Phenotypes of Pregnant Women Who Subsequently Develop Hypertension in Pregnancy

Abstract

BackgroundHypertensive disorders complicating pregnancy are a major cause of maternal death. Our objective was to evaluate maternal clinical, hemodynamic, and placental prognostic indicators in a consolidated manner to identify women who develop hypertension in pregnancy.Methods and ResultsTwenty‐six normotensive pregnant women from a specialized Placenta Clinic at increased risk of developing de novo hypertension and 20 normotensive healthy pregnant controls were recruited at 22 to 26 weeks' gestation. Fourteen maternal clinical, hemodynamic, and placental characteristics were assessed in the second trimester and aggregated. Principal component analysis of this combined data set determined that 3 dimensions accounted for 56% of the cohort variability. The first dimension accounted for 31% of the cohort variability, with significant contributions from total peripheral resistance, endoglin, and cardiac output. The second dimension was predominantly influenced by body mass index and mean arterial pressure, while uric acid and myeloperoxidase mainly contributed to the third dimension. Unsupervised clustering identified 3 groups within this combined data set. Total peripheral resistance was the most significant distinguishing parameter between these groups (P<0.0001), followed by placental growth factor, endoglin, and cardiac output (P<0.0001). Using these 4 parameters, a receiver operating curve was constructed with an area under the curve of 0.975 (95% confidence interval 0.93–1) for the prediction of developing hypertension in pregnancy.ConclusionsConsolidated assessment of prognostic indicators in the second trimester of pregnancy may be useful to characterize and distinguish pathways by which women may develop hypertension in pregnancy. This approach could contribute to the development of pathway‐specific preventative and antihypertensive treatment strategies.

Hemodynamic Prediction and Stratification of Hypertensive Disorders of Pregnancy: A Dream That Is Coming True?

“…Many of the latest studies have shown that, among the hemodynamic parameters, TVR and CO represent a cornerstone for the understanding of the preclinical and clinical stages of the HDP. McLaughlin et al,13 in accordance with other reports, found in their study that maternal TVR was the best single predictive factor for the development of hypertension in pregnancy, followed by endoglin, mean arterial pressure, placental growth factor, and soluble Fms‐like tyrosine kinase‐1. TVR represents the equilibrium between SV, blood pressure, and heart rate.…”

“…The first one has been the uterine artery Doppler interrogation in the second trimester, and has been introduced since the past 2 decades of the past century 1. Lately, biochemical and central hemodynamic parameters have been used to refine and improve the classification and the prediction of HDP 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13…”

“…In this issue of the Journal of the American Heart Association ( JAHA ), McLaughlin et al13 propose an interesting study to identify, through a hieratical cluster analysis, phenotypes of pregnant women with different risk of developing HDP: low‐, moderate‐, and high‐risk patients.…”

“…In particular, 14 different clinical, biochemical, and hemodynamic parameters were included in the analysis. Lately, many groups of researchers have used different methods for the detection of hemodynamic parameters in pregnancy: echocardiography8, 9, 10, 11; UltraSonic Cardiac Output Monitor and Non‐Invasive Cardiac Output Monitor (noninvasive Doppler method to determine hemodynamic values with a nonimaging continuous‐wave Doppler transducer)14; and impedance cardiography and thermodilution 13, 15. Many of the latest studies have shown that, among the hemodynamic parameters, TVR and CO represent a cornerstone for the understanding of the preclinical and clinical stages of the HDP.…”

“…The question that arises, and that McLaughlin et al13 try to discuss, is related to the usefulness of the hemodynamic monitoring of pregnancy for directing a preventive treatment. In normotensive high‐risk patients and gestational hypertensive women, elevated TVR early in pregnancy strongly correlates with subsequent severe complications (ie, preeclampsia, severe hypertension, fetal growth restriction, abruption placentae, and Hemolysis, Elevated Liver enzymes, and Low platelet count [HELLP] syndrome) 8, 9.…”