Hypertension has long been associated with multiple adverse pregnancy outcomes (APOs). Growing recognition of the impact of hypertension on maternal and fetal outcomes has helped drive recent changes to lower treatment targets for the condition during pregnancy.

“More aggressive treatment of hypertension in pregnancy helps to prevent the development of severe hypertension, a marker of APOs,” said Kartik K. Venkatesh, MD, PhD, Assistant Professor of Epidemiology and of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, who explored the latest updates and controversies in hypertension in pregnancy during The Heart of the Matter—Cardiovascular Health during Pregnancy and Beyond.

“More aggressive diagnosis and treatment can prevent preeclampsia, which occurs in up to 40% of pregnancies with hypertension, and gestational diabetes,” he continued. “Rates of adverse perinatal outcomes, including fetal growth abnormalities, fetal morbidity, and fetal mortality, are higher among offspring of mothers with longer duration and greater severity of hypertension.”

The American Heart Association/American College of Cardiology (AHA/ACA) lowered hypertension guidelines to blood pressure less than 120/80 in 2017. The new guideline resulted in an 18% absolute increase in the overall prevalence of hypertension and a 21% improved diagnosis of preeclampsia.

Severe hypertension, blood pressure greater than 140/90, requires immediate treatment to reduce the risk of maternal and fetal complications, Dr. Venkatesh said.

The Chronic Hypertension and Pregnancy (CHAP) trial opened new treatment pathways for non-severe hypertension.

Individuals on antihypertensive therapy with well-controlled blood pressure should remain on therapy during pregnancy with a target blood pressure of 120-139/80-90. Those with end-organ damage may target blood pressure less than 120/80. And those not on antihypertensive therapy should initiate treatment at 140/90. Dr. Venkatesh noted that current American College of Obstetricians and Gynecologists (ACOG) guidelines incorporate the new treatment pathways.

Hypertriglyceridemia in pregnancy

“Nothing scares me like a woman with severe hypertriglyceridemia (HTG) in pregnancy,” said Neha J. Pagidipati, MD, MPH, Associate Professor of Medicine, Duke University School of Medicine, and Director of the Duke Cardiometabolic Prevention Clinic. “We are trying to balance the health of mom and fetus in a total data vacuum. It takes a team to take care of these high-risk women.”

Triglycerides (TG) originate from both dietary intake and hepatic synthesis, Dr. Pagidipati said. TG levels normally double or triple during pregnancy, then drop back to normal after delivery. In most women, TG levels seldom rise above 300 mg/dL, but can top 1,000 mg/dL in severe gestational HTG.

“We have no idea how common HTG is during pregnancy because there is almost no research,” she said.

Genetic factors can play a role in HTG, but diabetes is the primary cause during pregnancy. Increasing maternal TG is associated with hypertension, preeclampsia, and acute pancreatitis in the mother. Fetal implications include macrosomia, preterm birth, and fetal death related to maternal pancreatitis.

“Management is a delicate balance,” Dr. Pagidipati said. “There are no lipid treatment guidelines during pregnancy. You need to build a team to care for these women, screen women with a family history of HTG, and closely monitor women who have HTG.”

Management starts with a low-fat diet, progressing to omega-3 fatty acids and medium chain triglycerides, and fibrates as needed after the first trimester. Insulin, parenteral nutrition, plasmapheresis, and hospitalization may be needed for persistent and severe HTG.

“These women need to be surrounded by multiple disciplines—primary care, cardiology, obstetrics, dietitian, and likely a diabetes nurse educator,” Dr. Pagidipati said. “I start nutritional interventions around the 500 mg/dL range because I don’t want things to get any worse.”

Breastfeeding boosts cardiometabolic health

Preeclampsia/eclampsia, gestational hypertension, gestational diabetes, preterm birth, intrauterine growth restriction, and other APOs are female-specific cardiometabolic risk factors that can increase cardiovascular disease (CVD) risk severalfold. Lactation is a female-specific mitigating factor.

“Breastfeeding, lactation, can be a risk mitigator for long-term diabetes and cardiovascular risk,” said Erica P. Gunderson, PhD, MS, MPH, RD, Senior Research Scientist and Professor of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine. “In addition to traditional risk factors such as diabetes, smoking, obesity, physical inactivity, hypertension, and dyslipidemia, inadequate lactation is emerging as a risk factor for atherosclerotic cardiovascular disease.”

Multiple studies around the world show similar associations between lactation and cardiometabolic outcomes in middle age and beyond, Dr. Gunderson said. Lactation, and longer duration of lactation, are associated with reduced CVD and coronary heart disease risk, including reduced incidence of metabolic syndrome and carotid artery atherosclerotic plaques.

“Lactation redirects lipids to milk production, which can have a lasting effect on cardiovascular health,” Dr. Gunderson said. “We need to support women in breastfeeding.”