Evidence Report/Technology Assessment

Number 14

Prepared for:
Agency for Healthcare Research and Quality

U.S. Department of Health and Human Services
2101 East Jefferson Street
Rockville, MD 20852

Contract No. 290-97-0012

Prepared by:
San Antonio Evidence-based Practice Center based at
the University of Texas Health Science Center at San Antonio
Cynthia D. Mulrow, M.D., M.S.c.
Program Director

Elaine Chiquette, PharmD.
Project Director

Robert L. Ferrer, M.D., M.P.H.
Baha M. Sibai, M.D.
Kathleen R. Stevens, R.N., Ed.D.
Molly Harris, M.A., M.L.S.
Kelly A. Montgomery, M.P.H.
Karen Stamm, B.A.
Investigators

AHRQ Publication No. 00-E011

August 2000

The Agency for Healthcare Research and Quality (AHRQ), formerly the Agency for Health Care Policy and Research, through its Evidence-based Practice Centers (EPCs), sponsors the development of evidence reports and technology assessments to assist public- and private-sector organizations in their efforts to improve the quality of health care in the United States. The reports and assessments provide organizations with comprehensive, science-based information on common, costly medical conditions and new health care technologies. The EPCs systematically review the relevant scientific literature on topics assigned to them by AHRQ and conduct additional analyses when appropriate prior to developing their reports and assessments.

To bring the broadest range of experts into the development of evidence reports and health technology assessments, AHRQ encourages the EPCs to form partnerships and enter into collaborations with other medical and research organizations. The EPCs work with these partner organizations to ensure that the evidence reports and technology assessments they produce will become building blocks for health care quality improvement projects throughout the Nation. The reports undergo peer review prior to their release.

AHRQ expects that the EPC evidence reports and technology assessments will inform individual health plans, providers, and purchasers as well as the health care system as a whole by providing important information to help improve health care quality.

We welcome written comments on this evidence report. They may be sent to: Director, Center for Practice and Technology Assessment, Agency for Healthcare Research and Quality, 6010 Executive Blvd., Suite 300, Rockville, MD 20852.

John M. Eisenberg, M.D.	Douglas B. Kamerow, M.D.
Director Agency for Healthcare Research and Quality	Director, Center for Practice and Technology Assessment Agency for Healthcare Research and Quality

The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services of a particular drug, device, test, treatment, or other clinical service.

We owe a major debt of gratitude to the following groups of multidisciplinary experts from around the world who assisted in preparing this report: the 14 technical experts who defined the scope and helped shape the content, 26 peer reviewers representing a variety of backgrounds and viewpoints, 14 scientific authors who provided additional data from their studies, 2 organizational partnerships, and 8 staff members who offered their skill, expertise, and dedication. Their names are listed in Appendix B.

Of the nearly 4 million women giving birth in the United States each year, between 1 and 5 percent suffer from chronic hypertension. Chronic hypertension is associated with serious maternal and fetal complications, including superimposed preeclampsia, fetal growth restriction, premature delivery, placental abruption, and stillbirth. There is uncertainty and practice variability in monitoring and treatment strategies for chronic hypertension in pregnancy. This evidence report addresses several questions related to management of chronic hypertension. It summarizes research evidence concerning the magnitude of maternal and fetal risks associated with chronic hypertension, risks and benefits of antihypertensive agents before and during pregnancy, risks and benefits of aspirin and nonpharmacological therapies during pregnancy, and the role of various monitoring strategies in detecting fetal complications of chronic hypertension.

English and non-English research literature was identified from 16 electronic databases, references of pertinent articles and reviews, a primary text that routinely systematically reviews and categorizes teratogenicity risks, and technical experts. In general, electronic bibliographical sources were searched from 1947 or from their inception to February 1999. Four general search strategies were used to identify evidence relevant to: (1) efficacy, (2) harms, (3) blood pressure risks, and (4) monitoring techniques.

Selection criteria varied according to the specific question addressed. For questions concerning treatment efficacy, the investigators of this evidence report selected randomized trials of antihypertensive agents or aspirin compared with either placebo or usual care that included a population of pregnant women with chronic hypertension and that reported clinical maternal and/or fetal outcomes. For the question regarding harm associated with antihypertensive therapy, we selected case reports, case-control and cohort studies, randomized trials, and surveillance studies that reported adverse maternal and/or fetal outcomes. To estimate the magnitude of risk associated with chronic hypertension, we examined case-control and cohort studies that compared maternal and fetal outcomes in women with chronic hypertension compared with those in either a general obstetrical population or pregnant women without chronic hypertension. For the question concerning monitoring techniques, we sought case series, cohort studies, and randomized trials that reported clinical perinatal morbidity or mortality outcomes.

Two or more persons independently screened the 5,558 titles and abstracts identified in the searches. Two reviewers abstracted articles meeting inclusion criteria except for articles addressing adverse effects, which were reviewed by only one person. Data were synthesized descriptively, emphasizing methodological characteristics of the studies such as populations enrolled, definitions of selection and outcome criteria, interventions and comparisons, and study designs. Because of concerns about heterogeneity in study populations and interventions, quantitative methods were not used to combine trial results. Random effects methods were used to estimate summary odds ratios or risk of perinatal mortality and abruption associated with chronic hypertension.

• Benefits of treating chronic hypertension before conception. There was no evidence that addressed the effect of blood pressure control before conception on fetal outcomes. With regard to maternal outcomes, evidence from randomized trials involving nonpregnant women 30 to 54 years of age showed that approximately 250 (95 percent confidence interval 158 to 1,606) such women with mild to moderate hypertension need to be treated for 5 years to prevent one cardiovascular event such as stroke or myocardial infarction. Much larger numbers of women younger than age 30 (approximately 8,000) would need to be treated for 1 year to prevent a cardiovascular event.
• Benefit of treating chronic hypertension during pregnancy. There was insufficient evidence to prove or disprove moderate to large clinical effects of antihypertensive agents on perinatal outcomes.
• Adverse effects of antihypertensive drugs. The quality of evidence addressing this question was poor. The best-established adverse effect of antihypertensive agents in pregnancy was renal failure associated with use of the angiotensin-converting enzyme inhibitors. There was evidence suggesting that atenolol used early in pregnancy may be associated with small-for-gestational-age fetuses.
• Effects of nonpharmacological interventions. There was no evidence to address this question.
• Optimum levels for initiating therapy and risk of chronic hypertension in pregnancy. There was insufficient evidence to identify an optimum blood pressure at which treatment should be initiated and thereafter maintained. Chronic hypertension in pregnancy tripled the risk of perinatal mortality and doubled the risk of placental abruption. The risks of preeclampsia and small-for-gestational-age infants also were increased. Increased risk was evident even in the absence of superimposed preeclampsia.
• Effect of aspirin. A single trial showed low-dose aspirin begun before 26 weeks gestational age neither reduced perinatal morbidity and mortality nor increased maternal risks in women with chronic hypertension. Although the trial was of moderate size, small increases or reductions in benefits or risks could have been missed.
• Effectiveness of monitoring strategies. There was insufficient evidence to evaluate the effectiveness of any particular monitoring test or sequence of tests for women with chronic hypertension in pregnancy.

Despite the burden of illness and costs imposed by chronic hypertension in pregnancy, evidence to date remains scant and provides little direction for clinicians. Epidemiological data demonstrate increased risks of perinatal morbidity and mortality in pregnant women with mild to moderate chronic hypertension. Treatment with antihypertensive agents has not been proven to lower those risks, though the evidence base is too small to rule out moderate to large effects on perinatal mortality, preeclampsia, and intrauterine growth retardation. Data on adverse effects of drug treatment is scant; the data on angiotensin-converting enzyme inhibitors suggest that their adverse effects are substantially greater than for other drugs. Moderate to large benefits of low dose aspirin begun early in pregnancy for women with chronic hypertension have been disproved. Nonpharmacological treatments remain unevaluated, as do monitoring strategies that are frequently used in pregnancies complicated by chronic hypertension.

Many important clinical issues faced by clinicians who care for pregnant women with chronic hypertension remain unresolved. Research in this area is critical. More pregnancies will be complicated by chronic hypertension as the trend continues for women to delay childbearing to older ages. Multicenter collaborative studies are needed with sufficient power to detect differences in outcomes such as perinatal mortality, preeclampsia, and small-for-gestational-age infants. Information from such trials can be augmented by well-designed surveillance systems to monitor outcomes and safety data from clinical practice. Finally, comparative studies with clinical outcomes are sorely needed to assess benefits, costs, and harms of various fetal monitoring strategies for the pregnant woman with chronic hypertension.

This document is in the public domain and may be used and reprinted without permission except those copyrighted materials noted for which further reproduction is prohibited without the specific permission of copyright holders.

Mulrow CD, Chiquette E, Ferrer RL, et al. Management of chronic hypertension during pregnancy. Evidence Report/Technology Assessment No. 14 (Prepared by the San Antonio Evidence-based Practice Center based at the University of Texas Health Science Center at San Antonio under Contract No. 290-97-0012). AHRQ Publication No. 00-E011. Rockville, MD: Agency for Healthcare Research and Quality. August 2000.