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...
These results demonstrate that weight loss has a blood pressure-lowering effect that is distinct from energy restriction and that is related to changes in blood volume and cardiac output.
T he hypertensive disorders of pregnancy are associated with increased maternal and fetal/neonatal mortality and morbidity. They are responsible for one in 50 stillbirths in normal fetuses, 10% of all preterm births, a third of severe maternal morbidities, and a large percentage of pregnancy-related maternal deaths in the United Kingdom. This article summarizes the latest recommendations on management of hypertensive disorders in pregnancy by the National Institute for Health and Clinical Excellence (NICE), based on the best available evidence.Prevention begins preconceptionally by providing women information on their risk for these diseases. Moderate risk factors for preeclampsia include age Z40 years, first pregnancy, multiple gestation, >10 years interval since last pregnancy, body mass index of Z35, and family history. High risk factors are chronic hypertension, kidney disease, hypertensive disorder in a previous pregnancy, diabetes, and autoimmune disease. Women with Z1 high risk factor or Z2 moderate factors should take 75 mg of aspirin daily from 12 weeks' gestation through delivery. Other so-called preventive treatments, such as supplements (including additional calcium) have not proven effective.Angiotensin-related drugs and chlorothiazide diuretics taken during pregnancy can increase the risk of congenital abnormalities and other neonatal complications. These medications should be stopped and replaced with safer antihypertensive drugs before and during pregnancy, with specific treatment tailored to the individual. Symptom recognition by the patient to include severe headache vision problems severe pain below the ribs vomiting, and sudden swelling of face, hands, or feet, and reporting of these symptoms to healthcare personnel will facilitate early diagnosis and treatment. During pregnancy, blood pressure (BP) should be kept <150/100 mm Hg, with diastolic BP no less than 80 mm Hg, in parturients with uncomplicated chronic hypertension. Birth before 37 weeks' gestation is unwise if BP is <160/110 mm Hg. For new-onset hypertension during pregnancy, proteinuria should be assessed to diagnose preeclampsia (a protein:creatinine ratio of >30 mg/mmol or validated 24-hour urine collection that shows >300 mg protein are criteria for the diagnosis).The management of gestational hypertensive disorders includes assessment for possible hospital admission, treatment of hypertension, close monitoring of BP and proteinuria, and appropriate blood tests. Pregnancy is managed conservatively until 34 weeks' gestation unless hematologic or clinical thresholds are met that require delivery at an earlier gestational age. Fetal monitoring should include abdominal ultrasound to assess fetal growth and amniotic fluid volume and umbilical artery Doppler velocimetry at 28 to 30 weeks and 32 to 34 weeks gestation. Intrapartum, patients with moderate hypertension should have their BP measured hourly. Continual BP monitoring is indicated if hypertension is severe. Antenatal antihypertensive treatment should be continued during labor, ...
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