Proteinuria and outcome of 444 pregnancies complicated by hypertension

doi:10.1016/0002-9378(90)90387-M

American Journal of Obstetrics and Gynecology

Volume 162, Issue 2, February 1990, Pages 366-371

https://doi.org/10.1016/0002-9378(90)90387-M Get rights and content

The purpose of this study was to determine the role of proteinuria on pregnancy outcome in 444 hypertensive women with singleton pregnancies. The patients were divided into three hypertensive groups: 98 with chronic hypertension, 199 with nonproteinuric gestational hypertension, and 147 with proteinuric preeclampsia and chronic hypertension with superimposed proteinuric preeclampsia. The presence of increased proteinuria (>0.3 gm/L) predicted an adverse pregnancy outcome. Furthermore, the majority of small-for-gestational-age infants occurred in the group with proteinuric preeclampsia (52%), whereas the rate of small-for-gestational-age infants was 18% and 12% in the group with nonproteinuric gestational hypertension and chronic hypertension, respectively. The group with chronic hypertension did not show any increased risk for fetal outcome. Perinatal mortality rate was extremely poor in the group with proteinuric preeclampsia at 129 per 1000, four times higher than those of the other two groups.

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Cited by (147)

Proteinuria during pregnancy: definition, pathophysiology, methodology, and clinical significance
2022, American Journal of Obstetrics and Gynecology
Citation Excerpt :
An important question to be answered in order to assess the importance of proteinuria during pregnancy is whether pregnant women with new-onset hypertension with proteinuria have different maternal or perinatal outcomes compared with hypertensive women without proteinuria. Proteinuria in combination with hypertension has long been considered to be predictive of increased maternal and neonatal adverse outcomes compared with women with gestational hypertension alone,68–71 and before the Task Force on Hypertension in 2013, proteinuria was an essential part of the diagnosis of preeclampsia.4,72 Furthermore, the amount of protein was previously related to the severity of the disease.
Qualitative and quantitative measurement of urine protein excretion is one of the most common tests performed during pregnancy. For more than 100 years, proteinuria was necessary for the diagnosis of preeclampsia, but recent guidelines recommend that proteinuria is sufficient but not necessary for the diagnosis. Still, in clinical practice, most patients with gestational hypertension will be diagnosed as having preeclampsia based on the presence of proteinuria. Although the reference standard for measuring urinary protein excretion is a 24-hour urine collection, spot urine protein-to-creatinine ratio is a reasonable “rule-out” test for proteinuria. Urine dipstick screening for proteinuria does not provide any clinical benefit and should not be used to diagnose proteinuria. The classic cutoff cited to define proteinuria during pregnancy is a value of >300 mg/24 hours or a urine protein-to-creatinine ratio of at least 0.3. Using this cutoff, the rate of isolated proteinuria in pregnancy may reach 8%, whereas preeclampsia occurs among 3% to 8% of pregnancies. Although this threshold is widely accepted, its origin is not based on evidence on adverse pregnancy outcomes but rather on expert opinion and results of small studies. After reviewing the available data, the most important factor that influences maternal and neonatal outcome is the severity of blood pressures and presence of end organ damage, rather than the excess protein excretion. Because the management of gestational hypertension and preeclampsia without severe features is almost identical in frequency of surveillance and timing of delivery, the separation into 2 disorders is unnecessary. If the management of women with gestational hypertension with a positive assessment of proteinuria will not change, we believe that urine assessment for proteinuria is unnecessary in women who develop new-onset blood pressure at or after 20 weeks’ gestation. Furthermore, we do not recommend repeated measurement of proteinuria for women with preeclampsia, the amount of proteinuria does not seem to be related to poor maternal and neonatal outcomes, and monitoring proteinuria may lead to unindicated preterm deliveries and related neonatal complications. Our current diagnosis of preeclampsia in women with chronic kidney disease may be based on a change in protein excretion, a baseline protein excretion evaluation is critical in certain conditions such as chronic hypertension, diabetes, and autoimmune or other renal disorders. The current definition of superimposed preeclampsia possesses a diagnostic dilemma, and it is unclear whether a change in the baseline proteinuria reflects another systemic disease such as preeclampsia or whether women with chronic disease such as chronic hypertension or diabetes will experience a different “normal” pattern of protein excretion during pregnancy. Finally, limited data are available regarding angiogenic and other biomarkers in women with chronic kidney disease as a potential aid in distinguishing the worsening of baseline chronic kidney disease and chronic hypertension from superimposed preeclampsia.
Epidemiology of Hypertensive Disorders in Pregnancy
2021, Chesley’s Hypertensive Disorders in Pregnancy
The epidemiologic literature relating to hypertension in pregnancy has grown exponentially since Chesley’s 20-page chapter in the first edition of his 1978 treatise. New data characterize the occurrence, risk factors, predictors, natural history, and molecular epidemiology of preeclampsia. Those epidemiologic findings and the methods used to conduct them are critically assessed in this updated revision of the chapter. New evidence indicating that preeclampsia is a syndrome secondary to multiple pathophysiological pathways is presented. We address the heterogeneity among risk factors and clinical predictors that serve as “markers” of the disorder, but also consider the possibility that preeclampsia is a potential cause of future cardiovascular disease.
Severe early-onset PE with or without FGR in Chinese women
2020, Placenta
Early-onset preeclampsia (PE) is a severe condition with highest risk of perinatal complications. In current study, we compared PE severity, laboratory results and placental pathological lesions between early-onset PE with fetal growth restriction (PE + FGR) and appropriate gestational age (PE + AGA) neonates, with the aim to identify potential maternal risk factors associated with FGR. A retrospective case study was conducted in 304 PE women, and 31 cases with mild PE were excluded. 276 patients with severe PE were divided into PE + FGR (163, 59.1%) and PE + AGA (113, 40.9%) groups and underwent clinical analysis. 244 cases were further submitted for pathologic examinations to compare the differences of placental lesions between these two groups. As compared to PE + AGA, the maternal pre-pregnancy BMI (P = 0.003) and the rate of anemia (P = 0.004) were lower in PE + FGR; while the rate of severe low serum albumin (P = 0.020) was higher. Moreover, severe low serum albumin level (aOR = 2.43, P = 0.046) and abnormal uric acid (aOR = 2.19, P = 0.033) were positively correlated to the incidence of FGR, while pre-pregnancy BMI (aOR = 0.39, P = 0.001) and anemia (aOR = 0.33, P = 0.001) showed negative correlation. The placental examinations further showed positively correlation between chronic villitis (aOR = 4.32, P = 0.028) and FGR. Surprisingly, general measures of maternal illness severity failed to present any significant correlation to FGR, except for blood pressure, which showed negative correlation. For the first time, we studied a relatively large case series of Chinses early-onset PE women, and identified multiple factors associated with FGR incidence. Our study provided some opinions on clinal diagnosis and treatment for early-onset PE with FGR.
Association between changes in gestational blood pressure and vanadium exposure in China
2020, Environmental Toxicology and Pharmacology
Citation Excerpt :
In the present study, BP levels decreased in the second trimester but subsequently increased in the third trimester, which was consistent with the general pattern of BP changes during pregnancy (Grindheim et al., 2012; Ochsenbein-Kolble et al., 2004). A significant increase in BP during gestation is associated with adverse pregnancy outcomes, such as preterm birth, fetal growth restriction, and low birth weight (Bakker et al., 2011; Ferrazzani et al., 1990). Elevation in BP which does not exceed the normal range (prehypertension: SBP of 120–139 mmHg and/or DBP of 80–90 mmHg) may also increase the risk of adverse obstetrical outcomes (Rosner et al., 2019).
To investigate the association between urinary vanadium concentrations and blood pressure (BP) changes in Chinese pregnant women.
This longitudinal study included 716 pregnant women who visited our hospital in Wuhan, China, from 2014 to 2016. Urinary sample collection and BP measurements were performed at 9–15, 21–27, and 34–40 weeks of gestation. Outcomes were repeated BP measurements (systolic blood pressure [SBP], diastolic blood pressure [DBP], pulse pressure [PP], and mean arterial pressure [MAP]) during pregnancy.
The geometric mean of urinary vanadium concentrations was 0.65 μg/g creatinine. After adjusting for potential confounders, each threefold increase in urinary vanadium concentration was observed to be associated with a 1.06 mmHg decrease in SBP (95 % confidence interval [CI]: −1.80, −0.32), a 0.68 mmHg decrease in DBP (95 % CI: −1.32, −0.04), and a 0.81 mmHg decrease in MAP (95 % CI: −1.42, −0.19). Cross-sectional analysis showed a negative association between urinary vanadium concentrations and BP in the third trimester. Specifically, each threefold increase in urinary vanadium concentration in the second trimester was associated with decreases in SBP, DBP, PP, and MAP by 2.72 mmHg (95 % CI: −4.02, −1.41), 1.57 mmHg (95 % CI: −2.72, −0.42), 1.14 mmHg (95 % CI: −2.15, −0.14), and 1.95 mmHg (95 % CI: −3.06, −0.85), respectively, in the third trimester.
To the best of our knowledge, this is the first longitudinal study that suggests the negative association between vanadium exposure and BP among pregnant women in China.
Predictive value of 24-hour proteinuria in neonatal outcome in preeclamptic patients
2017, Clinica e Investigacion en Ginecologia y Obstetricia
Determinar el valor predictivo de la proteinuria en 24 h en las resultantes neonatales de las preeclámpsicas.
Se seleccionó a 87 preeclámpsicas que acudieron a urgencias del Hospital Central «Dr. Urquinaona», Maracaibo, Venezuela. Se evaluaron las características generales de las pacientes, los valores de proteinuria en 24 h y resultante neonatal.
La edad promedio de las pacientes fue de 26,0 ± 5,4 años. La edad gestacional en el momento fue de 32,9 ± 3,3 semanas. Los valores promedio de proteinuria en 24 h fue de 4,5 ± 1,8 g. Al separar la proteinuria en cuartiles dependiendo de la concentración (baja, moderada, alta y muy alta), se observó que los valores más bajos de peso neonatal pertenecían a los grupos de concentraciones altas y muy altas comparado con el grupo de concentraciones bajas (p < 0,05). No se encontraron diferencias significativas entre los grupos con respecto a la resultante y la mortalidad perinatal entre los grupos (p = ns). Se encontró que un punto de corte para la proteinuria en 24 h de 3 g no presentó un valor de área bajo la curva mayor de 0,70 que fuese significativa y permitiera su uso en la predicción de la resultante y mortalidad neonatales (p = ns).
La proteinuria en 24 h no tiene valor predictivo en la resultante neonatal en preeclámpsicas.
To determine the predictive value of 24-hour proteinuria in neonatal outcome in preeclamptic patients.
We selected 87 preeclamptic patients attending the Accident and Emergency Department of the Dr. Urquinaona Central Hospital, in Maracaibo, Venezuela. General characteristics, 24-hour proteinuria values, and neonatal outcome were evaluated.
The mean age of patients was 26.0 ± 5.4 years. Gestational age at diagnosis was 32.9 ± 3.3 weeks. The mean value of 24-hour proteinuria was 4.5 ± 1.8 grams. When proteinuria was separated in quartiles depending on concentration (low, moderate, high and extremely high), we observed that lower values of neonatal weight corresponded to groups of high and extremely high concentrations compared with the group with low concentrations (P<.05). No significant differences were found among groups in neonatal complications and mortality (P=ns). A cut-off of 3 grams for 24-hour proteinuria did not show an area below the curve higher than 0.70, the value necessary to be significant, nor was this value significant (P=ns) in predicting neonatal complications and mortality (P=ns).
This study did not find that 24-hour proteinuria had any value in predicting neonatal outcomes in preeclamptic patients.
Pregnancy in chronic kidney disease and kidney transplantation
2017, Kidney International
Chronic kidney disease (CKD) affects up to 6% of women of childbearing age in high income countries, and is estimated to affect 3% of pregnant women. Advanced renal dysfunction, proteinuria, hypertension, and poorly controlled underlying primary renal disease are all significant risks for adverse maternal, fetal, and renal outcomes. In order to achieve the best outcomes, it is therefore of paramount importance that these pregnancies are planned, where possible, to allow the opportunity to counsel women and their partners in advance and to optimize these risks. These pregnancies should be deemed high risk and they require close antenatal monitoring from an expert multidisciplinary team. We discuss the effect of pregnancy on CKD, and also current guidelines and literature with specific reference to transplantation, autoimmune disease, and medication use in pregnancy. We also discuss the benefits of prepregnancy counseling and give practical recommendations to advise pregnant women with renal disease.

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View full text

Proteinuria and outcome of 444 pregnancies complicated by hypertension

Am J Obstet Gynecol

Eur J Obstet Gynecol Reprod Biol

Am J Obstet Gynecol

Influence of blood pressure changes with and without proteinuria upon outcome of pregnancy

Am J Obstet Gynecol

Superimposed preeclampsia or eclampsia

The effect of pregnancy hypertension on fetal growth

Pregnancy outcome in 211 patients with mild chronic hypertension

Obstet Gynecol

Pregnancy outcome of intensive therapy in severe hypertension in first trimester

Obstet Gynecol