Hypertension issues during pregnancy are on the rise

The escalating rate of high blood pressure disorders during pregnancy has pushed a national advisory panel to reiterate its call for screening pregnant women for them at every prenatal visit.

According to research prepared to support the U.S. Preventive Services Task Force’s (USPSTF) new recommendation, hypertensive disorders in pregnancy doubled from about 500 cases per 10,000 deliveries in 1993 to more than 1,000 cases per 10,000 deliveries in 2016 and 2017. Also cited in supporting evidence:

• The United States’ maternal death rate is two to 20 times that of other developed nations.
• U.S. maternal death rates during pregnancy through 42 days after giving birth are 2.5 times higher for Black women than white women. The death rates from eclampsia and preeclampsia are estimated to be five times higher for Black women than white women.
• Higher maternal death rates also occur in Native Americans and Alaskan Natives.

On September 19, the USPSTF issued its new recommendation, which targets pregnant women who have not previously been diagnosed with hypertension (high blood pressure) or related disorders, notably eclampsia and preeclampsia. These conditions can cause strokes, seizures, damage to eyes, kidneys and liver, low birth weight and death for the mother and child. The task force also called for management of at-risk mothers based not only on blood pressure, but an initial screening for protein in urine and a thorough medical history.

Cape Cod Hospital obstetrician and gynecologist Lindsay LaCorte, DO, said the rise in cases of hypertension disorders in pregnancy is evident locally.

“We’re definitely seeing an increase in these cases in our patients.”

Risk factors

Checking pregnant women for high blood pressure at every visit has been routine in her practice for several years now, Dr. LaCorte said. “What’s different is risk factors,” she said.

The American College of Obstetricians and Gynecologists (ACOG) lists these factors for high risk of preeclampsia:

• Preeclampsia in previous pregnancy
• Multiple fetuses
• Chronic hypertension
• Diabetes
• Kidney disease
• Lupus and other autoimmune conditions

ACOG lists these factors for moderate risk of preeclampsia:

• First pregnancy
• Pregnancy more than 10 years after last pregnancy
• BMI (body mass index) over 30
• 35 years or older
• Mother or sister had preeclampsia
• Complications in previous pregnancy
• In vitro fertilization (IVF)
• Being Black (the risk is attributed to historical, societal challenges faced by Blacks resulting in barriers to self-care and NOT related to the genetics or biology of Black individuals)
• Having a low income

Dr. LaCorte explains that at the first prenatal visit, the intake visit, they review the patient's history at length and identify risk factors.

Previous Recommendations and Treatment

The USPSTF issued a similar recommendation for blood pressure screening in April 2017, which upgraded a January 1996 statement that said all pregnant women should be screened for high blood pressure at their first prenatal visit and occasionally afterward. In 2018, two medical organizations, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics followed suit, putting forth guidelines stressing the value of more frequent prenatal visits for patients with certain risk factors, and blood pressure measurements at every visit.

In 2020, ACOG set forth recommendations for diagnosing and managing gestational hypertension (high blood pressure during pregnancy) and preeclampsia. Preeclampsia is a potentially fatal condition, for which the only cure is delivery of the baby and placenta, according to the Preeclampsia Foundation.

“Now there is more emphasis on screening and prevention. We can monitor for warning signs by screening blood pressure more frequently and checking lab work earlier in the pregnancy to get a baseline of the patient's kidney and liver function,” Dr. LaCorte said. “We may recommend more ultrasounds as well. The only preventative medication for preeclampsia is low-dose aspirin. When it comes to treatment, we may treat high blood pressure, if it occurs as well, especially in severe hypertensive disease. Since the only way to stop the disease from progressing is delivery of the baby, we may also recommend inducing labor early if the disease is progressing depending on gestational age.”

Race, Ethnicity and Social Factors

“Race and ethnicity have been identified as risk factors,” she said. “However, the current research points more to social determinants of health than race itself. This requires looking at our community resources and access to healthcare.”

There is a committee at Cape Cod Healthcare currently tasked with looking at preeclampsia in the community to determine where these types of health disparities can be addressed, if found, she added.

Cape Cod Healthcare has a strategic focus on maternal health disparity and preeclampsia among its patients, and efforts are underway this year to reach equitable health in high blood pressure in the Black community, based on recommendations from the health equity committee and community feedback, according to Kumara Sidhartha, MD, DPH, CCHC chief health equity and wellness officer.

The research supporting the USPSTF’s recommendation said inequities associated with race and ethnicity that can affect patient outcomes include:

• Higher rates of chronic conditions, such as hypertension, obesity and diabetes;
• Less access to prenatal care and obstetric care, and poorer quality care;
• Racism;
• Poverty and lack of health insurance;
• Segregation;
• Greater exposure to environmental pollution.