Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period

What are the essential components of antenatal care? A systematic review of the literature and development of signal functions to guide monitoring and evaluation

BACKGROUND

Antenatal care (ANC) is one of the key care packages required to reduce global maternal and perinatal mortality and morbidity.

OBJECTIVES

To identify the essential components of ANC and develop signal functions.

SEARCH STRATEGY

MESH headings for databases including Cinahl, Cochrane, Global Health, Medline, PubMed and Web of Science.

SELECTION CRITERIA

Papers and reports on content of ANC published from 2000 to 2020.

DATA COLLECTION AND ANALYSIS

Narrative synthesis of data and development of signal function through 7 consensus-building workshops with 184 stakeholders.

MAIN RESULTS

A total of 221 papers and reports are included from which 28 essential components of ANC were extracted and used to develop 15 signal functions with the equipment, medication and consumables required for implementation of each. Signal functions for the prevention and management of infectious diseases (malaria, HIV, tuberculosis, syphilis and tetanus) can be applied depending on population disease burden. Screening and management of pre-eclampsia, gestational diabetes, anaemia, mental and social health (including intimate partner violence) are recommended universally. Three signal functions address monitoring of fetal growth and wellbeing, and identification and management of obstetric complications. Promotion of health and wellbeing via education and support for nutrition, cessation of substance abuse, uptake of family planning, recognition of danger signs and birth preparedness are included as essential components of ANC.

CONCLUSIONS

New signal functions have been developed which can be used for monitoring and evaluation of content and quality of ANC. Country adaptation and validation is recommended.

Guidelines-similarities and dissimilarities: a systematic review of international clinical practice guidelines for pregnancy hypertension

OBJECTIVE

This study aimed to review pregnancy hypertension clinical practice guidelines to inform international clinical practice and research priorities.

STUDY ELIGIBILITY CRITERIA

Relevant national and international clinical practice guidelines, 2009-19, published in English, French, Dutch or German.

STUDY APPRAISAL AND SYNTHESIS METHODS

Following published methods and prospective registration (CRD42019123787), a literature search was updated. CPGs were identified by 2 authors independently who scored quality and usefulness for practice (Appraisal of Guidelines for Research and Evaluation II instrument), abstracted data, and resolved any disagreement by consensus.

RESULTS

Of note, 15 of 17 identified clinical practice guidelines (4 international) were deemed "clinically useful" and had recommendations abstracted. The highest Appraisal of Guidelines for Research and Evaluation II scores were from government organizations, and scores have improved over time. The following were consistently recommended: (1) automated blood pressure measurement with devices validated for pregnancy and preeclampsia, reflecting increasing recognition of the prevalence of white-coat hypertension and the potential usefulness of home blood pressure monitoring; (2) use of dipstick proteinuria testing for screening followed by quantitative testing by urinary protein-to-creatinine ratio or 24-hour urine collection; (3) key definitions and most aspects of classification, including a broad definition of preeclampsia (which includes proteinuria and maternal end-organ dysfunction, including headache and visual symptoms and laboratory abnormalities of platelets, creatinine, or liver enzymes) and a recognition that it can worsen after delivery; (4) preeclampsia prevention with aspirin; (5) treatment of severe hypertension, most commonly with intravenous labetalol, oral nifedipine, or intravenous hydralazine; (6) treatment for nonsevere hypertension when undertaken, with oral labetalol (in particular), methyldopa, or nifedipine, with recommendations against the use of renin-angiotensin-aldosterone inhibitors; (7) magnesium sulfate for eclampsia treatment and prevention among women with "severe" preeclampsia; (8) antenatal corticosteroids for preterm birth but not hemolysis, elevated liver enzymes, and low platelet count syndrome; (9) delivery at term for preeclampsia; (10) a focus on usual labor and delivery care but avoidance of ergometrine; and (11) an appreciation that long-term health complications are increased in incidence, mandating lifestyle change and risk factor modification. Lack of uniformity was seen in the following areas: (1) the components of a broad preeclampsia definition (specifically respiratory and gastrointestinal symptoms, fetal manifestations, and biomarkers), what constitutes severe preeclampsia, and whether the definition has utility because at present what constitutes severe preeclampsia by some guidelines that mandate proteinuria now defines any preeclampsia for most other clinical practice guidelines; (2) how preeclampsia risk should be identified early in pregnancy, and aspirin administered for preeclampsia prevention, because multivariable models (with biomarkers and ultrasonography added to clinical risk markers) used in this way to guide aspirin therapy can substantially reduce the incidence of preterm preeclampsia; (3) the value of calcium added to aspirin for preeclampsia prevention, particularly for women with low intake and at increased risk of preeclampsia; (4) emerging recommendations to normalize blood pressure with antihypertensive agents even in the absence of comorbidities; (5) fetal neuroprotection as an indication for magnesium sulfate in the absence of "severe" preeclampsia; and (6) timing of birth for chronic and gestational hypertension and preterm preeclampsia.

CONCLUSION

Consistent recommendations should be implemented and audited. Inconsistencies should be the focus of research.

Early Preeclampsia Effect on Preterm Newborns Outcome

BACKGROUND

An early form of preeclampsia is rare. Abnormal placentation, placental perfusion disorders, and inflammatory cytokine release will have an effect on the fetus and newborn.

MATERIAL AND METHODS

The study group consisted of preterm newborns whose mothers had a history of preeclampsia and a gestational age of between 30 weeks and 34 weeks + 6 days. The control group consists of neonates matched for gestational age with the case group, whose mothers had normal blood pressure. The incidence and severity of respiratory distress syndrome (RDS), intraventricular hemorrhage, hypoglycemia, pH gas changes, and hematological parameters were analyzed in the two groups.

RESULTS

The study group of preterm neonates had a lower birth weight than the control group (p < 0.001). Most of the deliveries in the group of newborns exposed to preeclampsia were performed by cesarean section. Severe forms of RDS were two times more frequent in the group of newborns exposed to preeclampsia compared to those in the control group. Even though we expected to see a lower incidence, owing to the high number of deliveries by cesarean section, we still observed a higher rate of intraventricular hemorrhage in the preeclampsia group (16 cases in the study group vs. 7 in the control, p = 0.085). Neutropenia and thrombocytopenia were more frequent in preterm newborns exposed to preeclampsia.

CONCLUSIONS

The study shows that early preeclampsia increases the risk of complications in preterm neonates. RDS was more frequent in the exposed group than in the control group. The severity of preeclampsia correlates with hematological changes.

The Importance of Cardiovascular Risk Assessment and Pregnancy Heart Team in the Management of Cardiovascular Disease in Pregnancy

Pregnancy-related maternal morbidity and mortality is increasing because of complications from cardiovascular disease. Pregnancy results in physiologic changes that can adversely impact the cardiovascular system and lead to adverse pregnancy outcomes. A multidisciplinary pregnancy heart team is essential to safely navigate women with heart disease through pregnancy. This role of the pregnancy heart team is to offer preconception counseling, determine pregnancy risks and educate women about those risks, develop a comprehensive antenatal and delivery plan, and ensure appropriate postpartum follow-up. These steps are important to improve cardiovascular outcomes in pregnancy.

Advances in Maternal Fetal Medicine: Perinatal Quality Collaboratives Working Together to Improve Maternal Outcomes

State-based perinatal quality collaboratives (PQCs) address preventable causes of maternal and infant morbidity and mortality by implementing statewide quality improvement (QI) initiatives. They work with hospital clinical teams, obstetric provider and nursing leaders, patients and families, public health officials, and other stakeholders to provide opportunities for collaborative learning, rapid-response data, and QI science support to achieve clinical culture change. PQCs show that the application of collaborative improvement science methods to advance evidence-informed clinical practices using QI strategies contributes to improved perinatal outcomes. With appropriate staffing, infrastructure, and partnerships, PQCs can achieve sustainable improvements in perinatal care.

Drugs for treating severe hypertension in pregnancy: a network meta-analysis and trial sequential analysis of randomized clinical trials

AIMS

Several antihypertensive drugs are used in the treatment of severe hypertension in pregnancy. The present study is a network meta-analysis comparing the efficacy and safety of these drugs.

METHODS

Electronic databases were searched for randomized clinical trials comparing drugs used in the treatment of severe hypertension in pregnancy. The number of women achieving the target blood pressure (BP) was the primary outcome. Doses required and time taken for achieving the target BP, failure rate, and incidences of maternal tachycardia, palpitation, hypotension, headache, and neonatal death and stillbirth were the secondary outcomes. Mixed treatment comparison pooled estimates were generated using a random-effects model. Odds ratios for the categorical and mean difference for the numerical outcomes were the effect estimates.

RESULTS

Fifty-one studies were included in the systematic review and 46 in the meta-analysis. No significant differences in the number of patients achieving target BP was observed between any of the drugs. Diazoxide [-15 (-20.6, -9.4)], nicardipine [-11.8 (-22.3, -1.2)], nifedipine/celastrol [-19.3 (-27.4, -11.1)], nifedipine/vitamin D [-17.1 (-25.7, -9.7)], nifedipine/resveratrol [-13.9 (-22.6, -5.2)] and glyceryl trinitrate [-33.8 (-36.7, -31)] were observed to achieve the target BP (in minutes) more rapidly than hydralazine. Nifedipine required fewer doses than hydralazine for achieving the target BP. Glyceryl trinitrate and labetalol were associated with fewer incidences of tachycardia and palpitation respectively than hydralazine. Trial sequential analysis concluded adequate evidence for hydralazine and nifedipine compared with labetalol. Moderate quality of evidence was observed for direct comparison estimate between labetalol and hydralazine but was either low or very low for other comparisons.

CONCLUSION

The present evidence suggests similar efficacy between nifedipine, hydralazine and labetalol in the treatment of severe hypertension in pregnancy. Subtle differences may exist in their safety profile. The evidence is inadequate for other drugs.

Hypertensive Disorders of Pregnancy: Overview and Current Recommendations

Hypertensive disorders of pregnancy include chronic hypertension, gestational hypertension, preeclampsia-eclampsia, and chronic hypertension with superimposed preeclampsia. These disorders are an important cause of maternal and fetal morbidity and mortality. Although advances in effective treatments have been made, current research has yet to identify a biochemical or diagnostic imaging marker to reliably predict preeclampsia. Despite current guidelines that address diagnosis and management of hypertensive disorders in pregnancy, health care providers may overlook or be unaware of signs that require immediate evaluation and treatment. This article reviews the definitions of hypertensive disorders of pregnancy, diagnosis, pathophysiology of preeclampsia, indications for treatment, neurologic sequelae, and counseling about the implications of hypertension in pregnancy for subsequent health.