restricted access 12. Iatrogenic Aspects of Hypertension in Pregnancy: Focus on Preeclampsia
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HYPERTENSION IN PREGNANCY: WHERE DO WE STAND? Hypertensive disorders in pregnancy (HDP), especially preeclampsia, are closely associated with increased maternal and perinatal morbidity and mortality (1). However , the lack of consensus on the classification and diagnostic criteria for HDP has contributed to controversial clinical attitudes ­ toward management of the disease. Traditionally, blood pressure (BP) and proteinuria represented the two main clinical pillars on which dif­ fer­ ent classifications and definitions of HDP have been proposed by vari­ ous international socie­ ties (2–5). In 2014, the International Society for the Study of Hypertension in Pregnancy (ISSHP) recommended that proteinuria should not be considered a stable clinical partner of hypertension for the diagnosis of preeclampsia (5). Indeed, abnormal placental function or placentation may result in dif­ fer­ ent clinical manifestations and consequences for ­ woman and fetus that may develop before the establishment of proteinuria. Dif­ fer­ ent biomarkers (e.g., angiogenic ­ factors, metabolomics) have been proposed as early predictors of HDP (6). However, the diagnosis of the disease still remains clinical ­ because the clinical value of such biomarkers has not been proven in large cohorts of pregnant ­ women. According to the recent classification proposed by ISSHP (5), HDP comprise the following disorders: 1. Chronic hypertension: History of hypertension before pregnancy or high BP (i.e., systolic BP greater than or equal to 140 mmHg and/or diastolic BP greater than or equal to 90 mmHg) occurs during the first trimester of pregnancy. Chronic hypertension may be essential or secondary. Although essential chronic hypertension is by far the most frequent phenotype, known or suspected secondary forms may also be detected. Suspected secondary hypertension in the first trimester could be at least partly investigated by noninvasive testing such as cardiovascular and renal echography for the following ­ causes: primary renal parenchymal disease, renal artery stenosis (fibromuscular hyperplasia), and coarctation of aorta. Definitive diagnosis of suspected primary hyperalosteronism is not feasible during pregnancy. Although sleep apnea represents a usual bystander of essential hypertension in ­ women of reproductive age, it is not yet CHAPTER 12 Iatrogenic Aspects of Hypertension in Pregnancy Focus on Preeclampsia Costas Thomopoulos and Thomas Makris 144 / Iatrogenic Aspects of Hypertension in Pregnancy: Focus on Preeclampsia • To what levels should BP be lowered? • Should lifestyle changes (e.g., weight loss, reduced salt consumption) be advised during pregnancy? • How should pregnancies at high risk for HDP development be discriminated? Navigating Through Definitions and Recommendations HDP definition and classification are ever changing and debated, raising the hypothesis that evidence is not always supported by enough and strong data. Generally, the clarity of disease definition might help good clinical practice attitudes and result in outcome benefits for both ­ woman and fetus. However, when definitions and recommendations rely mainly on expert opinion, the real-­ world evidence in the field remains highly questionable. The scarcity of well-­ designed controlled studies in HDP makes it almost compelling to draw evidence only from cohort or case-­ control studies and to recruit opinions based on personal clinical experience or reports of expert committees. The low quality of evidence irrespective of the strength of recommendations is the main barrier to good clinical practice and represents the main source of clinical bias and iatrogenic issues in HDP (see Figure 12-1). BP Mea­sure­ment Iatrogenic aspects can result from inadequate BP mea­ sure­ ment during pregnancy. Confirming or excluding the diagnosis of hypertension has impor­ tant consequences for the remaining course of pregnancy and can lead to ­ either unnecessary treatment including preterm delivery or conservative management of a high-­ risk pregnancy with already established HDP. In the general population , treatment of hypertension can prevent outcomes that may occur ­ after several years or de­ cades from initial diagnosis, but diagnosis and treatment of HDP anticipate maternal and perinatal outcomes for only a few weeks. In addition, it is impor­ tant to confirm normal BP values ­ either prepregnancy or in early pregnancy, before the observed physiological BP decline in early midpregnancy (8). For example, a ­ woman with unknown preexisting hypertension and without BP evaluation in the first trimester may pres­ ent well established ­ whether its diagnosis may be pursued in pregnancy (7). 2. Gestational hypertension: De novo hypertension (i.e., systolic BP greater than or equal to 140 mmHg and/or diastolic BP greater than or equal to 90 mmHg) occurs­ after the 20th week of gestation. In this case, exclusion of preeclampsia is mandatory to validate the final diagnosis. 3. Preeclampsia (de novo or superimposed on chronic hypertension): ­ Either gestational or chronic hypertension...


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