- Tita AT, Szychowski JM, Boggess K, Dugoff L, Sibai B, Lawrence K, Hughes BL, Bell J, Aagaard K, Edwards RK, Gibson K, Haas DM, Plante L, Metz T, Casey B, Esplin S, Longo S, Hoffman M, Saade GR, Hoppe KK, Foroutan J, Tuuli M, Owens MY, Simhan HN, Frey H, Rosen T, Palatnik A, Baker S, August P, Reddy UM, Kinzler W, Su E, Krishna I, Nguyen N, Norton ME, Skupski D, El-Sayed YY, Ogunyemi D, Galis ZS, Harper L, Ambalavanan N, Geller NL, Oparil S, Cutter GR, Andrews WW
- Chronic hypertension affects >2% of pregnancies in the United States and disproportionately affects Black women. The condition is also associated with an increased risk of adverse neonatal outcomes, including preeclampsia, placental abruption, pretermbirth, small for gestational age (SGA), or perinatal death, andmaternal outcomes, includingmaternal death, heart failure, stroke, pulmonary edema, or acute kidney injury. Although antihypertensive therapy is the standard of care for nonpregnant people, clinical recommendations for pregnant peoplewith hypertension vary. This is because antihypertensive treatment during pregnancy has not demonstrated improvement in maternal and neonatal outcomes, despite reducing the risk of severe hypertension. Although there is consensus to treat pregnant people with severe hypertension, it is unclear whether to provide antihypertensive therapy to those with mild chronic hypertension until the condition is severe (=160-105mmHg). The aimof this study was to assess whether antihypertension therapy for pregnant women with mild chronic hypertension would improve maternal and perinatal outcomes compared with reserving treatment until their blood pressure reached severe levels.The Chronic Hypertension and Pregnancy project was a randomized controlled trial, conducted at >70 recruiting sites across the United States. Included were women with viable singleton pregnancies and a known or new diagnosis of chronic hypertension (=140/90 mm Hg) before 23 weeks of gestation. Excluded were those with severe hypertension or the need for >1 antihypertensive medication, known secondary hypertension, high-risk coexisting illnesses, complications that warrant treatment at a lower blood-pressure level, obstetric conditions with increased fetal risk, and contraindications to antihypertensive therapy during pregnancy. Patients were randomized into 2 groups: the active treatment group, which received antihypertension therapy with a blood-pressure goal of <140/90 mm Hg, and the control group, which did not receive antihypertension therapy unless severe hypertension developed. The primary outcome was a composite of preeclampsia with severe features, medically indicated preterm birth at <35 weeks of gestation, placental abruption, or fetal or neonatal death. The safety outcome was SGA below the 10th percentile for gestational age. Secondary outcomes included composites of serious neonatal and maternal complications, preeclampsia, and preterm birth.A total of 2408 pregnant womenwithmild chronic hypertension were included in the analysis, with 1208 in the active treatment group and 1200 in the control group. The primary composite outcome was lower in the active treatment group versus the control group (30.2% vs 37.0%, respectively; adjusted risk ratio [RR], 0.82; 95% confidence interval [CI], 0.74-0.92; P < 0.001). There were fewer women in the active treatment group than control group to experience preeclampsia with severe features (23.3% vs 29.1%; adjusted RR, 0.80; 95% CI, 0.70-0.92) and preterm birth at <35 weeks (12.2% vs 16.7%; adjusted RR, 0.73; 95% CI, 0.60-0.89). To prevent one event of the primary composite outcome, 14.7 patients would need to be treated (95% CI, 9.4-33.7). The safety, SGA outcome was also higher in the active treatment group versus the control group, but the difference was not significant (11.2% vs 10.4%, respectively; adjusted RR, 1.04; 95% CI, 0.82-1.31; P = 0.76).The incidence of serious maternal complications was low in both the active treatment group and control group (2.1% vs 2.8%, respectively; RR, 0.75; 95% CI, 0.45-1.26). Fewer women in the active group experienced preeclampsia, with or without severe features, than in the control group (24.4% vs 31.1%).The incidence of severe neonatal complications was also low in both groups (2.0% vs 2.6%; RR, 0.77; 95% CI, 0.45-1.30). Fewer women in the active group experienced preterm birth at <37 weeks (27.5% vs 31.4%; RR, 0.87; 95% CI, 0.77-0.99) and birth weight <2500 g (19.2% vs 23.1%; RR, 0.83; 95% CI, 0.71-0.79) than in those in the control group.In this study, women with mild chronic hypertension who received antihypertension therapy had improved pregnancy outcomes compared with those whose antihypertensive therapy was reserved until severe hypertension developed.
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