Bree A. Porcelli’s research while affiliated with Washington University in St. Louis and other places

Objective The primary objective of this study was to evaluate coronavirus 2019 (COVID-19) pandemic–related changes in the antenatal utilization of high-risk obstetric services. Our secondary objective was to characterize change in stillbirth rate during the pandemic. Study Design This is a retrospective, observational study performed at a single, tertiary care center. Maternal-Fetal Medicine (MFM) visits, ultrasounds, and antenatal tests of fetal well-being during the pandemic epoch (2020), which spans the first 12 weeks of the year to include pandemic onset and implementation of mitigation efforts, were compared with the same epoch of the three preceding years visually and using general linear models to account for week and year effect. An analysis of stillbirth rate comparing the pandemic time period to prepandemic was also performed. Results While there were decreased MFM visits and antenatal tests of fetal well-being during the pandemic epoch compared with prepandemic epochs, only the decrease in MFM visits by year was statistically significant (p < 0.001). The stillbirth rate during the pandemic epoch was not significantly different when compared with the prepandemic period and accounting for both week (p = 0.286) and year (p = 0.643) effect. Conclusion The COVID-19 pandemic resulted in a significant decrease in MFM visits, whereas obstetric ultrasounds and antenatal tests of fetal well-being remained unchanged. While we observed no change in the stillbirth rate compared with the prepandemic epoch, our study design and sample size preclude us from making assumptions of association. Our findings may support future work investigating how changes in prenatal care for high-risk obstetric patients influence perinatal outcomes. Key Points

Background: Chronic hypertension complicates up to 5% of pregnancies and is increasing in prevalence. Women with hypertension have increased risks of serious maternal morbidity and mortality in pregnancy including the development of preeclampsia. In 2017, new guidelines reclassified blood pressure into four categories: normal (<120/<80 mmHg), elevated (120-129/<80 mmHg), stage 1 hypertension (130-139/80-89 mmHg), and stage 2 hypertension (>140/>90 mmHg). This new classification doubles the number of reproductive aged women with hypertension. Furthermore, studies have demonstrated that women entering pregnancy with stage 1 hypertension have an increased risk of developing hypertensive disorders of pregnancy compared to their normotensive counterparts but the time course to development of hypertensive disorder of pregnancy in these women remains uncertain. Objective: We sought to evaluate the risk of developing a hypertensive disorder of pregnancy and the time to development of these disorders in women with stage 1 hypertension compared to both normotensive women and those with stage 2 hypertension. Study Design: This is a retrospective cohort study of all patients from a single tertiary care center with singleton gestations from 2014 to 2016. Blood pressure at prenatal visits prior to 20 weeks patients classified into 3 groups: normotensive (<130/80 mmHg), stage 1 hypertension (130-139/80-89 mmHg), or stage 2 hypertension (≥ 140/90 or a history of chronic hypertension). The primary outcome, time to development of a hypertensive disorder of pregnancy was compared between groups was compared using Kaplan Meier curves and log-rank test. Cox proportion hazard models were used to adjust for age, race/ethnicity, pregestational diabetes, and body mass index. Multiple secondary obstetric, maternal, and neonatal outcomes were also assessed. Results: Of the 3,000 women in our cohort, 2,370 (79.0%) were classified as normotensive, 315 (10.5%) were classified as stage 1 hypertension, and 315 (10.5%) were classified as stage 2 hypertension. The gestational age at diagnosis was significantly earlier in gestation across blood pressure groups (normotensive 38.7 [37.0, 39.7], vs stage 1 hypertension 38.0 [36.4, 39.4], vs stage 2 hypertension 36.4 [33.7, 37.8]; p<0.001). When the analysis was restricted to only those patients diagnosed with preeclampsia with severe features the same findings were observed. Women with stage 1 hypertension exhibited a 2-fold increased risk of developing hypertensive disorders of pregnancy compared to normotensive women. When compared to stage 2 hypertension women with stage 1 hypertension exhibited a more mild phenotype of hypertensive disorders of pregnancy and exhibited significantly less risk of maternal and neonatal morbidities. Conclusions: Women with stage 1 hypertension are at increased risk of developing hypertensive disorders of pregnancy at earlier gestational ages compared to normotensive women, however, their development of a hypertensive disorder of pregnancy is skewed towards milder disease than women with stage 2 hypertension. These new insights into the graded risk profile of obstetric hypertensive disease associated with new blood pressure categories can better inform our antepartum counseling and monitoring and surveillance plans near term and in the postpartum period.

Background Diagnostic criteria for hypertensive disorders of pregnancy have historically been based on the American Heart Association/American College of Cardiology’s definition of hypertension, previously defined as a blood pressure ≥140/90 mmHg. With the recent redefinition of hypertension, blood pressures of 130-139/80-89 mmHg are now considered abnormal. Objective We aimed to test whether new-onset blood pressure elevations of 130-139/80-89 mmHg after 20 weeks of gestation in previously normotensive women are associated with increased risk of adverse pregnancy outcomes, specifically development of hypertensive disorders of pregnancy. Study Design We performed a retrospective cohort study from a single tertiary care center of all women who delivered singleton gestations after 20 weeks from January 1, 2014 to June 8, 2016. Normotensive patients were defined as having maximum blood pressure <130/80 mmHg prior to 20 weeks of gestation with no prior diagnosis of chronic hypertension. Patients that remained normotensive for the remainder of pregnancy were then compared to patients who developed new blood pressure elevations 130-139/80-89 mmHg after twenty weeks gestation but prior to admission for delivery. The primary outcome was development of a hypertensive disorder of pregnancy at or during delivery admission. Clinical outcomes were assessed using χ²and multivariable logistic regression. Results Of the 2,090 normotensive women from our cohort who were analyzed, 1318 (63.0%) remained normotensive for their entire antenatal course prior to delivery admission and 772 (37.0%) had new-onset blood pressure elevations between 130-139/80-89 mmHg. Women with new onset blood pressure elevations between 130-139/80-89 mmHg after 20 weeks have a significantly increased risk of developing a hypertensive disorder of pregnancy at or during their delivery admission (adjusted RR 2.41, 95% CI 2.02-2.85) including an almost 3-fold increased risk for preeclampsia with severe features, even after adjusting for confounders. There were no differences in other secondary obstetric outcomes. Conclusion Normotensive women with newly elevated blood pressures between 130-139/80-89mmHg after 20 weeks of gestation are more likely to develop hypertensive disorders of pregnancy and preeclampsia with severe features at or during their delivery hospitalization. These more modest blood pressure elevations may be an early indicator of disease and call into question our current blood pressure threshold for diagnosis of hypertensive diseases of pregnancy.