The aim of this guideline is to improve the standard of, and to reduce regional variation in, the care of women with CKD in the UK who are pregnant, planning a pregnancy or post-partum. Scope This guidance covers the care of women with CKD (including renal transplant recipients) who are planning a pregnancy, pregnant, or in the post-partum period. It also covers contraception and fertility for women with CKD. This guideline can be used in the following settings: General practice Community and hospital antenatal clinics Antenatal, labour and postnatal wards Renal outpatients Renal wards Dialysis units The target audience and intended users of this guideline are nephrologists, obstetricians, obstetric physicians, midwives, renal nurses, pharmacists, specialist trainees in both nephrology and obstetrics, and women with CKD who are pregnant or considering pregnancy. Qualitative data on the experience of pregnancy and renal disease is provided in Appendix 1. A summary of clinical responsibility for elements of the guideline is provided in Appendix 2. The clinical issues covered in this guideline are: Structure of care Medication Pre-pregnancy care 3.1.Contraception 3.2.Fertility 3.3.Pre-pregnancy counselling and optimisation for pregnancy Pregnancy care 4.1 Assessment of renal function in pregnancy 4.2 Antenatal care 4.3 Pre-eclampsia prophylaxis 4.4 Blood pressure management 4.5 Thromboembolism prophylaxis 4.6 Anaemia 4.7 Bone health 4.8 Renal biopsy 4.9 Peripartum care 4.10 Postnatal care Pregnancy Care Assessment of renal function in pregnancy Guideline 4.1.1 We recommend renal function in pregnancy is assessed using serum creatinine concentrations as estimated GFR (eGFR) is not valid for use in pregnancy (1C). Guideline 4.1.2 We recommend women with CKD have formal quantification of proteinuria in pregnancy (1D). Guideline 4.1.3 We recommend quantification of proteinuria is undertaken by protein:creatinine ratio (uPCR) or albumin:creatinine ratio (uACR). Twenty-four hour urine collection for quantification of protein is not required (1B). Antenatal care Guideline 4.2.1 We suggest pregnant women with CKD who have not had pre-pregnancy counselling by the MDT are referred to the MDT and receive the same counselling and optimisation as for women attending pre-pregnancy (2D). Guideline 4.2.2 We recommend pregnant women with CKD receive routine antenatal care, in addition to specialist input (1D). Guideline 4.2.3 We recommend pregnant women with CKD be referred for assessment by a consultant obstetrician (1D). Guideline 4.2.4 We recommend pregnant women with CKD have access to usual trisomy screening with specialist interpretation of high-risk results (1C). Guideline 4.2.5 We recommend women with CKD exposed to teratogenic drugs in the first trimester are referred to a specialist fetal medicine unit (1D). Guideline 4.1.6 We recommend pregnant women with CKD have scans to assess fetal growth and wellbeing in the third trimester (1C). Guideline 4.2.7 We recommend pregnant women taking prednisolone and/or calcineurin inhib...
ObjectivesTo identify research priorities for hypertensive disorders of pregnancy from individuals with lived experience and healthcare professionals.DesignProspective surveys and consensus meetings using principles outlined by the James Lind Alliance.SettingUK.MethodsA steering group was established and ‘uncertainties’ were gathered using an online survey and literature search. An interim online survey ranked long-listed questions and the top 10 research questions were reached by consensus at a final prioritisation workshop.ParticipantsWomen, partners, relatives and friends of those with lived experience of pregnancy hypertension, researchers and healthcare professionals.ResultsThe initial online survey was answered by 278 participants (180 women with lived experience, 9 partners/relatives/friends, 71 healthcare professionals and 18 researchers). Together with a literature search, this identified 764 questions which were refined into 50 summary questions. All summary questions were presented in an interim prioritisation survey that was answered by 155 participants (87 women with lived experience, 4 partners/relatives/friends, 49 healthcare professionals and 15 researchers). The top 25 highest ranked questions were considered by the final prioritisation workshop. The top 10 uncertainties were identified by consensus and ranked as follows in order of priority: long-term consequences of pregnancy hypertension (for the woman and baby), short-term complications of pregnancy hypertension (for the woman and baby), screening tests for pre-eclampsia, prevention of long-term problems (for the woman and baby), causes of pregnancy hypertension, prevention of recurrent pregnancy hypertension, educational needs of healthcare professionals, diagnosis of pre-eclampsia, management of pregnancy hypertension, provision of support for women and families.ConclusionsResearch priorities shared by those with lived experience of pregnancy hypertension and healthcare professionals have been identified. Researchers should use these to inform the choice of future studies in this area.
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Introduction Women with pre-existing morbidity arising from medical conditions or previous caesarean section are at higher risk of adverse pregnancy outcomes compared to women without such morbidity. Women often face complex pregnancy-related decision-making that may be characterized by conflicting maternal and perinatal priorities. The aim of this systematic review and meta-analysis was to assess randomised controlled trials of decision aids to evaluate whether they are effective at reducing decisional conflict scores and to evaluate what type of decision aids are most effective for women with pre-existing morbidity in pregnancy. Methods We searched Medline (via Ovid), Embase (via Ovid), CINAHL (via EBSCO) from the earliest entries until September 2021. We selected randomised controlled trials comparing patient decision aids for women with pre-existing morbidity with usual clinical practice or a control intervention. Study characteristics and Jadad risk of bias was recorded. Meta-analysis by pre-existing morbidity type was performed using Stata 17 and the data was presented with a Forest Plot. Random effects models were used to calculate summary estimates if there was substantial clinical or statistical heterogeneity and post mean DCS scores were described in a sensitivity analysis and presented as a line graph, to improve clinical interpretation of results.. A narrative synthesis of the selected studies evaluated what type of decision aid works and for in what circumstances. Results Ten randomised controlled trials, which reported data from 4028 women, were included. Patient decision aids were evaluated in women with pre-existing morbidity who were undertaking pregnancy-related decision-making. Patient decision aids reduced decisional conflict scale scores by an additional − 3.7, 95% Confidence Interval − 5.9% to − 1.6%) compared to the control group. Women with pre-existing medical conditions were more conflicted at baseline and had greater reductions in decisional conflict scale score (mean difference vs. control group: − 6.6%; 95% CI − 9.8% to − 3.3%), in contrast to those with previous caesarean section (mean difference − 2.4%; 95% CI − 4.8% to − 0.1%). There was limited evidence on the effect of decision aids on health outcomes. Decision aids reduced unwanted variation in decision-making support across maternity settings. Conclusion Patient decision aids are effective tools to support personalised care planning and informed decision-making in women with pre-existing morbidity. Women with pre-existing medical morbidity were more conflicted at baseline and were more likely to benefit from decision aids. Adoption of aids in this population may lead to improve adherence and health outcomes, warranting further research.
ObjectiveTo evaluate the implementation of National Institute for Health and Care Excellence antenatal hypertension guidelines, to identify strategies to reduce incidences of severe hypertension and associated maternal and perinatal morbidity and mortality in pregnant women with chronic hypertension.MethodsWe used a multiple method multisite approach to establish implementation of guidelines and the associated barriers and facilitators. We used a national survey of healthcare professionals (n=97), case notes review (n=55) and structured observations (n=42) to assess implementation. The barriers and facilitators to implementation were identified from semistructured qualitative interviews with healthcare professionals (n=13) and pregnant women (n=18) using inductive thematic analysis. The findings were integrated and evaluated using the Consolidated Framework for Implementation Research.Setting and participantsPregnant women with chronic hypertension and their principal carers (obstetricians, midwives and physicians), at three National Health Service hospital trusts with different models of care.ResultsWe found severe hypertension to be prevalent (46% of case notes reviewed) and target blood pressure practices to be suboptimal (56% of women had an antenatal blood pressure target documented). Women were infrequently given information (52%) or offered choice (19%) regarding antihypertensives. Women (14/18) reported internal conflict in taking antihypertensives and non-adherence was prevalent (8/18). Women who were concordant with treatment recommendations described having mutual trust with professionals mediated through appropriate information, side effect management and involvement in decision making. Professionals reported needing updates and tools for target blood pressure setting and shared decision making underpinned by antihypertensive safety and effectiveness research.ConclusionsWomen’s non-adherence to antihypertensives is higher than anticipated. Suboptimal information provision around treatment, choice of antihypertensives and target setting practices by healthcare professionals may be contributory. Understanding the reasons for non-adherence will inform education and decision-making strategies needed to address both clinician and women’s behaviour. Further research into the effectiveness and long-term safety of common antihypertensives is also required.
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