Gestational Hypertension and Preeclampsia: An Overview of National and International Guidelines.

IMPORTANCE: Gestational hypertension and preeclampsia are leading causes of maternal and perinatal morbidity and mortality worldwide. Τhe lack of effective screening and management policies appears to be one of the main reasons. OBJECTIVE: The aim of this study was to review and compare recommendations from published guidelines on these common pregnancy complications. EVIDENCE ACQUISITION: A descriptive review of guidelines from the National Institute for Health and Care Excellence, the Society of Obstetric Medicine of Australia and New Zealand, the International Society of Hypertension, the International Society for the Study of Hypertension in Pregnancy, the European Society of Cardiology, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynaecologists of Canada, the American College of Obstetricians and Gynecologists, the International Society of Ultrasound in Obstetrics and Gynecology, the World Health Organization, and the US Preventive Services Task Force on gestational hypertension and preeclampsia was carried out. RESULTS: There is an overall agreement that, in case of suspected preeclampsia or new-onset hypertension, blood and urine tests should be carried out, including dipstick test for proteinuria, whereas placental growth factor-based testing is only recommended by the National Institute for Health and Care Excellence and the European Society of Cardiology. In addition, there is a consensus on the recommendations for the medical treatment of severe and nonsevere hypertension, the management of preeclampsia, the appropriate timing of delivery, the optimal method of anesthesia and the mode of delivery, the administration of antenatal corticosteroids and the use of magnesium sulfate for the treatment of eclamptic seizures, the prevention of eclampsia in cases of severe preeclampsia, and the neuroprotection of preterm neonates. The reviewed guidelines also state that, based on maternal risk factors, pregnant women identified to be at high risk for preeclampsia should receive low-dose aspirin starting ideally in the first trimester until labor or 36 to 37 weeks of gestation, although the recommended dose varies between 75 and 162 mg/d. Moreover, most guidelines recommend calcium supplementation for the prevention of preeclampsia and discourage the use of other agents. However, controversy exists regarding the definition and the optimal screening method for preeclampsia, the need for treating mild hypertension, the blood pressure treatment targets, and the postnatal blood pressure monitoring. CONCLUSIONS: The development and implementation of consistent international protocols will allow clinicians to adopt effective universal screening, as well as preventive and management strategies with the intention of improving maternal and neonatal outcomes.

Design of the Pregnancy REmote MOnitoring II study (PREMOM II): a multicenter, randomized controlled trial of remote monitoring for gestational hypertensive disorders.

BACKGROUND: Observational data from the retrospective, non-randomized Pregnancy REmote MOnitoring I (PREMOM I) study showed that remote monitoring (RM) may be beneficial for prenatal observation of women at risk for gestational hypertensive disorders (GHD) in terms of clinical outcomes, health economics, and stakeholder perceptions. PREMOM II is a prospective, randomized, multicenter follow-up study that was performed to explore these promising results. METHODS: After providing written consent, 3922 pregnant women aged ≥18 years who are at increased risk of developing GHD will be randomized (1:1:1 ratio) to (a) conventional care (control group), (b) a patient self-monitoring group, and (c) a midwife-assisted RM group. The women in each group will be further divided (1:1 ratio) to evaluate the outcomes of targeted or non-targeted (conventional) antihypertensive medication. Women will be recruited in five hospitals in Flanders, Belgium: Ziekenhuis Oost-Limburg, Universitaire Ziekenhuis Antwerpen, Universitaire Ziekenhuis Leuven, AZ Sint Jan Brugge-Oostende, and AZ Sint Lucas Brugge. The primary outcomes are: (1) numbers and types of prenatal visits; (2) maternal outcomes; (3) neonatal outcomes; (4) the applicability and performance of RM; and (5) compliance with RM and self-monitoring. The secondary outcomes are: (1) cost-effectiveness and willingness to pay; (2) patient-reported outcome measures (PROMS) questionnaires on the experiences of the participants; and (3) the maternal and perinatal outcomes according to the type of antihypertensive medication. Demographic, and maternal and neonatal outcomes are collected from the patients' electronic records. Blood pressure and compliance rate will be obtained from an online digital coordination platform for remote data handling. Information about the healthcare-related costs will be obtained from the National Coordination Committee of Belgian Health Insurance Companies (Intermutualistisch Agentschap). PROMS will be assessed using validated questionnaires. DISCUSSION: To our knowledge, this is the first randomized trial comparing midwife-assisted RM and self-monitoring of prenatal blood pressure versus conventional management among women at increased risk of GHD. Positive results of this study may lead to a practical framework for caregivers, hospital management, and payers to introduce RM into the prenatal care programs of high-risk pregnancies. TRIAL REGISTRATION: This study was registered on clinicaltrials.gov , identification number NCT04031430. Registered 24 July 2019, https://clinicaltrials.gov/ct2/show/NCT04031430?cond=premom+ii&draw=2&rank=1 .

Consequences of Iodine Deficiency and Excess in Pregnancy and Neonatal Outcomes: A Prospective Cohort Study in Rio de Janeiro, Brazil.

Background: Insufficient or excessive iodine intake during gestation may compromise adaptive mechanisms in maternal thyroid function and lead to adverse pregnancy outcomes. In this context, we aimed to study the effects of maternal iodine status in the first and third trimesters of gestation on obstetric and neonatal outcomes in an iodine-sufficient population in Rio de Janeiro, Brazil. Methods: A total of 214 pregnant women in the first trimester of gestation were enrolled and prospectively followed until delivery between 2014 and 2017. All participants were ≥18 and ≤35 years, had a spontaneous single pregnancy, and had no history of thyroid or other chronic diseases, nor were they taking iodine-containing supplements at enrollment. In the first trimester, we obtained clinical information and determined thyroid function and the urinary iodine concentration (UIC) of the participants. Thyroid function and UIC were reassessed in the third trimester. Iodine status was determined by the median of UIC obtained from six urine spot samples by the inductively coupled plasma mass spectrometry method. Pregnancy and neonatal outcomes and delivery information were obtained from medical records. Results: The median UIC in the whole population was 219.7 µg/L. The prevalence of UIC <150 µg/L was 17.2%, and 38.7% had UIC ≥250 µg/L. Gestational diabetes (GDM) was higher in the group with UIC 250-499 µg/L (n = 77) compared with the group with UIC 150-249 µg/L (n = 94) (20.3% vs. 9.7%, p < 0.05). Ultimately, UIC ≥250 µg/L was an independent risk factors for GDM (relative risk [RR] = 2.9 [confidence interval, CI = 1.1-7.46], p = 0.027) and hypertensive disorders of pregnancy (HDP) (RR = 4.6 [CI = 1.1-18.0], p = 0.029). Among 196 live-born newborns, lower birth length was observed in infants whose mothers had UIC <150µg/L (n = 37) in the first trimester compared with those with UIC 150-249 µg/L (n = 86) (median interquartile range: 48.0 [2.2] vs. 49.0 [4.0] cm, p = 0.01). Maternal UIC <150 µg/L was negatively associated with birth length of newborns (Exp (B) = 0.33 [CI = 0.1-0.9], p = 0.03). Conclusions: In a population whose median iodine intake is sufficient, extensive individual variation occurs. Such abnormalities are associated with increased GDM and HDP when UIC is ≥250 µg/L, and lower infant birth length when UIC is <150 µg/L.

Implementation of a standardized nurse initiated protocol to manage severe hypertension in pregnancy.

Objectives: Hypertensive disorders of pregnancy are a leading cause of maternal morbidity and mortality, studies have shown that standardized protocols for treating severe hypertension improves outcomes. Our goal was to examine the effects of a protocol for treating severe hypertension.Methods: Using quality improvement methodology, we developed an evidence-based nurse-initiated protocol for management of severe hypertension. We used a before and after study design, with the primary outcome of time to administration of antihypertensive medications and time to achieve blood pressure control. Secondary outcomes included medication usage, time to repeat blood pressure, and proportion of women receiving appropriate treatment. Statistical analysis was completed with Stata, using data medians, 95% confidence intervals and a rank-sum test.Results: Data was collected for 5 months before and 5 months after protocol implementation, with 67 patients included before and 125 patients after implementation. The median time to treatment of severe range blood pressure decreased from 25 min before to 11 min after protocol implementation, p <.001. Twenty-four% of women were treated within 15 min before and 60.6% were treated within 15 min after protocol implementation. Median time required to regain sustained mild range blood pressure was reduced from 45 min before to 41 min after protocol implementation, p = .004. 67.5% of women regained mild range blood pressure within 60 min before and 81.9% achieved blood pressure control within 60 min after protocol implementation. These improved outcomes were evident within the first month after protocol implementation and remained stable throughout the follow-up period.Discussion: Implementation of an evidence-based nurse-initiated protocol for the treatment of severe hypertension in pregnancy decreases the time required to administer antihypertensive medication, time required to regain blood pressure control and nonbeneficial clinical variation. In addition, these benefits were achieved rapidly within a large hospital setting.

The effect of labetalol and nifedipine MR on blood pressure in women with chronic hypertension in pregnancy.

AIM: To compare the blood pressure (BP) lowering effects of labetalol and nifedipine modified release (MR) in hypertensive pregnant women. We also investigated the effect on the heart rate (HR) and determined the proportion of time spent in target. METHODS: This was an exploratory study. Women with chronic hypertension taking either labetalol or nifedipine were offered 24-h ambulatory blood pressure monitoring (ABPM). Sleep, wake and drug ingestion times were self-reported. An indirect response model was used to analyse the systolic BP (SBP), diastolic BP (DBP) and HR time-series; the effect of gestation and type of drug was evaluated. RESULTS: Forty-eight women were recruited: 24 in each group. There was no difference in clinical characteristics. In women taking nifedipine there was a positive association between the dose of nifedipine and pre-dose BP p = .002, this was not present in the labetalol group. There was a difference between the drug effects on both the SBP and DBP time-series (p = .014). In comparison to labetalol, there was less variation in day time BP in those women prescribed nifedipine. Women on labetalol spent a larger proportion of time with their DBP below target (<80 mmHg). The HR dynamics were qualitatively different, a stimulatory effect was found with nifedipine compared to an inhibitory effect with labetalol. CONCLUSION: There are significant and important differences between the BP lowering effects of nifedipine and labetalol. A large randomised control trial is required to investigate the relationship between BP variability and time in target on pregnancy outcomes.

Lipid profile and cytokines in hypertension of pregnancy: A comparison of preeclampsia therapies.

Hypertensive disorders complicating pregnancy can be classified as gestational hypertension, mild preeclampsia, and severe preeclampsia. It is necessary to evaluate and predict the grade in advance. The first study comprised 40 healthy pregnancies, 40 gestational hypertension, 40 mild preeclampsia, and 40 severe preeclampsia cases. The participants' lipid profile and cytokine levels were statistically compared. The efficacy and safety of oral nifedipine (n = 71) and intravenous labetalol (n = 72) for the treatment of severe preeclampsia were evaluated in the next study according to maternal and neonatal outcomes. The levels of lipid profile and cytokines were linked with the presence and severity of hypertensive disorders complicating pregnancy. Both oral nifedipine and intravenous labetalol are effective for safely reducing blood pressure to target levels in patients with severe preeclampsia. Our study suggests that lipid profile and cytokines can be used in the evaluation of the severity of hypertensive disorders complicating pregnancy, and oral nifedipine requires more study.

Comparison of risk factors and outcomes of gestational hypertension and pre-eclampsia.

BACKGROUND: It remains an enigma whether gestational hypertension (GH) and pre-eclampsia (PE) are distinct entities or different spectrum of the same disease. We aimed to compare the risk factors and outcomes between GH and PE. METHOD: A total of 7,633 pregnant women recruited between 12 and 20 weeks of gestation in the Ottawa and Kingston Birth Cohort from 2002 to 2009 were included in the analysis. Cox proportional hazards model was used to identify and compare the risk factors for GH and PE by treating gestational age at delivery as the survival time. Logistic regression model was used to compare outcome. Subgroup analysis was performed for early- and late-onset PE. RESULTS: GH and PE shared most risk factors including overweight and obesity, nulliparity, PE history, type 1 and 2 diabetes, and twin birth. Effect size of PE history (RR = 14.1 for GH vs. RR = 6.4 for PE) and twin birth (RR = 4.8 for GH vs. RR = 10.3 for PE) showed substantial difference. Risk factors modified gestational age at delivery in patients with GH and PE in similar pattern. Subgroup analysis showed that early- and late-onset PE shared some risk factors with different effect sizes, whereas folic acid supplementation showed protective effect for early-onset PE only. PE was strongly associated with several adverse outcomes including cesarean section, placental abruption, small for gestational age, preterm birth, and 5 min Apgar score < 7, whereas GH was associated with increased risk of preterm birth only. CONCLUSIONS: GH and PE shared common risk factors. Differences in effect sizes of risk factors and outcomes indicate that the conditions may have different pathophysiology and mechanism.

Postpartum Hypertension: Etiology, Diagnosis, and Management.

IMPORTANCE: Postpartum hypertension complicates approximately 2% of pregnancies and, similar to antepartum severe hypertension, can have devastating consequences including maternal death. OBJECTIVE: This review aims to increase the knowledge and skills of women's health care providers in understanding, diagnosing, and managing hypertension in the postpartum period. RESULTS: Hypertension complicating pregnancy, including postpartum, is defined as systolic blood pressure 140 mm Hg or greater and/or diastolic blood pressure 90 mm Hg or greater on 2 or more occasions at least 4 hours apart. Severe hypertension is defined as systolic blood pressure 160 mm Hg or greater and/or diastolic blood pressure 110 mm Hg or greater on 2 or more occasions repeated at a short interval (minutes). Workup for secondary causes of hypertension should be pursued, especially in patients with severe or resistant hypertension, hypokalemia, abnormal creatinine, or a strong family history of renal disease. Because severe hypertension is known to cause maternal stroke, women with severe hypertension sustained over 15 minutes during pregnancy or in the postpartum period should be treated with fast-acting antihypertension medication. Labetalol, hydralazine, and nifedipine are all effective for acute management, although nifedipine may work the fastest. For persistent postpartum hypertension, a long-acting antihypertensive agent should be started. Labetalol and nifedipine are also both effective, but labetalol may achieve control at a lower dose with fewer adverse effects. CONCLUSIONS AND RELEVANCE: Providers must be aware of the risks associated with postpartum hypertension and educate women about the symptoms of postpartum preeclampsia. Severe acute hypertension should be treated in a timely fashion to avoid morbidity and mortality. Women with persistent postpartum hypertension should be administered a long-acting antihypertensive agent. TARGET AUDIENCE: Obstetricians and gynecologists, family physicians. LEARNING OBJECTIVES: After completing this activity, the learner should be better able to assist patients and providers in identifying postpartum hypertension; provide a framework for the evaluation of new-onset postpartum hypertension; and provide instructions for the management of acute severe and persistent postpartum hypertension.

Preventing deaths due to the hypertensive disorders of pregnancy.

In this chapter, taking a life cycle and both civil society and medically oriented approach, we will discuss the contribution of the hypertensive disorders of pregnancy (HDPs) to maternal, perinatal and newborn mortality and morbidity. Here we review various interventions and approaches to preventing deaths due to HDPs and discuss effectiveness, resource needs and long-term sustainability of the different approaches. Societal approaches, addressing sustainable development goals (SDGs) 2.2 (malnutrition), 3.7 (access to sexual and reproductive care), 3.8 (universal health coverage) and 3c (health workforce strengthening), are required to achieve SDGs 3.1 (maternal survival), 3.2 (perinatal survival) and 3.4 (reduced impact of non-communicable diseases (NCDs)). Medical solutions require greater clarity around the classification of the HDPs, increased frequency of effective antenatal visits, mandatory responses to the HDPs when encountered, prompt provision of life-saving interventions and sustained surveillance for NCD risk for women with a history of the HDPs.

Severe pre-eclampsia and hypertensive crises.

Hypertensive disorders of pregnancy are one of the leading causes of peripartum morbidity and mortality globally. Hypertensive disease in pregnancy is associated with a spectrum of severity, ranging from mild pregnancy-induced hypertension to eclampsia. Although most cases of pre-eclampsia may be managed successfully, severe pre-eclampsia is a life-threatening multisystem disease associated with eclampsia, HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome, acute kidney injury, pulmonary oedema, placental abruption and intrauterine foetal death. Management of severe pre-eclampsia includes identification of high-risk patients, optimisation of antenatal care, early intervention and the identification and early management of complications. In the first instance, oral anti-hypertensive agents, including labetalol, nifedipine and methyldopa, should be tried. If oral anti-hypertensive agents have failed to adequately control blood pressure, intravenous anti-hypertensives should be considered. Commonly used intravenous anti-hypertensives include labetalol, hydralazine and glyceryl trinitrate. In addition to anti-hypertensive agents, close attention should be given to regular clinical examination, assessment of fluid balance, neurologic status and monitoring of other vital signs. Magnesium sulphate should be considered early to prevent seizures. Delivery of the baby is the definitive management of severe pre-eclampsia.

Nifedipina de liberación programada en micro-gránulos para el control de la enfermedad hipertensiva del embarazo / Release nifedipine programmed micro-pellets for the control of hipertensive disease of pregnancy

Determinar la eficacia y efectividad de la utilización de la nifedipina de liberación programada en micro-gránulos en el tratamiento de la enfermedad hipertensiva del embarazo. Se admitieron sesenta y dos pacientes consecutivas con enfermedad hipertensiva del embarazo con edad gestacional mayor de 20 semanas, fueron asignados a recibir 30 o 60 mg de nifedipina de liberación programada en micro-gránulos en la mañana con el punto final de obtener un control eficaz de la presión arterial (presión arterial sistólica ≤ 120 y presión arterial diastólica ≤ 80 mmHg), cuantificada con esfigmomanómetro de mercurio. Casos con historia de insuficiencia cardíaca y que recibían tratamiento antihipertensivo durante el curso del actual embarazo fueron excluidos. Se cuantificó el tiempo requerido para obtener el control eficaz de la presión arterial y se identificaron los episodios de crisis hipertensiva con el tratamiento así como los efectos adversos en la madre o el feto. El promedio de edad de las pacientes fue de 28,2±7,8 años. Peso 75,1±13,2 kg, talla 162,3±7,0 cm. Ídice de masa corporal 28,5 ± 4,6 kg/m2. Las reducciones de las presiones arteriales fueron: decúbito. Presión arterial sistólica (de 140,0±8,1 a 119,0±8,8 mmHg. P < 0,0001), presió arterial diastóica (de 89,7±7,7 a 72,7±7,8 mmHg. P < 0,0001), frecuencia cardíca (de 82,2±10 a 81,3±10 Lat/min. P = 0,31). Sentadas. Presió arterial sistóica (de 140,3±6,8 a 117,9±8,9 mmHg. P < 0,0001), PAD (de 88,6±8,1 a 71,5±8,5 mmHg. P < 0,0001), frecuencia cardíca (de 84,2±9,0 a 82,3±9,4 Lat/min. P = 0,12). De pie. Presió arterial sistóica (de 141,7±6,76 a 118,3±8,5 mmHg. P < 0,0001), presió arterial diastóica (de 88,9±6,9 a 72,6±8,6 mmHg. P < 0,0001), frecuencia cardíca (de 84,8±9,2 a 83,6±9,6 lat/min. P =0,24). El control de las cifras de presió arterial se logróen un promedio de 6 semanas de tratamiento con nifedipina de liberació programada en micro-gránulos. No se produjo nuevos eventos de crisis hipertensiva ni efectos...

Determine the efficacy and effectiveness of the use of programmed liberate nifedipine on microgranules in the treatment of the hypertensive disease in pregnancy. Sixty two serial patients were admitted with hypertensive disease in pregnancy with age gestacional superior than 20 weeks, were they assigned to receive 30 or 60 mg of programmed liberate nifedipine on micro-granules in the morning with the final objective from obtaining an effective control of the blood pressure (systolic blood pressure ≤ 120 and diastolic blood pressure ≤ 80 mmHg), quantified with a mercury sphygmomanometer. Cases with history of heart inadequacy and that they received antihypertensive treatment during the course of the current pregnancy they were excluded. The time required to obtain the effective control of the blood pressure was quantified and the episodes of hypertensive crisis were identified with the treatment as well as the adverse effects in the mother or the fetus. The age of the patients was of 28.2±7.8 years, weigh 75.1±13.2 kilos, height 162.3±7.0 cm, Index of corporal mass 28.5 ± 4.6 kg/m2. The reductions of the arterial pressures were: decubitus. Systolic blood pressure (of 140.0±8.1 at 119.0±8.8 mmHg. P <0.0001), diastolic blood pressure (of 89.7±7.7 at 72.7±7.8 mmHg. P <0.0001), heart rate (of 82.2±10 to 81.3±10 beats/min. P = 0.31). Seated Systolic blood pressure (of 140.3±6.8 at 117.9±8.9 mmHg. P <0.0001), diastolic blood pressure (of 88.6±8.1 at 71.5±8.5 mmHg. P <0.0001), heart rate (of 84.2±9,0 to 82.3±9.4 beats/min. P = 0.12). Of foot. Systolic blood pressure (of 141.7±6.76 at 118.3±8.5 mmHg. P <0.0001), diastolic blood pressure (of 88.9±6.9 at 72.6±8.6 mmHg. P <0.0001), heart rate (of 84.8±9.2 to 83.6±9.6 beats/min. P = 0.24). The blood pressure control was achievement in an average of 6 weeks of treatment with programmed liberate nifedipine on micro-granules. A new event of hypertensive crisis wasn`t happens, neither adverse effect didn`t see in the mother...

[Modern methods of early screening for preeclampsia and pregnancy-induced hypertension--a review]. / Wspólczesne metody wczesnej diagnostyki stanu przedrzucawkowego i nadcisnienia indukowanego ciaza.

Preeclampsia remains to be a serious perinatal complication and early screening for this disease to identify the high risk population before the first symptoms develop constitutes a considerable clinical challenge. Modern methods of screening for preeclampsia and pregnancy-induced hypertension include patients history biochemical serum markers and foetal DNA and RNA in maternal serum. They aid the process of developing an optimal protocol to initiate treatment in early pregnancy and to reduce the rate of complications. Our review presents an overview of the novel methods and techniques used for early screening for preeclampsia and pregnancy-induced hypertension. Most of the research focuses on 11-13 weeks of gestation due to the fact that the first prenatal examination is performed at that time. The most important information seems to be: weight, mass, mean blood pressure, history of pregnancy-induced hypertension or preeclampsia at previous pregnancies as well as the ethnic origin. During an ultrasound scan, pulsatility index of the uterine arteries is measured. Blood samples are obtained during the last part of the examination. At the moment only a few markers seem to be strong predictors of hypertensive disorders during pregnancy: pregnancy-associated plasma protein-A (PAPP-A), placental growth factor (PIGF) and soluble fms-like tyrosine kinase-1 (sFlt-1). Also, fetal DNA and RNA in maternal plasma are helpful in the prediction of preeclampsia as they are markers of the trophoblast apoptosis. Researchers aim at identifying the population at high risk of pregnancy-induced hypertension and preeclampsia in order to offer appropriate antenatal care to these women. At the moment many drugs and diet supplements are investigated to reduce the prevalence of hypertensive disorders in pregnancy. These medications are usually administrated in early gestation (up to 16 week of gestation) before the first clinical symptoms present. Low doses of aspirin were found to decrease the risk of preeclampsia in high-risk groups. Moreover, according to some recent research, also essential omega-3 fatty acids reduce the incidence of preeclampsia. None of the other investigated diet supplements or antioxidants were proven to successfully reduce incidents of hypertensive disorders. So far, there is available evidence on the lack of any effect for vitamines C, D or E. Further studies are necessary to define clinical useful markers of gestational hypertension.

Impetigo herpetiformis with gestational hypertension: a case report and literature review.

BACKGROUND: Impetigo herpetiformis (IH) is a rare skin disorder that occurs during pregnancy. It was previously associated with high maternal and fetal mortality and morbidity, but now has a better prognosis. CASE REPORT: We report a case of a pregnant woman with IH who presented with generalized erythematous pustular eruptions in the 32nd week of gestation. The IH progressed rapidly, and gestational hypertension was observed in the 36th week. The lesions did not subside, despite treatment with corticosteroids and phototherapy. She delivered a healthy male baby via cesarean section in the 37th week. One month after her delivery, her skin returned to normal, except for residual pigmentation, with complete recovery 3 months postpartum. CONCLUSION: An experienced medical team comprising obstetricians, dermatologists, perinatologists and neonatologists is critical to aggressively treat this life-threatening specific dermatosis of pregnancy and to prevent ensuing complications, such as fluid and electrolyte imbalance, secondary infection and placental insufficiency.

Hypertension in pregnancy: a comprehensive update.

Hypertensive disorders of pregnancies remain a central public health concern throughout the world, and are a major cause of maternal mortality in the developing world. Although treatment options have not significantly changed in recent years, insight on the pathogenesis of preeclampsia/eclampsia has been remarkable. With improved animal models of preeclampsia and large-scale human trials, we have embarked upon a new era where angiogenic biomarkers based on mechanism of disease can be designed to assist in early diagnosis and treatment. There is also a growing recognition of how elusive the diagnosis of eclampsia can be, especially in the postpartum period. Proper treatment of these patients depends heavily on the correct diagnosis, especially by the emergency physician. Finally, large epidemiologic studies have revealed that preeclampsia, once thought to be a self-limited entity, now appears to portend real damage to the cardiovascular and other organ systems in the long term. This review will present the latest update on our understanding of the various hypertensive disorders of pregnancies and their treatment options.

Antenatal screening and predicting hypertension in pregnancy for midwives.

BACKGROUND: The cause of hypertension in pregnancy remains unknown and results in increased risk of complications for mother and baby. Symptoms of developing pre-eclampsia, such as an elevated blood pressure, can be vague and singular. The purpose of this literature review is to evaluate research investigating antenatal screening practices for hypertension which fall within the midwives scope of practice. METHOD: Inclusion criteria for this literature review were English language, peer reviewed primary research journal articles, published in the previous 20 years where the population under study was pregnant with reported outcomes of prevention, screening or prediction of hypertension in pregnancy. A large number of papers (n=201) were identified and these were screened and subsequently excluded if they addressed diagnostic testing, screening and interpretation that depended solely on a medical practitioner. RESULTS: There was no single predictive factor found, however the relevant papers included in this review (n=33) found evidence of modifiable, non-modifiable and clinical assessment factors for inclusion in a midwifery screening model. CONCLUSIONS: Further research should be focused on the factors observed by midwives during history taking and the antenatal course in the second and third trimesters and whether or not these can be synthesised in to a hypertension-specific diagnostic tool for use in midwifery practice.

Time poor: rushing decreases the accuracy and reliability of blood pressure measurement technique in pregnancy.

BACKGROUND: In pregnancy, absolute blood pressure (BP) limits define preeclampsia. Therefore, BP in pregnancy should be measured accurately and in accordance with accepted guidelines. Accuracy of BP readings determined by rate of cuff deflation was analyzed. This study also investigated the compliance of clinical staff at Royal Prince Alfred Hospital, Australia, to guidelines for BP measurement. METHODS: The study was an observational trial of 98 normotensive antenatal or recently postnatal patients. Two BP readings were taken, each with fast (>5 mm Hg/sec) and slow (