Journal Club

Greene MF, Williams WW. Treating Hypertension in Pregnancy. 2022.

www.nejm.org/doi/pdf/10.1056/NEJMe2203388

Anu Joseph

Senior Consultant, Obstetrics and Gynecology, Kauvery Hospital, Electronic City, Bengaluru, India

*Correspondence: [email protected]

Hypertension has been a largely multifactorial and difficult issue to treat in pregnancy. While we have well-defined protocols to predict, assess, prognosticate and treat pre-eclampsia, Chronic hypertension has been on a back seat with recommendations mainly about the teratogenicity of antihypertensives, pre-conceptional modification, and look out for superimposed preeclampsia. Treatment has been traditionally advocated for severe chronic hypertension (BP above 160/105mmHg) and for chronic hypertension with superimposed pre-eclampsia. The strict control of blood pressure in Chronic mild hypertension without superimposed pre-eclampsia is not advocated due to fear of lower uterine perfusion and small for gestational age fetuses in the 3rd trimester in the absence of any potential maternal benefits.

The present editorial brings to our notice the Chronic hypertension and Pregnancy (CHAP) trial and its breakthrough findings on the advantages of treating mild hypertension in pregnancy. The findings of the present study, and a few other recent investigations like the CHIP (Control of Hypertension in Pregnancy) Study, compels one to look into stricter treatment for even the mild cases of chronic hypertension in pregnancy.

The advantages enlisted are lesser preterm births, lesser superimposed pre-eclampsia and its complications, lesser abruption placenta, and lesser intrauterine demises, in the backdrop of a non-significant increase in lower birth weights and maternal complications. The finding is extremely important in the setting of today’s Obstetric practice with Pregnancy in women of higher age and BMI are on the rise.

However, the questions to ponder are also about the few missing discussions. Of all the women in the study, all known to have hypertension, only 45 % were on Aspirin at the enrolment, the mean gestational age for enrolment being 15.4weeks. This increased to only 75% even during the entire course of study. With a known risk why weren’t all 100% on Aspirin? Was there a difference in the aspirin group vs non-aspirin group? Can adverse outcomes be reduced in the treatment group beyond 30% in the adjuvant aspirin group?

Yet another question is about the cost of treatment advantage for the outcomes seen. Is it cost effective to treat and follow up women with mild hypertension for a 7% difference in preterm birth? Because the incidence of severe neonatal complications was similar in both the treatment and non-treatment groups at about 2% and the incidence of preterm birth was only decreased by 4%.

Hopefully, further analysis of the results in various categories and future studies in this regard will bring to light these questions and guide our way to further change the protocols of treatment in mild hypertension and pregnancy.

Dr.-Anu-Joseph

Dr. Anu Joseph

Consultant Obstetrician and Gynaecologist

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