hipertensión en el embarazo acog2013

1122 VOL. 122, NO. 5, NOVEMBER 2013 OBSTETRICS & GYNECOLOGY

Hypertension in PregnancyReport 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 FOLQLFLDQVFLHQWLVWV IURP WKHHOGVRI REVWHWULFVPDWHUQDO IHWDOPHGLFLQHK\SHUWHQVLRQLQWHUQDOPHGLFLQHQHSKURORJ\DQHVWKHVLRORJ\SK\VLRORJ\DQGSDWLHQWDGYRFDF\7KLVH[HF-utive summary includes a synopsis of the content and task force recommendations of each chapter in the report and is LQWHQGHGWRFRPSOHPHQWQRWVXEVWLWXWHWKHUHSRUW

Hypertensive disorders of pregnancy remain a major health issue for women and their infants in the United 6WDWHV3UHHFODPSVLDHLWKHUDORQHRUVXSHULPSRVHGRQSUH-H[LVWLQJ FKURQLF K\SHUWHQVLRQ SUHVHQWV WKH PDMRU ULVN$OWKRXJK DSSURSULDWH SUHQDWDO FDUH ZLWK REVHUYDWLRQ RIwomen for signs of preeclampsia and then delivery to termi-QDWH WKHGLVRUGHU KDV UHGXFHG WKHQXPEHU DQG H[WHQW RISRRURXWFRPHVVHULRXVPDWHUQDOIHWDOPRUELGLW\DQGPRU-tality still occur. Some of these adverse outcomes are avoid-DEOH ZKHUHDV RWKHUV FDQ EH DPHOLRUDWHG $OVR DOWKRXJKsome of the problems that face neonates are related directly WRSUHHFODPSVLDDODUJHSURSRUWLRQDUHVHFRQGDU\WRSUHPD-turity that results from the appropriate induced delivery of the fetuses of women who are ill. Optimal management UHTXLUHVFORVHREVHUYDWLRQIRUVLJQVDQGSUHPRQLWRU\QG-LQJV DQG DIWHU HVWDEOLVKLQJ WKH GLDJQRVLV GHOLYHU\ DW WKHoptimal 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-HYHU PDWHUQDO DQG IHWDO PRUELGLW\ LQFUHDVH GUDPDWLFDOO\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 RUZKHWKHUSUHHFODPSVLDKDVGHYHORSHG,QWKLVUHSRUWWKHtask force provides suggestions for the recognition and man-agement of this challenging condition. ,QWKHSDVW\HDUVWKHUHKDYHEHHQVXEVWDQWLDODGYDQFHV

in the understanding of preeclampsia as well as increased HRUWV WR REWDLQ HYLGHQFH WR JXLGH WKHUDS\ 1RQHWKHOHVVthere remain areas on which evidence is scant. The evidence is now clear that preeclampsia is associated with later-life FDUGLRYDVFXODU &9 GLVHDVH KRZHYHU IXUWKHU UHVHDUFK LVneeded to determine how best to use this information to KHOSSDWLHQWV7KHWDVNIRUFHDOVRKDVLGHQWLHGLVVXHVLQWKHmanagement of preeclampsia that warrant special atten-WLRQ)LUVWLVWKHIDLOXUHE\KHDOWKFDUHSURYLGHUVWRDSSUHFL-ate the multisystemic nature of preeclampsia. This is in part GXHWRDWWHPSWVDWULJLGGLDJQRVLVZKLFKLVDGGUHVVHGLQWKHUHSRUW6HFRQGSUHHFODPSVLDLVDG\QDPLFSURFHVVDQGDdiagnosis such as mild preeclampsia (which is discour-aged) applies only at the moment the diagnosis is estab-OLVKHG EHFDXVH SUHHFODPSVLD E\ QDWXUH LV SURJUHVVLYHDOWKRXJKDWGLHUHQWUDWHV$SSURSULDWHPDQDJHPHQWPDQ-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 PregnancyZDVGHYHORSHGE\WKH7DVN)RUFHRQ+\SHUWHQVLRQLQ3UHJQDQF\-DPHV05REHUWV0'&KDLU3K\OOLV$$XJXVW0'03+*HRUJH%DNULV0'-RKQ5%DUWRQ0',UD0%HUQVWHLQ0'0DXULFH'UX]LQ0'5REHUW5*DLVHU0'-RH\3*UDQJHU3K'$UXQ-H\DEDODQ0'06'RQQD'-RKQVRQ0'6$QDQWK.DUXPDQFKL0'0DUVKDOO/LQGKHLPHU0'0LFKHOOH

VOL. 122, NO. 5, NOVEMBER 2013 Executive Summary: Hypertension in Pregnancy 1123

for many years that preeclampsia can worsen or present for WKHUVWWLPHDIWHUGHOLYHU\ZKLFKFDQEHDPDMRUVFHQDULRIRUDGYHUVHPDWHUQDOHYHQWV ,Q WKLV UHSRUW WKH WDVN IRUFHprovides 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-PHQGDWLRQV $VVHVVPHQW 'HYHORSPHQW DQG (YDOXDWLRQ*5$'(:RUNLQJ*URXSDYDLODEOHDWZZZJUDGHZRUNLQJ JURXSRUJLQGH[KWP %HFDXVH RI LWV XWLOLW\ WKLV VWUDWHJ\KDVEHHQDGDSWHGZRUOGZLGHE\DODUJHQXPEHURIRUJDQL]D-WLRQV:LWKWKH*5$'(:RUNLQJ*URXSDSSURDFKWKHIXQF-tion of expert task forces and working groups is to evaluate WKH DYDLODEOH HYLGHQFH UHJDUGLQJ D FOLQLFDO GHFLVLRQ WKDWEHFDXVHRIOLPLWHGWLPHDQGUHVRXUFHVZRXOGEHGLFXOWIRUthe 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-RPPHQGDWLRQ WKH LPSOLFDWLRQV DQG WKH FRQGHQFH LQHVWLPDWHV RI HHFW:LWK WKLV FRPELQDWLRQ WKH DYDLODEOHinformation was evaluated and recommendations were PDGH ,Q WKLVUHSRUW WKHFRQGHQFH LQHVWLPDWHVRIHHFWTXDOLW\RIWKHDYDLODEOHHYLGHQFHLVMXGJHGDVYHU\ORZORZPRGHUDWHRUKLJK

Recommendations are practices agreed to by the task force as the most appropriate course of action; they are JUDGHGDVVWURQJRUTXDOLHG$VWURQJUHFRPPHQGDWLRQLVone that is so well supported that it would be the approach appropriate for virtually all patients. It could be the basis for KHDOWKFDUHSROLF\$TXDOLHGUHFRPPHQGDWLRQLVDOVRRQHWKDWZRXOGEHMXGJHGDVDSSURSULDWHIRUPRVWSDWLHQWVEXWit might not be the optimal recommendation for some SDWLHQWVZKRVHYDOXHVDQGSUHIHUHQFHVGLHURUZKRKDYHGLHUHQWDWWLWXGHVWRZDUGXQFHUWDLQW\LQHVWLPDWHVRIHHFW:KHQWKHWDVNIRUFHKDVPDGHDTXDOLHGUHFRPPHQGDWLRQthe 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 Pregnancy7KH WDVN IRUFH FKRVH WR FRQWLQXH XVLQJ WKH FODVVLFDWLRQVFKHPDUVW LQWURGXFHGLQE\WKH&ROOHJHDQGPRGLHG LQ WKH DQG UHSRUWV RI WKH:RUNLQJ*URXS RI WKH 1DWLRQDO +LJK %ORRG 3UHVVXUH (GXFDWLRQ 3URJUDP6LPLODUFODVVLFDWLRQVFDQEHIRXQGLQWKH$PHULFDQ6RFL-HW\RI+\SHUWHQVLRQJXLGHOLQHVDVZHOODV&ROOHJH3UDFWLFH

%XOOHWLQV$OWKRXJKWKHWDVNIRUFHKDVPRGLHGVRPHRIWKHFRPSRQHQWV RI WKH FODVVLFDWLRQ WKLV EDVLF SUHFLVH DQGSUDFWLFDOFODVVLFDWLRQZDVXVHGZKLFKFRQVLGHUVK\SHUWHQ-sion during pregnancy in only four categories: 1) pre- HFODPSVLDHFODPSVLD FKURQLF K\SHUWHQVLRQ RI DQ\FDXVHFKURQLFK\SHUWHQVLRQZLWKVXSHULPSRVHGSUHHF-ODPSVLDDQGJHVWDWLRQDOK\SHUWHQVLRQ,PSRUWDQWO\WKHIROORZLQJFRPSRQHQWVZHUHPRGLHG,QUHFRJQLWLRQRIWKHV\QGURPLFQDWXUHRISUHHFODPSVLDWKHWDVNIRUFHKDVHOLPL-nated the dependence of the diagnosis on proteinuria. In WKH DEVHQFH RI SURWHLQXULD SUHHFODPSVLD LV GLDJQRVHG DVhypertension in association with thrombocytopenia (plate-OHW FRXQW OHVV WKDQ PLFUROLWHU LPSDLUHG OLYHUfunction (elevated blood levels of liver transaminases to WZLFHWKHQRUPDOFRQFHQWUDWLRQWKHQHZGHYHORSPHQWRIUHQDOLQVXFLHQF\HOHYDWHGVHUXPFUHDWLQLQHJUHDWHUWKDQ PJG/RUDGRXEOLQJRIVHUXPFUHDWLQLQHLQWKHDEVHQFHRI RWKHU UHQDO GLVHDVH SXOPRQDU\ HGHPD RU QHZRQVHWFHUHEUDO RU YLVXDO GLVWXUEDQFHV VHH %R[ (Gestational hypertensionLV%3HOHYDWLRQDIWHUZHHNVRIJHVWDWLRQLQthe absence of proteinuria or the aforementioned systemic QGLQJVFhronic hypertension is hypertension that predates pregnancy; and superimposed preeclampsia is chronic hyper-tension in association with preeclampsia.

Establishing the Diagnosis of Preeclampsia or EclampsiaThe BP criteria are maintained from prior recommendations. ProteinuriaLVGHQHGDVWKHH[FUHWLRQRIPJRUPRUHRISURWHLQLQDKRXUXULQHFROOHFWLRQ$OWHUQDWLYHO\DWLPHGH[FUHWLRQWKDWLVH[WUDSRODWHGWRWKLVKRXUXULQHYDOXHRUDSURWHLQFUHDWLQLQHUDWLRRIDWOHDVWHDFKPHDVXUHGDVPJG/ LV XVHG %HFDXVH RI WKH YDULDELOLW\ RI TXDOLWDWLYHGHWHUPLQDWLRQV GLSVWLFN WHVW WKLVPHWKRG LV GLVFRXUDJHGfor diagnostic use unless other approaches are not readily DYDLODEOH,IWKLVDSSURDFKPXVWEHXVHGDGHWHUPLQDWLRQRI LV FRQVLGHUHG DV WKH FXWR IRU WKH GLDJQRVLV RI SUR-teinuria. In view of recent studies that indicate a minimal relationship between the quantity of urinary protein and SUHJQDQF\ RXWFRPH LQ SUHHFODPSVLD PDVVLYH SURWHLQXULD(greater than 5 g) has been eliminated from the consider-DWLRQRISUHHFODPSVLDDVVHYHUH$OVREHFDXVHIHWDOJURZWKrestriction is managed similarly in pregnant women with DQGZLWKRXWSUHHFODPSVLDLWKDVEHHQUHPRYHGDVDQGLQJLQGLFDWLYHRIVHYHUHSUHHFODPSVLD7DEOH(

Prediction of Preeclampsia$JUHDWGHDORIHRUWKDVEHHQGLUHFWHGDWWKHLGHQWLFDWLRQRIGHPRJUDSKLFIDFWRUVELRFKHPLFDODQDO\WHVRUELRSK\VLFDO QGLQJV DORQH RU LQ FRPELQDWLRQ WR SUHGLFW HDUO\ LQ 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)

U -VLìiv}}i]`>VLìiv}}iVV>>i>{>>ii>iLiìi>iiii>>i`Livii

U /LVi>>iiVi>]Vi

U >iìvV>`V>i`L>L>ii>i`L`VVi>viiiVi>VVi>]iiiii}i>`>i}>V>i-ii`V>>`>VVi`vL>i>i`>}i]L

U *}iii>vwViViVi>iVVi>}i>i>}`>`L}viiVi>iVVi>i>LiVivii>ì>i

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U iiViiL>>`L>Vi

WKHUHDUHVRPHHQFRXUDJLQJQGLQJVWKHVHWHVWVDUHQRW\HWready for clinical use.

TASK FORCE RECOMMENDATION

6FUHHQLQJWRSUHGLFWSUHHFODPSVLDEH\RQGREWDLQLQJDQappropriate medical history to evaluate for risk factors is not recommended.

Quality of evidence: Moderate Strength of recommendation: Strong

Prevention of Preeclampsia,WLVFOHDUWKDWWKHDQWLR[LGDQWVYLWDPLQ&DQGYLWDPLQ(DUHQRW HHFWLYH LQWHUYHQWLRQV WR SUHYHQW SUHHFODPSVLD RUadverse 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 ZLWKORZFDOFLXPLQWDNHEXWWKLVQGLQJLVQRWUHOHYDQWWRDSRSXODWLRQ ZLWK DGHTXDWH FDOFLXP LQWDNH VXFK DV LQ WKHUnited States. The administration of low-dose aspirin (6080 mg) to prevent preeclampsia has been examined in PHWDDQDO\VHVRIPRUHWKDQZRPHQDQGLWDSSHDUVWKDW WKHUH LV D VOLJKW HHFW WR UHGXFH SUHHFODPSVLD DQGDGYHUVHSHULQDWDORXWFRPHV7KHVHQGLQJVDUHQRWFOLQLFDOO\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

)RUZRPHQZLWKDPHGLFDOKLVWRU\RIHDUO\RQVHWSUHHF-ODPSVLDDQGSUHWHUPGHOLYHU\DWOHVVWKDQZHHNVRIgestation or preeclampsia in more than one prior preg-

QDQF\ LQLWLDWLQJ WKH DGPLQLVWUDWLRQ RI GDLO\ ORZGRVHPJDVSLULQEHJLQQLQJLQWKHODWHUVWWULPHVWHULVsuggested.*

Quality of evidence: ModerateStrength of recommendation: 4XDOLHG

0HWDDQDO\VLVRIPRUHWKDQZRPHQLQUDQGRPL]HGWULDOVof aspirin to prevent preeclampsia indicates a small reduction in the incidence and morbidity of preeclampsia and reveals no HYLGHQFHRIDFXWHULVNDOWKRXJKORQJWHUPIHWDOHHFWVFDQQRWbe excluded. The number of women to treat to have a thera-SHXWLFHHFWLVGHWHUPLQHGE\SUHYDOHQFH,QYLHZRIPDWHUQDOVDIHW\DGLVFXVVLRQRI WKHXVHRIDVSLULQ LQ OLJKWRI LQGLYLGXDOULVNLVMXVWLHG

7KHDGPLQLVWUDWLRQRIYLWDPLQ&RUYLWDPLQ(WRSUHYHQWpreeclampsia is not recommended.

Quality of evidence: High Strength of recommendation: Strong

,W LV VXJJHVWHG WKDW GLHWDU\ VDOW QRW EH UHVWULFWHG GXU ing pregnancy for the prevention of preeclampsia.

Quality of evidence: /RZStrength of recommendation:4XDOLHG

,W LV VXJJHVWHG WKDW EHG UHVW RU WKH UHVWULFWLRQ RI RWKHUphysical activity not be used for the primary prevention of preeclampsia and its complications.


Management of Preeclampsia and HELLP SyndromeClinical trials have provided an evidence base to guide man-DJHPHQW RI VHYHUDO DVSHFWV RI SUHHFODPSVLD 1RQHWKHOHVV


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 DEVHQFH RI SURWHLQXULD )XUWKHUPRUH DFFXPXODWLQJ LQIRU-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-WHPLFQGLQJVZLWKQHZRQVHWK\SHUWHQVLRQFDQIXOOO WKHdiagnosis 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-ODPSVLDZLWKRXWVHYHUHIHDWXUHVZKLFKEDVHGRQHYLGHQFHLVVXJJHVWHGDWZHHNVRIJHVWDWLRQDQGDQLQFUHDVLQJawareness of the importance of preeclampsia in the postpar-tum period. Health care providers are reminded of the con-WULEXWLRQ RI QRQVWHURLGDO DQWLLQDPPDWRU\ DJHQWV WRincreased 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.


7KHFORVHPRQLWRULQJRIZRPHQZLWKJHVWDWLRQDOK\SHU-tension or preeclampsia ZLWKRXW VHYHUH IHDWXUHV ZLWKserial assessment of maternal symptoms and fetal move-ment (daily byWKHZRPDQVHULDOPHDVXUHPHQWVRI%3WZLFHZHHNO\ DQGDVVHVVPHQWRISODWHOHW FRXQWV DQGOLYHUHQ]\PHVZHHNO\LVVXJJHVWHG

Quality of evidence: ModerateStrength of recommendation:4XDOLHG

)RU ZRPHQ ZLWK JHVWDWLRQDO K\SHUWHQVLRQ PRQLWRULQJ BP at least once weekly with proteinuria assessment in WKHRFHDQGZLWKDQDGGLWLRQDOZHHNO\PHDVXUHPHQWRI%3DWKRPHRULQWKHRFHLVVXJJHVWHG


)RUZRPHQZLWKPLOGJHVWDWLRQDOK\SHUWHQVLRQRUSUHHF-lampsia with a persistent BP of less than 160 mm Hg V\VWROLFRUPP+JGLDVWROLFLWLVVXJJHVWHGWKDWDQWL-hypertensive medications not be administered.


TABLE E-1. Diagnostic Criteria for Preeclampsia

Blood pressure U i>i>i>{}V}i>i>i>}`>VVV>>i>{>>>viiiv}i>>>>i>L`ii

U i>i>i>}V}i>i>i>} `>V]iiV>LiVwi`>i>iv>V>ii>iiii>

>`

Proteinuria U i>i>i>}i{iViV>i>>i`v>i`ViV

U *iVi>i>}i>i>i>I

U Vi>`}vi`vi>>ii`>>>Li

"i>LiVivi>]iiiiiiiv>viv}\

Thrombocytopenia U *>iiVi>]Vi

Renal insufciency U -iVi>iVVi>}i>i>}`>`L}viiVi>iVVi>i>LiVivii>`i>i

Impaired liver function U i>i`L`VVi>vi>>>iVi>VVi>

Pulmonary edema

Cerebral or visual symptoms

I>Vi>i`>}`


)RUZRPHQZLWKJHVWDWLRQDOK\SHUWHQVLRQRUSUHHFODPS-VLDZLWKRXWVHYHUHIHDWXUHVLWLVVXJJHVWHGWKDWVWULFWEHGrest not be prescribed.*

Quality of evidence:/RZStrength of recommendation:4XDOLHG

*The task force acknowledged that there may be situations in ZKLFKGLHUHQWOHYHOVRIUHVWHLWKHUDWKRPHRULQWKHKRVSLWDOmay be indicated for individual women. The previous recom-mendations do not cover advice regarding overall physical ac-WLYLW\DQGPDQXDORURFHZRUN

:RPHQPD\QHHGWREHKRVSLWDOL]HGIRUUHDVRQVRWKHUWKDQEHGUHVWVXFKDVIRUPDWHUQDODQGIHWDOVXUYHLOODQFH7KHWDVNIRUFHDJUHHGWKDWKRVSLWDOL]DWLRQIRUPDWHUQDODQGIHWDOVXUYHLOODQFHis resource intensive and should be considered as a priority for research and future recommendations.

)RUZRPHQZLWKSUHHFODPSVLDZLWKRXW VHYHUH IHDWXUHVuse of ultrasonography to assess fetal growth and antena-tal testing to assess fetal status is suggested.

Quality of evidence: Moderate Strength of recommendation:4XDOLHG

,IHYLGHQFHRIIHWDOJURZWKUHVWULFWLRQLVIRXQGLQZRPHQZLWK SUHHFODPSVLD IHWRSODFHQWDO DVVHVVPHQW WKDW LQ-FOXGHVXPELOLFDODUWHU\'RSSOHUYHORFLPHWU\DVDQDGMXQFWantenatal test is recommended.


)RUZRPHQZLWKPLOGJHVWDWLRQDOK\SHUWHQVLRQRUSUHHF-lampsia without severe features and no indication for GHOLYHU\DWOHVVWKDQZHHNVRIJHVWDWLRQH[SHF-tant management with maternal and fetal monitoring is suggested.


)RUZRPHQZLWKPLOGJHVWDWLRQDOK\SHUWHQVLRQRUSUHHF-ODPSVLD ZLWKRXW VHYHUH IHDWXUHV DW RU EH\RQG ZHHNVRIJHVWDWLRQGHOLYHU\UDWKHUWKDQFRQWLQXHGREVHU-vation is suggested.


)RUZRPHQZLWK SUHHFODPSVLDZLWK V\VWROLF %3 RI OHVVthan 160 mm Hg and a diastolic BP less than 110 mm Hg DQGQRPDWHUQDOV\PSWRPVLWLVVXJJHVWHGWKDWPDJQH-sium sulfate not be administered universally for the pre-vention of eclampsia.


)RUZRPHQZLWK VHYHUH SUHHFODPSVLD DW RU EH\RQG ZHHNV RI JHVWDWLRQ DQG LQ WKRVH ZLWK XQVWDEOH maternal or fetal conditions irrespective of gestational

DJHGHOLYHU\VRRQDIWHUPDWHUQDOVWDELOL]DWLRQLVUHFRP-mended.

Quality of evidence: ModerateStrength of recommendation: Strong

)RU ZRPHQ ZLWK VHYHUH SUHHFODPSVLD DW OHVV WKDQ 0/7 weeks of gestation with stable maternal and fetal FRQGLWLRQVLWLVUHFRPPHQGHGWKDWFRQWLQXHGSUHJQDQF\be undertaken only at facilities with adequate mater-nal and neonatal intensive care resources.


)RUZRPHQZLWKVHYHUHSUHHFODPSVLDUHFHLYLQJH[SHFWDQWPDQDJHPHQWDWZHHNVRU OHVVRI JHVWDWLRQ WKHadministration of corticosteroids for fetal lung maturity EHQHWLVUHFRPPHQGHG

Quality of evidence: HighStrength of recommendation: Strong

)RUZRPHQZLWKSUHHFODPSVLDZLWKVHYHUHK\SHUWHQVLRQduring pregnancy (sustained systolic BP of at least 160 PP+JRUGLDVWROLF%3RIDWOHDVWPP+JWKHXVHRIantihypertensive therapy is recommended.


)RU ZRPHQZLWK SUHHFODPSVLD LW LV VXJJHVWHG WKDW D delivery decision should not be based on the amount of proteinuria or change in the amount of proteinuria.


)RUZRPHQZLWK VHYHUH SUHHFODPSVLD DQG EHIRUH IHWDO YLDELOLW\GHOLYHU\DIWHUPDWHUQDO VWDELOL]DWLRQ LV UHFRP-PHQGHG([SHFWDQWPDQDJHPHQWLVQRWUHFRPPHQGHG


,WLVVXJJHVWHGWKDWFRUWLFRVWHURLGVEHDGPLQLVWHUHGDQGGHOLYHU\ GHIHUUHG IRU KRXUV LI PDWHUQDO DQG IHWDO conditions remain stable for women with severe preeclampsia and a viable fetus at ZHHNVRUOHVVRIgestation with any of the following:

preterm premature rupture of membranes labor ORZSODWHOHWFRXQWOHVVWKDQPLFUROLWHU SHUVLVWHQWO\DEQRUPDOKHSDWLFHQ]\PHFRQFHQWUDWLRQV

(twice or more the upper normal values) IHWDOJURZWKUHVWULFWLRQOHVVWKDQWKHIWKSHUFHQWLOH VHYHUH ROLJRK\GUDPQLRV DPQLRWLF XLG LQGH[ OHVV

than 5 cm)


UHYHUVHG HQGGLDVWROLF RZ RQ XPELOLFDO DUWHU\ 'RSSOHUVWXGLHV

new-onset renal dysfunction or increasing renal dys-function


,WLVUHFRPPHQGHGWKDWFRUWLFRVWHURLGVEHJLYHQLIWKHIH-WXVLVYLDEOHDQGDWZHHNVRUOHVVRIJHVWDWLRQEXWthat delivery not be delayed after initial maternal stabili-]DWLRQUHJDUGOHVVRIJHVWDWLRQDODJHIRUZRPHQZLWKVH-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


)RUZRPHQZLWKSUHHFODPSVLD LW LV VXJJHVWHG WKDW WKHmode of delivery need not be cesarean delivery. The mode of delivery should be determined by fetal gesta-WLRQDODJHIHWDOSUHVHQWDWLRQFHUYLFDOVWDWXVDQGPDWHU-nal and fetal conditions.


)RUZRPHQZLWKHFODPSVLDWKHDGPLQLVWUDWLRQRISDUHQ-teral magnesium sulfate is recommended.


)RUZRPHQZLWKVHYHUHSUHHFODPSVLDWKHDGPLQLVWUDWLRQof intrapartumpostpartum magnesium sulfate to pre-vent eclampsia is recommended.


)RU ZRPHQ ZLWK SUHHFODPSVLD XQGHUJRLQJ FHVDUHDQ GHOLYHU\WKHFRQWLQXHGLQWUDRSHUDWLYHDGPLQLVWUDWLRQRIparenteral magnesium sulfate to prevent eclampsia is recommended.


)RUZRPHQZLWK+(//3V\Qdrome and before the gesta-WLRQDODJHRIIHWDOYLDELOLW\LWLVUHFRPPHQGHGWKDWGHOLY-ery be undertaken shortly after initial maternal stabili-]DWLRQ


)RUZRPHQZLWK+(//3 V\QGURPH DW ZHHNV RUPRUH RI JHVWDWLRQ LW LV UHFRPPHQGHG WKDW GHOLYHU\ EHXQGHUWDNHQVRRQDIWHULQLWLDOPDWHUQDOVWDELOL]DWLRQ


)RUZRPHQZLWK+(//3V\QGURPHIURPWKHJHVWDWLRQDODJHRI IHWDOYLDELOLW\ WRZHHNVRIJHVWDWLRQ LW LVVXJJHVWHGWKDWGHOLYHU\EHGHOD\HGIRUKRXUVLIPD-ternal and fetal condition remains stable to complete a FRXUVHRIFRUWLFRVWHURLGVIRUIHWDOEHQHW


&RUWLFRVWHURLGVKDYHEHHQXVHGLQUDQGRPL]HGFRQWUROOHGWULDOVto attempt to improve maternal and fetal condition. In these VWXGLHVWKHUHZDVQRHYLGHQFHRIEHQHWWRLPSURYHRYHUDOOPD-ternal and fetal outcome (although this has been suggested in REVHUYDWLRQDOVWXGLHV7KHUHLVHYLGHQFHLQWKHUDQGRPL]HGWUL-als of improvement of platelet counts with corticosteroid treat-ment. In clinical settings in which an improvement in platelet FRXQWLVFRQVLGHUHGXVHIXOFRUWLFRVWHURLGVPD\EHMXVWLHG

)RUZRPHQZLWKSUHHFODPSVLDZKRUHTXLUHDQDOJHVLDIRUlabor or anesthesia for cesarean delivery and with a clin-LFDO VLWXDWLRQ WKDWSHUPLWV VXFLHQW WLPH IRU HVWDEOLVK-ment of aneVWKHVLDWKHDGPLQLVWUDWLRQRIQHXUD[LDODQHV-thesia (either spinal or epidural anesthesia) is recommended.


)RUZRPHQZLWKVHYHUHSUHHFODPSVLDLWLVVXJJHVWHGWKDWinvasive hemodynamic monitoring not be used routinely.


)RU ZRPHQ LQ ZKRP JHVWDWLRQDO K\SHUWHQVLRQ SUHHF-ODPSVLDRUVXSHULPSRVHGSUHHFODPSVLDLVGLDJQRVHGLWLVsuggested that BP be monitored in the hospital or that equivalent outpatient surveillance be performed for at OHDVW KRXUV SRVWSDUWXP DQG DJDLQ GD\V DIWHU delivery or earlier in women with symptoms.


)RUDOOZRPHQLQWKHSRVWSDUWXPSHULRGQRWMXVWZRPHQZLWK SUHHFODPSVLD LW LV VXJJHVWHG WKDW GLVFKDUJH LQ-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.



)RUZRPHQLQWKHSRVWSDUWXPSHULRGZKRSUHVHQWZLWKnew-onset hypertension associated with headaches or EOXUUHGYLVLRQRUSUHHFODPSVLDZLWKVHYHUHK\SHUWHQVLRQthe parenteral administration of magnesium sulfate is suggested.


)RUZRPHQZLWKSHUVLVWHQWSRVWSDUWXPK\SHUWHQVLRQ%3RIPP+JV\VWROLFRUPP+JGLDVWROLFRUKLJKHURQDWOHDVWWZRRFFDVLRQVWKDWDUHDWOHDVWKRXUVDSDUWantihypertensive therapy is suggested. Persistent BP of 160 mm Hg systolic or 110 mm Hg diastolic or higher should be treated within 1 hour.


Management of Women With Prior Preeclampsia

:RPHQZKRKDYHKDGSUHHFODPSVLD LQ DSULRUSUHJQDQF\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 QH[WSODQQHGSUHJQDQF\'XULQJWKHSUHFRQFHSWLRQYLVLWWKHprevious pregnancy history should be reviewed and the prognosis for the upcoming pregnancy should be discussed. 3RWHQWLDOO\PRGLDEOHOLIHVW\OHDFWLYLWLHVVXFKDVZHLJKWORVVDQGLQFUHDVHGSK\VLFDODFWLYLW\VKRXOGEHHQFRXUDJHG7KHFXUUHQW VWDWXV RI PHGLFDO SUREOHPV VKRXOG EH DVVHVVHGincluding laboratory evaluation if appropriate. Medical problems such as hypertension and diabetes should be EURXJKWLQWRWKHEHVWFRQWUROSRVVLEOH7KHHHFWRIPHGLFDOproblems on the pregnancy should be discussed. Medica-WLRQVVKRXOGEHUHYLHZHGDQGWKHLUDGPLQLVWUDWLRQPRGLHGfor 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-ODPSVLD LQPRUH WKDQRQHSUHJQDQF\ WKHXVHRI ORZGRVHaspirin in the upcoming pregnancy should be suggested. :RPHQZLWKDPHGLFDOKLVWRU\RISUHHFODPSVLD VKRXOGEHLQVWUXFWHGWRUHWXUQIRUFDUHHDUO\LQSUHJQDQF\'XULQJWKHQH[WSUHJQDQF\HDUO\XOWUDVRQRJUDSK\VKRXOGEHSHUIRUPHGWR GHWHUPLQH JHVWDWLRQDO DJH DQG DVVHVVPHQW DQG YLVLWVVKRXOGEHWDLORUHGWRWKHSULRUSUHJQDQF\RXWFRPHZLWKIUH-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.


)RUZRPHQZLWKSUHHFODPSVLDLQDSULRUSUHJQDQF\SUH-conception counseling and assessment is suggested.

Quality of evidence:/RZStrength of recommendation: 4XDOLHG

Chronic Hypertension and Superimposed Preeclampsia&KURQLFK\SHUWHQVLRQK\SHUWHQVLRQSUHGDWLQJSUHJQDQF\presents special challenges to health care providers. Health FDUHSURYLGHUVPXVWUVWFRQUPWKDW WKH%3HOHYDWLRQ LVQRWSUHHFODPSVLD2QFHWKLVLVHVWDEOLVKHGLIWKH%3HOHYD-WLRQKDVQRWEHHQSUHYLRXVO\HYDOXDWHGDZRUNXSVKRXOGEHSHUIRUPHG WRGRFXPHQW WKDW%3 LV WUXO\HOHYDWHGLHQRWwhite 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-VLGHUDWLRQVGXULQJSUHJQDQF\HVSHFLDOO\LQOLJKWRIHPHUJ-ing data that suggest lowering BP excessively might have DGYHUVHIHWDOHHFWV

Perhaps the greatest challenge is the recognition of SUHHFODPSVLDVXSHULPSRVHGRQFKURQLFK\SHUWHQVLRQDFRQ-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.


)RUZRPHQZLWKIeatures suggestive of secondary hyper-WHQVLRQUHIHUUDOWRDSK\VLFLDQZLWKH[SHUWLVHLQWUHDWLQJhypertension to direct the workup is suggested.


)RU SUHJQDQW ZRPHQ ZLWK FKURQLF K\SHUWHQVLRQ DQGSRRUO\FRQWUROOHG%3WKHXVHRIKRPH%3PRQLWRULQJLVsuggested.


)RUZRPHQZLWKVXVSHFWHGZKLWHFRDWK\SHUWHQVLRQWKHXVHRIDPEXODWRU\%3PRQLWRULQJWRFRQUPWKHGLDJQR-sis before the initiation of antihypertensive therapy is suggested.



,W LV VXJJHVWHG WKDW ZHLJKW ORVV DQG H[WUHPHO\ ORZ VRGLXPGLHWVOHVVWKDQP(TGQRWEHXVHGIRUPDQ-aging chronic hypertension in pregnancy.


)RUZRPHQZLWKFKURQLFK\SHUWHQVLRQZKRDUHDFFXV-WRPHGWRH[HUFLVLQJDQGLQZKRP%3LVZHOOFRQWUROOHGit is recommended that moderate exercise be continued during pregnancy.


)RUSUHJQDQWZRPHQZLWKSHUVLVWHQW FKURQLFK\SHUWHQ-sion with systolic BP of 160 mm Hg or higher or diastolic %3RIPP+JRUKLJKHUDQWLK\SHUWHQVLYHWKHUDS\LVrecommended.


)RUSUHJQDQWZomen with chronic hypertension and BP less than 160 mm Hg systolic or 105 mm Hg diastolic and QRHYLGHQFHRI HQGRUJDQGDPDJH LW LV VXJJHVWHG WKDWthey not be treated with pharmacologic antihyperten-sive therapy.

Quality of evidence:/RZStrength of recommendation: QualLHG

For pregnant women with chronic hypertension treated ZLWKDQWLK\SHUWHQVLYHPHGLFDWLRQLW LVVXJJHVWHGWKDW%3 OHYHOV EHPDLQWDLQHG EHWZHHQ PP+J V\VWROLFand 80 mm Hg diastolic and 160 mm Hg systolic and 105 mm Hg diastolic.


)RUWKHLQLWLDOWUHDWPHQWRISUHJQDQWZRPHQZLWKFKURQLFK\SHUWHQVLRQZKRUHTXLUHSKDUPDFRORJLF WKHUDS\ ODEH-WDOROQLIHGLSLQHRUPHWK\OGRSDDUHUHFRPPHQGHGDERYHall other antihypertensive drugs.


)RUZRPHQZLWKXQFRPSOLFDWHGFKURQLFK\SHUWHQVLRQLQSUHJQDQF\WKHXVHRIDQJLRWHQVLQFRQYHUWLQJHQ]\PHLQ-KLELWRUVDQJLRWHQVLQUHFHSWRUEORFNHUVUHQLQLQKLELWRUVand mineralocorticoid receptor antagonists is not rec-ommended.


)RUZRPHQRIUHSURGXFWLYHDJHZLWKFKURQLFK\SHUWHQ-VLRQ WKH XVH RI DQJLRWHQVLQFRQYHUWLQJ HQ]\PH LQKLEL-

WRUVDQJLRWHQVLQUHFHSWRUEORFNHUVUHQLQLQKLELWRUVDQGmineralocorticoid receptor antagonists is not recom-PHQGHGXQOHVVWKHUHLVDFRPSHOOLQJUHDVRQVXFKDVWKHpresence of proteinuric renal disease.


)RU ZRPHQ ZLWK FKURQLF K\SHUWHQVLRQ ZKR DUH DW Dgreatly increased risk of adverse pregnancy outcomes (history of early-onset preeclampsia and preterm de-OLYHU\DWOHVVWKDQZHHNVRIgestation or preec-ODPSVLDLQPRUHWKDQRQHSULRUSUHJQDQF\LQLWLDWLQJWKHadministration of daily low-dose aspirin (6080 mg) be-JLQQLQJLQWKHODWHUVWWULPHVWHULVVXJJHVWHG


0HWDDQDO\VLVRIPRUHWKDQZRPHQLQUDQGRPL]HGWULDOVof aspirin to prevent preeclampsia indicates a small reduction in the incidence and morbidity of preeclampsia and reveals no evidence of acuteULVNDOWKRXJKORQJWHUPIHWDOHHFWVFDQQRWbe excluded. The number of women to treat to have a thera-SHXWLFHHFWLVGHWHUPLQHGE\SUHYDOHQFH,QYLHZRIPDWHUQDOVDIHW\DGLVFXVVLRQRI WKHXVHRIDVSLULQ LQ OLJKWRI LQGLYLGXDOULVNLVMXVWLHG

)RUZRPHQZLWKFKURQLFK\SHUWHQVLRQWKHXVHRIXOWUD-sonography to screen for fetal growth restriction is sug-gested.


,I HYLGHQFH RI IHWDO JURZWK UHVWULFWLRQ LV IRXQG LQ ZRPHQZLWKFKURQLFK\SHUWHQVLRQIHWRSODFHQWDODVVHVV-PHQWWRLQFOXGHXPELOLFDODUWHU\'RSSOHUYHORFLPHWU\DVan adjunct antenatal test is recommended.


)RU ZRPHQ ZLWK FKURQLF K\SHUWHQVLRQ FRPSOLFDWHG E\ issues such as tKHQHHGIRUPHGLFDWLRQRWKHUXQGHUO\LQJPHGLFDO FRQGLWLRQV WKDW DHFW IHWDO RXWFRPH RU DQ\ HYLGHQFHRIIHWDOJURZWKUHVWULFWLRQDQGVXSHULPSRVHGSUHHFODPSVLDDQWHQDWDOIHWDOWHVWLQJLVVXJJHVWHG


)RUZRPHQZLWKFKURQLFK\SHUWHQVLRQDQGQRDGGLWLRQDOPDWHUQDORUIHWDOFRPSOLFDWLRQVGHOLYHU\EHIRUHweeks of gestation is not recommended.


)RUZRPHQZLWKVXSHULPSRVHGSUHHFODPSVLDZKRUHFHLYHH[SHFWDQWPDQDJHPHQW DW OHVV WKDQ ZHHNV RI


JHVWDWLRQWKHDGPLQLVWUDWLRQRIFRUWLFRVWHURLGVIRUIHWDOOXQJPDWXULW\EHQHWLVUHFRPPHQGHG


)RUZRPHQZLWKFKURQLFK\SHUWHQVLRQDQGVXSHULPSRVHGSUHHFODPSVLDZLWKVHYHUHIHDWXUHVWKHDGPLQLVWUDWLRQRIintrapartumpostpartum parenteral magnesium sulfate to prevent eclampsia is recommended.


)RUZRPHQZLWKVXSHULPSRVHGSUHHFODPSVLDZLWKRXWVH-YHUH IHDWXUHVDQGVWDEOHPDWHUQDODQG IHWDO FRQGLWLRQVH[SHFWDQWPDQDJHPHQWXQWLOZHHNVRIJHVWDWLRQLVsuggested.


'HOLYHU\VRRQDIWHUPDWHUQDOVWDELOL]DWLRQLVUHFRPPHQGHGLUUHVSHFWLYHRIJHVWDWLRQDODJHRUIXOOFRUWLFRVWHURLGEHQHWfor 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: ModerateStrength of the recommendation: Strong

)RUZRPHQZLWKVXSHULPSRVHGSUHHFODPSVLDZLWKVHYHUHIHDWXUHVDWOHVVWKDQZHHNVRIJHVWDWLRQZLWKVWD-EOH PDWHUQDO DQG IHWDO FRQGLWLRQV LW LV UHFRPPHQGHG that continued pregnancy should be undertaken only at facilities with adequate maternal and neonatal intensive care resources.

Quality of evidence: ModerateStrength of evidence: Strong

)RUZRPHQZLWKVXSHULPSRVHGSUHHFODPSVLDZLWKVHYHUHIHDWXUHVH[SHFWDQWPDQDJHPHQWEH\RQGZHHNVof gestation is not recommended.

Quality of evidence: ModerateStrength of the recommendation: Strong

Later-Life Cardiovascular Disease in Women With Prior Preeclampsia

2YHUWKHSDVW\HDUVLQIRUPDWLRQKDVDFFXPXODWHGLQGL-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 ELUWKEHIRUHZHHNVRIJHVWDWLRQ7KLVKDVEHHQUHF-RJQL]HGE\WKH$PHULFDQ+HDUW$VVRFLDWLRQZKLFKQRZUHF-ommends that a pregnancy history be part of the evaluation of CV risk in women. It is the general belief that preeclamp-VLDGRHVQRWFDXVH&9GLVHDVHEXWUDWKHUSUHHFODPSVLDDQGCV disease share common risk factors. Awareness that a woman has had a preeclamptic pregnancy might allow for WKH LGHQWLFDWLRQRIZRPHQQRWSUHYLRXVO\ UHFRJQL]HGDVat-risk for earlier assessment and potential intervention. +RZHYHULWLVXQNQRZQLIWKLVZLOOEHDYDOXDEOHDGMXQFWWRSUHYLRXVLQIRUPDWLRQ,IWKLVLVWKHFDVHZRXOGWKHFXUUHQWrecommendation of assessing risk factors for women by PHGLFDOKLVWRU\ OLIHVW\OHHYDOXDWLRQ WHVWLQJ IRUPHWDEROLFDEQRUPDOLWLHVDQGSRVVLEO\LQDPPDWRU\DFWLYDWLRQDWDJH \HDUV SURYLGH DOO RI WKH LQIRUPDWLRQ WKDW ZRXOG EHgained by knowing a woman had a past preeclamptic preg-QDQF\":RXOGLWEe valuable to perform this assessment at a younger age in women who had a past preeclamptic preg-QDQF\",IWKHULVNZDVLGHQWLHGHDUOLHUZKDWLQWHUYHQWLRQRWKHU WKDQ OLIHVW\OH PRGLFDWLRQ ZRXOG SRWHQWLDOO\ EHXVHIXODQGZRXOGLWPDNHDGLHUHQFH"$UHWKHUHULVNIDF-tors that could be unmasked by pregnancy other than con-ventional risk factors? Further research is needed to determine how to take advantage of this information relat-LQJSUHHFODPSVLDWRODWHUOLIH&9GLVHDVH$WWKLVWLPHWKHWDVN IRUFH FDXWLRXVO\ UHFRPPHQGV OLIHVW\OH PRGLFDWLRQPDLQWHQDQFHRIDKHDOWK\ZHLJKWLQFUHDVHGSK\VLFDODFWLY-LW\DQGQRWVPRNLQJDQGVXJJHVWVHDUO\HYDOXDWLRQIRUWKHmost high-risk women.


)RUZRPHQZLWKDPHGLFDOKLVWRU\RISUHHFODPSVLDZKRJDYHELUWKSUHWHUPOHVVWKDQZHHNVRIJHVWDWLRQRUZKRKDYHDPHGLFDOKLVWRU\RIUHFXUUHQWSUHHFODPSVLD\HDUO\DVVHVVPHQWRI%3OLSLGVIDVWLQJEORRGJOXFRVHDQGbody mass index is suggested.*


*Although there is clear evidence of an association between SUHHFODPSVLD DQG ODWHUOLIH &9 GLVHDVH WKH YDOXH DQG DSSUR-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.


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 SODLQ QRQPHGLFDO ODQJXDJH WDNLQJ WLPH WR VSHDN VORZO\reinforcing key issues in print using pictorially based infor-PDWLRQDQGUHTXHVWLQJIHHGEDFNWRLQGLFDWHWKDWWKHSDWLHQWXQGHUVWDQGVDQGZKHUHDSSOLFDEOHKHUSDUWQHU


,W LVVXJJHVWHGWKDWKHDOWKFDUHSURYLGHUVFRQYH\LQIRU-mation about preeclampsia in the context of prenatal care and postpartum care using proven health communi-cation practices.


The State of the Science and Research Recommendations

,QWKHSDVW\HDUVVWULNLQJLQFUHDVHVLQWKHXQGHUVWDQGLQJof 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 SUHHFODPSVLDLVDPXOWLV\VWHPLFGLVHDVHWKDWDHFWVDOORUJDQsystems 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-WLRQ DQG WKH UHGXFWLRQ LQ WURSKREODVW LQYDVLRQ OHDGV WRfailed 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 PHGLDWRUVLQFOXGLQJR[LGDWLYHDQGHQGRSODVPLFUHWLFXOXPVWUHVV DQG LQDPPDWLRQ DQG VHFRQGDU\PHGLDWRUV WKDW

LQFOXGHPRGLHUVRIHQGRWKHOLDOIXQFWLRQDQGDQJLRJHQHVLVThis 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-PHQWRI WKLV FRQFHSWXDO IUDPHZRUNZLWKDWWHQWLRQ WR WKHpossibility that preeclampsia is not one disease but that the syndrome may include subsets of pathophysiology.

Clinical research advances have shown approaches to WKHUDS\WKDWZRUNHJGHOLYHU\IRUZRPHQZLWKJHVWDWLRQDOhypertension and preeclampsia without severe features at ZHHNVRIJHVWDWLRQRUGRQRWZRUNYLWDPLQ&DQGYLWDPLQ(WRSUHYHQWSUHHFODPSVLD+RZHYHUWKHUHDUHIHZFOLQLFDOUHFRPPHQGDWLRQVWKDWFDQEHFODVVLHGDVVWURQJbecause 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 RU TXDOLHG EDVHG RQ HYLGHQFH RI HHFWLYHQHVV ZHLJKHGDJDLQVWHYLGHQFHRISRWHQWLDOKDUP,QDOOLQVWDQFHVWKHQDOdecision 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 EH DGDSWHG WRPDQ\GLHUHQW VLWXDWLRQV WDNLQJ LQWR DFFRXQW WKHQHHGVDQGUHVRXUFHVSDUWLFXODUWRWKHORFDOLW\WKHLQVWLWXWLRQRUWKHtype of practice. Variations and innovations that improve the quality of patient care are to be encouraged rather than restricted. The SXUSRVHRIWKHVHJXLGHOLQHVZLOOEHZHOOVHUYHGLIWKH\SURYLGHDUPbasis on which local norms may be built.

&RS\ULJKW E\ WKH $PHULFDQ &ROOHJH RI 2EVWHWULFLDQV DQG *\QHFRORJLVWVWK6WUHHW6:32%R[:DVKLQJWRQ'&$OOULJKWVUHVHUYHG1RSDUWRIWKLVSXEOLFDWLRQPD\EHUHSURGXFHG VWRUHG LQ D UHWULHYDO V\VWHP RU WUDQVPLWWHG LQ DQ\IRUP RU E\ DQ\ PHDQV HOHFWURQLF PHFKDQLFDO SKRWRFRS\LQJUHFRUGLQJRURWKHUZLVHZLWKRXWSULRUZULWWHQSHUPLVVLRQIURPWKHpublisher.

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hipertensión en el embarazo acog2013

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