LA CONSULTA SEMANAL

MARZO 2001

CONSULTA

1: Obstet Gynecol 2000 Nov;95(5 Pt 2):849-860
Management of mild chronic hypertension during pregnancy: a review.
Ferrer RL, Sibai BM, Mulrow CD, Chiquette E, Stevens KR, Cornell J
Department of Family Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
Objective: To conduct a systematic review of evidence relating to management of mild chronic hypertension during pregnancy, including associated risks, benefits, and harms of treatment with antihypertensive agents, nonpharmacologic measures, and aspirin and benefits of various monitoring strategies.Data Sources: Using four broad search strategies, we searched English and non-English-language citations in 16 electronic databases from their inception to February 1999 and consulted relevant textbooks, references, and experts.Study Selection: Reviewers screened 6228 abstracts and found 215 articles that met multiple prespecified patient selection, study population, and design criteria.Tabulation, Integration, and Results: Forty-six studies consistently showed that chronic hypertension triples the risk for perinatal mortality (odds ratio [OR] 3.4; 95% confidence interval [CI] 3.0, 3.7) and doubles the risk for placental abruption (OR 2.1; 95% CI 1.1, 3.9). Thirteen small, randomized controlled trials had inadequate power to rule in or rule out moderate-to-large (20%-50%) benefits of antihypertensive treatment. Possible adverse effects were fetal renal failure when angiotensin-converting enzyme inhibitors are used in the second or third trimester and growth restriction when atenolol is used early in pregnancy. Trials showed that aspirin neither reduces nor increases perinatal and maternal morbidity, but they did not rule out possible small-to moderate beneficial or adverse effects. No studies provide guidance on benefits or consequences of various nonpharmacologic therapies or monitoring strategies.Conclusion: Mild chronic hypertension is associated with increased maternal and fetal risks. Beneficial treatment and monitoring regimens are not clear, but some treatments, such as angiotensin-converting enzyme inhibitors, are best avoided.


2: WMJ 2000 Jun;99(3):65-70
Hypertension in women.
Rangarajan U, Kochar MS
Zablocki VA Medical Center, USA.
More women than men eventually develop hypertension in the United States due to their higher numbers and longer longevity. The white coat hypertension is also more common in women. Alcohol, obesity and oral contraceptives are important causes of rise in blood pressure among women. On the other hand, hormone replacement therapy may decrease cardiovascular mortality in the postmenopausal woman. Women with left ventricular hypertrophy are at a greater risk of death than men. Fibromuscular hyperplasia and primary aldosteronism are more common as causes of secondary hypertension in women. Nonpharmacologic therapy, such as weight reduction, exercise, salt and alcohol reduction, should always be tried prior to medical treatment of hypertension and are very useful adjunctive measures in controlling hypertension. ACE inhibitors and angiotensin receptor blockers are contraindicated in pregnancy and should be avoided in women with childbearing potential. Hypertension remains a major public health problem among black women. Although the antihypertensive drug therapy seems to benefit white women the least, proportionately more of them comply with their antihypertensive therapy. Hypertension is the most common chronic medical condition requiring visits to the physicians, as well as prescription medications, in the United States. The epidemiology, clinical course, response to treatment and ultimate outcome of essential hypertension may vary with gender. More women than men eventually develop hypertension in the US due to their higher numbers and longer longevity.
Publication Types:
Review
Review, tutorial


3: ACP J Club 2000 Mar-Apr;132(2):A19
Review: antihypertensive drugs improve maternal outcomes in mild chronic and pregnancy-induced hypertension.
Mulrow CD, Sibai B
Publication Types:
Letter


4: Eur J Obstet Gynecol Reprod Biol 2000 Jan;88(1):15-26
Risks and benefits of beta-receptor blockers for pregnancy hypertension: overview of the randomized trials.
Magee LA, Elran E, Bull SB, Logan A, Koren G
Division of Clinical Pharmacology/Toxicology, The Hospital for Sick Children, Toronto, Ont., Canada. laura.magee@utoronto.ca
OBJECTIVE: Examine the benefits/risks of beta-blockers for pregnancy hypertension. STUDY DESIGN: Meta-analysis of relevant trials identified by comprehensive literature review (1966-97). RESULTS: Included were 30 trials for pregnancy hypertension, and four others for perinatal outcomes only. For mild chronic hypertension treated throughout pregnancy (n=2 trials), oral beta-blockers (compared with no therapy) were associated with an inconsistent increase in small for gestational age (SGA) infants (OR 2.46 [1.02, 5.92]). For mild-moderate 'late-onset' pregnancy hypertension (i.e. either chronic treated only late in pregnancy, or pregnancy-induced) (n=8 trials), oral beta-blockers (compared with no therapy) were associated with a decrease in severe hypertension (OR 0.27 [0.16, 0.451), borderline decrease in development of proteinuria (OR 0.69 [0.48, 1.02]), decrease in RDS (OR 0.33 [0.13, 0.85]), but a borderline increase in SGA infants (OR 1.47 [0.96, 2.26]). Beta-blockers were equivalent to other agents (n=15 trials). For severe 'late-onset' pregnancy hypertension (n=5 trials), i.v. labetalol produced less maternal hypotension (OR 0.13 [0.03, 0.71]) and fewer cesareans (OR 0.23 [0.13, 0.63]) than i.v. hydralazine/diazoxide. CONCLUSIONS: It is not clear that the benefits outweigh the risks when beta-blockers are used to treat mild to moderate chronic or pregnancy-induced hypertension, given the unknown overall effect on perinatal outcomes. For severe 'late-onset' pregnancy hypertension, i.v. labetalol is safer than i.v. hydralazine or diazoxide.
Publication Types:
Meta-analysis


5: Ann Med 1999 Aug;31(4):246-52
Chronic hypertension in pregnancy.
Haddad B, Sibai BM
Department of Obstetrics and Gynecology, University of Tennessee, Memphis 38103, USA.
Pregnancies in women with chronic hypertension are at increased risk of superimposed pre-eclampsia, abruptio placentae, fetal growth retardation and prematurity. The frequencies of these complications are increased in those women who have high-risk chronic hypertension, ie severe hypertension or pre-existing cardiovascular or renal diseases, as well as in those with target organ damage. Such women should receive antihypertensive therapy and close management to improve maternal and fetal outcome. In women with low-risk chronic hypertension, antihypertensive treatments do not improve pregnancy outcome. Prophylactic low-dose acetylsalicylic acid treatment does not reduce the frequency of superimposed pre-eclampsia nor does it improve perinatal outcome in these pregnancies.
Publication Types:
Review
Review, tutorial


6: Clin Exp Hypertens 1999 Jul-Aug;21(5-6):907-16
Management of hypertension in pregnancy.
Brown MA, Whitworth JA
Department of Renal Medicine, St George Hospital & University of NSW, Kogarah.
Hypertension in pregnancy is generally defined as either an absolute BP > 140/90 mm Hg or a rise in systolic BP > or = 25 mm Hg and/or diastolic BP > or = 15 mm Hg from pre-conception or 1st trimester BP. Hypertension in pregnancy is classified as: a) Chronic--essential or secondary hypertension, b) De novo--pre-eclampsia or gestational hypertension, and c) Pre-eclampsia superimposed on chronic hypertension. Pre-eclampsia is a multisystem disorder in which hypertension is but one sign. The major maternal abnormalities occur in kidneys, liver, brain and coagulation systems. Impaired uteroplacental blood flow causes fetal growth retardation or intrauterine death. There is general agreement that BP > or = 170/110 mm Hg should be lowered rapidly to protect the mother against risk of stroke or eclampsia. There is dispute concerning the level at which lesser degrees of hypertension should be treated, and lowering BP is treating only one aspect of pre-eclampsia. Delivery remains the definitive management.
Publication Types:
Review
Review, tutorial


7: BMJ 1999 May 15;318(7194):1332-6 [Texto completo]
Fortnightly review: management of hypertension in pregnancy.
Magee LA, Ornstein MP, von Dadelszen P
Departments of Medicine, and Obstetrics and Gynaecology, University of Toronto, Toronto, Canada. laura.magee@utoronto.ca
Publication Types:
Review
Review literature
Comment in:
 ACP J Club. 1999 Nov-Dec;131(3):61


8: Rev Esp Cardiol 1998;51 Suppl 4:50-8
[Arterial hypertension and pregnancy: diagnostic criteria and therapeutic approach].
[Article in Spanish]
Palma Gamiz JL
Servicio de Cardiologia, Hospital Ramon y Cajal, Madrid.
Arterial hypertension is a relatively common complication of pregnancy, affecting about 10% of all normal pregnancies. The American College of Obstetric and Gynecology established in 1972 four different forms of arterial hypertension during pregnancy: a) arterial hypertension related to pregnancy, the so-called pre-eclampsia; b) arterial hypertension unrelated to pregnancy or chronic arterial hypertension; c) Pre-eclampsia superimposed on chronic arterial hypertension, and d) Transient or late arterial hypertension (third trimester). Pre-eclampsia and arterial hypertension are two different illnesses with different approaches and treatments. The mechanisms involved in arterial hypertension and pre-eclampsia of pregnant women are presently very well known, including genetic causes, alterations on the renin-angiotensin system, imbalance between vasoconstrictor and vasodilator agents derived from endothelial activity of the spiral arteries of the placenta, such as; prostacyclins, thromboxane A2, nitric oxide, endothelin-1, etc. The placenta is the key factor in inducing pre-eclampsia, and its expulsion during delivery or cesarean section is the definite cure of the process. All hypertensive forms during pregnancy increase the risks on both the mother and the fetus. Maternal risk is based on renal, metabolic and haematologic disorders, leading in some cases to cerebral haemorrhage or hepatic rupture. In the fetus, pre-eclampsia significantly increases the risk of still-birth, abruptio placentae, hypocalvaria, intrauterine growth retardation, and prematurity. Clinical, biochemical and haematologic manifestations of pre-eclampsia are very typical, facilitating an early and easy diagnosis.
Publication Types:
Review
Review, tutorial


9: Semin Perinatol 1998 Dec;22(6):471-84
Endocrine causes of hypertension in pregnancy--when to start looking for zebras.
Keely E
Department of Medicine, University of Ottawa, Ontario, Canada.
Hypertension is a common medical disorder in pregnancy that may predate or first appear in pregnancy. Endocrine disorders rarely are the cause of the elevated blood pressure. However, it is essential to have a high index of suspicion because they carry much higher fetal and maternal morbidity and mortality risks. Endocrine disorders presenting as hypertension are primarily the result of autonomous production of renin, aldosterone, cortisol, or catecholamines. This report discusses the physiological changes in pregnancy, presentation, investigation, and management of these disorders.
Publication Types:
Review
Review, tutorial


10: Diabetes Care 1998 Aug;21 Suppl 2:B27-32
Hypertension in women with gestational diabetes.
Roberts R
Ulster Hospital, Dundonald, Belfast, Northern Ireland, U.K.
Hypertension in pregnancy and gestational diabetes have in common a lack of universally accepted classification and nomenclature that hinders comparison of data between research groups and contributes to the lack of consensus in the literature on these conditions. The inter-relationship of hypertension and gestational diabetes can be considered from three viewpoints according to whether hypertension is present before, during, or after the pregnancy. The first question is whether hypertension predating pregnancy predisposes to gestational diabetes. Epidemiological evidence and physiological argument based on the common etiologic factor of insulin resistance would suggest that gestational diabetes should be more common in the presence of preexisting hypertension. The limited clinical data available support this hypothesis. There are three issues concerning the coexistence of hypertension and gestational diabetes: whether gestational diabetes predisposes to pregnancy-induced hypertension, whether pregnancy-induced hypertension predisposes to gestational diabetes and what effect the combination has on morbidity and mortality. A number of studies have investigated whether pregnancy-induced hypertension is more common in women with gestational diabetes, but no consensus has been reached. There is little direct clinical evidence on the reverse issue, but data are presented to suggest that pregnancy-induced hypertension may only predispose to gestational diabetes when its etiology is gestational hypertension and not preeclampsia. The issue of how the coexistence of pregnancy-induced hypertension and gestational diabetes affects maternal or neonatal morbidity and mortality is largely unanswered. The last question is whether gestational diabetes has any prognostic significance with regard to the future development of hypertension in the mother. It is well known that gestational diabetes predisposes to subsequent NIDDM and that NIDDM is associated with a high incidence of essential hypertension. Once again insulin resistance may be a unifying factor. However, there is no direct clinical evidence that gestational diabetes predisposes to future hypertension.
Publication Types:
Review
Review, tutorial


11: Can Fam Physician 1998 Jun;44:1245-7
Therapeutic approach to hypertension during pregnancy.
Lalkin A, Loebstein R, Addis A, Koren G
Hospital for Sick Children, Toronto.
Publication Types:
Review
Review, tutorial


12: J Am Soc Nephrol 1998 Feb;9(2):314-21
Hypertension in pregnancy.
Paller MS
University of Minnesota, Minneapolis 55455, USA.
Publication Types:
Review
Review, tutorial


13: Cardiol Clin 1998 Feb;16(1):79-101
Hypertension and pregnancy-related hypertension.
Perloff D
School of Medicine, Division of Cardiology, University of California, San Francisco, USA.
Pregnant women with hypertension can be divided into two groups: normotensive women who develop the uniquely pregnancy-related syndrome of preeclampsia, which is characterized by hypertension, proteinuria, and edema; and women with chronic hypertension who become pregnant and are at increased risk for developing superimposed preeclampsia. Preeclampsia is a syndrome of generalized endothelial dysfunction initiated by abnormal placentation and consequent placental under-perfusion, release of cytokines and other toxins, and vasoconstriction and platelet activation. Preeclampsia is the major cause of both maternal and fetal morbidity and mortality and may be complicated by eclampsia (seizures) and hepatic and renal failure. The process is completely reversible by delivery of the fetus and placenta, but intrauterine growth retardation and premature delivery pose major threats to the fetus and may require care in tertiary care center. Treatment of preexisting or pregnancy-induced hypertension does not prevent or reverse the process, but is justified to prevent maternal cardiovascular complications, especially during labor and delivery.
Publication Types:
Review
Review, tutorial


14: CMAJ 1997 Nov 1;157(9):1245-54 [Texto completo]
Report of the Canadian Hypertension Society Consensus Conference: 3. Pharmacologic treatment of hypertensive disorders in pregnancy.
Rey E, LeLorier J, Burgess E, Lange IR, Leduc L
Department of Medicine, University of Montreal, Que.
OBJECTIVE: To provide Canadian physicians with evidence-based guidelines for the pharmacologic treatment of hypertensive disorders in pregnancy. OPTIONS: No medication, or treatment with antihypertensive or anticonvulsant drugs. OUTCOMES: Prevention of maternal complications, and prevention of perinatal complications and death. EVIDENCE: Pertinent articles published from 1962 to September 1996 retrieved from the Pregnancy and Childbirth Module of the Cochrane Database of Systematic Reviews and from MEDLINE; additional articles retrieved through a manual search of bibliographies; and expert opinion. Recommendations were graded according to levels of evidence. VALUES: Maternal and fetal well-being were equally valued, with the belief that treatment side effects should be minimized. BENEFITS, HARMS AND COSTS: Reduction in the rate of adverse perinatal outcomes, including death. Potential side effects of antihypertensive drugs include placental hypoperfusion, intrauterine growth retardation and long-term effects on the infant. RECOMMENDATIONS: A systolic blood pressure greater than 169 mm Hg or a diastolic pressure greater than 109 mm Hg in a pregnant woman should be considered an emergency and pharmacologic treatment with hydralazine, labetalol or nifedipine started. Otherwise, the thresholds at which to start antihypertensive treatment are a systolic pressure of 140 mm Hg or a diastolic pressure of 90 mm Hg in women with gestational hypertension without proteinuria or pre-existing hypertension before 28 weeks' gestation, those with gestational hypertension and proteinuria or symptoms at any time during the pregnancy, those with pre-existing hypertension and underlying conditions or target-organ damage, and those with pre-existing hypertension and superimposed gestational hypertension. The thresholds in other circumstances are a systolic pressure of 150 mm Hg or a diastolic pressure of 95 mm Hg. For nonsevere hypertension, methyldopa is the first-line drug; labetalol, pindolol, oxprenolol and nifedipine are second-line drugs. Fetal distress attributed to placental hypoperfusion is rare, and long-term effects on the infant are unknown. Magnesium sulfate is recommended for the prevention and treatment of seizures. VALIDATION: The guidelines are more precise but compatible with those from the US and Australia.
Publication Types:
Consensus development conference
Guideline
Practice guideline
Review
Comment in:
 ACP J Club. 1998 May-Jun;128(3):63


15: CMAJ 1997 Oct 1;157(7):907-19 [Texto completo]
Report of the Canadian Hypertension Society Consensus Conference: 2. Nonpharmacologic management and prevention of hypertensive disorders in pregnancy.
Moutquin JM, Garner PR, Burrows RF, Rey E, Helewa ME, Lange IR, Rabkin SW
Department of Obstetrics and Gynecology, Laval University, Sainte-Foy, Que.
OBJECTIVE: To provide Canadian physicians with comprehensive, evidence-based guidelines for the nonpharmacologic management and prevention of gestational hypertension and pre-existing hypertension during pregnancy. OPTIONS: Lifestyle modifications, dietary or nutrient interventions, plasma volume expansion and use of prostaglandin precursors or inhibitors. OUTCOMES: In gestational hypertension, prevention of complications and death related to either its occurrence (primary or secondary prevention) or its severity (tertiary prevention). In pre-existing hypertension, prevention of superimposed gestational hypertension and intrauterine growth retardation. EVIDENCE: Articles retrieved from the pregnancy and childbirth module of the Cochrane Database of Systematic Reviews; pertinent articles published from 1966 to 1996, retrieved through a MEDLINE search; and review of original randomized trials from 1942 to 1996. If evidence was unavailable, consensus was reached by the members of the consensus panel set up by the Canadian Hypertension Society. VALUES: High priority was given to prevention of adverse maternal and neonatal outcomes in pregnancies with established hypertension and in those at high risk of gestational hypertension through the provision of effective nonpharmacologic management. BENEFITS, HARMS AND COSTS: Reduction in rate of long-term hospital admissions among women with gestational hypertension, with establishment of safe home-care blood pressure monitoring and appropriate rest. Targeting prophylactic interventions in selected high-risk groups may avoid ineffective use in the general population. Cost was not considered. RECOMMENDATION: Nonpharmacologic management should be considered for pregnant women with a systolic blood pressure of 140-150 mm Hg or a diastolic pressure of 90-99 mm Hg, or both, measured in a clinical setting. A short-term hospital stay may be required for diagnosis and for ruling out severe gestational hypertension (preeclampsia). In the latter case, the only effective treatment is delivery. Palliative management, dependent on blood pressure, gestational age and presence of associated maternal and fetal risk factors, includes close supervision, limitation of activities and some bed rest. A normal diet without salt restriction is advised. Promising preventive interventions that may reduce the incidence of gestational hypertension, especially with proteinuria, include calcium supplementation (2 g/d), fish oil supplementation and low-dose acetylsalicylic acid therapy, particularly in women at high risk for early-onset gestational hypertension. Pre-existing hypertension should be managed the same way as before pregnancy. However, additional concerns are the effects on fetal well-being and the worsening of hypertension during the second half of pregnancy. There is, as yet, no treatment that will prevent exacerbation of the condition. VALIDATION: The guidelines share the principles in consensus reports from the US and Australia on the nonpharmacologic management of hypertension in pregnancy.
Publication Types:
Consensus development conference
Guideline
Practice guideline
Review


16: Acta Obstet Gynecol Scand 1997 Feb;76(2):96-106
Hypertension in pregnancy: use of antihypertensive drugs.
Henriksen T
Department of Obstetrics and Gynecology, University of Oslo, Norway.
Publication Types:
Review
Review, tutorial