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Review
. 2022 Apr 5;11(7):e023694.
doi: 10.1161/JAHA.121.023694. Epub 2022 Mar 14.

Phenotype-Directed Management of Hypertension in Pregnancy

Kelsey McLaughlin  1 , John W Snelgrove  1 , Laura E Sienas  2 , Thomas R Easterling  2 , John C Kingdom  1 , Catherine M Albright  2
Affiliations
Review

Phenotype-Directed Management of Hypertension in Pregnancy

Kelsey McLaughlin et al. J Am Heart Assoc. .

Abstract

Hypertensive disorders of pregnancy are among the most serious conditions that pregnancy care providers face; however, little attention has been paid to the concept of tailoring clinical care to reduce associated adverse maternal and perinatal outcomes based on the underlying disease pathogenesis. This narrative review discusses the integration of phenotype-based clinical strategies in the management of high-risk pregnant patients that are currently not common clinical practice: real-time placental growth factor testing at Mount Sinai Hospital, Toronto and noninvasive hemodynamic monitoring to guide antihypertensive therapy at the University of Washington Medical Center, Seattle. Future work should focus on promoting more widespread integration of these novel strategies into obstetric care to improve outcomes of pregnancies at high risk of adverse maternal-fetal outcomes from these complications of pregnancy.

Keywords: antihypertensive agents; female sex; hemodynamic monitoring; humans; hypertension, pregnancy‐induced; placenta growth factor; pregnancy.

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Figures

Figure 1
Figure 1. Integration of placental growth factor (PlGF) testing into clinical care of high‐risk pregnant patients: key points.
Figure 2
Figure 2
Nomograms generated by the University of Washington Medical Center team to interpret the maternal hemodynamics. A, Longitudinal changes in cardiac output (mean±1 SD) in normotensive healthy pregnant patients, as estimated by UltraCom method at the University of Washington, Seattle. Blue line=mean cardiac output; red lines=1 SD. B, Relationship between mean arterial pressure and cardiac output. Isometric lines of total peripheral resistance (TPR) are included in order to display all parameters on 1 graph.
Figure 3
Figure 3. Persistent high output state with chronic hypertension and delivery at 37 weeks.
Serial hemodynamic assessments demonstrated high cardiac output. Treatment with atenolol at 15 weeks reduced cardiac output toward normal, but in all stages of pregnancy the patient was in a hyperdynamic state. A, Serial cardiac output measurements. B, Relationship between mean arterial pressure and cardiac output with total peripheral resistance (TPR) plotted as isometric lines.
Figure 4
Figure 4. Hemodynamically directed change in antihypertensive medications resulting in a 37‐week delivery in the setting of suspected growth restriction.
A, Serial cardiac output measurements. B, Relationship between mean arterial pressure and cardiac output with total peripheral resistance (TPR) plotted as isometric lines.
Figure 5
Figure 5. High resistance state noted at 32 weeks requiring increasing doses of hydralazine with ultimate delivery at 37 weeks.
A, Serial cardiac output measurements. B, Relationship between mean arterial pressure and cardiac output with total peripheral resistance (TPR) plotted as isometric lines.
Figure 6
Figure 6. Proposed recommendations for phenotype‐driven clinical care of hypertensive pregnant patients.
LMWH indicates low molecular weight heparin; PlGF, placental growth factor; and sFlt1, soluble fms‐like tyrosine kinase.
See this image and copyright information in PMC

References

    1. Say L, Chou D, Gemmill A, Tuncalp O, Moller AB, Daniels J, Gulmezoglu AM, Temmerman M, Alkema L. Global causes of maternal death: a WHO systematic analysis. Lancet Global Health. 2014;2:e323–e333. doi: 10.1016/S2214-109X(14)70227-X - DOI - PubMed
    1. Chappell LC, Cluver CA, Kingdom J, Tong S. Pre‐eclampsia. Lancet. 2021;398:341–354. doi: 10.1016/S0140-6736(20)32335-7 - DOI - PubMed
    1. Shen M, Smith GN, Rodger M, White RR, Walker MC, Wen SW. Comparison of risk factors and outcomes of gestational hypertension and pre‐eclampsia. PLoS One. 2017;12:e0175914. doi: 10.1371/journal.pone.0175914 - DOI - PMC - PubMed
    1. Grandi SM, Filion KB, Yoon S, Ayele HT, Doyle CM, Hutcheon JA, Smith GN, Gore GC, Ray JG, Nerenberg K, et al. Cardiovascular disease‐related morbidity and mortality in women with a history of pregnancy complications. Circulation. 2019;139:1069–1079. doi: 10.1161/CIRCULATIONAHA.118.036748 - DOI - PubMed
    1. Leon LJ, McCarthy FP, Direk K, Gonzalez‐Izquierdo A, Prieto‐Merino D, Casas JP, Chappell L. Preeclampsia and cardiovascular disease in a large UK pregnancy cohort of linked electronic health records: a CALIBER study. Circulation. 2019;140:1050–1060. doi: 10.1161/CIRCULATIONAHA.118.038080 - DOI - PubMed

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