7th Brazilian Guideline of Arterial Hypertension: Chapter 9 - Arterial Hypertension in pregnancy

MVB Malachias CEP Figueiredo N Sass IC Antonello MR Torloni MRFL Bortolotto

Epidemiology

The hypertensive syndromes of pregnancy cause expressive maternal and fetal morbidity and mortality. There is no accurate information on the incidence of preeclampsia (PE), but it is estimated to affect 4% of gestations. In Brazil, the incidence of PE is 1.5 %, while the incidence of eclampsia is 0.6%.11 Abalos E, Cuesta C, Grosso A, Chou D, Say L. Global and regional estimates of preeclampsia and eclampsia: a systematic review. Eur J Obstet Gynecol Reprod Biol. 2013;170(1):1-7. More developed areas have an incidence of eclampsia of 0.2%, with a maternal death rate of 0.8%, while for less favored regions those indices are 8.1% and 22%, respectively.22 Giordano JC, Parpinelli MA, Cecatti JG, Haddad SM, Costa ML, Surita FG, et al. The burden of eclampsia: results from a multicenter study on surveillance of severe maternal morbidity in Brazil. PLoS One. 2014;9(5):e97401. A population-based study shows AH in 7.5% of the gestations in Brazil, with 2.3% of PE and 0.5% of superimposed PE.33 Gaio DS, Schmidt MI, Duncan BB, Nucci LB, Matos MC, Branchtein L. Hypertensive disorders in pregnancy: frequency and associated factors in a cohort of Brazilian women. Hypertens Pregnancy. 2001;20(3):269-81. Arterial hypertension during pregnancy accounts for 20% to 25% of all causes of maternal death, and data from SUS show a trend towards stagnation.44 Sass N, Silveira MR, Oliveira LG, Facca T, Sato JL, Korkes HA, et al. Maternal mortality in Brazil and proportion to hypertensive disorders: a trend of stagnation. Pregnancy Hypertens. 2015;5(1):78.

Classification

This guideline recommends the American College of Obstetricians and Gynecologists's (ACOG) classification of hypertension in pregnancy55 American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122-31. (Chart 1). (GR: IIb; LE: C).

Chart 1
Classification of hypertension in pregnancy.

Concept and diagnosis criteria

Arterial hypertension in pregnancy is defined as the presence of SBP ≥ 140 mm Hg and/or DBP ≥ 90 mm Hg, considering the fifth Korotkoff sound, confirmed by another measurement after 4 hours. For BP measurement, the patient should be ideally sitting, or, alternatively, in the lateral decubitus position. Proteinuria is considered: a) protein ≥ 300 mg in 24-hour urine; b) urine albumin/creatinine ratio (UACR) ≥ 0.3 mg/mg in an isolated sample; c) positive reagent strip test in at least two samples (quantification is suggested).

Preeclampsia is defined as the presence of AH after the 20th gestational week, associated with significant proteinuria. In the absence of significant proteinuria, the diagnosis can be based on the presence of: headache, blurred vision, abdominal pain, low blood platelet count (< 100,000/mm³), elevation of liver enzymes (twice the baseline level), kidney impairment (creatinine > 1.1 mg/dL or twice the baseline level), pulmonary edema, visual or cerebral disorders, scotomas, and seizure. Eclampsia is defined as the presence of grand mal seizure in a pregnant woman with PE.

Chronic AH is defined by the detection of AH prior to pregnancy or before the 20th week of gestation. Preeclampsia might overlap. Gestational hypertension is characterized by AH after the 20th week of gestation without proteinuria.

Some clinical conditions increase the risk of PE dramatically. Severe PE should be considered in the presence of: SBP ≥ 160 or DBP ≥ 110 mm Hg; low blood platelet count; TGP twice the baseline level; persistent epigastric or right hypochondrial pain; acute kidney injury (AKI - creatinine > 1.1 mg/dL or twice the baseline level); pulmonary edema; visual or cerebral symptoms.55 American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122-31.

Preeclampsia prevention

Regarding PE prevention, there is no unequivocally effective strategy for all pregnant women. Calcium supplementation (> 1 g/day) is not recommended for pregnant women with normal intake of that ion66 Hofmeyr GJ, Lawrie TA, Atallah ÁN, Duley L, Torloni MR. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev. 2014 Jun 24;(6):CD001059. (GR: III; LE: A), but to those with low calcium intake and at intermediate and increased risk for PE.66 Hofmeyr GJ, Lawrie TA, Atallah ÁN, Duley L, Torloni MR. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev. 2014 Jun 24;(6):CD001059. (GR: I; LE: A). Low doses of acetylsalicylic acid (75-150 mg/day) at the end of the first gestational trimester can be useful for primary prevention of PE in pregnant women at intermediate and increased risk for PE.77 CLASP: a randomized trial of low-dose aspirin for the prevention and treatment of pre-eclampsia among 9364 pregnant women. CLASP (Collaborative Low dose Aspirin Study in Pregnancy) Collaborative Group. Lancet. 1994;343(8898):619-29.,88 Duley L, Henderson-Damart DJ, Meher S, King JF. Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD004659 (GR: IIa; LE: B). That use, however, is not recommended in the absence of risk.88 Duley L, Henderson-Damart DJ, Meher S, King JF. Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD004659 (GR: III; LE: A). Calcium supplementation (> 1 g/day) is associated with a reduction in the risk for PE, prematurity and a lower risk of gestational-hypertension-related death, particularly in women with a low-calcium diet (< 600 g).66 Hofmeyr GJ, Lawrie TA, Atallah ÁN, Duley L, Torloni MR. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev. 2014 Jun 24;(6):CD001059. For women at risk for PE, clinical trials have suggested a significant protective effect of the daily acetylsalicylic acid use.77 CLASP: a randomized trial of low-dose aspirin for the prevention and treatment of pre-eclampsia among 9364 pregnant women. CLASP (Collaborative Low dose Aspirin Study in Pregnancy) Collaborative Group. Lancet. 1994;343(8898):619-29. Low acetylsalicylic acid doses reduce the risk of PE by 17%, with a decrease in the fetal death risk of 14% and in the prematurity risk of 8%. Daily doses of 75-150 mg seem safe.88 Duley L, Henderson-Damart DJ, Meher S, King JF. Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD004659 Acetylsalicylic acid at low doses should be considered for primary prevention of women at high risk and should be initiated at the end of the first trimester.99 Bujold E, Roberge S, Lacasse Y, Bureau M, Audibert F, Marcoux S, et al. Prevention of preeclampsia and intrauterine growth restriction with aspirin started in early pregnancy: a meta-analysis. Obstet Gynecol. 2010;116(2 Pt 1):402-14.

Nonpharmacological treatment

For persistent AH > 150 mm Hg for more than 15 minutes, NPT alone should not be used to prevent irreversible neurological damage.1010 Committee on Obstetric Practice. Committee on Obstetric Practice. Committee Opinion No. 623: Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Obstet Gynecol. 2015;125(2):521-5. (GR: III; LE: B). Systolic BP > 155 mm Hg, especially > 160 mm Hg, is detected immediately before stroke.1111 Martin JN Jr, Thigpen BD, Moore RC, Rose CH, Cushman J, May W. Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Obstet Gynecol. 2005;105(2):246-54. Severe diastolic AH (DAH: > 105 or 110 mm Hg) does not develop before most strokes of pregnant women with severe PE.1111 Martin JN Jr, Thigpen BD, Moore RC, Rose CH, Cushman J, May W. Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Obstet Gynecol. 2005;105(2):246-54. To avoid maternal deaths, SBP > 150-160 mm Hg should indicate urgent treatment.1212 Cantwell R, Clutton-Brock T, Cooper G, Dawson A, Drife J, Garrod D, et al. Saving Mothers' Lives: reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG. 2011;118 Suppl 1:1-203. Erratum in: BJOG. 2015;122(5):e1.

Relative rest at hospital or day-hospital with monitoring is suggested for PE. (GR: IIa; LE: B). Hospitalization should be indicated to pregnant patients with severe AH. (GR: I; LE: B). A systematic review has shown no difference in outcomes between strict rest and relative rest for pregnant women with AH and proteinuria. Relative rest at hospital, as compared with routine house activity, reduces the risk for severe AH; however, data do not support a clear recommendation. Rest is not routinely indicated for gestational hypertension.1313 Meher S, Abalos E, Carroli G. Bed rest with or without hospitalisation for hypertension during pregnancy. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD003514. Prenatal care units and hospitals have similar clinical outcomes for mothers and newborns, but women might prefer day-hospitals.1414 Dowswell T, Middleton P, Weeks A. Antenatal day care units versus hospital admission for women with complicated pregnancy. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD001803.

Although there is no indication for specific care during hospitalization, maternal and fetal monitoring is required. Blood pressure should be periodically measured, with daily weight and diuresis assessment, and patients should be instructed about premonitory signs. Laboratory tests, such as hemogram with platelet count, liver enzymes, uric acid, creatinine and proteinuria, should be performed once to twice a week. Fetal follow-up comprises assessment of growth, movements, well-being and biophysical profile, as well as US.

Expectant management

Expectant management is not recommended after the 36th gestational week for women with gestational hypertension.1515 Koopmans CM, Bijlenga D, Groen H, Vijgen SM, Aarnoudse JG, Bekedam DJ, et al; HYPITAT study group. Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation (HYPITAT): a multicentre, open-label randomised controlled trial. Lancet. 2009;374(9694):979-88. (GR: III; LE: B). Expectant management is suggested between the 34th and 36th gestational weeks for stable women, without clinical worsening or severe hypertension.1616 Broekhuijsen K, van Baaren GJ, van Pampus MG, Ganzevoort W, Sikkema JM, Woiski MD, et al; HYPITAT-II study group. Immediate delivery versus expectant monitoring for hypertensive disorders of pregnancy between 34 and 37 weeks of gestation (HYPITAT-II): an open-label, randomised controlled trial. Lancet. 2015;385(9986):2492-501. Erratum in: Lancet. 2016;387(10021):848. (GR: IIa; LE: B). Premature delivery for patients with PE can be associated with decreased mortality. The ideal delivery time, before the 32nd-34th weeks, is a dilemma because of the uncertainty in the balance between maternal safety (end of pregnancy) and fetal maturity (expectant).1717 Ronsmans C, Campbell O. Quantifying the fall in mortality associated with interventions related to hypertensive diseases of pregnancy. BMC Public Health. 2011;11 Suppl 3:S8. After the 34th week, survival is high and the baby and placenta delivery is effective in developed countries.1717 Ronsmans C, Campbell O. Quantifying the fall in mortality associated with interventions related to hypertensive diseases of pregnancy. BMC Public Health. 2011;11 Suppl 3:S8.

The HYPITAT study has compared delivery induction versus expectant monitoring for severe AH or mild PE after the 36th week.1515 Koopmans CM, Bijlenga D, Groen H, Vijgen SM, Aarnoudse JG, Bekedam DJ, et al; HYPITAT study group. Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation (HYPITAT): a multicentre, open-label randomised controlled trial. Lancet. 2009;374(9694):979-88. Women in the intervention group had a 29% lower risk of worse maternal outcome, without affecting neonatal outcome, suggesting that expectant treatment after 36 weeks is not indicated.1515 Koopmans CM, Bijlenga D, Groen H, Vijgen SM, Aarnoudse JG, Bekedam DJ, et al; HYPITAT study group. Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation (HYPITAT): a multicentre, open-label randomised controlled trial. Lancet. 2009;374(9694):979-88. In the HYPTAT-II study, with non-severe AH between the 34th and 37th weeks, expectant management increased maternal risk as compared to immediate delivery, but decreased the occurrence of neonatal respiratory distress syndrome. In that situation, immediate delivery is not justified, and expectant monitoring until the clinical situation worsens should be considered.1616 Broekhuijsen K, van Baaren GJ, van Pampus MG, Ganzevoort W, Sikkema JM, Woiski MD, et al; HYPITAT-II study group. Immediate delivery versus expectant monitoring for hypertensive disorders of pregnancy between 34 and 37 weeks of gestation (HYPITAT-II): an open-label, randomised controlled trial. Lancet. 2015;385(9986):2492-501. Erratum in: Lancet. 2016;387(10021):848.

Pharmacological treatment

Urgent pharmacological treatment is indicated in severe AH (SBP > 155-160 mm Hg)1010 Committee on Obstetric Practice. Committee on Obstetric Practice. Committee Opinion No. 623: Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Obstet Gynecol. 2015;125(2):521-5.,1111 Martin JN Jr, Thigpen BD, Moore RC, Rose CH, Cushman J, May W. Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Obstet Gynecol. 2005;105(2):246-54. and presence of premonitory signs. (GR: I; LE: B). The treatment of severe AH in emergency situations can be performed with intravenous (IV) hydralazine (5 mg, repeat 5-10 mg IV every 30 minutes until the maximum of 20 mg). In exceptional situations, such as acute pulmonary edema (APE) and refractory severe SAH, the use of sodium nitroprusside (SNP) should be the preferential option for urgent BP control.1818 Sass N, Itamoto CH, Silva MP, Torloni MR, Atallah NA. Does sodium nitroprusside kill babies? A systematic review. Sao Paulo Med J. 2007;125(2):108-11. Oral administration of rapid-acting nifedipine (5 mg every 30 minutes) is an alternative, but associated complications have been reported.1919 Impey L. Severe hypotension and fetal distress following sublingual administration of nifedipine to a patient with severe pregnancy induced hypertension at 33 weeks. Br J Obstet Gynaecol. 1993;100(10):959-61. Although sublingual nifedipine is not indicated in other forms of hypertensive crisis (HC), it is an alternative in gestational hypertension. Its use for hypertensive emergency (HE), however, has been considered bad practice, harmful to the patient in a report by the São Paulo Regional Medical Board.

Pharmacological treatment should be initiated whenever BP is > 150/100 mm Hg,1212 Cantwell R, Clutton-Brock T, Cooper G, Dawson A, Drife J, Garrod D, et al. Saving Mothers' Lives: reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG. 2011;118 Suppl 1:1-203. Erratum in: BJOG. 2015;122(5):e1. aiming at maintaining it 130-150/80-100 mm Hg. (GR: IIa; LE: B). For stable patients with PE, not requiring immediate delivery, oral antihypertensive treatment is indicated. Treatment with antihypertensive agents reduces the risk for severe AH, but not the risk for PE, restricted intrauterine growth, placental abruption and neonatal outcomes.2020 Abalos E, Duley L, Steyn DW, Henderson-Smart DJ. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD002252. Treatment to meet the DBP target of 85 mm Hg as compared to 100 mm Hg showed neither maternal nor obstetric benefit, except for the less frequent occurrence of severe AH in the group with stricter control.2121 Magee LA, von Dadelszen P, Rey E, Ross S, Asztalos E, Murphy KE, et al. Less-tight versus tight control of hypertension in pregnancy. N Engl J Med. 2015;372(5):407-17.

The choice of the antihypertensive drug depends on the attending physician's experience and familiarity with the drug chosen and its possible side effects.2222 Duley L, Henderson-Smart DJ, Meher S. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD001449. (GR: IIb; LE: B). The use of ACEIs, ARBs and direct renin inhibitors is contraindicated in pregnancy (GR: I; LE: B), and atenolol and prazosin should be avoided.2222 Duley L, Henderson-Smart DJ, Meher S. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD001449.,2323 From the Centers for Disease Control and Prevention. Postmarketing surveillance for angiotensin-converting enzyme inhibitor use during the first trimester of pregnancy - United States, Canada and Israel, 1987-1995. JAMA. 1997;277(15):1193-4. (GR: IIa; LE: B). In Brazil, the available oral drugs usually used are methyldopa, BBs (except atenolol), hydralazine and CCBs (nifedipine, amlodipine and verapamil). Atenolol is associated with a reduction in fetal growth, and prazosin can cause natimortality.2424 Easterling TR, Carr DB, Brateng D, Diederichs C, Schmucker B. Treatment of hypertension in pregnancy: effect of atenolol on maternal disease, preterm delivery, and fetal growth. Obstet Gynecol. 2001;98(3):427-33.

25 Easterling TR, Brateng D, Schmucker B, Brown Z, Millard SP. Prevention of preeclampsia: a randomized trial of atenolol in hyperdynamic patients before onset of hypertension. Obstet Gynecol.1999;93(5 Pt 1):725-33.
-2626 Hall DR, Odendaal HJ, Steyn DW, Smith M. Nifedipine or prazosin as a second agent to control early severe hypertension in pregnancy: a randomized control trial. BJOG. 2000;107(6):759-65. For PE, the prescription of a DIU is usually avoided; thiazide DIUs, however, can be continued in pregnant women with chronic AH (CAH),2727 Sibai BM, Grossman RA, Grossman HG. Effects of diuretics on plasma volume in pregnancies with long-term hypertension. Am J Obstet Gynecol. 1984;150(7):831-5. as long as they do not cause volume depletion.

Magnesium sulfate is recommended for eclampsia prevention and treatment. (GR: I; LE: B). In case of HE or of hypertensive urgency (HU) requiring hospitalization, intensive monitoring, preterm delivery and parenteral administration of antihypertensive drugs, the IV administration of magnesium sulfate, considered the drug of choice to prevent and treat eclampsia, is recommended.55 American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122-31.,2828 Altman D, Carroli G, Duley L, Farrell B, Moodley J, Neilson J, et al; Magpie Trial Collaboration Group. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet. 2002;359(9321):1877-90.

29 Ministério da Saúde. Secretaria de Atenção à Saúde. Gestação de alto risco: manual técnico. 5a ed. Brasilia; 2012.
-3030 Sibai BM. Magnesium sulfate prophylaxis in preeclampsia: Lessons learned from recent trials. Am J Obstet Gynecol. 2004;190(6):1520-6. Magnesium sulfate is administered at an attack dose of 4-6 g IV for 10-20 minutes, followed by infusion of 1-3 g/h, usually for 24 hours. If the seizure reoccurs, 2-4 g can be administered IV. Deep intramuscular administration of 10 g (5 g in each gluteus), followed by intramuscular 5 g every 4 hours for 24 hours is an alternative. Magnesium sulfate is indicated during labor for patients with severe PE. Magnesium sulfate administration should continue for up to 24 hours after seizure, imminent eclampsia signs and delivery. Its administration should be generous to patients with PE, preferably before the administration of rapid-acting antihypertensive drugs to patients, in whom the possibility of eclampsia cannot be ruled out.

Other important aspects

Severe AH, per se, is not an indication for C section. In the presence of stable maternal clinical findings, good fetal vitality and lack of other C section indications, pregnancy termination can occur by delivery induction, always considering maternal clinical condition and fetal vitality during the procedure.55 American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122-31.,2929 Ministério da Saúde. Secretaria de Atenção à Saúde. Gestação de alto risco: manual técnico. 5a ed. Brasilia; 2012. Labor analgesia is recommended with local-regional techniques (peridural or combined analgesia). Severe thrombocytopenia contraindicates anesthesia with lumbar puncture, and, if C section is required, it should be performed under general anesthesia. Invasive central monitoring is reserved to cases with hemodynamic instability (respiratory failure, disseminated intravascular coagulation related to placental abruption, or HELLP syndrome).55 American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122-31.

Antihypertensive treatment in lactating women

Chart 2 shows the antihypertensive drugs available in Brazil considered safe, moderately safe and not recommended.3131 Chaves RG, Lamounier JA, César CC. Medicines and breastfeeding: update and revision applied to mother and baby care. Rev Paul Pediatr. 2007;25(3):276-88.,3232 Sociedade Brasileira de Cardiologia; Sociedade Brasileira de Hipertensão; Sociedade Brasileira de Nefrologia. [VI Brazilian Guidelines on Hypertension]. Arq Bras Cardiol. 2010;95(1 Suppl):1-51. Erratum in: Arq Bras Cardiol. 2010;95(4):553. (GR: IIb, LE: C).

Chart 2
Safety of the infant breastfed by a lactating woman on antihypertensive drugs.

References

  • 1
    Abalos E, Cuesta C, Grosso A, Chou D, Say L. Global and regional estimates of preeclampsia and eclampsia: a systematic review. Eur J Obstet Gynecol Reprod Biol. 2013;170(1):1-7.
  • 2
    Giordano JC, Parpinelli MA, Cecatti JG, Haddad SM, Costa ML, Surita FG, et al. The burden of eclampsia: results from a multicenter study on surveillance of severe maternal morbidity in Brazil. PLoS One. 2014;9(5):e97401.
  • 3
    Gaio DS, Schmidt MI, Duncan BB, Nucci LB, Matos MC, Branchtein L. Hypertensive disorders in pregnancy: frequency and associated factors in a cohort of Brazilian women. Hypertens Pregnancy. 2001;20(3):269-81.
  • 4
    Sass N, Silveira MR, Oliveira LG, Facca T, Sato JL, Korkes HA, et al. Maternal mortality in Brazil and proportion to hypertensive disorders: a trend of stagnation. Pregnancy Hypertens. 2015;5(1):78.
  • 5
    American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122-31.
  • 6
    Hofmeyr GJ, Lawrie TA, Atallah ÁN, Duley L, Torloni MR. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev. 2014 Jun 24;(6):CD001059.
  • 7
    CLASP: a randomized trial of low-dose aspirin for the prevention and treatment of pre-eclampsia among 9364 pregnant women. CLASP (Collaborative Low dose Aspirin Study in Pregnancy) Collaborative Group. Lancet. 1994;343(8898):619-29.
  • 8
    Duley L, Henderson-Damart DJ, Meher S, King JF. Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD004659
  • 9
    Bujold E, Roberge S, Lacasse Y, Bureau M, Audibert F, Marcoux S, et al. Prevention of preeclampsia and intrauterine growth restriction with aspirin started in early pregnancy: a meta-analysis. Obstet Gynecol. 2010;116(2 Pt 1):402-14.
  • 10
    Committee on Obstetric Practice. Committee on Obstetric Practice. Committee Opinion No. 623: Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Obstet Gynecol. 2015;125(2):521-5.
  • 11
    Martin JN Jr, Thigpen BD, Moore RC, Rose CH, Cushman J, May W. Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Obstet Gynecol. 2005;105(2):246-54.
  • 12
    Cantwell R, Clutton-Brock T, Cooper G, Dawson A, Drife J, Garrod D, et al. Saving Mothers' Lives: reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG. 2011;118 Suppl 1:1-203. Erratum in: BJOG. 2015;122(5):e1.
  • 13
    Meher S, Abalos E, Carroli G. Bed rest with or without hospitalisation for hypertension during pregnancy. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD003514.
  • 14
    Dowswell T, Middleton P, Weeks A. Antenatal day care units versus hospital admission for women with complicated pregnancy. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD001803.
  • 15
    Koopmans CM, Bijlenga D, Groen H, Vijgen SM, Aarnoudse JG, Bekedam DJ, et al; HYPITAT study group. Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation (HYPITAT): a multicentre, open-label randomised controlled trial. Lancet. 2009;374(9694):979-88.
  • 16
    Broekhuijsen K, van Baaren GJ, van Pampus MG, Ganzevoort W, Sikkema JM, Woiski MD, et al; HYPITAT-II study group. Immediate delivery versus expectant monitoring for hypertensive disorders of pregnancy between 34 and 37 weeks of gestation (HYPITAT-II): an open-label, randomised controlled trial. Lancet. 2015;385(9986):2492-501. Erratum in: Lancet. 2016;387(10021):848.
  • 17
    Ronsmans C, Campbell O. Quantifying the fall in mortality associated with interventions related to hypertensive diseases of pregnancy. BMC Public Health. 2011;11 Suppl 3:S8.
  • 18
    Sass N, Itamoto CH, Silva MP, Torloni MR, Atallah NA. Does sodium nitroprusside kill babies? A systematic review. Sao Paulo Med J. 2007;125(2):108-11.
  • 19
    Impey L. Severe hypotension and fetal distress following sublingual administration of nifedipine to a patient with severe pregnancy induced hypertension at 33 weeks. Br J Obstet Gynaecol. 1993;100(10):959-61.
  • 20
    Abalos E, Duley L, Steyn DW, Henderson-Smart DJ. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD002252.
  • 21
    Magee LA, von Dadelszen P, Rey E, Ross S, Asztalos E, Murphy KE, et al. Less-tight versus tight control of hypertension in pregnancy. N Engl J Med. 2015;372(5):407-17.
  • 22
    Duley L, Henderson-Smart DJ, Meher S. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD001449.
  • 23
    From the Centers for Disease Control and Prevention. Postmarketing surveillance for angiotensin-converting enzyme inhibitor use during the first trimester of pregnancy - United States, Canada and Israel, 1987-1995. JAMA. 1997;277(15):1193-4.
  • 24
    Easterling TR, Carr DB, Brateng D, Diederichs C, Schmucker B. Treatment of hypertension in pregnancy: effect of atenolol on maternal disease, preterm delivery, and fetal growth. Obstet Gynecol. 2001;98(3):427-33.
  • 25
    Easterling TR, Brateng D, Schmucker B, Brown Z, Millard SP. Prevention of preeclampsia: a randomized trial of atenolol in hyperdynamic patients before onset of hypertension. Obstet Gynecol.1999;93(5 Pt 1):725-33.
  • 26
    Hall DR, Odendaal HJ, Steyn DW, Smith M. Nifedipine or prazosin as a second agent to control early severe hypertension in pregnancy: a randomized control trial. BJOG. 2000;107(6):759-65.
  • 27
    Sibai BM, Grossman RA, Grossman HG. Effects of diuretics on plasma volume in pregnancies with long-term hypertension. Am J Obstet Gynecol. 1984;150(7):831-5.
  • 28
    Altman D, Carroli G, Duley L, Farrell B, Moodley J, Neilson J, et al; Magpie Trial Collaboration Group. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet. 2002;359(9321):1877-90.
  • 29
    Ministério da Saúde. Secretaria de Atenção à Saúde. Gestação de alto risco: manual técnico. 5a ed. Brasilia; 2012.
  • 30
    Sibai BM. Magnesium sulfate prophylaxis in preeclampsia: Lessons learned from recent trials. Am J Obstet Gynecol. 2004;190(6):1520-6.
  • 31
    Chaves RG, Lamounier JA, César CC. Medicines and breastfeeding: update and revision applied to mother and baby care. Rev Paul Pediatr. 2007;25(3):276-88.
  • 32
    Sociedade Brasileira de Cardiologia; Sociedade Brasileira de Hipertensão; Sociedade Brasileira de Nefrologia. [VI Brazilian Guidelines on Hypertension]. Arq Bras Cardiol. 2010;95(1 Suppl):1-51. Erratum in: Arq Bras Cardiol. 2010;95(4):553.

Publication Dates

  • Publication in this collection
    Sept 2016
Sociedade Brasileira de Cardiologia - SBC Av. Marechal Câmara, 160 - 3º Andar - Sala 330, 20020-907, Centro, Rio de Janeiro, RJ - Brazil, Tel.: +55 21 3478-2700, Fax: +55 21 3478-2770 - São Paulo - SP - Brazil
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