Preeclampsia: Postpartum Resolution of Hypertension, Proteinuria and Serum N-terminal B-type Natriuretic Peptide
Vandana Saini, Deepti Sanjay Kumar, Harshvardhan Singh, SK Gupta
Cardiovascular disease, Chronic kidney disease, Postpartum, Preeclampsia, Resolution of hypertension, Resolution of proteinuria, Serum NT-pro-BNP
Citation Information :
Saini V, Kumar DS, Singh H, Gupta S. Preeclampsia: Postpartum Resolution of Hypertension, Proteinuria and Serum N-terminal B-type Natriuretic Peptide. Indian J Med Biochem 2019; 23 (2):278-286.
Background: Postpartum persistent proteinuria and hypertension (HT) is associated with development of chronic kidney disease and cardiovascular disease in later life. AIMS & OBJECTIVES: To evaluate blood pressure, proteinuria and serum NT-pro-BNP in proteinuric preeclamptic (PE) women and study their postpartum resolution till 3 months and determine the associated risk factors.
Material and Methods: 100 PE women enrolled included 66 women with mild (group A) and 34 with severe PE (group B). BP, urinary protein:creatinine(P/C) ratio, S.NT-pro-BNP were evaluated at labor room admission, postpartum day 1, 6 weeks and 3 months.
Results: Group B women had significant higher baseline BP, urine P/C ratio and S. NT-pro-BNP compared to group A. Resolution of BP, proteinuria and S. NT-pro-BNP was complete in group A women at 6 weeks postpartum. Persistent hypertension was observed in 25 and 4 women at postpartum 6 weeks and 3 months respectively. Proteinuria persisted in 25 and 10 women at postpartum 6 weeks and 3 months respectively. Resolution of NT-pro-BNP was complete at 3 months. In logistic regression model persisting hypertension and proteinuria at 3 months was correlated with increasing age, higher BMI and lower gestational age at delivery. Negative predictive value of 100% was observed with baseline P/C ratio <5, BP <120 mm Hg diastolic and S.NT-pro-BNP <1000 pg/mL for development of persistent proteinuria and hypertension.
Conclusion: Women with severe PE should be followed up for persistent proteinuria and hypertension. These women require evaluation for chronic kidney disease and preventive strategies for cardiovascular disease.
Center for Health Informatics (CHI), at National Institute of Health and Family Welfare (NIHFW),by Ministry of Health and Family Welfare (Mo HFW), Govt. of India. Available at https://www.nhp.gov.in/disease/gynaecology-and-obstetrics/preeclampsia
Williams D. Pregnancy: a stress test for life. Curr Opin Obstet Gynecol 2003;15:465–471.
Smith GN. The development of preeclampsia provides a window of opportunity for early cardiovascular risk screening and intervention. Expert Rev Obstet Gynecol 2009;4:355–357.
Smith GN, Walker M, Liu A, Wen SW, Swansburg M, Ramshaw H, et al. A history of preeclampsia identifies women who have underlying cardiovascular risk factors. Am J Obstet Gynecol 2009;200:58.e1–e58.e8.
Smith GCS, Pell JP, Walsh D. Pregnancy complications and maternal risk of ischaemic heart disease: a retrospective cohort study of 129,290 births. Lancet 2001;357:2002–2006.
Retnakaran R. Glucose tolerance status in pregnancy: a window to the future risk of diabetes and cardiovascular disease in young women. Curr Diabetes Rev 2009;5:239–244.
Retnakaran R, Shah BR. Mild glucose intolerance in pregnancy and risk of cardiovascular disease: a population-based cohort study. CMAJ 2009;181:371–376.
Ray JG, Vermeulen MJ, Schull MJ, Redelmeier DA. Cardiovascular health after maternal placental syndromes (CHAMPS): population-based retrospective cohort study. Lancet 2005;366:1797–1803.
Ghossein-Doha C; Peeters L; van Heijster S; van Kuijk S; Spaan J; Delhaas T; Spaanderman M. Hypertension after preeclampsia is preceded by changes in cardiac structure and function.Hypertension. 2013; 62(2):382-390 (ISSN: 1524-4563)
Bellamy L, Casas JP, Hingorani AD, Williams DJ. Preeclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis. BMJ. 2007;335:974.
Mosca, L, Benjamin, EJ, Berra, K, Bezanson, JL, Dolor, RJ, Lloyd-Jones, D et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update. J Am Coll Cardiol. 2011;57:1404–1423.
Smith GN, Jessica Pudwell, Mark Walker, Shi-Wu Wen Ten-Year, Thirty-Year, and Lifetime Cardiovascular Disease Risk Estimates Following a Pregnancy Complicated by Preeclampsia. J Obstet Gynaecol Can 2012;34(9):830–835
Townsend R, Patrick O’Brien, and Asma Khalil. Current best practice in the management of hypertensive disorders in pregnancy. Integr Blood Press Control. 2016; 9:79–94.
Weber M, Hamm C. Role of B-type natriuretic peptide (BNP) and NT-pro-BNP in clinical routine. Heart. 2006;92(6):843-849.
Rodseth RN. B type natriuretic peptide-a diagnostic breakthrough in perioperative cardiac risk assessment? Anaesthesia. 2009;64(2):165-178.
Franz MB, Andreas M, Schiessl B, Zeisler H, Neubauer A, Kastl SP, et al. NTpro-BNP is increased in healthy pregnancies compared to non-pregnant controls. Acta Obstet Gynecol Scand. 2009;88(2):234-237.
Sagie AL, Oz BB, Salpeter L, Celnikier DH, Arad I, Nir A. Plasma concentrations of N-terminal Pro-B-type natriuretuic peptide in pregnant women near labour and during early puerperium. Clinical Chemistry. 2005;51(10):1909-1910.
Kale A, Kale E, Yalinkaya A, Akdeniz N, Canoruç N. The comparison of aminoterminal probrain natriuretic peptide levels in preeclampsia and normotensive pregnancy. J Perinat Med. 2005;33(2):121-124.
Morris RK, Riley RD, Doug M, Deeks JJ, Kilby MD, Diagnostic accuracy of spot urinary protein and albumin to creatinine ratios for detection of significant proteinuria or adverse pregnancy outcome in patients with suspected preeclampsia: systematic review and meta-analysis. Cite this as: BMJ 2012;345:e4342
Christenson RH, Tang WHW. Institute for Quality in Laboratory Medicine Series -Controversies in Laboratory Medicine: Insights Into B-type Natriuretic Peptide and N-terminal pro-B-type Natriuretic Peptide Measurements. Med Gen Med. 2006;8(2):62.
Tranquilli AL. Introduction to ISSHP new classification of preeclampsia. Pregnancy Hypertens. 2013; 3(2):58-9. doi: 10.1016/j.preghy.2013.04.006. Epub 2013 Jun 6.
Berks D, Steegers EA, Molas M, Visser W. Resolution of hypertension and proteinuria after preeclampsia. Obstet Gynecol. 2009; 114(6):1307-14. doi: 10.1097/AOG.0b013e3181c14e3e
Sibai BM. Etiology and management of postpartum hypertension-preeclampsia. Clinical Opinion. JUNE 2012 American Journal of Obstetrics & Gynecology 470-475
Bakacak M, Serin S, Ercan O, Köstü B, Bakacak Z, Kiran H. Association of serum N-terminal pro-brain natriuretic peptide levels with the severity of preeclampsia. J Matern Fetal Neonatal Med. 2016 Sep;29(17):2802-6. doi: 10.3109/14767058.2015.1104663. Epub 2015 Nov 23.
Kumari S, Gupta M, Vardhan H, Saini V, Gupta SK. NT-pro-BNP: A Biochemical Marker of Maternal Complications in Preeclampsia. JCDR. 2017; 11(11):QC12-16 DOI: 10.7860/JCDR/2017/28713.10855
Kaze FF, Njukeng FA, Kengne AP, Ashuntantang G, Mbu R, Halle MP, Asonganyi T. Postpartum trend in blood pressure levels, renal function and proteinuria in women with severe preeclampsia and eclampsia in Sub-Saharan Africa: A 6-months cohort study. BMC Pregnancy and Childbirth 2014 14:134. https://doi.org/10.1186/1471-2393-14-134
Prakash J, Vohra R, Pandey LK, Niwas SS, Behura SK, Singh U. Spectrum of Kidney Diseases in Patients with Preeclampsia-Eclampsia. JAPI • september 2010 • VOL. 58 543-546
Lioufas N, Ling J, Jaw J, Mathew M, Jose M, et al. (2016) Does Pre-Eclampsia Predispose Patients to the Development of Focal Segmental Glomerulosclerosis? “The Chicken or the Egg?”. J Clin Nephrol Ren Care 2016;2:012
AL Roberts, P Loughna, A Ferraro, F Broughton-Pipkin. PMM.27 Unresolved proteinuria after preeclampsia: detecting renal disease. Poster presentations BMFMS: Maternal Medicine
Unverdi S, Ceri M, Unverdi H, Yilmaz R, Akcay A, Duranay M. Wien Klin Wochenschr. 2013; 125:91. https://doi.org/10.1007/s00508-0320-8
Vikse BE, Irgens LM, Leivestad T, Skjaerven R, Iversen BM. Preeclampsia and the risk of end-stage renal disease. N Engl J Med. 2008;359:800-809.
Yattinamani BP, Guruvare S, Rai L. Postpartum Recovery Trends in Women with Hypertensive Disorders of Pregnancy. Journal of Clinical Outcomes Management. 2017 February;24(2)
Ndayambagye EB, Nakalembe M, Kaye DK.Factors associated with persistent hypertension after puerperium among women with preeclampsia/eclampsia in Mulago hospital, Uganda. BMC Pregnancy Childbirth 10: 12. doi:10.1186/147123931012. PubMed: 20222993.
Clark AB. Plasma endothelin levels in Preeclampsia: elevation and correlation with uric acid levels and renal impairment. Am J Obstet Gynecol. 1992;166:962-968. [PubMed]
Munkhaugen J, Bjørn Egil Vikse BE. New aspects of preeclampsia: lessons for the nephrologist . Nephrology Dialysis Transplantation, Volume 24, Issue 10, 1 October 2009, Pages 2964-2967, https://doi.org/10.1093/ndt/gfp341
Samwiil L, Mercer C, Jarrett P, O’Malley S; Genetics of Pre-Eclampsia Collaborative Study (GOPEC) Research Midwives. Blood pressure and urinalysis are often omitted in women who have suffered preeclampsia at their six-week postnatal check. BJOG 2004;111:623-625.
Task Force for Hypertension in Pregnancy (2013) Hypertension in Pregnancy. The American College of Obstetricians and Gynecologists, Women’s Health Care Physicians.