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Pregnancy outcomes in women with chronic kidney disease and chronic hypertension: a National cohort study.
Am J Obstet Gynecol. 2021 09; 225(3):298.e1-298.e20.AJ

Abstract

BACKGROUND

Maternal chronic kidney disease and chronic hypertension have been linked with adverse pregnancy outcomes. We aimed to examine the association between these conditions and adverse pregnancy outcomes over the last 3 decades.

OBJECTIVE

We conducted this national cohort study to assess the association between maternal chronic disease (CH, CKD or both conditions) and adverse pregnancy outcomes with an emphasis on the effect of parity, maternal age, and BMI on these associations over the last three decades. We further investigated whether different subtypes of CKD had differing effects.

STUDY DESIGN

We used data from the Swedish Medical Birth Register, including 2,788,490 singleton births between 1982 and 2012. Women with chronic kidney disease and chronic hypertension were identified from the Medical Birth Register and National Patient Register. Logistic regression models were performed to assess the associations between maternal chronic disease (chronic hypertension, chronic kidney disease, or both conditions) and pregnancy outcomes, including preeclampsia, in-labor and prelabor cesarean delivery, preterm birth, small for gestational age, and stillbirth.

RESULTS

During the 30-year study period, 22,397 babies (0.8%) were born to women with chronic kidney disease, 13,279 (0.48%) to women with chronic hypertension and 1079 (0.04%) to women with both conditions. Associations with chronic hypertension were strongest for preeclampsia (adjusted odds ratio, 4.57; 95% confidence interval, 4.33-4.84) and stillbirth (adjusted odds ratio, 1.65; 95% confidence interval, 1.35-2.03) and weakest for spontaneous preterm birth (adjusted odds ratio, 1.07; 95% confidence interval, 0.96-1.20). The effect of chronic kidney disease varied from (adjusted odds ratio, 2.05; 95% confidence interval, 1.92-2.19) for indicated preterm birth to no effect for stillbirth (adjusted odds ratio, 1.16; 95% confidence interval, 0.95-1.43). Women with both conditions had the strongest associations for in-labor cesarean delivery (adjusted odds ratio, 1.86; 95% confidence interval, 1.49-2.32), prelabor cesarean delivery (adjusted odds ratio, 2.68; 95% confidence interval, 2.18-3.28), indicated preterm birth (adjusted odds ratio, 9.09; 95% confidence interval, 7.61-10.7), and small for gestational age (adjusted odds ratio, 4.52; 95% confidence interval, 3.68-5.57). The results remained constant over the last 3 decades. Stratified analyses of the associations by parity, maternal age, and body mass index showed that adverse outcomes remained independently higher in women with these conditions, with worse outcomes in multiparous women. All chronic kidney disease subtypes were associated with higher odds of preeclampsia, in-labor cesarean delivery, and medically indicated preterm birth. Different subtypes of chronic kidney disease had differing risks; strongest associations of preeclampsia (adjusted odds ratio, 3.98; 95% confidence interval, 2.98-5.31) and stillbirth (adjusted odds ratio, 2.73; 95% confidence interval, 1.13-6.59) were observed in women with congenital kidney disease, whereas women with diabetic nephropathy had the most pronounced increase odds of in-labor cesarean delivery (adjusted odds ratio, 3.54; 95% confidence interval, 2.06-6.09), prelabor cesarean delivery (adjusted odds ratio, 7.50; 95% confidence interval, 4.74-11.9), and small for gestational age (adjusted odds ratio, 4.50; 95% confidence interval, 2.92-6.94). In addition, women with renovascular disease had the highest increased risk of preterm birth in both spontaneous preterm birth (adjusted odds ratio, 3.01; 95% confidence interval, 1.57-5.76) and indicated preterm birth (adjusted odds ratio, 8.09; 95% confidence interval, 5.73-11.4).

CONCLUSION

Women with chronic hypertension, chronic kidney disease, or both conditions are at an increased risk of adverse pregnancy outcomes which were independent of maternal age, body mass index, and parity. Multidisciplinary management should be provided with intensive clinical follow-up to support these women during pregnancy, particularly multiparous women. Further research is needed to evaluate the effect of disease severity on adverse pregnancy outcomes.

Links

Publisher Full Text (DOI)

Authors+Show Affiliations

Al Khalaf SY
School of Public Health, University College Cork, Cork, Ireland; INFANT Research Centre, University College Cork, Cork, Ireland. Electronic address: alkhalaf.sukainah@gmail.com.
O'Reilly ÉJ
School of Public Health, University College Cork, Cork, Ireland; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA.
McCarthy FP
INFANT Research Centre, University College Cork, Cork, Ireland; Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland.
Kublickas M
Department of Obstetrics and Gynaecology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.
Kublickiene K
Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.
Khashan AS
School of Public Health, University College Cork, Cork, Ireland; INFANT Research Centre, University College Cork, Cork, Ireland. Electronic address: a.khashan@ucc.ie.

MeSH

AdultCohort StudiesFemaleHumansHypertensionPre-EclampsiaPregnancyPregnancy ComplicationsPremature BirthRegistriesRenal Insufficiency, ChronicStillbirthSwedenYoung Adult

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

33823152

Citation

Al Khalaf, Sukainah Y., et al. "Pregnancy Outcomes in Women With Chronic Kidney Disease and Chronic Hypertension: a National Cohort Study." American Journal of Obstetrics and Gynecology, vol. 225, no. 3, 2021, pp. 298.e1-298.e20.
Al Khalaf SY, O'Reilly ÉJ, McCarthy FP, et al. Pregnancy outcomes in women with chronic kidney disease and chronic hypertension: a National cohort study. Am J Obstet Gynecol. 2021;225(3):298.e1-298.e20.
Al Khalaf, S. Y., O'Reilly, É. J., McCarthy, F. P., Kublickas, M., Kublickiene, K., & Khashan, A. S. (2021). Pregnancy outcomes in women with chronic kidney disease and chronic hypertension: a National cohort study. American Journal of Obstetrics and Gynecology, 225(3), e1-e20. https://doi.org/10.1016/j.ajog.2021.03.045
Al Khalaf SY, et al. Pregnancy Outcomes in Women With Chronic Kidney Disease and Chronic Hypertension: a National Cohort Study. Am J Obstet Gynecol. 2021;225(3):298.e1-298.e20. PubMed PMID: 33823152.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Pregnancy outcomes in women with chronic kidney disease and chronic hypertension: a National cohort study. AU - Al Khalaf,Sukainah Y, AU - O'Reilly,Éilis J, AU - McCarthy,Fergus P, AU - Kublickas,Marius, AU - Kublickiene,Karolina, AU - Khashan,Ali S, Y1 - 2021/04/03/ PY - 2020/11/20/received PY - 2021/03/04/revised PY - 2021/03/19/accepted PY - 2021/4/7/pubmed PY - 2021/9/28/medline PY - 2021/4/6/entrez KW - chronic hypertension KW - chronic kidney disease KW - fetal death KW - fetal outcome KW - obstetrical outcome KW - preeclampsia KW - pregnancy SP - 298.e1 EP - 298.e20 JF - American journal of obstetrics and gynecology JO - Am J Obstet Gynecol VL - 225 IS - 3 N2 - BACKGROUND: Maternal chronic kidney disease and chronic hypertension have been linked with adverse pregnancy outcomes. We aimed to examine the association between these conditions and adverse pregnancy outcomes over the last 3 decades. OBJECTIVE: We conducted this national cohort study to assess the association between maternal chronic disease (CH, CKD or both conditions) and adverse pregnancy outcomes with an emphasis on the effect of parity, maternal age, and BMI on these associations over the last three decades. We further investigated whether different subtypes of CKD had differing effects. STUDY DESIGN: We used data from the Swedish Medical Birth Register, including 2,788,490 singleton births between 1982 and 2012. Women with chronic kidney disease and chronic hypertension were identified from the Medical Birth Register and National Patient Register. Logistic regression models were performed to assess the associations between maternal chronic disease (chronic hypertension, chronic kidney disease, or both conditions) and pregnancy outcomes, including preeclampsia, in-labor and prelabor cesarean delivery, preterm birth, small for gestational age, and stillbirth. RESULTS: During the 30-year study period, 22,397 babies (0.8%) were born to women with chronic kidney disease, 13,279 (0.48%) to women with chronic hypertension and 1079 (0.04%) to women with both conditions. Associations with chronic hypertension were strongest for preeclampsia (adjusted odds ratio, 4.57; 95% confidence interval, 4.33-4.84) and stillbirth (adjusted odds ratio, 1.65; 95% confidence interval, 1.35-2.03) and weakest for spontaneous preterm birth (adjusted odds ratio, 1.07; 95% confidence interval, 0.96-1.20). The effect of chronic kidney disease varied from (adjusted odds ratio, 2.05; 95% confidence interval, 1.92-2.19) for indicated preterm birth to no effect for stillbirth (adjusted odds ratio, 1.16; 95% confidence interval, 0.95-1.43). Women with both conditions had the strongest associations for in-labor cesarean delivery (adjusted odds ratio, 1.86; 95% confidence interval, 1.49-2.32), prelabor cesarean delivery (adjusted odds ratio, 2.68; 95% confidence interval, 2.18-3.28), indicated preterm birth (adjusted odds ratio, 9.09; 95% confidence interval, 7.61-10.7), and small for gestational age (adjusted odds ratio, 4.52; 95% confidence interval, 3.68-5.57). The results remained constant over the last 3 decades. Stratified analyses of the associations by parity, maternal age, and body mass index showed that adverse outcomes remained independently higher in women with these conditions, with worse outcomes in multiparous women. All chronic kidney disease subtypes were associated with higher odds of preeclampsia, in-labor cesarean delivery, and medically indicated preterm birth. Different subtypes of chronic kidney disease had differing risks; strongest associations of preeclampsia (adjusted odds ratio, 3.98; 95% confidence interval, 2.98-5.31) and stillbirth (adjusted odds ratio, 2.73; 95% confidence interval, 1.13-6.59) were observed in women with congenital kidney disease, whereas women with diabetic nephropathy had the most pronounced increase odds of in-labor cesarean delivery (adjusted odds ratio, 3.54; 95% confidence interval, 2.06-6.09), prelabor cesarean delivery (adjusted odds ratio, 7.50; 95% confidence interval, 4.74-11.9), and small for gestational age (adjusted odds ratio, 4.50; 95% confidence interval, 2.92-6.94). In addition, women with renovascular disease had the highest increased risk of preterm birth in both spontaneous preterm birth (adjusted odds ratio, 3.01; 95% confidence interval, 1.57-5.76) and indicated preterm birth (adjusted odds ratio, 8.09; 95% confidence interval, 5.73-11.4). CONCLUSION: Women with chronic hypertension, chronic kidney disease, or both conditions are at an increased risk of adverse pregnancy outcomes which were independent of maternal age, body mass index, and parity. Multidisciplinary management should be provided with intensive clinical follow-up to support these women during pregnancy, particularly multiparous women. Further research is needed to evaluate the effect of disease severity on adverse pregnancy outcomes. SN - 1097-6868 UR - https://www.unboundmedicine.com/medline/citation/33823152/Pregnancy_outcomes_in_women_with_chronic_kidney_disease_and_chronic_hypertension:_a_National_cohort_study_ DB - PRIME DP - Unbound Medicine ER -