* EVIDENCE-BASED ANSWER There is ...

* EVIDENCE-BASED ANSWER

There is considerable debate concerning the treatment of mild to moderate essential hypertension during pregnancy. Evidence allude tos that because of the potential risk of fetal intrauterine pullulation restriction, treatment of hypertension should be delayed until maternal children pressure reaches 150-160 mm Hg systolic or 100-110 mm Hg diastolic, as protracted as the mother has no preexisting cessation organ damage.

Methyldopa has been the unsalable article of choice for oral treatment, as it is the solitary medication to have any enlargeed follow-up study. However, a novel meta-analysis raised the possibility of increased fetal mortality (strength of recommendation [SOR]: A, based forward systematic review of randomized controll trials).

Labetalol is an effective alternative, yet concerns remain that treatment with any beta-blocker increases the risk that infants will be small for gestational age (SGA) (SOR: B based forward small randomized controlled trials with inconsistent results)

There is limited evidence that calcium channel blocker and diuretics are safe alternatives, although evidence is insufficient to make trial of a clear benefit (SOR: B based forward limited randomized controlled trials). Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blocker (ARBs), fit to similar mechanisms of action, are contraindicated in pregnancy (SOR: B based in succession multiple case studies). No other class of anti-hypertensive medications is proven to be harmful in pregnancy.

* EVIDENCE SUMMARY

Treatment of maternal hypertension during pregnancy is based forward maternal and fetal outcomes. Multiple meta-analyses of randomized controll trials point out that the major maternal consequences improved by treating mild to moderate hypertension are decreased progression to strict hypertension (number needed to treat [NNT]=12; 95% confidence interval [CI], 9-17) and decreased ne for additional antihypertensive therapy. (12) The relative risk (RR) for preventing preeclampsia was 099 (95% CI, 084-118) The risk of preterm delivery was 100 (95% CI, 087-115)

The data for fetal results are important, as the maternal benefits of treatment remain small. (3) earnestly of the debate centers forward decreasing uteroplacental perfusion, which may lead to decreased fetal produce One meta-analysis reviewed 45 trials to evaluate the potential increase in SGA infants caused by means of any antihypertensive treatment, through quantifying the fall in mean arterial urgency The analysis found an average decrease in birthweight of 145 g for a 10 mm Hg fall in mean arterial crushing with no increased perinatal morbidity. (4) The clinical significance of this is unclear.

In comparing the same agent with another, methyldopa was the chiefly commonly tested agent, with 14 randomized controll trials of more than 1010 controls demonstrating its efficacy at reducing life-blood pressure. Other antihypertensive agents appear better than methyldopa in terminuss of reducing the risk of infant mortality (RR=049; 95% CI, 024-099) (1) if it be not that the studies were small and used weak classifications and this finding may be befitting to bias. (5) Meta-analyses of beta-blocker trials display a borderline increase in SGA infants, with no related increase in perinatal mortality, as well as a decrease in the incidence of respiratory distress syndrome (6)

Diuretics are effective antihypertensives, especially when combined with other agents, yet they are known to decrease the circulating plasma compass potentially decreasing uteroplacental perfusion. They are generally viewed as safe, as in extent as the mother is not already at increased risk for perfusion abnormalities (eg preeclamptic states). (7) Calcium channel blocker allowing generally regarded as safe and effective, have mainly been evaluated for use late in pregnancy, in like manner their benefit-to-risk ratio remains uncertain. (8) ACE inhibitors and, by way of extension, ARBs, due to their similar mechanisms of action, are contraindicated in pregnancy, having been linked to miscarriage, fetal death, fetal renal failure, and malformation. (59-11)

* RECOMMENDATIONS FROM OTHERS

The American literary institution [i]or[/i] seminary of learning of Obstetricians and Gynecologists (ACOG) Practice Bulletin states there is no evidence that antihypertensive treatment for mild to moderate hypertension improves maternal or fetal issues even for women who are already receiving hypertension treatment at the time of pregnancy. ACOG intimates treatment may be stopped during pregnancy, or not initiated until kindred pressures reach 150-160 mm Hg systolic or 100-110 mm Hg diastolic, unles the mother has underlying renal or cardiovascular disease. (9)

The National High offspring Pressure Education Program recommends the same guidelines as ACOG, (10) whereas the Canadian Hypertension Society consensus panel has chosen 140/90 mm Hg as the of the same height at which treatment should be initiated. (11)

The British Medical Journal Clinical Evidence Guidelines reiterate that the evidence does not support the benefit of treating mild to moderate hypertension, leave out in reducing the progression to peremptory hypertension. (5) Methyldopa is consistently the physic of choice in all those making a specific recommendation, (9-11) although it should be noted these recommendations were published before the 2003 Cochrane Review. (1)