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Prehypertension is associated with multiple poor maternal and fetal outcomes

Giovanni Sisti

PII: S0002-9378(19)32838-8
DOI: https://doi.org/10.1016/j.ajog.2019.12.019
Reference: YMOB 13022

To appear in: American Journal of Obstetrics and Gynecology

Received Date: 20 November 2019

Accepted Date: 21 December 2019

Please cite this article as: Sisti G, Prehypertension is associated with multiple poor maternal and
fetal outcomes, American Journal of Obstetrics and Gynecology (2020), doi: https://doi.org/10.1016/
j.ajog.2019.12.019.

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 1 Letter to the editor
2
3 Prehypertension is associated with multiple poor maternal and fetal outcomes
4
5 Giovanni Sisti
6
7 Department of Obstetrics and Gynecology, 5th floor, Lincoln Medical and Mental Health Center,
8 234 East 149th street, Bronx, NY, 10451
9 Email: gsisti83@gmail.com
10
11 Disclosure statement: the author declares no conflict of interest
12
13
14
15 I read with interest the paper titled “Chronic Hypertension in Pregnancy” accepted for

16 publication in the Journal in 20191. They wrote a thorough excursus thought classification,

17 diagnosis and treatment of this common maternal obstetrical pathology.

18

19 In the section dedicated to the “classification” of chronic hypertension during pregnancy,

20 Battarbee et al. acknowledge the new American College of Cardiology (ACC)/ American Heart

21 Association (AHA) blood pressure cut off for stage 1 hypertension2. The ACC/AHA in 2017

22 lowered the blood pressure cut off to diagnose stage 1 hypertension from 140/90 mmHg to

23 130/80 mmHg2 in non-pregnant patients.

24 The authors state that the American College of Obstetrics and Gynecology (ACOG) has not yet

25 supported the use of the new criteria for pregnant women3,4 and they invoke further research

26 to be done before changing the current guidelines.

27 Unfortunately, they reference only two articles associating stage 1 hypertension and poor

28 maternal outcomes5,6, and among the pregnancy outcomes they only mention preeclampsia.

29 Haurspurg et al. in 2019 associated the diagnosis of stage 1 hypertension in first trimester with

30 the subsequent occurrence of gestational hypertension (GTHN), gestational diabetes mellitus

31 (GDM), preterm birth and operative vaginal delivery, in addition to preeclampsia6.

32 Sutton et al. in 2018 associated the diagnosis of stage 1 hypertension before 20 weeks with

33 GDM and small for gestational age, in addition to preeclampsia5.

34 In addition to the 2 referenced articles, there is other supporting evidence available.

35 The other articles available still use the old terminology, calling prehypertension a blood

36 pressure lower than 140/90 mmHg but higher than 130/80 mmHg.
37 In 2015 Rosner et al. linked early prehypertension, measured before 20 weeks, to composite

38 adverse outcomes in the third trimester7. In 2016 the same group from New York University

39 (NYU) strengthened the same associations using a larger number of patients8.

40 In 2015 Black et al. conducted a prospective study and found significant evidence associating

41 prehypertension diagnosed before pregnancy or during the first trimester and hypertensive

42 pregnancy disorders9.

43 In 2018 Cao et al. conducted a large systematic review and meta-analysis linking

44 prehypertension measured in the subgroup of patients < 20 weeks and increased risk of SGA,

45 compared with the group with normal blood pressure10.

46 In conclusion, there is abundant evidence linking stage 1 hypertension, or as defined in the old

47 classification, “prehypertension”, blood pressure lower than 140/90 mmHg, and poor maternal

48 and fetal outcomes. The evidence is bigger than what is usually thought, and the list of

49 associated poor maternal and fetal outcomes extends beyond mere preeclampsia.

50 Hopefully these existing evidences will be incorporated in future reviews on chronic

51 hypertension during pregnancy and new clinical trials will be performed.

52
53
54 References
55
56
57 1. Battarbee, A.N., Sinkey, R.G., Harper, L.M., Oparil, S. & Tita, A.T.N. Chronic Hypertension
58 in Pregnancy. Am J Obstet Gynecol (2019).
59 2. Whelton, P.K., et al. 2017
60 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the
61 Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults:
62 Executive Summary: A Report of the American College of Cardiology/American Heart
63 Association Task Force on Clinical Practice Guidelines. Hypertension 71, 1269-1324
64 (2018).
65 3. ACOG. ACOG Practice Bulletin No. 202: Gestational Hypertension and Preeclampsia.
66 Obstet Gynecol 133, e1-e25 (2019).
67 4. ACOG. ACOG Practice Bulletin No. 203: Chronic Hypertension in Pregnancy. Obstet
68 Gynecol 133, e26-e50 (2019).
69 5. Sutton, E.F., Hauspurg, A., Caritis, S.N., Powers, R.W. & Catov, J.M. Maternal Outcomes
70 Associated With Lower Range Stage 1 Hypertension. Obstet Gynecol 132, 843-849
71 (2018).
72 6. Hauspurg, A., et al. Blood pressure trajectory and category and risk of hypertensive
73 disorders of pregnancy in nulliparous women. Am J Obstet Gynecol 221, 277 e271-277
74 e278 (2019).
75 7. Rosner, J.Y., et al. Prehypertension in early versus late pregnancy. J Matern Fetal
76 Neonatal Med 32, 188-192 (2019).
77 8. Rosner, J.Y., et al. Prehypertension in Early Pregnancy: What is the Significance? Am J
78 Perinatol 34, 117-122 (2017).
79 9. Black, M.H., et al. Prehypertension prior to or during early pregnancy is associated with
80 increased risk for hypertensive disorders in pregnancy and gestational diabetes. J
81 Hypertens 33, 1860-1867; discussion 1867 (2015).
82 10. Cao, C., et al. Prehypertension during pregnancy and risk of small for gestational age: a
83 systematic review and meta-analysis. J Matern Fetal Neonatal Med, 1-8 (2018).
84