Professional Documents
Culture Documents
Oponent
1. Dr. Rafiyandi
2. Dr. Setyo Teguh Waluyo
3. Dr. Sarlita Indah Permatasari
Introduction
Chronic hypertension is a common medical
condition in pregnancy, and its prevalence is
rising because a larger number of parturients
are obese and of advanced maternal age
OBJECTIVE
The purpose of the study
examine the association between
maternal chronic hypertension and the
risk of congenital malformations.
STUDY DESIGN
Exclusion
Exposure
Women without chronic hypertension
who did not receive antihypertensive
medications in first trimester
3 Groups
Outcomes
The primary outcome was defined as the presence of
a major congenital malformation in the offspring.
Secondary outcomes included each of the organ
spesific malformation
maternal
demographic
characteristics
5 groups of
potential
confounders
comorbid
medical conditions
obstetric characteristics/
conditions
maternal medications
measures of
health care utilization
Statistical Analyses
Women WITHOUT chronic
hypertension who did not
receive antihypertensive
medications in the first
trimester
Baseline
Characteristics
Controls
Treated
chronic
hypertension
Untreated
chronic
hypertension
Controls vs untreated
chronic hypertension
Sensitivity analyses
Excluding patients with any codes or
medications indicating the presence of
diabetes 88,937 patients excluded
Second sensitivity analysis excluding
patients with preterm delivery 98,049
patients excluded
Exploratory analyses
Examining the association of treated,
untreated hypertension & Spesific
congenital malformation
RESULT
Compared with normotensive controls,
pregnancies complicated by treated chronic
hypertension increased risk of congenital
malformations (odds ratio [OR], 1.3; 95%
confidence interval [CI], 1.2-1.5), as were
pregnancies
with
untreated
chronic
hypertension (OR 1.2; 95% CI, 1.1-1.3).
In analysis of organ-specific malformations
both
treated
and
untreated
chronic
hypertension was associated with a significant
increase in the risk of cardiac malformations
(OR, 1.6; 95% CI, 1.4-1.9 and OR, 1.5; 95%
CI, 1.3-1.7, respectively).
These associations persisted across a range
of sensitivity analyses.
858,337
8307
11,482
19
256,973 (29.9)
402 (4.8)
2063 (18)
20-24
308,140 (35.9)
1539 (18.5)
3435 (29.9
25-29
173,291 (20.2)
2396 (28.8)
2958 (25.8)
30-34
78,721 (9.2)
2201 (26.5)
1794 (15.6)
35-39
33,987 (4)
1361 (16.4)
949 (8.3)
40
7225 (0.8)
408 (4.9)
283 (2.5)
White, non-Hispanic
349,369 (40.7)
2684 (32.3)
4313 (37.6)
Black, non-Hispanic
289,867 (33.8)
4337 (52.2)
5179 (45.1)
Hispanic
131,057 (15.3)
689 (8.3)
1110 (9.7)
Asian
29,681 (3.5)
185 (2.2)
257 (2.2)
Other
41,039 (4.8)
248 (3)
402 (3.5)
Unknown
17,324 (2.0)
164 (2.0)
221 (1.9)
Preexisting DM
33,694 (3.9)
1989 (23.9)
1669 (14.5)
Gestational DM
67,081 (7.8)
2122 (25.5)
2216 (19.3)
9362 (1.1)
404 (4.9)
517 (4.5)
71,216 (8.3)
661 (8.0)
1007 (8.8)
Insulin
15,648 (1.8)
1343 (16.2)
1005 (8.8)
16,682 (1.9)
2042 (24.6)
1010 (8.8)
Total
Age group, y
Race/ethnicity
Patients characteristics
Comparison 1
Comparison 2
Without chronic
hypertension
Treated chronic
hypertension
Without chronic
hypertension
Treated chronic
hypertension
23,427
7809
34,434
11,478
19
1082 (4.6)
402 (5.2)
6069 (17.6)
2063 (18)
20-24
4590 (19.6)
1532 (19.6)
10,185 (29.6)
3434 (29.9)
25-29
6961 (29.7)
2322 (29.7)
9084 (26.4)
2957 (25.8)
30-34
6178 (26.4)
2006 (25.7)
5369 (15.6)
1793 (15.6)
35-39
3563 (15.2)
1187 (15.2)
2899 (8.4)
948 (8.3)
40
1053 (4.5)
360 (4.6)
828 (2.4)
283 (2.5)
White, non-Hispanic
7989 (34.1)
2585 (33.1)
13,362 (38.8)
4313 (37.6)
Black, non-Hispanic
11,793 (50.3)
3967 (50.8)
15,425 (44.8)
5175 (45.1)
Hispanic
2025 (8.6)
677 (8.7)
3205 (9.3)
1110 (9.7)
Asian
481 (2.1)
185 (2.4)
639 (1.9)
257 (2.2)
Other
692 (31)
241 (3.1)
157 (3.4)
402 (3.5)
Unknown
447 (1.9)
154 (2)
646 (1.9)
221 (1.9)
Total
Age group, y
Race/ethnicity
Patients characteristics
Preexisting DM
4375 (18.7)
1553 (19.9)
4788 (13.9)
1665 (14.5)
Gestational DM
5458 (23.3)
1781 (22.8)
6639 (19.3)
2214 (19.3)
986 (4.2)
319 (4.1)
1402 (4.1)
514 (4.5)
Tobacco use
1827 (7.8)
632 (8.1)
2992 (8.7)
1007 (8.8)
Insulin
2672 (11.4)
986 (12.6)
2843 (8.3)
1001 (8.7)
Oral diabetes
medications
3698 (15.8)
1398 (17.9)
2636 (7.7)
1006 (8.8)
Medication exposure
Unadjusted
PS matched
Unadjusted
PS matched
1.7 (1.61.9)
1.3 (1.21.5)
1.5 (1.41.6)
1.2 (1.11.3)
Central nervous
system malformations
2.0 (1.33)
1.4 (0.82.3)
1.4 (0.92.1)
1.2 (0.71.9)
Malformations of the
eye, ear, neck, or face
0.9 (0.51.7)
0.8 (0.41.8)
1.1 (0.71.9)
1.2 (0.72.1)
Cardiac malformations
2.6 (2.33)
1.6 (1.41.9)
2.1 (1.92.3)
1.5 (1.31.7)
Respiratory malformations
1.8 (1.22.7)
1.5 (0.92.4)
1.4 (0.92)
1.3 (0.82.1)
1.3 (0.72.3)
1.3 (0.62.6)
1.1 (0.71.9)
1.1 (0.62.1)
Gastrointestinal malformations
1.1 (0.81.5)
1.0 (0.71.5)
1.1 (0.91.4)
1.0 (0.71.3)
Genitourinary malformations
1.4 (1.11.8)
1.1 (0.81.5)
1.3 (1.11.7)
1.1 (0.91.5)
Musculoskeletal malformations
1.1 (0.91.4)
0.9 (0.71.2)
1.0 (0.81.2)
0.8 (0.71.1)
Other malformations
1.8 (1.32.4)
1.6 (1.12.3)
1.1 (0.81.5)
1.0 (0.71.4)
1.2 (1.01.4)
1.2 (1.11.3)
Cardiac malformations
1.5 (1.21.8)
1.5 (1.21.7)
1.3 (1.11.6)
1.1 (1.01.3)
Cardiac malformations
1.5 (1.21.9)
1.1 (0.91.4)
1.3 (1.21.6)
1.2 (0.91.6)
Cardiac malformations
1.6 (1.31.9)
1.3 (0.91.9)
1.2 (1.11.3)
1.2 (1.11.3)
Cardiac malformations
1.4 (1.31.6)
1.5 (1.31.6)
1.4 (1.02.0)
1.1 (0.81.5)
1.2 (0.26.2)
1.3 (0.43.5)
Single ventricle
3.0 (0.421.3)
4.5 (0.826.9)
1.5 (1.02.4)
1.3 (0.91.9)
Conotruncal defect
1.7 (0.83.5)
0.9 (0.41.8)
1.8 (0.84.1)
1.1 (0.52.2)
CONCLUSION
There is a similar increase in the risk of
congenital malformations (particularly
cardiac malformations) associated with
treated
and
untreated
chronic
hypertension that is independent of
measured confounders.
Studies
evaluating
the
teratogenic
potential of antihypertensive medications
must control for confounding by indication.
Fetuses and neonates of mothers with
chronic hypertension should be carefully
evaluated for potential malformations,
particularly cardiac defects.
CRITICAL APPRAISAL
Questions
Answers
Survey
Explanation
Questions
Answers
Explanation
Dependent variables: congenital
malformation (nominal)
Independent variables:
Chronic hypertension (nominal)
Control variables:
Age (ratio)
Race/ethnicity (nominal)
Patient characteristics (nominal)
Medication exposure (nominal)
5. Type of data,
primary, secondary or
tertiary resources?
Secondary
6. Group or ungroup
data?
Group data
Questions
7. Ad hoc or routine
data?
Answers
Ad hoc
Explanation
Data was collected for some period of
time during study
See page 9
Scatter-plot
Questions
Answers
High quality
12. Bias
Low risk of
bias
Not
mentioned
14. Sampling
technique
Total
sampling
Explanation
1. Data was derived from MAX and
approved by the Partners
Institutional Review Board (Boston,
MA)
2. Good operational definition
3. Using valid measurement technique
This study were careful to identify
potential confounders and residual
confounders. They did sensitivity
and exploratory analyses and
defined the strength (confounderoutcome relative risk) of a
hypothetical residual confounder.
Questions
Answers
Logistic
regression;
Propensity
score
matching
None
Good
Explanation
This study conducted 2 separate
comparisons in the analyses: (1)
controls vs subjects treated for
chronic hpertension and (2) controls
vs untreated for chronic hpertension
frequency and OR (95% CI)
To account the differences in the
baseline characteristics in the
groups that are being compared
propensity score analyses
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