J.
        • et al.
        Recommendations for blood pressure measurement in humans and experimental animals.
        Circulation. 2005; 111: 697-716
        • Facco F.L.
        • Parker C.B.
        • Reddy U.M.
        • et al.
        Association between sleep-disordered breathing and hypertensive disorders of pregnancy and gestational diabetes mellitus.
        Obstet Gynecol. 2017; 129: 31-41
        • ACOG Practice Bulletin No. 202
        Gestational Hypertension and Preeclampsia.
        Obstet Gynecol. 2019; 133: e1-e25
        • Topel M.L.
        • Duncan E.M.
        • Krishna I.
        • Badell M.L.
        • Vaccarino V.
        • Quyyumi A.A.
        Estimated impact of the 2017 American College of Cardiology/American Heart Association blood pressure guidelines on reproductive-aged women.
        Hypertension. 2018; 72
        • Smith G.
        • Pudwell J.
        • Saade G.
        Impact of the new American hypertension guidelines on the prevalence of postpartum hypertension.
        Am J Perinatol. 2019; 36: 440-442
        • ACOG Practice Bulletin No. 203
        Chronic Hypertension in Pregnancy.
        Obstet Gynecol. 2019; 133: e26-e50
        • Rosner J.Y.
        • Gutierrez M.
        • Dziadosz M.
        • et al.
        Prehypertension in early pregnancy: what is the significance?.
        Am J Perinatol. 2017; 34: 117-122
        • Cao C.
        • Cai W.
        • Niu X.
        • et al.
        Prehypertension during pregnancy and risk of small for gestational age: a systematic review and meta-analysis.
        J Matern Neonatal Med. 2018; : 1-8
        • Steel A.
        • Lucke J.
        • Adams J.
        The prevalence and nature of the use of preconception services by women with chronic health conditions: an integrative review.
        BMC Womens Health. 2015; 15: 14
        • Muntner P.
        • Carey R.M.
        • Gidding S.
        • et al.
        Potential US population impact of the 2017 ACC/AHA high blood pressure guideline.
        Circulation. 2018; 137: 109-118