PRACTICEFor the full versions of these articles see bmj.com benefit and should not be given for this purpose. The evidence for added calcium in the prevention of hypertensive disorders is conflicting and confusing, and more research is needed in this area. Chronic hypertension Preconception• Tell women taking angiotensin converting enzyme inhibitors and angiotensin II receptor blockers that taking these drugs during pregnancy increases the risk of congenital abnormalities, and that they should discuss other antihypertensive treatments with their healthcare professional if they are planning pregnancy. • Tell women taking chlorothiazide diuretics that taking these drugs during pregnancy increases the risk of congenital abnormalities and neonatal This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists Further information about the guidance, a list of members of the guideline development group, and the supporting evidence statements are in the full version on bmj.com. Why read this summary?Hypertensive disorders of pregnancy cover a spectrum of conditions, including chronic (pre-existing) hypertension, pre-eclampsia, and gestational hypertension (box 1). These conditions are associated with increased perinatal mortality and morbidity. Hypertensive disorders cause one in 50 stillbirths in normal babies and 10% of all preterm births. They contribute to a third of cases of severe maternal morbidity. 1 Pre-eclampsia is one of the most common causes of maternal death in the United Kingdom. 2 This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on how to manage hypertensive disorders during pregnancy. 3 Recommendations NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group's experience and opinion of what constitutes good practice. Evidence levels for the recommendations are in the full version of this article on bmj.com.Reducing the risk of hypertensive disorders in pregnancy • Advise pregnant women of their risk of developing hypertensive disorders during pregnancy (in particular pre-eclampsia; see box 2) and of the need to seek immediate advice from a healthcare professional if they experience symptoms of preeclampsia (severe headache; problems with vision, such as blurring or flashing before the eyes; severe pain just below the ribs; vomiting; sudden swelling of face, hands, or feet). • Advise women with at least one high risk factor for pre-eclampsia or at least two moderate risk factors for pre-eclampsia (box 2) to take 75 mg of aspirin daily from 12 weeks until the birth of the baby. • Although several drugs (nitric oxide donors, progesterone, diuretics, and low molecular weight heparin) and vitamin and nutrient supplement...

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Based on current evidence, routine screening for group B streptococcus colonisation in late pregnancy should not be introduced in the UK, as the potential harms of unnecessary treatment with antibiotics may outweigh the benefits, argue Farah Seedat and colleagues

Background: Velamentous cord insertion (VCI) is an umbilical cord attachment to the membranes surrounding the placenta instead of the central mass. VCI is strongly associated with vasa praevia (VP), where umbilical vessels lie in close proximity to the internal cervical os. VP leaves the vessels vulnerable to rupture, which can lead to fatal fetal exsanguination. Screening for VP using second-trimester transabdominal sonography (TAS) to detect VCI has been proposed. We conducted a rapid review investigating the quality, quantity and direction of evidence available on the epidemiology, screening test accuracy and post-screening management pathways for VCI. Methods: MEDLINE, Embase and the Cochrane Library were searched on 5 July 2016 and again on 11 October 2019, using general search terms for VP and VCI. Only peer-reviewed articles reporting on the epidemiology of VCI, the accuracy of the screening test and/or downstream management pathways for VCI pregnancies were included. Quality and risk of bias of each included study were assessed using pre-specified tools. Results: Forty-one relevant publications were identified; all but one were based on non-UK pregnancy cohorts, and most included relatively few VCI cases. The estimated incidence of VCI was 0.4-11% in singleton pregnancies, with higher incidence in twin pregnancies (1.6-40%). VCI incidence was also increased among pregnancies with one or more other risk factors, including in vitro fertilisation pregnancies or nulliparity. VCI incidence among women without any known risk factors was unclear. VCI was associated with adverse perinatal outcomes, most notably pre-term birth and emergency caesarean section in singleton pregnancies, and perinatal mortality in twins; however, associations varied across studies and the increased risk was typically low or moderate compared with pregnancies without VCI. In studies on limited numbers of cases, screening for VCI using TAS had good overall accuracy, driven by high specificity. No studies on post-screening management of VCI were identified. Conclusions: Literature on VCI epidemiology and outcomes is limited and low-quality. The accuracy of secondtrimester TAS and the benefits and harms of screening cannot be determined without prospective studies in large cohorts. Modelling studies may indicate the feasibility and value of studying the epidemiology of VCI and the potential impact of detecting VCI as part of a population screening programme for VP.

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