100%(1)100% au considerat acest document util (1 vot)
2K vizualizări10 pagini
The american College of obstetricians and gynecologists convened a task force on hypertension in pregnancy. The task force reviewed available data and published evidence-based recommendations for clinical practice. Hypertensive disorders of pregnancy remain a major health issue for women and their infants in the united states.
The american College of obstetricians and gynecologists convened a task force on hypertension in pregnancy. The task force reviewed available data and published evidence-based recommendations for clinical practice. Hypertensive disorders of pregnancy remain a major health issue for women and their infants in the united states.
Drepturi de autor:
Attribution Non-Commercial (BY-NC)
Formate disponibile
Descărcați ca PDF, TXT sau citiți online pe Scribd
The american College of obstetricians and gynecologists convened a task force on hypertension in pregnancy. The task force reviewed available data and published evidence-based recommendations for clinical practice. Hypertensive disorders of pregnancy remain a major health issue for women and their infants in the united states.
Drepturi de autor:
Attribution Non-Commercial (BY-NC)
Formate disponibile
Descărcați ca PDF, TXT sau citiți online pe Scribd
Hypertension in Pregnancy Report of the American College of Obstetricians and Gynecologists Task Force on Hypertension in Pregnancy Executive Summary T he American College of Obstetricians and Gyne- cologists (the College) convened a task force of experts in the management of hypertension in pregnancy to review available data and publish evidence-based recommendations for clinical practice. The Task Force on Hypertension in Pregnancy comprised 17 cliniciunscientists liom tle elds ol obstetiics, muteinul letul medicine, lypeitension, inteinul medicine, nepliology, unestlesiology, plysiology, und putient udvocucy. Tlis exec- utive summary includes a synopsis of the content and task force recommendations of each chapter in the report and is intended to complement, not substitute, tle iepoit. Hypertensive disorders of pregnancy remain a major health issue for women and their infants in the United Stutes. Pieeclumpsiu, eitlei ulone oi supeiimposed on pie- existing (clionic) lypeitension, piesents tle mujoi iisk. Altlougl uppiopiiute pienutul cuie, witl obseivution ol women for signs of preeclampsia and then delivery to termi- nute tle disoidei, lus ieduced tle numbei und extent ol pooi outcomes, seiious muteinulletul moibidity und moi- tality still occur. Some of these adverse outcomes are avoid- uble, wleieus otleis cun be umelioiuted. Also, ultlougl some of the problems that face neonates are related directly to pieeclumpsiu, u luige piopoition uie seconduiy to piemu- turity that results from the appropriate induced delivery of the fetuses of women who are ill. Optimal management iequiies close obseivution loi signs und piemonitoiy nd- ings und, ultei estublisling tle diugnosis, deliveiy ut tle optimal time for both maternal and fetal well-being. More recent clinical evidence to guide this timing is now avail- able. Chronic hypertension is associated with fetal morbid- ity in the form of growth restriction and maternal morbidity manifested as severely increased blood pressure (BP). How- evei, muteinul und letul moibidity incieuse diumuticully with the superimposition of preeclampsia. One of the major challenges in the care of women with chronic hypertension is deciphering whether chronic hypertension has worsened oi wletlei pieeclumpsiu lus developed. In tlis iepoit, tle task force provides suggestions for the recognition and man- agement of this challenging condition. In tle pust 10 yeuis, tleie luve been substuntiul udvunces in the understanding of preeclampsia as well as increased eoits to obtuin evidence to guide tleiupy. Nonetleless, there remain areas on which evidence is scant. The evidence is now clear that preeclampsia is associated with later-life cuidiovuscului (CV) diseuse; lowevei, luitlei ieseuicl is needed to determine how best to use this information to lelp putients. Tle tusk loice ulso lus identied issues in tle management of preeclampsia that warrant special atten- tion. Fiist, is tle luiluie by leultl cuie piovideis to uppieci- ate the multisystemic nature of preeclampsia. This is in part due to uttempts ut iigid diugnosis, wlicl is uddiessed in tle iepoit. Second, pieeclumpsiu is u dynumic piocess, und u diagnosis such as mild preeclampsia (which is discour- aged) applies only at the moment the diagnosis is estab- lisled becuuse pieeclumpsiu by nutuie is piogiessive, ultlougl ut dieient iutes. Appiopiiute munugement mun- dates frequent reevaluation for severe features that indi- cate the actions outlined in the recommendations (which are listed after the chapter summaries). It has been known Hypertension in Pregnancy wus developed by tle Tusk Foice on Hypeitension in Piegnuncy: Jumes M. Robeits, MD, Cluii; Plyllis A. August, MD, MPH; Geoige Bukiis, MD; Joln R. Buiton, MD; Iiu M. Beinstein, MD; Muuiice Diuzin, MD; Robeit R. Guisei, MD; Joey P. Giungei, PlD; Aiun Jeyubulun, MD, MS; Donnu D. Jolnson, MD; S. Anuntl Kuiumuncli, MD; Muislull Lindleimei, MD; Miclelle Y. Owens, MD, MS; Geoige R. Suude, MD; Bulu M. Sibui, MD; Cutleiine Y. Spong, MD; Eleni Tsigus; und tle Ameiicun College ol Obstetiiciuns und Gynecolo- gists' stu: Geiuld F. Josepl, MD; Nuncy O'Reilly, MHS; Alyssu Politzei; Suiul Son, MPH; und Kuiinu Nguizu. VOL. 122, NO. 5, NOVEMBER 2013 Executive Summary: Hypertension in Pregnancy 1123 for many years that preeclampsia can worsen or present for tle ist time ultei deliveiy, wlicl cun be u mujoi scenuiio loi udveise muteinul events. In tlis iepoit, tle tusk loice provides guidelines to attempt to reduce maternal morbid- ity and mortality in the postpartum period. The Approach The task force used the evidence assessment and recom- mendation strategy developed by the Grading of Recom- mendutions Assessment, Development und Evuluution (GRADE) Woiking Gioup (uvuiluble ut www.giudewoiking gioup.oig/index.ltm). Becuuse ol its utility, tlis stiutegy lus been udupted woildwide by u luige numbei ol oigunizu- tions. Witl tle GRADE Woiking Gioup uppioucl, tle lunc- tion of expert task forces and working groups is to evaluate tle uvuiluble evidence ieguiding u clinicul decision tlut, becuuse ol limited time und iesouices, would be dimcult loi the average health care provider to accomplish. The expert group then makes recommendations based on the evidence that are consistent with typical patient values and prefer- ences. The task force evaluated the evidence for each rec- ommendution, tle implicutions, und tle condence in estimutes ol eect. Witl tlis combinution, tle uvuiluble information was evaluated and recommendations were mude. In tlis iepoit, tle condence in estimutes ol eect (quulity) ol tle uvuiluble evidence is judged us veiy low, low, modeiute, oi ligl. Recommendations are practices agreed to by the task force as the most appropriate course of action; they are giuded us stiong oi quulied. A stiong iecommendution is one that is so well supported that it would be the approach appropriate for virtually all patients. It could be the basis for leultl cuie policy. A quulied iecommendution is ulso one tlut would be judged us uppiopiiute loi most putients, but it might not be the optimal recommendation for some putients (wlose vulues und pieleiences diei, oi wlo luve dieient uttitudes towuid unceituinty in estimutes ol eect). Wlen tle tusk loice lus mude u quulied iecommendution, the health care provider and patient are encouraged to work together to arrive at a decision based on the values and judgment and underlying health condition of a particular patient in a particular situation. Classication of Hypertensive Disorders of Pregnancy Tle tusk loice close to continue using tle clussicution sclemu ist intioduced in 1972 by tle College und modi- ed in tle 1990 und 2000 iepoits ol tle Woiking Gioup ol tle Nutionul Higl Blood Piessuie Educution Piogium. Similui clussicutions cun be lound in tle Ameiicun Soci- ety ol Hypeitension guidelines, us well us College Piuctice Bulletins. Altlougl tle tusk loice lus modied some ol tle components ol tle clussicution, tlis busic, piecise, und piucticul clussicution wus used, wlicl consideis lypeiten- sion during pregnancy in only four categories: 1) pre- eclumpsiueclumpsiu, 2) clionic lypeitension (ol uny cuuse), 3) clionic lypeitension witl supeiimposed pieec- lumpsiu, und 4) gestutionul lypeitension. Impoituntly, tle lollowing components weie modied. In iecognition ol tle syndiomic nutuie ol pieeclumpsiu, tle tusk loice lus elimi- nated the dependence of the diagnosis on proteinuria. In tle ubsence ol pioteinuiiu, pieeclumpsiu is diugnosed us hypertension in association with thrombocytopenia (plate- let count less tlun 100,000/miciolitei), impuiied livei function (elevated blood levels of liver transaminases to twice tle noimul concentiution), tle new development ol ienul insumciency (elevuted seium cieutinine gieutei tlun 1.1 mg/dL oi u doubling ol seium cieutinine in tle ubsence ol otlei ienul diseuse), pulmonuiy edemu, oi new-onset ceiebiul oi visuul distuibunces (see Box E-1). Gestational hypertension is BP elevution ultei 20 weeks ol gestution in the absence of proteinuria or the aforementioned systemic ndings; chronic hypertension is hypertension that predates pregnancy; and superimposed preeclampsia is chronic hyper- tension in association with preeclampsia. Establishing the Diagnosis of Preeclampsia or Eclampsia The BP criteria are maintained from prior recommendations. Proteinuria is dened us tle excietion ol 300 mg oi moie ol piotein in u 24-loui uiine collection. Alteinutively, u timed excietion tlut is extiupoluted to tlis 24-loui uiine vulue oi u piotein/cieutinine iutio ol ut leust 0.3 (eucl meusuied us mg/dL) is used. Becuuse ol tle vuiiubility ol quulitutive deteiminutions (dipstick test), tlis metlod is discouiuged for diagnostic use unless other approaches are not readily uvuiluble. Il tlis uppioucl must be used, u deteiminution ol 1+ is consideied us tle cuto loi tle diugnosis ol pio- teinuria. In view of recent studies that indicate a minimal relationship between the quantity of urinary protein and piegnuncy outcome in pieeclumpsiu, mussive pioteinuiiu (greater than 5 g) has been eliminated from the consider- ution ol pieeclumpsiu us seveie. Also, becuuse letul giowtl restriction is managed similarly in pregnant women with und witlout pieeclumpsiu, it lus been iemoved us u nding indicutive ol seveie pieeclumpsiu (Tuble E-1). Prediction of Preeclampsia A gieut deul ol eoit lus been diiected ut tle identicution ol demogiuplic luctois, bioclemicul unulytes, oi bioplysi- cul ndings, ulone oi in combinution, to piedict euily in pregnancy the later development of preeclampsia. Although 1124 Executive Summary: Hypertension in Pregnancy OBSTETRICS & GYNECOLOGY BOX E-1. Severe Features of Preeclampsia (Any of these ndings) Sysrolic 6lood pressure ol 10 mm Hg or |ig|er, or diosrolic 6lood pressure ol 110 mm Hg or |ig|er on rwo occosions or leosr 4 |ours oporr w|ile r|e porienr is on 6ed resr (unless onri|yperrensive r|eropy is iniriored 6elore r|is rime) T|rom6ocyropenio (ploreler counr less r|on 100,000/microlirer) mpoired liver luncrion os indicored 6y o6normolly elevored 6lood concenrrorions ol liver enzymes (ro rwice normol concenrrorion), severe persisrenr rig|r upper quodronr or epigosrric poin unrespon- sive ro medicorion ond nor occounred lor 6y olrernorive diognoses, or 6or| Frogressive renol insullciency (serum creorinine concenrrorion greorer r|on 1.1 mg/dL or o dou6ling ol r|e serum creorinine concenrrorion in r|e o6sence ol or|er renol diseose) Fulmonory edemo New-onser cere6rol or visuol disrur6onces tleie uie some encouiuging ndings, tlese tests uie not yet ready for clinical use. TASK FORCE RECOMMENDATION Scieening to piedict pieeclumpsiu beyond obtuining un appropriate medical history to evaluate for risk factors is not recommended. Quality of evidence: Moderate Strength of recommendation: Strong Prevention of Preeclampsia It is cleui tlut tle untioxidunts vitumin C und vitumin E uie not eective inteiventions to pievent pieeclumpsiu oi adverse outcomes from preeclampsia in unselected women at high risk or low risk of preeclampsia. Calcium may be useful to reduce the severity of preeclampsia in populations witl low culcium intuke, but tlis nding is not ielevunt to u populution witl udequute culcium intuke, sucl us in tle United States. The administration of low-dose aspirin (60 80 mg) to prevent preeclampsia has been examined in metu-unulyses ol moie tlun 30,000 women, und it uppeuis tlut tleie is u sliglt eect to ieduce pieeclumpsiu und udveise peiinutul outcomes. Tlese ndings uie not clinicully relevant to low-risk women but may be relevant to popula- tions at very high risk in whom the number to treat to achieve the desired outcome will be substantially less. There is no evidence that bed rest or salt restriction reduces preec- lampsia risk. TASK FORCE RECOMMENDATIONS Foi women witl u medicul listoiy ol euily-onset pieec- lumpsiu und pieteim deliveiy ut less tlun 34 0/7 weeks ol gestation or preeclampsia in more than one prior preg- nuncy, initiuting tle udministiution ol duily low-dose (6080 mg) uspiiin beginning in tle lute ist tiimestei is suggested.* Quality of evidence: Moderate Strength of recommendation: Quulied Metu-unulysis ol moie tlun 30,000 women in iundomized tiiuls of aspirin to prevent preeclampsia indicates a small reduction in the incidence and morbidity of preeclampsia and reveals no evidence ol ucute iisk, ultlougl long-teim letul eects cunnot be excluded. The number of women to treat to have a thera- peutic eect is deteimined by pievulence. In view ol muteinul sulety, u discussion ol tle use ol uspiiin in liglt ol individuul iisk is justied. Tle udministiution ol vitumin C oi vitumin E to pievent preeclampsia is not recommended. Quality of evidence: High Strength of recommendation: Strong It is suggested tlut dietuiy sult not be iestiicted dui- ing pregnancy for the prevention of preeclampsia. Quality of evidence: Low Strength of recommendation: Quulied It is suggested tlut bed iest oi tle iestiiction ol otlei physical activity not be used for the primary prevention of preeclampsia and its complications. Quality of evidence: Low Strength of recommendation: Quulied Management of Preeclampsia and HELLP Syndrome Clinical trials have provided an evidence base to guide man- ugement ol seveiul uspects ol pieeclumpsiu. Nonetleless, VOL. 122, NO. 5, NOVEMBER 2013 Executive Summary: Hypertension in Pregnancy 1125 several important questions remain unanswered. Reviews of maternal mortality data reveal that deaths could be avoided if health care providers remain alert to the likeli- hood that preeclampsia will progress. The same reviews indicate that intervention in acutely ill women with multiple organ dysfunction is sometimes delayed because of the ubsence ol pioteinuiiu. Fuitleimoie, uccumuluting inloi- mation indicates that the amount of proteinuria does not predict maternal or fetal outcome. It is for these reasons that the task force has recommended that alternative sys- temic ndings witl new-onset lypeitension cun lulll tle diagnosis of preeclampsia even in the absence of pro- teinuria. Perhaps the biggest changes in preeclampsia manage- ment relate to the timing of delivery in women with preec- lumpsiu witlout seveie leutuies, wlicl bused on evidence is suggested ut 37 0/7 weeks ol gestution, und un incieusing awareness of the importance of preeclampsia in the postpar- tum period. Health care providers are reminded of the con- tiibution ol nonsteioidul untiinummutoiy ugents to increased BP. It is suggested that these commonly used postpartum pain relief agents be replaced by other analge- sics in women with hypertension that persists for more than 1 day postpartum. TASK FORCE RECOMMENDATIONS Tle close monitoiing ol women witl gestutionul lypei- tension or preeclampsia witlout seveie leutuies, witl serial assessment of maternal symptoms and fetal move- ment (daily by tle womun), seiiul meusuiements ol BP (twice weekly), und ussessment ol plutelet counts und livei enzymes (weekly) is suggested. Quality of evidence: Moderate Strength of recommendation: Quulied Foi women witl gestutionul lypeitension, monitoiing BP at least once weekly with proteinuria assessment in tle omce und witl un udditionul weekly meusuiement ol BP ut lome oi in tle omce is suggested. Quality of evidence: Moderate Strength of recommendation: Quulied Foi women witl mild gestutionul lypeitension oi pieec- lampsia with a persistent BP of less than 160 mm Hg systolic oi 110 mm Hg diustolic, it is suggested tlut unti- hypertensive medications not be administered. Quality of evidence: Moderate Strength of recommendation: Quulied TABLE E-1. Diagnostic Criteria for Preeclampsia Blood pressure Creorer r|on or equol ro 140 mm Hg sysrolic or greorer r|on or equol ro 0 mm Hg diosrolic on rwo occosions or leosr 4 |ours oporr olrer 20 wee|s ol gesrorion in o womon wir| o previously normol 6lood pressure Creorer r|on or equol ro 10 mm Hg sysrolic or greorer r|on or equol ro 110 mm Hg diosrolic, |yperrension con 6e conlrmed wir|in o s|orr inrervol (minures) ro locilirore rimely onri|yperrensive r|eropy ond Proteinuria Creorer r|on or equol ro 300 mg per 24-|our urine collecrion (or r|is omounr exrropolored lrom o rimed collecrion) or Frorein/creorinine rorio greorer r|on or equol ro 0.3* Dipsric| reoding ol 1- (used only il or|er quonrirorive mer|ods nor ovoilo6le) r in r|e o6sence ol proreinurio, new-onser |yperrension wir| r|e new onser ol ony ol r|e lollowing: Thrombocytopenia Floreler counr less r|on 100,000/microlirer Renal insufciency Serum creorinine concenrrorions greorer r|on 1.1 mg/dL or o dou6ling ol r|e serum creorinine concenrrorion in r|e o6sence ol or|er renol diseose Impaired liver function Elevored 6lood concenrrorions ol liver rronsominoses ro rwice normol concenrrorion Pulmonary edema Cerebral or visual symptoms *Eoc| meosured os mg/dL. 1126 Executive Summary: Hypertension in Pregnancy OBSTETRICS & GYNECOLOGY Foi women witl gestutionul lypeitension oi pieeclump- siu witlout seveie leutuies, it is suggested tlut stiict bed rest not be prescribed. * Quality of evidence: Low Strength of recommendation: Quulied *The task force acknowledged that there may be situations in wlicl dieient levels ol iest, eitlei ut lome oi in tle lospitul, may be indicated for individual women. The previous recom- mendations do not cover advice regarding overall physical ac- tivity und munuul oi omce woik.
Women muy need to be lospitulized loi ieusons otlei tlun bed
iest, sucl us loi muteinul und letul suiveillunce. Tle tusk loice ugieed tlut lospitulizution loi muteinul und letul suiveillunce is resource intensive and should be considered as a priority for research and future recommendations. Foi women witl pieeclumpsiu witlout seveie leutuies, use of ultrasonography to assess fetal growth and antena- tal testing to assess fetal status is suggested. Quality of evidence: Moderate Strength of recommendation: Quulied Il evidence ol letul giowtl iestiiction is lound in women witl pieeclumpsiu, letoplucentul ussessment tlut in- cludes umbilicul uiteiy Dopplei velocimetiy us un udjunct antenatal test is recommended. Quality of evidence: Moderate Strength of recommendation: Strong Foi women witl mild gestutionul lypeitension oi pieec- lampsia without severe features and no indication for deliveiy ut less tlun 37 0/7 weeks ol gestution, expec- tant management with maternal and fetal monitoring is suggested. Quality of evidence: Low Strength of recommendation: Quulied Foi women witl mild gestutionul lypeitension oi pieec- lumpsiu witlout seveie leutuies ut oi beyond 37 0/7 weeks ol gestution, deliveiy iutlei tlun continued obsei- vation is suggested. Quality of evidence: Moderate Strength of recommendation: Quulied Foi women witl pieeclumpsiu witl systolic BP ol less than 160 mm Hg and a diastolic BP less than 110 mm Hg und no muteinul symptoms, it is suggested tlut mugne- sium sulfate not be administered universally for the pre- vention of eclampsia. Quality of evidence: Low Strength of recommendation: Quulied Foi women witl seveie pieeclumpsiu ut oi beyond 34 0/7 weeks ol gestution, und in tlose witl unstuble maternal or fetal conditions irrespective of gestational uge, deliveiy soon ultei muteinul stubilizution is iecom- mended. Quality of evidence: Moderate Strength of recommendation: Strong Foi women witl seveie pieeclumpsiu ut less tlun 34 0/7 weeks of gestation with stable maternal and fetal conditions, it is iecommended tlut continued piegnuncy be undertaken only at facilities with adequate mater- nal and neonatal intensive care resources. Quality of evidence: Moderate Strength of recommendation: Strong Foi women witl seveie pieeclumpsiu ieceiving expectunt munugement ut 34 0/7 weeks oi less ol gestution, tle administration of corticosteroids for fetal lung maturity benet is iecommended. Quality of evidence: High Strength of recommendation: Strong Foi women witl pieeclumpsiu witl seveie lypeitension during pregnancy (sustained systolic BP of at least 160 mm Hg oi diustolic BP ol ut leust 110 mm Hg), tle use ol antihypertensive therapy is recommended. Quality of evidence: Moderate Strength of recommendation: Strong Foi women witl pieeclumpsiu, it is suggested tlut u delivery decision should not be based on the amount of proteinuria or change in the amount of proteinuria. Quality of evidence: Moderate Strength of recommendation: Strong Foi women witl seveie pieeclumpsiu und beloie letul viubility, deliveiy ultei muteinul stubilizution is iecom- mended. Expectunt munugement is not iecommended. Quality of evidence: Moderate Strength of recommendation: Strong It is suggested tlut coiticosteioids be udministeied und deliveiy deleiied loi 48 louis il muteinul und letul conditions remain stable for women with severe pre- eclampsia and a viable fetus at 33 6/7 weeks oi less ol gestation with any of the following: preterm premature rupture of membranes labor low plutelet count (less tlun 100,000/miciolitei) peisistently ubnoimul leputic enzyme concentiutions (twice or more the upper normal values) letul giowtl iestiiction (less tlun tle ltl peicentile) seveie oligolydiumnios (umniotic uid index less than 5 cm) VOL. 122, NO. 5, NOVEMBER 2013 Executive Summary: Hypertension in Pregnancy 1127 ieveised end-diustolic ow on umbilicul uiteiy Dopplei studies new-onset renal dysfunction or increasing renal dys- function Quality of evidence: Moderate Strength of recommendation: Quulied It is iecommended tlut coiticosteioids be given il tle le- tus is viuble und ut 33 6/7 weeks oi less ol gestution, but that delivery not be delayed after initial maternal stabili- zution ieguidless ol gestutionul uge loi women witl se- vere preeclampsia that is complicated further with any of the following: uncontrollable severe hypertension eclampsia pulmonary edema abruptio placentae disseminated intravascular coagulation evidence of nonreassuring fetal status intrapartum fetal demise Quality of evidence: Moderate Strength of recommendation: Strong Foi women witl pieeclumpsiu, it is suggested tlut tle mode of delivery need not be cesarean delivery. The mode of delivery should be determined by fetal gesta- tionul uge, letul piesentution, ceivicul stutus, und mutei- nal and fetal conditions. Quality of evidence: Moderate Strength of recommendation: Quulied Foi women witl eclumpsiu, tle udministiution ol puien- teral magnesium sulfate is recommended. Quality of evidence: High Strength of recommendation: Strong Foi women witl seveie pieeclumpsiu, tle udministiution of intrapartumpostpartum magnesium sulfate to pre- vent eclampsia is recommended. Quality of evidence: High Strength of recommendation: Strong Foi women witl pieeclumpsiu undeigoing cesuieun deliveiy, tle continued intiuopeiutive udministiution ol parenteral magnesium sulfate to prevent eclampsia is recommended. Quality of evidence: Moderate Strength of recommendation: Strong Foi women witl HELLP syndrome and before the gesta- tionul uge ol letul viubility, it is iecommended tlut deliv- ery be undertaken shortly after initial maternal stabili- zution. Quality of evidence: High Strength of recommendation: Strong Foi women witl HELLP syndiome ut 34 0/7 weeks oi moie ol gestution, it is iecommended tlut deliveiy be undeituken soon ultei initiul muteinul stubilizution. Quality of evidence: Moderate Strength of recommendation: Strong Foi women witl HELLP syndiome liom tle gestutionul uge ol letul viubility to 33 6/7 weeks ol gestution, it is suggested tlut deliveiy be deluyed loi 24 48 louis il mu- ternal and fetal condition remains stable to complete a couise ol coiticosteioids loi letul benet. Quality of evidence: Low Strength of recommendation: Quulied Coiticosteioids luve been used in iundomized contiolled tiiuls to attempt to improve maternal and fetal condition. In these studies, tleie wus no evidence ol benet to impiove oveiull mu- ternal and fetal outcome (although this has been suggested in obseivutionul studies). Tleie is evidence in tle iundomized tii- als of improvement of platelet counts with corticosteroid treat- ment. In clinical settings in which an improvement in platelet count is consideied uselul, coiticosteioids muy be justied. Foi women witl pieeclumpsiu wlo iequiie unulgesiu loi labor or anesthesia for cesarean delivery and with a clin- icul situution tlut peimits sumcient time loi estublisl- ment of anestlesiu, tle udministiution ol neuiuxiul unes- thesia (either spinal or epidural anesthesia) is recom- mended. Quality of evidence: Moderate Strength of recommendation: Strong Foi women witl seveie pieeclumpsiu, it is suggested tlut invasive hemodynamic monitoring not be used routinely. Quality of evidence: Low Strength of recommendation: Quulied Foi women in wlom gestutionul lypeitension, pieec- lumpsiu, oi supeiimposed pieeclumpsiu is diugnosed, it is suggested that BP be monitored in the hospital or that equivalent outpatient surveillance be performed for at leust 72 louis postpuitum und uguin 710 duys ultei delivery or earlier in women with symptoms. Quality of evidence: Moderate Strength of recommendation: Quulied Foi ull women in tle postpuitum peiiod (not just women witl pieeclumpsiu), it is suggested tlut discluige in- structions include information about the signs and symp- toms of preeclampsia as well as the importance of prompt reporting of this information to their health care providers. 1128 Executive Summary: Hypertension in Pregnancy OBSTETRICS & GYNECOLOGY Quality of evidence: Low Strength of recommendation: Quulied Foi women in tle postpuitum peiiod wlo piesent witl new-onset hypertension associated with headaches or bluiied vision oi pieeclumpsiu witl seveie lypeitension, the parenteral administration of magnesium sulfate is suggested. Quality of evidence: Low Strength of recommendation: Quulied Foi women witl peisistent postpuitum lypeitension, BP ol 1S0 mm Hg systolic oi 100 mm Hg diustolic oi liglei, on ut leust two occusions tlut uie ut leust 46 louis upuit, antihypertensive therapy is suggested. Persistent BP of 160 mm Hg systolic or 110 mm Hg diastolic or higher should be treated within 1 hour. Quality of evidence: Low Strength of recommendation: Quulied Management of Women With Prior Preeclampsia Women wlo luve lud pieeclumpsiu in u piioi piegnuncy should receive counseling and assessments before their next pregnancy. This can be initiated at the postpartum visit but is ideally accomplished at a preconception visit before the next plunned piegnuncy. Duiing tle pieconception visit, tle previous pregnancy history should be reviewed and the prognosis for the upcoming pregnancy should be discussed. Potentiully modiuble lilestyle uctivities, sucl us weiglt loss und incieused plysicul uctivity, slould be encouiuged. Tle cuiient stutus ol medicul pioblems slould be ussessed, including laboratory evaluation if appropriate. Medical problems such as hypertension and diabetes should be biouglt into tle best contiol possible. Tle eect ol medicul problems on the pregnancy should be discussed. Medica- tions slould be ieviewed und tleii udministiution modied for upcoming pregnancy. Folic acid supplementation should be recommended. If a woman has given birth to a preterm infant during a preeclamptic pregnancy or has had preec- lumpsiu in moie tlun one piegnuncy, tle use ol low-dose aspirin in the upcoming pregnancy should be suggested. Women witl u medicul listoiy ol pieeclumpsiu slould be instiucted to ietuin loi cuie euily in piegnuncy. Duiing tle next piegnuncy, euily ultiusonogiuply slould be peiloimed to deteimine gestutionul uge, und ussessment und visits slould be tuiloied to tle piioi piegnuncy outcome, witl lie- quent visits beginning earlier in women with prior preterm preeclampsia. The woman should be educated about the signs and symptoms of preeclampsia and instructed when and how to contact her health care provider. TASK FORCE RECOMMENDATION Foi women witl pieeclumpsiu in u piioi piegnuncy, pie- conception counseling and assessment is suggested. Quality of evidence: Low Strength of recommendation: Quulied Chronic Hypertension and Superimposed Preeclampsia Clionic lypeitension (lypeitension pieduting piegnuncy), presents special challenges to health care providers. Health cuie piovideis must ist conim tlut tle BP elevution is not pieeclumpsiu. Once tlis is estublisled, il tle BP elevu- tion lus not been pieviously evuluuted, u woikup slould be peiloimed to document tlut BP is tiuly elevuted (ie, not white coat hypertension) and to check for secondary hyper- tension and end-organ damage. The choice of which women to treat and how to treat them requires special con- sideiutions duiing piegnuncy, especiully in liglt ol emeig- ing data that suggest lowering BP excessively might have udveise letul eects. Perhaps the greatest challenge is the recognition of pieeclumpsiu supeiimposed on clionic lypeitension, u con- dition that is commonly associated with adverse maternal and fetal outcomes. Recommendations are provided to guide health care providers in distinguishing women who may have superimposed preeclampsia without severe fea- tures (only hypertension and proteinuria) and require only observation from women who may have superimposed preeclampsia with severe features (evidence of systemic involvement beyond hypertension and proteinuria) and require intervention. TASK FORCE RECOMMENDATIONS Foi women witl leatures suggestive of secondary hyper- tension, ieleiiul to u plysiciun witl expeitise in tieuting hypertension to direct the workup is suggested. Quality of evidence: Low Strength of recommendation: Quulied Foi piegnunt women witl clionic lypeitension und pooily contiolled BP, tle use ol lome BP monitoiing is suggested. Quality of evidence: Moderate Strength of recommendation: Quulied Foi women witl suspected wlite cout lypeitension, tle use ol umbulutoiy BP monitoiing to conim tle diugno- sis before the initiation of antihypertensive therapy is suggested. Quality of evidence: Low Strength of recommendation: Quulied VOL. 122, NO. 5, NOVEMBER 2013 Executive Summary: Hypertension in Pregnancy 1129 It is suggested tlut weiglt loss und extiemely low- sodium diets (less tlun 100 mEq/d) not be used loi mun- aging chronic hypertension in pregnancy. Quality of evidence: Low Strength of recommendation: Quulied Foi women witl clionic lypeitension wlo uie uccus- tomed to exeicising, und in wlom BP is well contiolled, it is recommended that moderate exercise be continued during pregnancy. Quality of evidence: Low Strength of recommendation: Quulied Foi piegnunt women witl peisistent clionic lypeiten- sion with systolic BP of 160 mm Hg or higher or diastolic BP ol 10S mm Hg oi liglei, untilypeitensive tleiupy is recommended. Quality of evidence: Moderate Strength of recommendation: Strong Foi piegnunt women with chronic hypertension and BP less than 160 mm Hg systolic or 105 mm Hg diastolic and no evidence ol end-oigun dumuge, it is suggested tlut they not be treated with pharmacologic antihyperten- sive therapy. Quality of evidence: Low Strength of recommendation: Qualied For pregnant women with chronic hypertension treated witl untilypeitensive medicution, it is suggested tlut BP levels be muintuined between 120 mm Hg systolic and 80 mm Hg diastolic and 160 mm Hg systolic and 105 mm Hg diastolic. Quality of evidence: Low Strength of recommendation: Quulied Foi tle initiul tieutment ol piegnunt women witl clionic lypeitension wlo iequiie pluimucologic tleiupy, lube- tulol, niledipine, oi metlyldopu uie iecommended ubove all other antihypertensive drugs. Quality of evidence: Moderate Strength of recommendation: Strong Foi women witl uncomplicuted clionic lypeitension in piegnuncy, tle use ol ungiotensin-conveiting enzyme in- libitois, ungiotensin ieceptoi blockeis, ienin inlibitois, and mineralocorticoid receptor antagonists is not rec- ommended. Quality of evidence: Moderate Strength of recommendation: Strong Foi women ol iepioductive uge witl clionic lypeiten- sion, tle use ol ungiotensin-conveiting enzyme inlibi- tois, ungiotensin ieceptoi blockeis, ienin inlibitois, und mineralocorticoid receptor antagonists is not recom- mended unless tleie is u compelling ieuson, sucl us tle presence of proteinuric renal disease. Quality of evidence: Low Strength of recommendation: Quulied Foi women witl clionic lypeitension wlo uie ut u greatly increased risk of adverse pregnancy outcomes (history of early-onset preeclampsia and preterm de- liveiy ut less tlun 34 0/7 weeks ol gestation or preec- lumpsiu in moie tlun one piioi piegnuncy), initiuting tle administration of daily low-dose aspirin (6080 mg) be- ginning in tle lute ist tiimestei is suggested. Quality of evidence: Moderate Strength of recommendation: Quulied Metu-unulysis ol moie tlun 30,000 women in iundomized tiiuls of aspirin to prevent preeclampsia indicates a small reduction in the incidence and morbidity of preeclampsia and reveals no evidence of acute iisk, ultlougl long-teim letul eects cunnot be excluded. The number of women to treat to have a thera- peutic eect is deteimined by pievulence. In view ol muteinul sulety, u discussion ol tle use ol uspiiin in liglt ol individuul iisk is justied. Foi women witl clionic lypeitension, tle use ol ultiu- sonography to screen for fetal growth restriction is sug- gested. Quality of evidence: Low Strength of recommendation: Quulied Il evidence ol letul giowtl iestiiction is lound in women witl clionic lypeitension, letoplucentul ussess- ment to include umbilicul uiteiy Dopplei velocimetiy us an adjunct antenatal test is recommended. Quality of evidence: Moderate Strength of recommendation: Strong Foi women witl clionic lypeitension complicuted by issues such as tle need loi medicution, otlei undeilying medicul conditions tlut uect letul outcome, oi uny evidence ol letul giowtl iestiiction, und supeiimposed pieeclumpsiu, untenutul letul testing is suggested. Quality of evidence: Low Strength of recommendation: Quulied Foi women witl clionic lypeitension und no udditionul muteinul oi letul complicutions, deliveiy beloie 38 0/7 weeks of gestation is not recommended. Quality of evidence: Moderate Strength of recommendation: Strong Foi women witl supeiimposed pieeclumpsiu wlo ieceive expectunt munugement ut less tlun 34 0/7 weeks ol 1130 Executive Summary: Hypertension in Pregnancy OBSTETRICS & GYNECOLOGY gestution, tle udministiution ol coiticosteioids loi letul lung mutuiity benet is iecommended. Quality of evidence: High Strength of recommendation: Strong Foi women witl clionic lypeitension und supeiimposed pieeclumpsiu witl seveie leutuies, tle udministiution ol intrapartumpostpartum parenteral magnesium sulfate to prevent eclampsia is recommended. Quality of evidence: Moderate Strength of recommendation: Strong Foi women witl supeiimposed pieeclumpsiu witlout se- veie leutuies und stuble muteinul und letul conditions, expectunt munugement until 37 0/7 weeks ol gestution is suggested. Quality of evidence: Low Strength of recommendation: Quulied Deliveiy soon ultei muteinul stubilizution is iecommended iiiespective ol gestutionul uge oi lull coiticosteioid benet for women with superimposed preeclampsia that is com- plicated further by any of the following: uncontrollable severe hypertension eclampsia pulmonary edema abruptio placentae disseminated intravascular coagulation nonreassuring fetal status Quality of evidence: Moderate Strength of the recommendation: Strong Foi women witl supeiimposed pieeclumpsiu witl seveie leutuies ut less tlun 34 0/7 weeks ol gestution witl stu- ble muteinul und letul conditions, it is iecommended that continued pregnancy should be undertaken only at facilities with adequate maternal and neonatal intensive care resources. Quality of evidence: Moderate Strength of evidence: Strong Foi women witl supeiimposed pieeclumpsiu witl seveie leutuies, expectunt munugement beyond 34 0/7 weeks of gestation is not recommended. Quality of evidence: Moderate Strength of the recommendation: Strong Later-Life Cardiovascular Disease in Women With Prior Preeclampsia Ovei tle pust 10 yeuis, inloimution lus uccumuluted indi- cating that a woman who has had a preeclamptic pregnancy is at an increased risk of later-life CV disease. This increase ranges from a doubling of risk in all cases to an eightfold to ninefold increase in women with preeclampsia who gave biitl beloie 34 0/7 weeks ol gestution. Tlis lus been iec- ognized by tle Ameiicun Heuit Associution, wlicl now iec- ommends that a pregnancy history be part of the evaluation of CV risk in women. It is the general belief that preeclamp- siu does not cuuse CV diseuse, but iutlei pieeclumpsiu und CV disease share common risk factors. Awareness that a woman has had a preeclamptic pregnancy might allow for tle identicution ol women not pieviously iecognized us at-risk for earlier assessment and potential intervention. Howevei, it is unknown il tlis will be u vuluuble udjunct to pievious inloimution. Il tlis is tle cuse, would tle cuiient recommendation of assessing risk factors for women by medicul listoiy, lilestyle evuluution, testing loi metubolic ubnoimulities, und possibly inummutoiy uctivution ut uge 40 yeuis piovide ull ol tle inloimution tlut would be gained by knowing a woman had a past preeclamptic preg- nuncy? Would it be valuable to perform this assessment at a younger age in women who had a past preeclamptic preg- nuncy? Il tle iisk wus identied euiliei, wlut inteivention (otlei tlun lilestyle modicution) would potentiully be uselul und would it muke u dieience? Aie tleie iisk luc- tors that could be unmasked by pregnancy other than con- ventional risk factors? Further research is needed to determine how to take advantage of this information relat- ing pieeclumpsiu to lutei-lile CV diseuse. At tlis time, tle tusk loice cuutiously iecommends lilestyle modicution (muintenunce ol u leultly weiglt, incieused plysicul uctiv- ity, und not smoking) und suggests euily evuluution loi tle most high-risk women. TASK FORCE RECOMMENDATION Foi women witl u medicul listoiy ol pieeclumpsiu wlo guve biitl pieteim (less tlun 37 0/7 weeks ol gestution) oi wlo luve u medicul listoiy ol iecuiient pieeclumpsiu, yeuily ussessment ol BP, lipids, lusting blood glucose, und body mass index is suggested.* Quality of evidence: Low Strength of recommendation: Quulied *Although there is clear evidence of an association between pieeclumpsiu und lutei-lile CV diseuse, tle vulue und uppio- priate timing of assessment is not yet established. Health care providers and patients should make this decision based on their judgment of the relative value of extra information versus ex- pense and inconvenience. Patient Education Patient and health care provider education is key to the successful recognition and management of preeclampsia. VOL. 122, NO. 5, NOVEMBER 2013 Executive Summary: Hypertension in Pregnancy 1131 Health care providers need to inform women during the prenatal and postpartum periods of the signs and symp- toms of preeclampsia and stress the importance of contact- ing health care providers if these are evident. The recognition of the importance of patient education must be complemented by the recognition and use of strategies that facilitate the successful transfer of this information to women with varying degrees of health literacy. Recom- mended strategies to facilitate this process include using pluin nonmedicul lunguuge, tuking time to speuk slowly, reinforcing key issues in print using pictorially based infor- mution, und iequesting leedbuck to indicute tlut tle putient undeistunds, und, wleie upplicuble, lei puitnei. TASK FORCE RECOMMENDATION It is suggested tlut leultl cuie piovideis convey inloi- mation about preeclampsia in the context of prenatal care and postpartum care using proven health communi- cation practices. Quality of evidence: Low Strength of recommendation: Quulied The State of the Science and Research Recommendations In tle pust 10 yeuis, stiiking incieuses in tle undeistunding of the pathophysiology of preeclampsia have occurred. Clin- ical research advances also have emerged that have pro- vided evidence to guide therapy. It is now understood that pieeclumpsiu is u multisystemic diseuse tlut uects ull oigun systems and is far more than high BP and renal dysfunction. The placenta is evident as the root cause of preeclampsia. It is with the delivery of the placenta that preeclampsia begins to resolve. The insult to the placenta is proposed as an immunologically initiated alteration in trophoblast func- tion, und tle ieduction in tioploblust invusion leuds to failed vascular remodeling of the maternal spiral arteries that perfuse the placenta. The resulting reduced perfusion and increased velocity of blood perfusing the intervillous space alter placental function. The altered placental func- tion leads to maternal disease through putative primary mediutois, including oxidutive und endoplusmic ieticulum stiess und inummution, und seconduiy mediutois tlut include modieis ol endotleliul lunction und ungiogenesis. This understanding of preeclampsia pathophysiology has not translated into predictors or preventers of preeclamp- sia or to improved clinical care. This has led to a reassess- ment ol tlis conceptuul liumewoik, witl uttention to tle possibility that preeclampsia is not one disease but that the syndrome may include subsets of pathophysiology. Clinical research advances have shown approaches to tleiupy tlut woik (eg, deliveiy loi women witl gestutionul hypertension and preeclampsia without severe features at 37 0/7 weeks ol gestution) oi do not woik (vitumin C und vitumin E to pievent pieeclumpsiu). Howevei, tleie uie lew clinicul iecommendutions tlut cun be clussied us stiong` because there are huge gaps in the evidence base that guides therapy. These knowledge gaps form the basis for research recommendations to guide future therapy. Conclusion The task force provides evidence-based recommendations for the management of patients with hypertension during and after pregnancy. Recommendations are graded as strong oi quulied bused on evidence ol eectiveness weigled uguinst evidence ol potentiul luim. In ull instunces, tle nul decision is made by the health care provider and patient after consideration of the strength of the recommendations in relation to the values and judgments of the individual patient. The information in Hypertension in Pregnancy should not be viewed as a body of rigid rules. The guidelines are general and intended to be udupted to muny dieient situutions, tuking into uccount tle needs und iesouices puiticului to tle loculity, tle institution, oi tle type of practice. Variations and innovations that improve the quality of patient care are to be encouraged rather than restricted. The puipose ol tlese guidelines will be well seived il tley piovide u im basis on which local norms may be built. Copyiiglt 2013 by tle Ameiicun College ol Obstetiiciuns und Gynecologists, 409 12tl Stieet, SW, PO Box 96920, Wuslington, DC 20090-6920. All iiglts ieseived. No puit ol tlis publicution muy be iepioduced, stoied in u ietiievul system, oi tiunsmitted, in uny loim oi by uny meuns, electionic, meclunicul, plotocopying, iecoiding, oi otleiwise, witlout piioi wiitten peimission liom tle publisher. Executive summuiy: lypeitension in piegnuncy. Ameiicun College ol Obstetiiciuns und Gynecologists. Obstet Gynecol 2013;122:112231.
Summary: Fast Like a Girl: A Woman’s Guide to Using the Healing Power of Fasting to Burn Fat, Boost Energy, and Balance Hormones: Key Takeaways, Summary and Analysis