欧洲欧洲妊娠高血压疾病指南.docx

欧洲欧洲妊娠高血压疾病指南.docx

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欧洲欧洲妊娠高血压疾病指南

2019欧洲欧洲妊娠高血压疾病指南

Hypertensivedisordersinpregnancyremainamajorcauseofmaternal,fetal,andneonatalmorbidityandmortalityindevelopingandindevelopedcountries.Thesewomenareathigherriskforseverecomplicationssuchasabruptioplacentae,cerebrovascularaccident,organfailure,anddisseminatedintravascularcoagulation.Thefetusisatriskforintrauterinegrowthretardation,prematurity,andintrauterinedeath.Hypertensionisthemostcommonmedicalprobleminpregnancy,complicatingupto15%ofpregnanciesandaccountingforaboutaquarterofallantenataladmissions.t1DiagnosisandriskassessmentHighBPreadingsshouldbeconfirmedontwooccasions,usingmercurysphygmomanometry（KorotkoffVforreadingDBP）inthesittingposition,orananeroiddevice.BPmeasurementsintheleftlateralrecumbencyareareasonablealternative.OnlyvalidatedmeasuringdevicesandvalidatedambulatoryBPmonitoring（ABPM）devicesshouldbeused.Hypertensioninpregnancy,asdiagnosedbyABPM,issuperiortotheofficemeasurementofBPinpredictingoutcomes.Basiclaboratoryinvestigationsrecommendedformonitoringpregnantpatientswithhypertensionincludeurinalysis,bloodcount,haematocrit,liverenzymes,serumcreatinine,andserumuricacid.Proteinuriashouldbestandardizedin24hurinecollection（if.2g/day,closemonitoringiswarranted;if.3g/day,deliveryshouldbeconsidered）.Ultrasoundinvestigationoftheadrenalsandurinemetanephrineandnormetanephrineassaysmaybeconsideredinpregnantwomenwithhypertensiontoexcludepheochromocytomawhichmaybeasymptomaticand,ifnotdiagnosedbeforelabour,fatal.Dopplerultrasoundofuterinearteries,performedduringthesecondtrimester（.16weeks）,isusefultodetectuteroplacentalhypoperfusion,whichisassociatedwithahigherriskofpre-eclampsiaandintrauterinegrowthretardation,inbothhighriskandlowriskwomen.2DefinitionandclassificationofhypertensioninpregnancyThedefinitionofhypertensioninpregnancyisbasedonabsoluteBPvalues（SBP140mmHgorDBP90mmHg）.anddistinguishesmildly（140159/90109mmHg）orseverely（160/110mmHg）elevatedBP,incontrasttothegradesusedbytheEuropeanSocietyofHypertension（ESH）/ESC,orothers.Hypertensioninpregnancyisnotasingleentitybutcomprises：

pre-existinghypertensiongestationalhypertensionpre-existinghypertensionplussuperimposedgestationalhypertensionwithproteinuriaantenatallyunclassifiablehypertension.2.1Pre-existinghypertensionPre-existinghypertensioncomplicates15%ofpregnanciesandisdefinedasBP140/90mmHgthateitherprecedespregnancyordevelopsbefore20weeksofgestation.Hypertensionusuallypersists.42dayspost-partum.Itmaybeassociatedwithproteinuria.UndiagnosedhypertensivewomenmayappearnormotensiveinearlypregnancybecauseofthephysiologicalBPfallcommencinginthefirsttrimester.Thismaymaskthepre-existinghypertensionand,whenhypertensionisrecordedlaterinpregnancy,itmaybeinterpretedasgestational.2.2GestationalhypertensionGestationalhypertensionispregnancy-inducedhypertensionwithorwithoutproteinuria,andcomplicates67%ofpregnancies.Itisassociatedwithclinicallysignificantproteinuria（0.3g/dayina24hurinecollectionor30mg/mmolurinarycreatinineinaspotrandomurinesample）andisthenknownaspre-eclampsia.Gestationalhypertensiondevelopsafter20weeksgestationandresolvesinmostcaseswithin42dayspost-partum.Itischaracterizedbypoororganperfusion.Pre-eclampsiaisapregnancy-specificsyndromethatoccursaftermid-gestation,definedbythedenovoappearanceofhypertension,accompaniedbynew-onsetofsignificantproteinuria.0.3g/24h.Itisasystemicdisorderwithbothmaternalandfetalmanifestations.Oedemaisnolongerconsideredpartofthediagnosticcriteria,asitoccursinupto60%ofnormalpregnancies.Overall,pre-eclampsiacomplicates57%ofpregnancies,butincreasesto25%inwomenwithpre-existinghypertension.Pre-eclampsiaoccursmorefrequentlyduringthefirstpregnancy,inmultiplefetuses,hydatidiformmole,ordiabetes.Itisassociatedwithplacentalinsufficiency,oftenresultinginfetalgrowthrestriction.Additionally,pre-eclampsiaisoneofthemostcommoncausesofprematurity,accountingfor25%ofallinfantswithverylowbirthweight（,1500g）.Symptomsandsignsofseverepre-eclampsiainclude:

rightupperquadrant/epigastricpainduetoliveroedema+hepatichaemorrhageheadache+visualdisturbance（cerebraloedema）occipitallobeblindnesshyperreflexia+clonusconvulsions（cerebraloedema）HELLPsyndrome:

haemolysis,elevatedliverenzymes,lowplateletcount.Managementofpre-eclampsiafocusesessentiallyonrecognitionoftheconditionand,ultimately,deliveryoftheplacenta,whichiscurative.Asproteinuriamaybealatemanifestationofpre-eclampsia,itshouldbesuspectedwhendenovohypertensionisaccompaniedbyheadache,visualdisturbances,abdominalpain,orabnormallaboratorytests,specificallylowplateletcountandabnormalliverenzymes;itisrecommendedtotreatsuchpatientsashavingpre-eclampsia.2.3Pre-existinghypertensionplussuperimposedgestationalhypertensionwithproteinuriaWhenpre-existinghypertensionisassociatedwithfurtherworseningofBPandproteinexcretion3g/dayin24hurinecollectionafter20weeksgestation,itisclassifiedaspre-existinghypertensionplussuperimposedgestationalhypertensionwithproteinuria.2.4AntenatallyunclassifiablehypertensionWhenBPisfirstrecordedafter20weeksgestationandhypertension（withorwithoutsystemicmanifestation）isdiagnosed,itisantenatallyunclassifiablehypertension.Re-assessmentisnecessaryatorafter42dayspost-partum.3ManagementofhypertensioninpregnancyThemajorityofwomenwithpre-existinghypertensioninpregnancyhavemildtomoderatehypertension（140160/90109mmHg）,andareatlowriskforcardiovascularcomplicationswithintheshorttimeframeofpregnancy.Womenwithessentialhypertensionandnormalrenalfunctionhavegoodmaternalandneonataloutcomesandarecandidatesfornon-drugtherapybecausethereisnoevidencethatpharmacologicaltreatmentresultsinimprovedneonataloutcome.Somewomenwithtreatedpre-existinghypertensionareabletostoptheirmedicationinthefirsthalfofpregnancybecauseofthephysiologicalfallinBPduringthisperiod.However,closemonitoringand,ifnecessary,resumptionoftreatmentisnecessary.Theonlytrialoftreatmentofhypertensioninpregnancywithadequateinfantfollow-up（7.5years）wasperformed.30yearsagowitha-methyldopa.4Non-pharmacologicalmanagementandpreventionofhypertensioninpregnancyNon-pharmacologicalmanagementshouldbeconsideredforpregnantwomenwithSBPof140150mmHgorDBPof9099mmHg,orboth.Ashort-termhospitalstaymayberequiredforconfirmingthediagnosisofandrulingoutseveregestationalhypertension（pre-eclampsia）,inwhichtheonlyeffectivetreatmentisdelivery.ManagementdependsonBP,gestationalage,andthepresenceofassociatedmaternalandfetalriskfactors,andincludesclosesupervision,limitationofactivities,andsomebedrestintheleftlateralposition.Anormaldietwithoutsaltrestrictionisadvised,particularlyclosetodelivery,assaltrestrictionmayinducelowintravascularvolume.Calciumsupplementationofatleast1gdailyduringpregnancyalmosthalvedtheriskofpre-eclampsiawithoutcausinganyharm.Theeffectwasgreatestforhighriskwomen.However,theevidenceforaddedcalciuminthepreventionofhypertensivedisordersisconflicting.Fishoilsupplementationaswellasvitaminandnutrientsupplementshavenoroleinthepreventionofhypertensivedisorders.Lowdoseacetylsalicylicacid（75100mg/day）isusedprophylacticallyinwomenwithahistoryofearly-onset（,28weeks）pre-eclampsia。

Itshouldbeadministeredatbedtime,startingpre-pregnancyorfromdiagnosisofpregnancy,butbefore16weeksgestation,andshouldbecontinueduntildelivery.Weightreductionisnotrecommendedduringpregnancyinobesewomen,becauseitcanleadtoreducedneonatalweightandslowersubsequentgrowthininfantsofdietingobesemothers.However,asmaternalobesitycanresultinnegativeoutcomesforbothwomenandfetuses,guidelinesforhealthyrangesofweightgaininpregnancyhavebeenestablished.Inpregnantwomenwithnormalbodymassindex（BMI,25kg/m2）,therecommendedweightgainis11.215.9kg;foroverweightpregnantwomen（BMI25.029.9kg/m2）itis6.811.2kg;andforobesepregnantwomen（BMI30kg/m2）therecommendedweightgainis,6.8kg.5PharmacologicalmanagementofhypertensioninpregnancyDrugtreatmentofseverehypertensioninpregnancyisrequiredandbeneficial,yettreatmentoflessseverehypertensioniscontroversial.AlthoughitmightbebeneficialforthemotherwithhypertensiontoreduceherBP,alowerBPmayimpairuteroplacentalperfusionandtherebyjeopardizefetaldevelopment.Womenwithpre-existinghypertensionmaycontinuetheircurrentmedicationexceptforACEinhibitors,ARBs,anddirectrenininhibitors,whicharestrictlycontraindicatedinpregnancybecauseofseverefetotoxicity,particularlyinthesecondandthirdtrimesters.Iftakeninadvertentlyduringthefirsttrimester,switchingtoanothermedicationandclosemonitoringincludingfetalultrasoundareadvisableandusuallyaresufficient.a-Methyldopaisthedrugofchoiceforlong-termtreatmentofhypertensionduringpregnancy.Thea-/b-blockerlabetalolhasefficacycomparablewithmethyldopa.Ifthereisseverehypertensionitcanbegiveni.v.Metoprololisalsorecommended.Calciumchannelblockerssuchasnifedipine（oral）orisradipine（i.v.）aredrugs