( Obstet Gynecol . 2024;144(3):386–393. doi: 10.1097/AOG.0000000000005676) Chronic hypertension (cHTN) is a condition affecting pregnant women. These pregnancies are associated with higher risk of adverse events, including preterm birth, preeclampsia, and general poor outcomes for both the mother and neonate. There are differing opinions from clinicians on what the optimal timing is for deliveries in affected women. There is a recommendation from the American College of Obstetricians and Gynecologists (ACOG) that deliveries occur between 37 + 0 weeks and 39 + 6 of gestation. Often clinicians assisting with pregnancies experiencing complications recommend induction before the 39th week of gestation, but with cHTN, there does not seem to be a reduction of risk with such timing. Overall, additional research on the timing of delivery in mothers affected by cHTN is needed. This publication seeks to provide more evidence and support to clinicians assisting in decision making for such cases.

OBJECTIVE:To evaluate associations among antepartum pulse pressure and maternal and perinatal outcomes in women with mild chronic hypertension. METHODS:Secondary analysis of the CHAP (Chronic Hypertension and Pregnancy) trial, an open-label randomized controlled trial of antihypertensives (vs none) for mild chronic hypertension (blood pressure below 160/105 mm Hg). Patients without pulse pressure information or outcomes were excluded. The exposure was mean pulse pressure using clinic measurements after enrollment but before delivery, and the primary analysis assessed whether mean pulse pressure was associated with an adverse composite outcome. This composite included preeclampsia with severe features, medically indicated preterm birth (PTB) before 35 weeks of gestation, placental abruption or fetal or neonatal death, and small-for-gestational-age (SGA) birth weight. Logistic regression models were adjusted for randomization assignment. RESULTS:Two thousand three hundred twenty-five patients were eligible. The mean (SD) pulse pressure among patients was 50.2 (7.9) mm Hg. Increasing mean antepartum pulse pressure was associated with an increasing frequency of the adverse composite outcome (adjusted odds ratio [aOR] per 5 mm Hg 1.1; 95% CI, 1.0-1.2), preeclampsia with severe features (aOR 1.2; 95% CI, 1.0-1.1), and indicated PTB before 35 weeks of gestation (aOR 1.1; 95% CI, 1.0-1.2). Conversely, increasing pulse pressure was associated with decreasing rates of SGA birth weight below the 5th percentile (aOR 0.9; 95% CI, 0.9-1.0) but was not associated with SGA birth weight below the 10th percentile (aOR 0.9; 95% CI, 0.9-1.0). CONCLUSION:Increasing pulse pressure was modestly associated with an adverse composite, specifically preeclampsia with severe features and indicated PTB before 35 weeks of gestation, but it was negatively associated with SGA birth weight less than the 5th percentile. The role of antepartum pulse pressure in reducing adverse pregnancy outcomes in patients with chronic hypertension should be further investigated.

OBJECTIVE:To estimate the association between third-trimester maternal low blood pressure (BP) and delivery of a neonate with small-for-gestational-age (SGA) birth weight in patients treated for mild chronic hypertension. METHODS:This is a secondary analysis of the CHAP (Chronic Hypertension and Pregnancy) study, which randomized pregnant participants with mild chronic hypertension to treatment to achieve goal BP below 140/90 mm Hg compared with usual care. We calculated mean systolic and diastolic BPs between 28 and 34 weeks of gestation and excluded those with systolic BP of 140 mm Hg or higher or diastolic BP of 90 mm Hg or higher. We defined low BP as mean systolic BP below 110 and mean diastolic BP below 70 mm Hg or mean arterial pressure below 80 mm Hg and compared those individuals with participants with mean systolic BP of 110-139 mm Hg or mean diastolic BP of 71-89 mm Hg or both or mean arterial pressure of 80 mm Hg or higher. Our primary outcome was delivery of a neonate with SGA birth weight (birth weight below the 5th percentile). Logistic regression estimated the association between low BP and SGA birth weight, and adjusted odds ratios (aORs) and 95% CIs were reported. RESULTS:Of 2,408 CHAP participants, 1,205 (50.0%) met analysis criteria. Of those 1,205, 31 (2.6%) had low BP and 1,174 (97.4%) had mean BP 110/70-139/89 mm Hg; 33 (2.7%) had mean arterial pressure below 80 mm Hg, and 1,172 (97.3%) had mean arterial pressure of 80 mm Hg or higher. Having a neonate with SGA birth weight below the 5th percentile occurred in 62 participants (5.1%): 1 of the 31 (3.2%) with BP below 110/70 mm Hg and 1 of the 33 (3.0%) with mean arterial pressure below 80 mm Hg. There was no significant association between delivery of a neonate with SGA birth weight less than the 5th percentile and low BP by either mean systolic BP and mean diastolic BP (aOR 0.46, 95% CI, 0.06-3.58) or mean arterial pressure (aOR 0.53, 95% CI, 0.07-4.01). We found a nonlinear relationship between mean arterial pressure and delivery of a neonate with SGA birth weight less than the 5th percentile, and, as mean arterial pressure decreased, there was lower probability of having a neonate with SGA birth weight ( P =.02). CONCLUSION:Pharmacologic treatment of mild chronic hypertension infrequently results in low BP and does not appear to be associated with delivery of a neonate with SGA birth weight less than the 5th percentile for birth weight.

To evaluate the association of longitudinal systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) in early pregnancy with later development of superimposed preeclampsia with severe features in pregnancies complicated by mild chronic hypertension. This secondary analysis used data from the CHAP (Chronic Hypertension and Pregnancy) trial, a multicenter randomized controlled trial that involved pregnant individuals with chronic hypertension. Participants were categorized based on the development of superimposed preeclampsia with severe features. Longitudinal blood pressure measurements from enrollment to the development of superimposed preeclampsia with severe features or delivery were assessed using regression models. Separate models were created for SBP, DBP, and MAP to evaluate their associations with the primary outcome. Predictive performance was assessed using area under the curve (AUC) values, the integrated calibration index, and a Brier score. Of 2,316 individuals with chronic hypertension, 600 (25.9%) developed superimposed preeclampsia with severe features. Higher SBP, DBP, and MAP all were associated with superimposed preeclampsia with severe features, with MAP demonstrating the strongest association. Adjusted hazard ratios (HR) indicated that increased MAP, SBP, and DBP were significantly associated with the risk of superimposed preeclampsia with severe features (eg, adjusted HR 1.1556 [95% credible interval: 1.1332–1.1784] per mm Hg increase in MAP). Although MAP showed slightly better predictive metrics compared with SBP and DBP, overall predictive precision remained moderate. The lowest Brier score and highest AUC values were observed for MAP models, though differences among blood pressure metrics were minimal. In pregnancies complicated by chronic hypertension, longitudinal MAP trends provide a stronger association with superimposed preeclampsia with severe features compared with SBP or DBP. Although predictive performance was only moderate, these findings support the consideration of MAP as an important component of vital sign monitoring in prenatal care. Further research is warranted to refine risk prediction models through the integration of additional clinical and biomarker data. ClinicalTrials.gov, NCT02299414.

OBJECTIVE:To investigate the optimal gestational age to deliver pregnant people with chronic hypertension to improve perinatal outcomes. METHODS:We conducted a planned secondary analysis of a randomized controlled trial of chronic hypertension treatment to different blood pressure goals. Participants with term, singleton gestations were included. Those with fetal anomalies and those with a diagnosis of preeclampsia before 37 weeks of gestation were excluded. The primary maternal composite outcome included death, serious morbidity (heart failure, stroke, encephalopathy, myocardial infarction, pulmonary edema, intensive care unit admission, intubation, renal failure), preeclampsia with severe features, hemorrhage requiring blood transfusion, or abruption. The primary neonatal outcome included fetal or neonatal death, respiratory support beyond oxygen mask, Apgar score less than 3 at 5 minutes, neonatal seizures, or suspected sepsis. Secondary outcomes included intrapartum cesarean birth, length of stay, neonatal intensive care unit admission, respiratory distress syndrome (RDS), transient tachypnea of the newborn, and hypoglycemia. Those with a planned delivery were compared with those expectantly managed at each gestational week. Adjusted odds ratios (aORs) with 95% CIs are reported. RESULTS:We included 1,417 participants with mild chronic hypertension; 305 (21.5%) with a new diagnosis in pregnancy and 1,112 (78.5%) with known preexisting hypertension. Groups differed by body mass index (BMI) and preexisting diabetes. In adjusted models, there was no association between planned delivery and the primary maternal or neonatal composite outcome in any gestational age week compared with expectant management. Planned delivery at 37 weeks of gestation was associated with RDS (7.9% vs 3.0%, aOR 2.70, 95% CI, 1.40-5.22), and planned delivery at 37 and 38 weeks was associated with neonatal hypoglycemia (19.4% vs 10.7%, aOR 1.97, 95% CI, 1.27-3.08 in week 37; 14.4% vs 7.7%, aOR 1.82, 95% CI, 1.06-3.10 in week 38). CONCLUSION:Planned delivery in the early-term period compared with expectant management was not associated with a reduction in adverse maternal outcomes. However, it was associated with increased odds of some neonatal complications. Delivery timing for individuals with mild chronic hypertension should weigh maternal and neonatal outcomes in each gestational week but may be optimized by delivery at 39 weeks.

OBJECTIVE:To compare differences in postpartum blood pressure (BP) control (BP below 140/90 mm Hg) for participants with hypertension randomized to receive antihypertensive treatment compared with no treatment during pregnancy. METHODS:This study was a planned secondary analysis of a multicenter, open-label, randomized controlled trial (The CHAP [Chronic Hypertension and Pregnancy] trial). Pregnant participants with mild chronic hypertension (BP below 160/105 mm Hg) were randomized into two groups: active (antihypertensive treatment) or control (no treatment unless severe hypertension, BP 160/105 mm Hg or higher). Study outcomes were BP control below 140/90 mm Hg (primary) and medication nonadherence based on a composite score threshold (secondary) at the 6-week postpartum follow-up visit. Participants without follow-up BP measurements were excluded from analysis of the BP control outcome. Participants without health care professional-prescribed antihypertensives at delivery were excluded from the analysis of the adherence outcome. Multivariable logistic regression was used to adjust for potential confounders. RESULTS:Of 2,408 participants, 1,684 (864 active, 820 control) were included in the analysis. A greater percentage of participants in the active group achieved BP control (56.7% vs 51.5%; adjusted odds ratio [aOR] 1.22, 95% CI, 1.00-1.48) than in the control group. Postpartum antihypertensive prescription was higher in the active group (81.7% vs 58.4%, P <.001), and nonadherence did not differ significantly between groups (aOR 0.81, 95% CI, 0.64-1.03). CONCLUSION:Antihypertensive treatment of mild chronic hypertension during pregnancy was associated with better BP control below 140/90 mm Hg in the immediate postpartum period.

OBJECTIVE: To evaluate maternal and neonatal outcomes by type of antihypertensive used in participants of the CHAP (Chronic Hypertension in Pregnancy) trial. METHODS: We conducted a planned secondary analysis of CHAP, an open-label, multicenter, randomized trial of antihypertensive treatment compared with standard care (no treatment unless severe hypertension developed) in pregnant patients with mild chronic hypertension (blood pressure 140–159/90–104 mm Hg before 20 weeks of gestation) and singleton pregnancies. We performed three comparisons based on medications prescribed at enrollment: labetalol compared with standard care, nifedipine compared with standard care, and labetalol compared with nifedipine. Although active compared with standard care groups were randomized, medication assignment within the active treatment group was not random but based on clinician or patient preference. The primary outcome was the occurrence of superimposed preeclampsia with severe features, preterm birth before 35 weeks of gestation, placental abruption, or fetal or neonatal death. The key secondary outcome was small for gestational age (SGA) neonates. We also compared medication adverse effects between groups. Relative risks (RRs) and 95% CIs were estimated with log binomial regression to adjust for confounding. RESULTS: Of 2,292 participants analyzed, 720 (31.4%) received labetalol, 417 (18.2%) received nifedipine, and 1,155 (50.4%) received no treatment. The mean gestational age at enrollment was 10.5±3.7 weeks; nearly half of participants (47.5%) identified as non-Hispanic Black; and 44.5% used aspirin. The primary outcome occurred in 217 (30.1%), 130 (31.2%), and 427 (37.0%) in the labetalol, nifedipine, and standard care groups, respectively. Risk of the primary outcome was lower among those receiving treatment (labetalol use vs standard adjusted RR 0.82, 95% CI, 0.72–0.94; nifedipine use vs standard adjusted RR 0.84, 95% CI, 0.71–0.99), but there was no significant difference in risk when labetalol was compared with nifedipine (adjusted RR 0.98, 95% CI, 0.82–1.18). There were no significant differences in SGA or serious adverse events between participants receiving labetalol and those receiving nifedipine. CONCLUSION: No significant differences in predetermined maternal or neonatal outcomes were detected on the basis of the use of labetalol or nifedipine for treatment of chronic hypertension in pregnancy. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02299414.

As the diagnosis and treatment of patients with inborn errors of metabolism has improved dramatically over the years, more people with these conditions are surviving into child-bearing years. Given the changes in metabolism throughout pregnancy, this time presents a unique challenge in their care. Overall metabolic shifts in pregnancy go from anabolism to catabolism driven by endocrinologic changes, along with changes in rates of gluconeogenesis, glucose consumption, amino acid transport, protein consumption, and lipid breakdown, result in a complicated metabolic picture. Additionally, maternal inborn errors of metabolism can affect a fetus, as in phenylketonuria, and fetal inborn errors of metabolism can affect the mother, as in certain fatty acid oxidation disorders. Data on these conditions is often very limited. A summary of the current literature, risks associated with pregnancy in inborn errors of metabolism, and suggestions for management of these conditions will be presented.

OBJECTIVE: To estimate the association between mean arterial pressure during pregnancy and neonatal outcomes in participants with chronic hypertension using data from the CHAP (Chronic Hypertension and Pregnancy) trial. METHODS: A secondary analysis of the CHAP trial, an open-label, multicenter randomized trial of antihypertensive treatment in pregnancy, was conducted. The CHAP trial enrolled participants with mild chronic hypertension (blood pressure [BP] 140–159/90–104 mm Hg) and singleton pregnancies less than 23 weeks of gestation, randomizing them to active treatment (maintained on antihypertensive therapy with a goal BP below 140/90 mm Hg) or standard treatment (control; antihypertensives withheld unless BP reached 160 mm Hg systolic BP or higher or 105 mm Hg diastolic BP or higher). We used logistic regression to measure the strength of association between mean arterial pressure (average and highest across study visits) and to select neonatal outcomes. Unadjusted and adjusted odds ratios (per 1-unit increase in millimeters of mercury) of the primary neonatal composite outcome (bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, or intraventricular hemorrhage grade 3 or 4) and individual secondary outcomes (neonatal intensive care unit admission [NICU], low birth weight [LBW] below 2,500 g, and small for gestational age [SGA]) were calculated. RESULTS: A total of 2,284 participants were included: 1,155 active and 1,129 control. Adjusted models controlling for randomization group demonstrated that increasing average mean arterial pressure per millimeter of mercury was associated with an increase in each neonatal outcome examined except NEC, specifically neonatal composite (adjusted odds ratio [aOR] 1.12, 95% CI, 1.09–1.16), NICU admission (aOR 1.07, 95% CI, 1.06–1.08), LBW (aOR 1.12, 95% CI, 1.11–1.14), SGA below the fifth percentile (aOR 1.03, 95% CI, 1.01–1.06), and SGA below the 10th percentile (aOR 1.02, 95% CI, 1.01–1.04). Models using the highest mean arterial pressure as opposed to average mean arterial pressure also demonstrated consistent associations. CONCLUSION: Increasing mean arterial pressure was positively associated with most adverse neonatal outcomes except NEC. Given that the relationship between mean arterial pressure and adverse pregnancy outcomes may not be consistent at all mean arterial pressure levels, future work should attempt to further elucidate whether there is an absolute threshold or relative change in mean arterial pressure at which fetal benefits are optimized along with maternal benefits. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02299414.

BACKGROUND:Increased duration of breastfeeding improves maternal cardiovascular health and may be especially beneficial in high-risk populations, such as those with chronic hypertension. Others have shown that individuals with hypertension are less likely to breastfeed, and there has been limited research aimed at supporting breastfeeding goals in this population. The impact of perinatal blood pressure control on breastfeeding outcomes among people with chronic hypertension is unknown. OBJECTIVE:This study aimed to evaluate whether breastfeeding initiation and short-term duration assessed at the postpartum clinic visit differed according to perinatal blood pressure treatment strategy (targeting blood pressure <140/90 mm Hg vs reserving antihypertensive treatment for blood pressure ≥160/105 mm Hg). STUDY DESIGN:We performed a secondary analysis of the Chronic Hypertension and Pregnancy trial. This was an open-label, multicenter, randomized trial where pregnant participants with mild chronic hypertension were randomized to receive antihypertensive medications with goal blood pressure <140/90 mm Hg (active treatment) or deferred treatment until blood pressure ≥160/105 mm Hg (control). The primary outcome was initiation and duration of breastfeeding, assessed at the postpartum clinic visit. We performed bivariate analyses and log-binomial and cumulative logit regression models, adjusting models for variables that were unbalanced in bivariate analyses. We performed additional analyses to explore the relationship between breastfeeding duration and blood pressure measurements at the postpartum visit. RESULTS:Of the 2408 participants from the Chronic Hypertension and Pregnancy trial, 1444 (60%) attended the postpartum study visit and provided breastfeeding information. Participants in the active treatment group had different body mass index class distribution and earlier gestational age at enrollment, and (by design) were more often discharged on antihypertensives. Breastfeeding outcomes did not differ significantly by treatment group. In the active and control treatment groups, 563 (77.5%) and 561 (78.1%) initiated breastfeeding, and mean durations of breastfeeding were 6.5±2.3 and 6.3±2.1 weeks, respectively. The probability of ever breastfeeding (adjusted relative risk, 0.99; 95% confidence interval, 0.93-1.05), current breastfeeding at postpartum visit (adjusted relative risk, 1.01; 95% confidence interval, 0.94-1.10), and weeks of breastfeeding (adjusted odds ratio, 0.87; 95% confidence interval, 0.68-1.12) did not differ by treatment group. Increased duration (≥2 vs <2 weeks) of breastfeeding was associated with slightly lower blood pressure measurements at the postpartum visit, but these differences were not significant in adjusted models. CONCLUSION:In a secondary analysis of the cohort of Chronic Hypertension and Pregnancy trial participants who attended the postpartum study visit and provided breastfeeding information (60% of original trial participants), breastfeeding outcomes did not differ significantly by treatment group. This suggests that maintaining goal blood pressure <140/90 mm Hg throughout the perinatal period is associated with neither harm nor benefit for short-term breastfeeding goals. Further study is needed to understand long-term breastfeeding outcomes among individuals with chronic hypertension and how to support this population in achieving their breastfeeding goals.

OBJECTIVE: To evaluate the association between maternal blood pressure (BP) below 130/80 mm Hg compared with 130–139/80–89 mm Hg and pregnancy outcomes. METHODS: We conducted a planned secondary analysis of CHAP (Chronic Hypertension and Pregnancy), an open label, multicenter, randomized controlled trial. Participants with mean BP below 140/90 mm Hg were grouped as below 130/80 mm Hg compared with 130–139/80–89 mm Hg by averaging postrandomization clinic BP throughout pregnancy. The primary composite outcome was preeclampsia with severe features, indicated preterm birth before 35 weeks of gestation, placental abruption, or fetal or neonatal death. The secondary outcome was small for gestational age (SGA). RESULTS: Of 2,408 patients in CHAP, 2,096 met study criteria; 1,328 had mean BP 130–139/80–89 mm Hg and 768 had mean BP below 130/80 mm Hg. Participants with mean BP below 130/80 mm Hg were more likely to be older, on antihypertensive medication, in the active treatment arm, and to have lower BP at enrollment. Mean clinic BP below 130/80 mm Hg was associated with lower frequency of the primary outcome (16.0% vs 35.8%, adjusted relative risk 0.45; 95% CI 0.38–0.54) as well as lower risk of severe preeclampsia and indicated birth before 35 weeks of gestation. There was no association with SGA. CONCLUSION: In pregnant patients with mild chronic hypertension, mean BP below 130/80 mm Hg was associated with improved pregnancy outcomes without increased risk of SGA. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02299414.

Pregnancy-associated breast cancer is defined as breast cancer diagnosed during pregnancy or in the first postpartum year. Breast cancer is one of the most common malignancies to occur during pregnancy. As more women delay childbearing, the incidence of breast cancer in pregnancy is increasing. This article provides an overview of diagnosis, staging, and treatment of pregnancy-associated breast cancer. Recommendations for management of breast cancer in pregnancy are discussed.

Although pregnancy is generally contraindicated in advanced heart failure (AHF), successful pregnancies have been observed in patients with left ventricular assist devices (LVADs). The number of pregnancies in patients with LVADs is increasing, yet optimal management strategies remain undefined. Additionally, no successful pregnancies have been reported with the HeartMate 3 (HM3) (Abbott) LVAD. A systematic review of pregnancy in patients with LVADs was prepared utilizing 3 major scientific databases. We also present the first reported case of successful pregnancy and delivery in a patient supported by an HM3 LVAD. The systematic search yielded 95 results. After filtering to include only relevant citations, eight unique cases were identified. Cases were compared on the basis of several clinical factors. Although pregnancies supported by LVADs are medically complex, several cases of successful deliveries have been observed. Clinical management between cases, however, did vary significantly. Several areas requiring further study were identified.

Pregnancy-associated breast cancer is defined as breast cancer diagnosed during pregnancy or in the first postpartum year. Breast cancer is one of the most common malignancies to occur during pregnancy. As more women delay childbearing, the incidence of breast cancer in pregnancy is increasing. This article provides an overview of diagnosis, staging, and treatment of pregnancy-associated breast cancer. Recommendations for management of breast cancer in pregnancy are discussed.

Female childhood, adolescent, and young adult cancer survivors have an increased risk of adverse pregnancy outcomes related to their cancer- or treatment-associated sequelae. Optimal care for childhood, adolescent, and young adult cancer survivors can be facilitated by clinical practice guidelines that identify specific adverse pregnancy outcomes and the clinical characteristics of at-risk subgroups. However, national guidelines are scarce and vary in content. Here, the International Late Effects of Childhood Cancer Guideline Harmonization Group offers recommendations for the counseling and surveillance of obstetrical risks of childhood, adolescent, and young adult survivors. A systematic literature search in MEDLINE database (through PubMed) to identify all available evidence published between January 1990 and December 2018. Published articles on pregnancy and perinatal or congenital risks in female cancer survivors were screened for eligibility. Study designs with a sample size larger than 40 pregnancies in childhood, adolescent, and young adult cancer survivors (diagnosed before the age of 25 years, not pregnant at that time) were eligible. This guideline from the International Late Effects of Childhood Cancer Guideline Harmonization Group systematically appraised the quality of available evidence for adverse obstetrical outcomes in childhood, adolescent, and young adult cancer survivors using Grading of Recommendations Assessment, Development, and Evaluation methodology and formulated recommendations to enhance evidence-based obstetrical care and preconception counseling of female childhood, adolescent, and young adult cancer survivors. Healthcare providers should discuss the risk of adverse obstetrical outcomes based on cancer treatment exposures with all female childhood, adolescent, and young adult cancer survivors of reproductive age, before conception. Healthcare providers should be aware that there is no evidence to support an increased risk of giving birth to a child with congenital anomalies (high-quality evidence). Survivors treated with radiotherapy to volumes exposing the uterus and their healthcare providers should be aware of the risk of adverse obstetrical outcomes such as miscarriage (moderate-quality evidence), premature birth (high-quality evidence), and low birthweight (high-quality evidence); therefore, high-risk obstetrical surveillance is recommended. Cardiomyopathy surveillance is reasonable before pregnancy or in the first trimester for all female survivors treated with anthracyclines and chest radiation. Female cancer survivors have increased risks of premature delivery and low birthweight associated with radiotherapy targeting the lower body and thereby exposing the uterus, which warrant high-risk pregnancy surveillance.

INTRODUCTION: We present a rare case of sporadic cerebellar hemangioblastoma diagnosed in pregnancy. METHODS: A 37-year-old gravida 3 para 2002 with no significant history reported nausea and throbbing, bitemporal headaches at her 15 week visit. They were most bothersome in the evenings and upon waking. At her 21 week visit she reported persistent headaches with new onset dizziness. An echocardiogram and laboratory studies were normal. She was referred to neurology. At 23 weeks she had right and left beating nystagmus on exam and an unsteady gait. MRI revealed a 4 cm cystic lesion within the right cerebellum, mass effect on the fourth ventricle, and mild hydrocephalus with tonsillar and upward transtentorial herniation consistent with a hemangioblastoma. Neurosurgery planned urgent craniotomy and resection. RESULTS: The patient underwent uncomplicated surgery and pathology confirmed hemangioblastoma. Her postoperative course was uneventful with reassuring fetal status throughout admission. Her balance was markedly improved and neurologic exam was normal four weeks postoperatively. Testing for Von Hippel-Lindau syndrome was negative. The remainder of her pregnancy was uncomplicated. The team determined that she was a candidate for vaginal delivery. She underwent elective induction of labor at 39 weeks and progressed to vaginal delivery of a healthy female infant weighing 3370 g with Apgar scores of 9 and 9. She was discharged home with her infant on postpartum day one. CONCLUSION: Headaches, vomiting, and dizziness are common in pregnancy. Patients with severe, unrelenting symptoms require imaging and neurology consultation. Excellent outcomes are possible with a multidisciplinary approach involving obstetrics, maternal fetal medicine, neurology, and neurosurgery.

INTRODUCTION: This case report describes successful management of severe idiopathic fetal hydrops with thoracoamniotic shunts. METHODS: Patient is a 38 y/o G2P0010 who initiated care at 6 weeks. She was evaluated by perinatology for AMA and a fibroid uterus. First trimester and anatomy ultrasounds were unremarkable. She had low-risk genetic screening and normal MSAFP. A growth ultrasound at 23 weeks demonstrated bilateral pleural effusions. Evaluation included: normal fetal echocardiogram, Rh positive with no antibodies, negative serum TORCH titers, normal microarray, and negative amniotic fluid TORCH PCR. Due to worsening bilateral pleural effusions and development of fetal hydrops, patient underwent left-sided thoracoamniotic shunt placement at 25 and 26 weeks after receiving antenatal corticosteroids with resolution of left-sided pleural effusion and hydrops. She was admitted at 31 weeks for re-accumulation of left-sided pleural effusion and administration of rescue corticosteroids. At 32 weeks the fetus was again noted to have fetal hydrops and delivery was recommended. A primary LTCS was performed due to nonreassuring fetal heart tones. Patient delivered a female fetus weighing 1845 gram with APGARS of 2/7. The neonate spent 25 days in NICU with no evidence of pulmonary hypoplasia and was discharged home in stable condition. There was no identified etiology for hydrops and neonate was thriving at 6 week postpartum visit. CONCLUSION: Fetal intervention in a severe case of fetal hydrops can lead to an excellent neonatal outcome. Placement of thoracoamniotic shunts allowed for fetal lung development in setting of severe pleural effusions and allowed an additional 6 weeks of intrauterine growth.

HomeHypertensionVol. 72, No. 4Estimated Impact of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guidelines on Reproductive-Aged Women Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBEstimated Impact of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guidelines on Reproductive-Aged Women Matthew L. Topel, Erin M. Duncan, Iris Krishna, Martina L. Badell, Viola Vaccarino and Arshed A. Quyyumi Matthew L. TopelMatthew L. Topel Correspondence to Matthew L. Topel, Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1462 Clifton Rd NE, Suite 513, Atlanta, GA 30322. E-mail E-mail Address: [email protected] From the Division of Cardiology, Department of Medicine (M.L.T., A.A.Q.), Emory University School of Medicine, Atlanta, GA Search for more papers by this author , Erin M. DuncanErin M. Duncan Atlanta Gynecology and Obstetrics, GA (E.M.D.) Search for more papers by this author , Iris KrishnaIris Krishna Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics (I.K., M.L.B.), Emory University School of Medicine, Atlanta, GA Search for more papers by this author , Martina L. BadellMartina L. Badell Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics (I.K., M.L.B.), Emory University School of Medicine, Atlanta, GA Search for more papers by this author , Viola VaccarinoViola Vaccarino Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (V.V.). Search for more papers by this author and Arshed A. QuyyumiArshed A. Quyyumi From the Division of Cardiology, Department of Medicine (M.L.T., A.A.Q.), Emory University School of Medicine, Atlanta, GA Search for more papers by this author Originally published10 Sep 2018https://doi.org/10.1161/HYPERTENSIONAHA.118.11660Hypertension. 2018;72:e39–e42Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: September 10, 2018: Ahead of Print To the Editor:Currently, hypertensive disorders of pregnancy (HDP) affect up to 10% of all pregnancies in the United States and are associated with adverse outcomes and increased cost.3,4 The American College of Obstetricians and Gynecologists (ACOG) defines hypertension in pregnancy as BP ≥140/90 mm Hg.3 We sought to describe the impact of reclassifying hypertension for reproductive-aged women in the United States using the 2017 ACC/AHA guidelines.We analyzed cross-sectional data from noninstitutionalized women 20 to 44 years of age from the 2011 to 2012 and 2013 to 2014 waves of the National Health and Nutrition Examination Survey.5 This study was considered exempt by the Emory Institutional Review Board, and written informed consent was previously obtained from all participants by National Health and Nutrition Examination Survey.Three consecutive BP readings were obtained from participants in a seated position after 5 minutes of rest, and in participants with at least 2 measurements, mean values were used to define systolic BP (SBP) and diastolic BP (DBP). Hypertension was defined as SBP ≥140 mm Hg or DBP ≥90 mm Hg for ACOG guidelines3 and SBP ≥130 mm Hg or DBP ≥80 mm Hg for 2017 ACC/AHA guidelines.1 Participants on antihypertensive medication were considered to have hypertension by both guidelines, irrespective of SBP and DBP. Current pregnancy was determined by positive lab pregnancy test or an affirmative response to the question “Are you pregnant now?” and history of pregnancy was determined by self-report. Sociodemographic information and history of CVD, cancer, and diabetes mellitus were determined by self-report. Obesity was defined as body mass index ≥30.National Health and Nutrition Examination Survey sampling weights were used to obtain nationally representative prevalence estimates, and current population tables were used to estimate the number of women reclassified as having hypertension.6Of 2311 participants, the mean age was 31.9 years (SE=0.4), 57.1% were non-Hispanic white and 67.6% were currently or previously pregnant in weighted analyses. The prevalence of hypertension by ACOG and 2017 ACC/AHA guidelines was 10.2% (95% CI, 8.7%–11.6%) and 18.9% (95% CI, 16.8%–21.1%), respectively (Figure). Using current population estimates, an additional 4.5 million women aged 20 to 44 years had hypertension by 2017 ACC/AHA guidelines compared with ACOG guidelines. The relative increase in hypertension by 2017 ACC/AHA guidelines was consistent across strata of age, race/ethnicity, and family income; however, in women with a history of diabetes mellitus, CVD, or cancer, differences in hypertension prevalence by ACOG and 2017 ACC/AHA guidelines were reduced (Figure).Download figureDownload PowerPointFigure. Prevalence of hypertension in women age 20 to 44 y by American College of Obstetricians and Gynecologists (ACOG) and 2017 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines. Estimated prevalence of hypertension by ACOG (light gray bar) and 2017 ACC/AHA (full bar height) guidelines for United States women 20 to 44 y of age. Previous pregnancy was determined by an affirmative response to the question “Have you ever been pregnant?” Obesity was defined as a body mass index ≥30 kg/m2. CVD indicates cardiovascular disease; and NH, non-Hispanic.Subgroup analysis was performed to approximate a low-risk cohort of women with current or previous pregnancy. After excluding high-risk individuals with a history of diabetes mellitus, CVD, or cancer (N=201), the prevalence of hypertension by ACOG and 2017 ACC/AHA guidelines was 8.2% (95% CI, 6.7%–9.7%) and 17.1% (95% CI, 14.7%–19.5%), respectively (Table). Further exclusion of individuals without a previous or current pregnancy (N=812) resulted in a final cohort of 1298 low-risk, formerly or currently pregnant women who had a prevalence of hypertension by ACOG guidelines of 10.0% (95% CI, 8.1%–11.9%) and by 2017 ACC/AHA guidelines of 20.8% (95% CI, 18.0%–23.6%). The observed 2-fold increase in hypertension persisted in all sociodemographic strata (Table).Table. Prevalence of Hypertension by ACOG and 2017 ACC/AHA Guidelines for Low-Risk Reproductive-Aged Women in the United States, 2011–2014CharacteristicPrevalence of Hypertension, % (95% CI)Women*, Age 20–44 (n=2110)Women*, Age 20–44, Previously or Currently Pregnant† (n=1298)2017 ACC/AHA GuidelineACOG Guideline2017 ACC/AHA GuidelineACOG GuidelineOverall17.1 (14.7–19.5)8.2 (6.7–9.7)20.8 (18.0–23.6)10.0 (8.1–11.9)Age, y 20–3410.1 (7.6–12.6)3.6 (2.6–4.7)11.9 (8.4–15.4)4.3 (2.8–5.8) 35–4428.7 (25.1–32.3)15.7 (12.8–18.7)30.8 (27.0–34.7)16.4 (13.5–19.3)Race/ethnicity Non-Hispanic white16.8 (13.2–20.3)7.2 (4.9–9.5)21.6 (16.8–23.4)8.7 (5.6–11.9) Non-Hispanic black27.2 (22.7–31.6)16.8 (13.7–19.9)30.1 (24.4–35.8)19.8 (15.6–24.1) Non-Hispanic Asian10.3 (6.2–14.3)5.0 (2.8–7.2)12.2 (6.7–17.6)6.3 (2.6–9.9) Hispanic or Mexican American12.0 (8.7–15.4)6.3 (4.0–8.5)12.6 (8.6–16.5)6.6 (3.8–9.3)Annual family income, $ <25 00015.6 (12.8–18.4)7.3 (5.3–9.2)19.8 (15.2–24.4)10.1 (7.5–12.6) 25 000–65 00017.8 (13.9–21.7)8.9 (7.0–10.8)21.5 (16.3–26.7)11.3 (8.0–14.6) ≥65 00017.2 (13.4–20.9)8.3 (5.2–11.4)20.7 (15.8–25.6)8.8 (5.3–12.4)Obese‡28.6 (25.0–32.2)15.4 (12.6–18.2)31.9 (28.2–35.6)17.4 (14.3–20.6)Previously pregnant†20.8 (18.0–23.7)9.9 (8.0–11.9)NANAACC/AHA indicates American College of Cardiology/American Heart Association; ACOG, American College of Obstetricians and Gynecologists; and NA, not applicable.*Excludes women with self-reported diabetes mellitus, cardiovascular disease, or cancer.†Current pregnancy was determined by positive lab pregnancy test or an affirmative response to the question “Are you pregnant now?”; previous pregnancy was determined by an affirmative response to the question “Have you ever been pregnant?”‡Body mass index ≥30 kg/m2.Approximately twice as many reproductive-aged women will have hypertension by 2017 ACC/AHA guidelines compared with previous definitions of hypertension. These differences persist within a subset of low-risk women with a history of pregnancy. Although these estimates approximate the burden of chronic hypertension only, the prevalence of other HDP, including preeclampsia, may also increase if the 2017 ACC/AHA definition of hypertension is adopted during pregnancy.Concurrent with the publication of the 2017 ACC/AHA hypertension guidelines, Muntner et al2 showed that, although the prevalence of hypertension among adults in the United States would increase by ≈31 million people, only 4 million of those individuals would be newly recommended for antihypertensive medication. The implication that new BP thresholds for hypertension should not necessarily equate to large-scale increases in medication use was especially notable in young, otherwise-healthy people; however, for women of reproductive age who become pregnant, a lower threshold for defining HDP may have significant implications for both obstetric management and risk assessment in the antepartum, intrapartum, and postpartum periods.Maternal mortality has increased to a rate of 17.3 pregnancy-related deaths per 100 000 live births in 2013.7 And while the proportion of maternal deaths from HDP has decreased overall, other pregnancy-related mortality rates affected by hypertension, including stroke, have increased.8 Importantly, hypertension remains a major risk factor for stroke in pregnancy, as women with HDP are 5× more likely to have a stroke than normotensive women, and their rate of stroke-related complications is substantially higher.9 Because all HDP are associated with an increased risk of CVD,10–13 pregnant women with a diagnosis of chronic hypertension often have more frequent office visits and additional screening tests for various maternal-fetal complications, such as preeclampsia and intrauterine fetal growth restriction.3,14 This increase in resource utilization leads to increased healthcare costs—deliveries complicated by HDP cost an estimated 25% to 385% more than uncomplicated deliveries.4Furthermore, it is unclear whether lowering the BP threshold for the diagnosis of HDP would significantly affect risk assessment for adverse outcomes in pregnancy. Most studies demonstrating an association between HDP and maternal-fetal complications or future CVD use hypertension as a binary variable and infrequently report actual BP measurements. However, 2 studies from the Kaiser Permanente health system in California showed that BP 120 to 130/80 to 89 mm Hg during pregnancy was associated with a 2-fold increase in subsequent HDP.15,16 Recently, Youngstrom et al17 demonstrated that women with controlled chronic hypertension, defined as BP <140/90 before 20 weeks gestation, were at increased risk of fetal complications and preeclampsia, irrespective of antihypertensive use. These findings are compelling and suggest that lower BP thresholds for HDP may result in better, earlier risk assessment in pregnant women.Last, it is still unknown whether treatment to lower BP levels during pregnancy is beneficial. For women with a history of hypertension, tight (DBP <85 mm Hg) versus loose (DBP <100 mm Hg) BP control during pregnancy was associated with less severe maternal hypertension and no change in outcomes for the fetus.18 This is supported by findings from a recent systematic review and meta-analysis that showed antihypertensive therapy was associated with reduced rates of severe maternal hypertension, whereas results for other maternal-fetal outcomes were either mixed or null.19 There is even less guidance about specific antihypertensive therapies, as head-to-head trials are limited.19 The 2017 ACC/AHA guidelines specifically reference the paucity of data regarding hypertension treatment for risk reduction during pregnancy and calls for more research to determine if lower BP targets are safe and associated with improved maternal-fetal outcomes.1 However, there may be benefits to lower BP targets for women with HDP beyond consideration for antihypertensive therapy. ACOG guidelines recommend low-dose aspirin to prevent superimposed preeclampsia in pregnant women with chronic hypertension. Hauspurg et al20 recently showed that women with stage 1 hypertension by 2017 ACC/AHA guidelines (BP 130–139/80–89 mm Hg) had a significantly reduced risk of preeclampsia with low-dose aspirin therapy compared with normotensive controls. Further investigation is needed to determine the utility of targeting lower BP for medical therapy in women with HDP.In conclusion, the current study demonstrates that adoption of the 2017 ACC/AHA guideline definition for hypertension would approximately double the prevalence of hypertension in women of reproductive age. If ACOG was to adopt the 2017 ACC/AHA definition of hypertension, a similar increase in the prevalence of HDP would be expected. Further research is needed to determine if lower BP thresholds are safe and effective in reducing maternal and fetal complications related to HDP.Sources of FundingM.L. Topel is supported by the National Institutes of Health (T32HL13002502) and the Abraham J. & Phyllis Katz Foundation Grant (Atlanta, GA). A.A. Quyyumi is supported by the National Institutes of Health (grants RF1AG05163301S2, P30DK11102402, and R61HL13865701).DisclosuresNone.FootnotesAll data used in this study have been made publicly available at the Centers for Disease Control and Prevention and can be accessed at https://www.cdc.gov/nchs/nhanes/index.htm.Correspondence to Matthew L. Topel, Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1462 Clifton Rd NE, Suite 513, Atlanta, GA 30322. E-mail [email protected]eduReferences1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.J Am Coll Cardiol. 2018; 71:e127–e248. doi: 10.1016/j.jacc.2017.11.006CrossrefMedlineGoogle Scholar2. Muntner P, Carey RM, Gidding S, Jones DW, Taler SJ, Wright JT, Whelton PK. Potential US population impact of the 2017 ACC/AHA high blood pressure guideline.Circulation. 2018; 137:109–118. doi: 10.1161/CIRCULATIONAHA.117.032582LinkGoogle Scholar3. American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy.Obstet Gynecol. 2013; 122(5):1122–1131. doi: 10.1097/01.AOG.0000437382.03963.88MedlineGoogle Scholar4. Pourat N MA, Jones JM, Gregory KD, Korst L, Kominski GF. Cost of Gestational Hypertensive Disorders in California: Hypertension, Preeclampsia, and Eclampsia. Los Angeles, CA: UCLA Center for Health Policy Research; 2013.Google Scholar5. National Health and Nutrition Examination Survey. Centers for Disease Control and Prevention.https://www.cdc.gov/nchs/nhanes/index.htm. Accessed January 31, 2018.Google Scholar6. NHANES Response Rates and Population Totals. Centers for Disease Control and Prevention.https://www.cdc.gov/nchs/nhanes/response_rates_CPS.htm. Accessed February 1, 2018.Google Scholar7. Pregnancy-Related Mortality Surveillance. Centers for Disease Control and Prevention.https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html. Accessed June 25, 2018.Google Scholar8. Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-related mortality in the United States, 2011-2013.Obstet Gynecol. 2017; 130:366–373. doi: 10.1097/AOG.0000000000002114CrossrefMedlineGoogle Scholar9. Leffert LR, Clancy CR, Bateman BT, Bryant AS, Kuklina EV. Hypertensive disorders and pregnancy-related stroke: frequency, trends, risk factors, and outcomes.Obstet Gynecol. 2015; 125:124–131. doi: 10.1097/AOG.0000000000000590CrossrefMedlineGoogle Scholar10. Cirillo PM, Cohn BA. Pregnancy complications and cardiovascular disease death: 50-year follow-up of the Child Health and Development Studies pregnancy cohort.Circulation. 2015; 132:1234–1242. doi: 10.1161/CIRCULATIONAHA.113.003901LinkGoogle Scholar11. Riise HKR, Sulo G, Tell GS, et al. Association between gestational hypertension and risk of cardiovascular disease among 617 589 Norwegian Women.J Am Heart Assoc. 2018; 7(10):e008337. doi: 10.1161/JAHA.117.008337LinkGoogle Scholar12. Scantlebury DC, Kattah AG, Weissgerber TL, et al. Impact of a history of hypertension in pregnancy on later diagnosis of atrial fibrillation.J Am Heart Assoc. 2018; 7(10):e007584. doi: 10.1161/JAHA.117.007584LinkGoogle Scholar13. Tooher J, Thornton C, Makris A, Ogle R, Korda A, Hennessy A. All hypertensive disorders of pregnancy increase the risk of future cardiovascular disease.Hypertension. 2017; 70:798–803. doi: 10.1161/HYPERTENSIONAHA.117.09246LinkGoogle Scholar14. Townsend R, O’Brien P, Khalil A. Current best practice in the management of hypertensive disorders in pregnancy.Integr Blood Press Control. 2016; 9:79–94. doi: 10.2147/IBPC.S77344CrossrefMedlineGoogle Scholar15. Black MH, Zhou H, Sacks DA, Dublin S, Lawrence JM, Harrison TN, Reynolds K. Prehypertension prior to or during early pregnancy is associated with increased risk for hypertensive disorders in pregnancy and gestational diabetes.J Hypertens. 2015; 33:1860–1867; discussion 1867. doi: 10.1097/HJH.0000000000000646CrossrefMedlineGoogle Scholar16. Hedderson MM, Darbinian JA, Sridhar SB, Quesenberry CP. Prepregnancy cardiometabolic and inflammatory risk factors and subsequent risk of hypertensive disorders of pregnancy.Am J Obstet Gynecol. 2012; 207:68.e1–68.e9. doi: 10.1016/j.ajog.2012.05.017CrossrefGoogle Scholar17. Youngstrom M, Tita A, Grant J, Szychowski JM, Harper LM. Perinatal outcomes in women with a history of chronic hypertension but normal blood pressures before 20 weeks of gestation.Obstet Gynecol. 2018; 131:827–834. doi: 10.1097/AOG.0000000000002574CrossrefMedlineGoogle Scholar18. Magee LA, von Dadelszen P, Rey E, et al. Less-tight versus tight control of hypertension in pregnancy.N Engl J Med. 2015; 372:407–417. doi: 10.1056/NEJMoa1404595CrossrefMedlineGoogle Scholar19. Webster LM, Conti-Ramsden F, Seed PT, Webb AJ, Nelson-Piercy C, Chappell LC. Impact of antihypertensive treatment on maternal and perinatal outcomes in pregnancy complicated by chronic hypertension: a systematic review and meta-analysis.J Am Heart Assoc. 2017; 6(5):e005526. doi: 10.1161/JAHA.117.005526LinkGoogle Scholar20. Hauspurg A, Sutton EF, Catov JM, Caritis SN. Aspirin effect on adverse pregnancy outcomes associated with stage 1 hypertension in a high-risk cohort.Hypertension. 2018; 72:202–207. doi: 10.1161/HYPERTENSIONAHA.118.11196LinkGoogle ScholarNovelty and SignificanceWhat Is New?An additional 4.5 million women of reproductive age will have a diagnosis of hypertension by 2017 American College of Cardiology/American Heart Association guidelines compared with American College of Obstetricians and Gynecologists guidelines.The approximate doubling of hypertension prevalence in reproductive-aged women extends to a cohort of low-risk women with current or previous pregnancy.What is Relevant?If 2017 American College of Cardiology/American Heart Association definition for hypertension is adopted by American College of Obstetricians and Gynecologists, the burden of pregnant women with a diagnosis of chronic hypertension will increase substantially.Further study is needed to determine if lower BP targets in pregnant women are safe, effective, and associated with improved outcomes.SummaryApproximately twice as many women of reproductive age will have a diagnosis of hypertension by 2017 American College of Cardiology/American Heart Association guidelines compared with American College of Obstetricians and Gynecologists guidelines. Previous Back to top Next FiguresReferencesRelatedDetailsCited By Ford N, Robbins C, Hayes D, Ko J and Loustalot F (2022) Prevalence, Treatment, and Control of Hypertension Among US Women of Reproductive Age by Race/Hispanic Origin, American Journal of Hypertension, 10.1093/ajh/hpac053, 35:8, (723-730), Online publication date: 1-Aug-2022. Ackerman‐Banks C, Grechukhina O, Spatz E, Lundsberg L, Chou J, Smith G, Greenberg V, Reddy U, Xu X, O’Bryan J, Smith S, Perley L and Lipkind H (2022) Seizing the Window of Opportunity Within 1 Year Postpartum: Early Cardiovascular Screening, Journal of the American Heart Association, 11:8, Online publication date: 19-Apr-2022. de Groot C, Umans J, Jeyabalan A and Staff A (2022) Clinical Management and Antihypertensive Treatment of Hypertensive Disorders of Pregnancy Chesley's Hypertensive Disorders in Pregnancy, 10.1016/B978-0-12-818417-2.00012-9, (375-403), . 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Hauspurg A, Sutton E, Caritis S, Powers R and Catov J (2019) In Reply, Obstetrics & Gynecology, 10.1097/AOG.0000000000003046, 133:1, (190-191), Online publication date: 1-Jan-2019. October 2018Vol 72, Issue 4 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/HYPERTENSIONAHA.118.11660PMID: 30354726 Originally publishedSeptember 10, 2018 PDF download Advertisement