Gestational hypertension resident survival guide: Difference between revisions
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! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align="center" |{{fontcolor|#2B3B44|Gestational hypertension Resident Survival Guide Microchapters}} | |||
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Gestational hypertension resident survival guide#Overview|Overview]] | |||
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Gestational hypertension resident survival guide#Causes|Causes]] | |||
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Gestational hypertension resident survival guide#Diagnosis|Diagnosis]] | |||
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Gestational hypertension resident survival guide#Treatment|Treatment]] | |||
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Gestational hypertension resident survival guide#Dos|Dos]] | |||
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Gestational hypertension resident survival guide#Don'ts|Don'ts]] | |||
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{{WikiDoc CMG}}; {{AE}} {{RAB}} {{ Samah Obaiah}} | |||
{{SK}} Approach to pregnancy-induced hypertension; Gestational hypertension workup, Gestational hypertension management | |||
{{SK}} | |||
==Overview== | ==Overview== | ||
[[Gestational hypertension]] or [[Pregnancy-induced hypertension]] (PIH) , is defined as systolic blood pressure (SBP) >140 mmHg and diastolic blood pressure (DBP) >90 mmHg on at least two occasions at least 6 hours apart after the 20th week of gestation in women known to be normotensive before pregnancy and before 20 weeks’ gestation. The BP recordings used to establish the diagnosis should be no more than 7 days apart. Gestational hypertension is considered severe if there is sustained elevations in systolic | [[Gestational hypertension]] or [[Pregnancy-induced hypertension]] (PIH) , is defined as [[systolic blood pressure]] (SBP) >140 mmHg and [[diastolic blood pressure]] (DBP) >90 mmHg on at least two occasions at least 6 hours apart after the 20th week of [[gestation]] in women known to be [[normotensive]] before [[pregnancy]] and before 20 weeks’ [[gestation]]. The [[BP]] recordings used to establish the [[diagnosis]] should be no more than 7 days apart. [Gestational hypertension]] is considered severe if there is sustained elevations in [[systolic blood pressure]] to at least 160 mm Hg and/or in [[diastolic blood pressure]] to at least 110 mm Hg for at least 6 hours. It is classified as mild , moderate , and severe . The WHO classified it is one of the main causes of maternal, [[fetal]], and [[neonatal]] [[mortality]] and [[morbidity]].<ref name="pmid26158653">{{cite journal| author=Kintiraki E, Papakatsika S, Kotronis G, Goulis DG, Kotsis V| title=Pregnancy-Induced hypertension. | journal=Hormones (Athens) | year= 2015 | volume= 14 | issue= 2 | pages= 211-23 | pmid=26158653 | doi=10.14310/horm.2002.1582 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26158653 }} </ref>.[[gestational hypertension]] is one of the most common medical disorders affecting [[pregnancy]]. The most serious [[maternal]] complications of [[gestational hypertension]] include [[intracerebral hemorrhage]],[[eclampsia]], and [[renal failure]], as well as [[hemolysis]], elevated [[liver enzymes]], and low [[platelets]] ([[HELLP]]) syndrome and posterior reversible [[encephalopathy]] syndrome (PRES).<ref name="pmid19332964">{{cite journal| author=Marik PE| title=Hypertensive disorders of pregnancy. | journal=Postgrad Med | year= 2009 | volume= 121 | issue= 2 | pages= 69-76 | pmid=19332964 | doi=10.3810/pgm.2009.03.1978 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19332964 }} </ref>Treatment of [[gestational hypertension]] depends on blood pressure levels, [[gestational]] age, presence of symptoms and associated risk factors. | ||
==Causes== | ==Causes== | ||
The cause of [[gestational hypertension]] is unknown. If untreated will be life-threatening, severe [[gestational hypertension]] may cause dangerous [[seizures]] (eclampsia) and even death in the mother and [[fetus]]. Because of these risks, it may be necessary for the baby to be delivered early, before the full term of [[pregnancy]]. Some conditions may increase the risk of developing the condition, including the following: | The cause of [[gestational hypertension]] is unknown. If untreated will be life-threatening, severe [[gestational hypertension]] may cause dangerous [[seizures]] ([[eclampsia]]) and even death in the mother and [[fetus]]. Because of these risks, it may be necessary for the baby to be delivered early, before the full term of [[pregnancy]]. Some conditions may increase the risk of developing the condition, including the following<ref name="urlHypertension In Pregnancy - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK430839/ |title=Hypertension In Pregnancy - StatPearls - NCBI Bookshelf |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><ref name="pmid16580277">{{cite journal |vauthors=Villar J, Carroli G, Wojdyla D, Abalos E, Giordano D, Ba'aqeel H, Farnot U, Bergsjø P, Bakketeig L, Lumbiganon P, Campodónico L, Al-Mazrou Y, Lindheimer M, Kramer M |title=Preeclampsia, gestational hypertension and intrauterine growth restriction, related or independent conditions? |journal=Am J Obstet Gynecol |volume=194 |issue=4 |pages=921–31 |date=April 2006 |pmid=16580277 |doi=10.1016/j.ajog.2005.10.813 |url= |issn=}}</ref>: | ||
*History of [[hypertension]] | *History of [[hypertension]] | ||
*[[Kidney disease]] | *[[Kidney disease]] | ||
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*Multiple [[fetuses]] ([[twins]], [[triplets]]) | *Multiple [[fetuses]] ([[twins]], [[triplets]]) | ||
*African-American race | *African-American race | ||
===Common Causes=== | ===Common Causes=== | ||
Pathogenesis theories developed about the passable causes: | Pathogenesis theories developed about the passable causes: | ||
*Insufficient [[blood flow]] to the [[uterus]] or abnormal [[placental]] [[implantation]] | |||
*Insufficient [[blood flow]] to the uterus or abnormal [[placental]] implantation | |||
*Damage to the [[blood vessels]] | *Damage to the [[blood vessels]] | ||
*A problem with the [[immune system]] | *A problem with the [[immune system]] | ||
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==Diagnosis== | ==Diagnosis== | ||
Shown below is an algorithm summarizing the diagnosis of | Shown below is an algorithm summarizing the diagnosis of [[Gestational]] [[Hypertension]]. <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref><ref name="urlHypertension In Pregnancy - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK430839/ |title=Hypertension In Pregnancy - StatPearls - NCBI Bookshelf |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><ref name="pmid30050697">{{cite journal |vauthors=Portelli M, Baron B |title=Clinical Presentation of Preeclampsia and the Diagnostic Value of Proteins and Their Methylation Products as Biomarkers in Pregnant Women with Preeclampsia and Their Newborns |journal=J Pregnancy |volume=2018 |issue= |pages=2632637 |date=2018 |pmid=30050697 |pmc=6046127 |doi=10.1155/2018/2632637 |url= |issn=}}</ref> | ||
{{ | |||
{{ | |||
{{ | |||
{{Family tree/start}} | |||
{{Family tree | | | | | | | A01 | | | | | | | |A01= Pregnant woman with complaints of elevated [[blood pressure]]}} | |||
{{Family tree | | | | | | | |!| | | | | | | | |}} | |||
{{Family tree | | | | | | | B01 | | | | | | | |B01=<div style="float: left; text-align: left; "> Take complete history}} | |||
{{Family tree | | | | | | | |!| | | | | | | | |}} | |||
{{Family tree | | | | | | | B02 | | | | | | | |B02= <div style="float: left; text-align: left; height: 17em; "> '''Record the [[Vital signs|vitals]]:'''<br> | |||
---- | |||
❑ [[Blood pressure]]<br><br> | |||
❑ [[Temperature]]<br><br>❑ [[Respiratory rate]]<br><br>❑ [[Heart rate]] </div>| | | | | | | |}} | |||
{{Family tree | | | | | | | |!| | | | | | | | |}} | |||
{{Family tree | | | | | | | B02 | | | | | | | |B02= <div style="float: left; text-align: left;"> '''Take [[obstetric]] history:'''<br> | |||
---- | |||
❑ Date of last [[menstrual]] period? <br><br>❑ Estimated date of [[delivery]]<br><br>❑ Confirm the [[gestational]] age, [[gravidity]] and [[parity]].<br><br> ❑ Check if this is a single or multiple [[gestation]].<br><br> </div>| | | | | | | |}} | |||
{{Family tree | | | | | | | |!| | | | | | | | |}} | |||
{{Family tree | | | | | | | B01 | | | | | | | |B01= <div style="float: left; text-align: left;"> '''Ask about previous obstetric history if she was previously [[pregnant]]:'''<br> | |||
---- | |||
❑ Ask about previous [[pregnancies]] including [[miscarriages]] and [[Termination of pregnancy|terminations]]. <br><br>❑ Length of [[gestation]]. <br><br>❑ Ask about mode of delivery. <br><br>❑ Ask if there was similar complaints during previous [[pregnancy]]?<br><br>❑ Was there any complications throughout the [[pregnancy]] or during [[delivery]] such as [[shoulder dystocia]], [[postpartum haemorrhage]] ?<br><br></div>| | | | | | | | }} | |||
{{Family tree | | | | | | | |!| | | | | | | | |}} | |||
{{Family tree | | | | | | | B02 | | | | | | | |B02= <div style="float: left; text-align: left;"> '''Ask the following questions about [[menstrual]] history:'''<br> | |||
---- | |||
❑ Age of [[menarche]] <br><br>❑ Last [[menstrual]] period<br><br>❑ Is the [[menstrual]] flow normal? How many pads she has to use in a day? <br><br>❑ Is there any foul smell or colour change?<br><br>❑ How many days does the [[menstruation]] stay?<br><br>❑ [[Contraceptive]] history for example [[oral]] [[contraceptives]], [[intrauterine device]]<br><br></div>| | | | | | | |}} | |||
{{Family tree | | | | | | | |!| | | | | | | | |}} | |||
{{Family tree | | | | | | | B02 | | | | | | | |B02= <div style="float: left; text-align: left; height: 28em; "> '''See if following factors are present:'''<br> | |||
---- | |||
❑ History of [[hypertension]]<br><br> | |||
❑ [[Kidney disease]]<br><br> | |||
❑ [[Diabetes]]<br><br> | |||
❑ [[Hypertension]] with a previous [[pregnancy]]<br><br> | |||
❑ Mother's age younger than 20 or older than 40<br><br> | |||
❑ Multiple [[fetuses]] ([[twins]], [[triplets]])<br><br> | |||
❑ African-American race<br><br> </div>| | | | | | |}} | |||
{{Family tree | | | | | | | |!| | | | | | | | |}} | |||
{{Family tree | | | | | | | B02 | | | | | | | |B02= <div style="float: left; text-align: left; height: 20em; "> '''Ask about present complaints:'''<br> | |||
---- | |||
❑ Ask if there is any discomfort or [[pain]] in the [[chest]]<br><br> | |||
❑ Ask if the patient has [[swelling]] of legs<br><br>❑ Ask if there is any changes in [[vision]]<br><br>❑ Ask if there is any history of [[headache]] </div>| | | | | | | |}} | |||
{{Family tree | | | | | | | |!| | | | | | | | |}} | |||
{{Family tree | | | | | | | B02 | | | | | | | |B02= <div style="float: left; text-align: left; height: 16em; "> '''[[Gestational Hypertension]] <ref name="pmid23403779">{{cite journal |vauthors=Lo JO, Mission JF, Caughey AB |title=Hypertensive disease of pregnancy and maternal mortality |journal=Curr Opin Obstet Gynecol |volume=25 |issue=2 |pages=124–32 |date=April 2013 |pmid=23403779 |doi=10.1097/GCO.0b013e32835e0ef5 |url= |issn=}}</ref>'''<br> | |||
---- | |||
❑ [[Blood pressure]] higher than 140/90 measured on two separate occasions, more than 6 hours apart. <ref name="pmid23403779">{{cite journal |vauthors=Lo JO, Mission JF, Caughey AB |title=Hypertensive disease of pregnancy and maternal mortality |journal=Curr Opin Obstet Gynecol |volume=25 |issue=2 |pages=124–32 |date=April 2013 |pmid=23403779 |doi=10.1097/GCO.0b013e32835e0ef5 |url= |issn=}}</ref><br><br> | |||
❑ Absence of [[protein]] in the [[urine]] and diagnosed after 20 weeks of gestation. <ref name="pmid23403779">{{cite journal |vauthors=Lo JO, Mission JF, Caughey AB |title=Hypertensive disease of pregnancy and maternal mortality |journal=Curr Opin Obstet Gynecol |volume=25 |issue=2 |pages=124–32 |date=April 2013 |pmid=23403779 |doi=10.1097/GCO.0b013e32835e0ef5 |url= |issn=}}</ref> </div>| | | | | | | |}} | |||
{{Family tree | | | | | | | |!| | | | | | | | |}} | |||
{{Family tree | | | | | | | B02 | | | | | | | |B02= <div style="float: left; text-align: left; height: 37em; "> '''Ask about associated symptoms to exclude [[preeclampsia]]: <ref name="pmid30050697">{{cite journal |vauthors=Portelli M, Baron B |title=Clinical Presentation of Preeclampsia and the Diagnostic Value of Proteins and Their Methylation Products as Biomarkers in Pregnant Women with Preeclampsia and Their Newborns |journal=J Pregnancy |volume=2018 |issue= |pages=2632637 |date=2018 |pmid=30050697 |pmc=6046127 |doi=10.1155/2018/2632637 |url= |issn=}}</ref>'''<br> | |||
---- | |||
❑ Severe [[headaches]]<br><br> | |||
❑ Changes in [[vision]], including temporary loss of [[vision]], [[blurred vision]] or [[light sensitivity]]<br><br> | |||
❑ [[Upper abdominal pain]], usually under [[ribs]] on the right side<br><br> | |||
❑ [[Nausea and vomiting|Nausea or vomiting]]<br><br> | |||
❑ Decreased [[urine output]]<br><br> | |||
❑ Decreased levels of [[platelets]] in your blood (thrombocytopenia)<br><br> | |||
❑ Impaired [[liver function]]<br><br> | |||
❑ [[Shortness of breath]], caused by [[fluid]] in the [[lungs]]<br><br> </div>| | | | | | | |}} | |||
{{familytree/end}} | {{familytree/end}} | ||
==Treatment== | ==Treatment== | ||
Management of [[gestational hypertension]] remains controversial, as does the classification of its severity. Delaying the interruption of pregnancy may lead to the progression of [[pre-eclampsia]], eventually resulting in [[Placental|placental insufficiency]] and maternal organ dysfunction, with increased risk of maternal and [[perinatal]] mortality. Aims of management are minimizing further [[pregnancy]]-related complications, avoiding unnecessary prematurity, and maximizing maternal and infant survival. | Management of [[gestational hypertension]] remains controversial, as does the classification of its severity. Delaying the interruption of [[pregnancy]] may lead to the progression of [[pre-eclampsia]], eventually resulting in [[Placental|placental insufficiency]] and [[maternal]] organ dysfunction, with increased risk of [[maternal]] and [[perinatal]] mortality. Aims of management are minimizing further [[pregnancy]]-related complications, avoiding unnecessary prematurity, and maximizing maternal and infant survival. | ||
Shown below is an algorithm summarizing the treatment of [[gestational hypertension]] | Shown below is an algorithm summarizing the treatment of [[gestational hypertension]]. | ||
{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=PE diagnosis Algorithm.}} | ||
{{familytree | | | | | | | | A01 |A01= Woman comes with gestational hypertension}} | {{familytree | | | | | | | | A01 |A01= Woman comes with [[gestational hypertension]]}} | ||
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }} | {{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }} | ||
{{familytree | | | B01 | | | | | | | | B02 | | |B01= Non- pharmacological treatment|B02= Pharmacological treatment }} | {{familytree | | | B01 | | | | | | | | B02 | | |B01= Non-pharmacological treatment <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref>|B02= [[Pharmacological treatment]]<ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref> }} | ||
{{familytree | | | |!| | | | | | | | | |!| }} | {{familytree | | | |!| | | | | | | | | |!| }} | ||
{{familytree | | | |!| | | | | | | | | |!| }} | {{familytree | | | |!| | | | | | | | | |!| }} | ||
{{familytree | | | L01 | | | | | | | | K01 | K01=<div style="float: left; text-align: left;height: 62em; width: 32em "> | {{familytree | | | L01 | | | | | | | | K01 | K01=<div style="float: left; text-align: left;height: 62em; width: 32em "> | ||
❑ [[Methyl-dopa]]: a centrally acting [[Alpha-2 receptor|alpha-2 adrenergic]] [[agonist]], used as a first line agent mainly because of its longstanding history of safety and use in [[pregnancy]]. [[Blood pressure]] control is gradual over 6-8 hours because of the indirect mechanism of action and is best for [[treatment]] of mild [[hypertension]] rather than moderate or severe [[hypertension]].<br><br> | ❑ [[Methyl-dopa]]: <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref> a centrally acting [[Alpha-2 receptor|alpha-2 adrenergic]] [[agonist]], used as a first line agent mainly because of its longstanding history of safety and use in [[pregnancy]]. [[Blood pressure]] control is gradual over 6-8 hours because of the indirect mechanism of action and is best for [[treatment]] of mild [[hypertension]] rather than moderate or severe [[hypertension]].<br><br> | ||
❑ [[Labetalol]]: a nonselective [[beta-blocker]]. Should not be given in patients with[[asthma]] as it can cause [[bronchospasm]]. It is used widely in [[pregnancy]] and has proven effective in the [[treatment]] of mild to moderate [[hypertension]], though some data shows a slight increase in small for [[gestational]] age (SGA) infants.<br><br> | ❑ [[Labetalol]]: <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref> a nonselective [[beta-blocker]]. Should not be given in patients with[[asthma]] as it can cause [[bronchospasm]]. It is used widely in [[pregnancy]] and has proven effective in the [[treatment]] of mild to moderate [[hypertension]], though some data shows a slight increase in small for [[gestational]] age (SGA) infants.<br><br> | ||
❑ [[Procardia]]: a [[calcium channel blocker]], often used in [[pregnancy]] to treat mild to moderate [[hypertension]]. It has shown indication of adverse [[perinatal]] outcomes or decreased uterine [[blood flow]]. <br><br> | ❑ [[Procardia]]: <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref> a [[calcium channel blocker]], often used in [[pregnancy]] to treat mild to moderate [[hypertension]]. It has shown indication of adverse [[perinatal]] outcomes or decreased uterine [[blood flow]]. <br><br> | ||
❑ [[Diuretics]]: can be used as second line [[medication]]. It has some usefulness in [[pregnancy]], specifically with salt-sensitive [[hypertension]] and for patients with reduced [[renal function]]. It should be carefully prescribed to avoid hypokalemia and fetal growth restriction from intravascular volume depletion.<br><br> | ❑ [[Diuretics]]: <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref> can be used as second line [[medication]]. It has some usefulness in [[pregnancy]], specifically with salt-sensitive [[hypertension]] and for patients with reduced [[renal function]]. It should be carefully prescribed to avoid [[hypokalemia]] and [[fetal]] [[growth]] restriction from [[intravascular]] volume depletion.<br><br> | ||
❑ [[Hydralazine]] and [[clonidine]] have been used in certain circumstances, but are not commonly used in the longitudinal treatment of gestational or chronic hypertension.<br><br> | ❑ [[Hydralazine]] and [[clonidine]]: <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref> have been used in certain circumstances, but are not commonly used in the longitudinal treatment of gestational or chronic hypertension.<br><br> | ||
❑ [[ACE inhibitors]], [[angiotensin receptor blockers]], [[mineralocorticoid]] receptor antagonists, and [[nitroprusside]] are contraindicated in [[pregnancy]] as these are [[teratogenic]].<br><br> | ❑ [[ACE inhibitors]], [[angiotensin receptor blockers]], [[mineralocorticoid]] receptor antagonists, and [[nitroprusside]] are contraindicated in [[pregnancy]] as these are [[teratogenic]]. <ref name="urlHypertension In Pregnancy - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK430839/ |title=Hypertension In Pregnancy - StatPearls - NCBI Bookshelf |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><br><br> | ||
❑ [[Nitroprusside]] can be used as a last resort in treatment-resistant [[hypertension]]. | ❑ [[Nitroprusside]] can be used as a last resort in treatment-resistant [[hypertension]]. <ref name="urlHypertension In Pregnancy - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK430839/ |title=Hypertension In Pregnancy - StatPearls - NCBI Bookshelf |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> | ||
❑ Low [[dose]] [[aspirin]] of 81 mg or less to be initiated before 20 weeks of [[gestation]] to prevent [[preeclampsia]] as a sequelae of [[hypertension]]. </div> | L01=<div style="float: left; text-align: left;height: 62em; | ❑ Low [[dose]] [[aspirin]] of 81 mg or less to be initiated before 20 weeks of [[gestation]] to prevent [[preeclampsia]] as a sequelae of [[hypertension]]. </div> | L01=<div style="float: left; text-align: left;height: 62em;"> | ||
<br><br><br> | <br><br><br> | ||
❑ 30 minutes of moderate exercise on most days of the week to stimulate [[placental]] [[angiogenesis]] and improve maternal [[endothelial]] dysfunction.<br><br>❑ Strict bed rest should be avoided and encouraged to maintain normal physical activity levels, as prolonged bed rest can increase the risk for [[venous]] [[thromboembolism]], especially given the physiological [[hypercoagulability]] of [[pregnancy]].<ref name="pmid24201164">{{cite journal |vauthors=Abdul Sultan A, West J, Tata LJ, Fleming KM, Nelson-Piercy C, Grainge MJ |title=Risk of first venous thromboembolism in pregnant women in hospital: population based cohort study from England |journal=BMJ |volume=347 |issue= |pages=f6099 |date=November 2013 |pmid=24201164 |pmc=3898207 |doi=10.1136/bmj.f6099 |url= |issn=}}</ref><br><br>}} | ❑ 30 minutes of moderate exercise on most days of the week to stimulate [[placental]] [[angiogenesis]] and improve maternal [[endothelial]] dysfunction.<br><br>❑ Strict bed rest should be avoided and encouraged to maintain normal physical activity levels, as prolonged bed rest can increase the risk for [[venous]] [[thromboembolism]], especially given the physiological [[hypercoagulability]] of [[pregnancy]]. <ref name="pmid24201164">{{cite journal |vauthors=Abdul Sultan A, West J, Tata LJ, Fleming KM, Nelson-Piercy C, Grainge MJ |title=Risk of first venous thromboembolism in pregnant women in hospital: population based cohort study from England |journal=BMJ |volume=347 |issue= |pages=f6099 |date=November 2013 |pmid=24201164 |pmc=3898207 |doi=10.1136/bmj.f6099 |url= |issn=}}</ref><br><br>}} | ||
{{familytree | | | |!| | | | | | | | | |!| }} | {{familytree | | | |!| | | | | | | | | |!| }} | ||
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{{familytree | | | | | | | M01 | | | | | |M01=Fetal evaluation<ref name="urlTreatment Options for Gestational Hypertension">{{cite web |url=https://www.verywellfamily.com/treatment-options-for-gestational-hypertension-1764122 |title=Treatment Options for Gestational Hypertension |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><div style="float: left; text-align: left;height: 29em; | {{familytree | | | | | | | M01 | | | | | |M01=Fetal evaluation<ref name="urlTreatment Options for Gestational Hypertension">{{cite web |url=https://www.verywellfamily.com/treatment-options-for-gestational-hypertension-1764122 |title=Treatment Options for Gestational Hypertension |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><div style="float: left; text-align: left;height: 29em;> | ||
❑ An [[ultrasound]] should be done at 16-20 weeks to provide an accurate baseline reading to evaluate the baby’s growth.<br><br>❑ [[Fetal]] movement should be counted by checking the kicks and movements. Any change in the number of kicks or how often the baby kicks may mean it is under stress.<br><br> | ❑ An [[ultrasound]] should be done at 16-20 weeks to provide an accurate baseline reading to evaluate the baby’s [[growth]].<br><br>❑ [[Fetal]] movement should be counted by checking the kicks and movements. Any change in the number of kicks or how often the baby kicks may mean it is under stress.<br><br> | ||
❑ Non-stress test: this measures baby’s heart rate in response to his or her movements.<br><br>❑ Biophysical profile: this test combines a non-stress test with an ultrasound to observe the baby.<br><br>❑ Doppler flow studies: ultrasound that uses sound waves to measure the flow of the baby’s blood through a blood vessel. </div> || }} | ❑ [[Non-stress test]]: this measures baby’s heart rate in response to his or her movements.<br><br>❑ [[Biophysical profile]]: this test combines a [[non-stress test]] with an [[ultrasound]] to observe the baby.<br><br>❑ [[Doppler]] flow studies: ultrasound that uses sound waves to measure the flow of the baby’s blood through a [[blood vessel]]. </div> || }} | ||
{{familytree | | | | | | | |!| | | | | | | }} | {{familytree | | | | | | | |!| | | | | | | }} | ||
{{familytree | | | | | | | K01| | | | | |K01=Indications for preterm delivery | {{familytree | | | | | | | K01| | | | | |K01=Indications for [[preterm]] [[delivery]] <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref> }} | ||
{{familytree | | | | | | | |!| | | | | | | }} | {{familytree | | | | | | | |!| | | | | | | }} | ||
{{familytree | | | | | | | l01| | | | | |l01= <div style="float: left; text-align: left;height: | {{familytree | | | | | | | l01| | | | | |l01= <div style="float: left; text-align: left;height: 15em; width: 32em ">The recommendations for [[delivery]] are as follows: <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref> | ||
---- | ---- | ||
❑ 38-39 6/7 weeks of gestation for women not requiring medication.<br><br>❑ 37- 39 6/7 weeks of gestation for women with hypertension controlled with medication.<br><br>❑36-37 6/7 weeks of gestation for women with severe hypertension difficult to control</div>| }} | ❑ 38-39 6/7 weeks of [[gestation]] for women not requiring [[medication]].<br><br>❑ 37- 39 6/7 weeks of [[gestation]] for women with [[hypertension]] controlled with [[medication]].<br><br>❑36-37 6/7 weeks of [[gestation]] for women with severe [[hypertension]] difficult to control</div>| }} | ||
{{familytree | | | | | | | |!| | | | | | | }} | {{familytree | | | | | | | |!| | | | | | | }} | ||
{{familytree | | | | | | | K01| | | | | |K01=<div style="float: left; text-align: left;height: | {{familytree | | | | | | | K01| | | | | |K01=<div style="float: left; text-align: left;height: 12em; width: 32em ">[[Intrapartum]] management: <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref> | ||
---- | ---- | ||
❑ It is outside of the scope of the primary care provider and includes [[intravenous]] medications for acute [[blood pressure]] treatment, [[intravenous]] [[magnesium sulfate]] administration for [[seizure]] [[prophylaxis]] with suspected [[preeclampsia]] and serial serology. </div> }} | ❑ It is outside of the scope of the primary care provider and includes [[intravenous]] [[medications]] for acute [[blood pressure]] [[treatment]], [[intravenous]] [[magnesium sulfate]] administration for [[seizure]] [[prophylaxis]] with suspected [[preeclampsia]] and serial [[serology]]. </div> }} | ||
{{familytree | | | | | | | |!| | | | | | | }} | {{familytree | | | | | | | |!| | | | | | | }} | ||
{{familytree | | | | | | | K01| | | | | |K01=<div style="float: left; text-align: left;height: | {{familytree | | | | | | | K01| | | | | |K01=<div style="float: left; text-align: left;height: 10em; width: 32em ">[[Postpartum]] management: <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref> | ||
---- | ---- | ||
❑ [[Postpartum]] [[hypertension]] until 12 weeks [[postpartum]] should be managed with [[medications]] that are safe for breastfeeding | ❑ [[Postpartum]] [[hypertension]] until 12 weeks [[postpartum]] should be managed with [[medications]] that are safe for [[breastfeeding]]. </div> }} | ||
{{familytree/end}} | {{familytree/end}} | ||
== | ==Dos<ref name="urlHypertension In Pregnancy - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK430839/ |title=Hypertension In Pregnancy - StatPearls - NCBI Bookshelf |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>== | ||
* [[Pregnant]] woman with [[gestational hypertension]] should be advised to visit her health care provider regularly throughout the [[pregnancy]].<ref name="urlHypertension In Pregnancy - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK430839/ |title=Hypertension In Pregnancy - StatPearls - NCBI Bookshelf |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> | |||
*The | * Patient should be encouraged to take her [[blood pressure]] medication as prescribed. | ||
* The health care provider should prescribe the safest [[medication]] at the most appropriate dose. | |||
* [[Pregnant]] woman with [[gestational hypertension]] should stay active and follow her health care provider's recommendations for physical activity. | |||
* [[Pregnant]] woman with [[gestational hypertension]] should have a healthy diet and if additional help is needed, she can speak with a [[nutritionist]]. | |||
* [[Pregnant]] woman with [[gestational hypertension]] should talk to her health care provider before taking over-the-counter [[medications]]. | |||
==Don'ts== | ==Don'ts== | ||
*Strength [[training]] and pure [[isometric exercise]], such as lifting weights and [[aerobic exercise]] should be discouraged as it can acutely elevate [[blood pressure]] to severe levels. It can also increase the risk for adverse events such as [[stroke]]. | * Strength [[training]] and pure [[isometric exercise]], such as lifting weights and [[aerobic exercise]] should be discouraged as it can acutely elevate [[blood pressure]] to severe levels. It can also increase the risk for adverse events such as [[stroke]].<ref name="pmid10804484">{{cite journal |vauthors=Yeo S, Steele NM, Chang MC, Leclaire SM, Ronis DL, Hayashi R |title=Effect of exercise on blood pressure in pregnant women with a high risk of gestational hypertensive disorders |journal=J Reprod Med |volume=45 |issue=4 |pages=293–8 |date=April 2000 |pmid=10804484 |doi= |url= |issn=}}</ref> | ||
*There is no evidence that | * There is no evidence that suggests benefits in restricting [[sodium]] intake during [[pregnancy]], thus it is not recommended to limit the intake in the prevention of [[Pre-eclampsia|preeclampsia]]. | ||
* [[Pregnant]] woman should avoid [[alcohol]],recreational [[drugs]], [[smoking]].<ref name="urlHypertension In Pregnancy - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK430839/ |title=Hypertension In Pregnancy - StatPearls - NCBI Bookshelf |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
[[Category:Resident survival guide]] | [[Category:Resident survival guide]] | ||
[[Category: | [[Category:Up-to-date] | ||
Latest revision as of 19:10, 4 October 2021
Gestational hypertension Resident Survival Guide Microchapters |
---|
Overview |
Causes |
Diagnosis |
Treatment |
Dos |
Don'ts |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S. Samah Obaiah, MD[2]
Synonyms and keywords: Approach to pregnancy-induced hypertension; Gestational hypertension workup, Gestational hypertension management
Overview
Gestational hypertension or Pregnancy-induced hypertension (PIH) , is defined as systolic blood pressure (SBP) >140 mmHg and diastolic blood pressure (DBP) >90 mmHg on at least two occasions at least 6 hours apart after the 20th week of gestation in women known to be normotensive before pregnancy and before 20 weeks’ gestation. The BP recordings used to establish the diagnosis should be no more than 7 days apart. [Gestational hypertension]] is considered severe if there is sustained elevations in systolic blood pressure to at least 160 mm Hg and/or in diastolic blood pressure to at least 110 mm Hg for at least 6 hours. It is classified as mild , moderate , and severe . The WHO classified it is one of the main causes of maternal, fetal, and neonatal mortality and morbidity.[1].gestational hypertension is one of the most common medical disorders affecting pregnancy. The most serious maternal complications of gestational hypertension include intracerebral hemorrhage,eclampsia, and renal failure, as well as hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome and posterior reversible encephalopathy syndrome (PRES).[2]Treatment of gestational hypertension depends on blood pressure levels, gestational age, presence of symptoms and associated risk factors.
Causes
The cause of gestational hypertension is unknown. If untreated will be life-threatening, severe gestational hypertension may cause dangerous seizures (eclampsia) and even death in the mother and fetus. Because of these risks, it may be necessary for the baby to be delivered early, before the full term of pregnancy. Some conditions may increase the risk of developing the condition, including the following[3][4]:
- History of hypertension
- Kidney disease
- Diabetes
- Hypertension with a previous pregnancy
- Mother's age younger than 20 or older than 40
- Multiple fetuses (twins, triplets)
- African-American race
Common Causes
Pathogenesis theories developed about the passable causes:
- Insufficient blood flow to the uterus or abnormal placental implantation
- Damage to the blood vessels
- A problem with the immune system
- Certain genes
- Platelet activation
- Hyperlipidaemia and insulin resistance
Diagnosis
Shown below is an algorithm summarizing the diagnosis of Gestational Hypertension. [5][3][6]
Pregnant woman with complaints of elevated blood pressure | |||||||||||||||||||||||||||||||||||||||||||||||
Take complete history | |||||||||||||||||||||||||||||||||||||||||||||||
Ask about previous obstetric history if she was previously pregnant: ❑ Ask about previous pregnancies including miscarriages and terminations. ❑ Length of gestation. ❑ Ask about mode of delivery. ❑ Ask if there was similar complaints during previous pregnancy? ❑ Was there any complications throughout the pregnancy or during delivery such as shoulder dystocia, postpartum haemorrhage ? | |||||||||||||||||||||||||||||||||||||||||||||||
Ask the following questions about menstrual history: ❑ Age of menarche ❑ Last menstrual period ❑ Is the menstrual flow normal? How many pads she has to use in a day? ❑ Is there any foul smell or colour change? ❑ How many days does the menstruation stay? ❑ Contraceptive history for example oral contraceptives, intrauterine device | |||||||||||||||||||||||||||||||||||||||||||||||
See if following factors are present: ❑ History of hypertension | |||||||||||||||||||||||||||||||||||||||||||||||
Gestational Hypertension [7] ❑ Blood pressure higher than 140/90 measured on two separate occasions, more than 6 hours apart. [7] | |||||||||||||||||||||||||||||||||||||||||||||||
Ask about associated symptoms to exclude preeclampsia: [6] ❑ Severe headaches | |||||||||||||||||||||||||||||||||||||||||||||||
Treatment
Management of gestational hypertension remains controversial, as does the classification of its severity. Delaying the interruption of pregnancy may lead to the progression of pre-eclampsia, eventually resulting in placental insufficiency and maternal organ dysfunction, with increased risk of maternal and perinatal mortality. Aims of management are minimizing further pregnancy-related complications, avoiding unnecessary prematurity, and maximizing maternal and infant survival.
Shown below is an algorithm summarizing the treatment of gestational hypertension.
Woman comes with gestational hypertension | |||||||||||||||||||||||||||||||||
Non-pharmacological treatment [5] | Pharmacological treatment[5] | ||||||||||||||||||||||||||||||||
❑ Strict bed rest should be avoided and encouraged to maintain normal physical activity levels, as prolonged bed rest can increase the risk for venous thromboembolism, especially given the physiological hypercoagulability of pregnancy. [8] | ❑ Methyl-dopa: [5] a centrally acting alpha-2 adrenergic agonist, used as a first line agent mainly because of its longstanding history of safety and use in pregnancy. Blood pressure control is gradual over 6-8 hours because of the indirect mechanism of action and is best for treatment of mild hypertension rather than moderate or severe hypertension. | ||||||||||||||||||||||||||||||||
Fetal evaluation[9] ❑ An ultrasound should be done at 16-20 weeks to provide an accurate baseline reading to evaluate the baby’s growth. ❑ Biophysical profile: this test combines a non-stress test with an ultrasound to observe the baby. ❑ Doppler flow studies: ultrasound that uses sound waves to measure the flow of the baby’s blood through a blood vessel. | |||||||||||||||||||||||||||||||||
Indications for preterm delivery [5] | |||||||||||||||||||||||||||||||||
The recommendations for delivery are as follows: [5]
❑ 38-39 6/7 weeks of gestation for women not requiring medication. ❑ 37- 39 6/7 weeks of gestation for women with hypertension controlled with medication. ❑36-37 6/7 weeks of gestation for women with severe hypertension difficult to control | |||||||||||||||||||||||||||||||||
Intrapartum management: [5]
❑ It is outside of the scope of the primary care provider and includes intravenous medications for acute blood pressure treatment, intravenous magnesium sulfate administration for seizure prophylaxis with suspected preeclampsia and serial serology. | |||||||||||||||||||||||||||||||||
Postpartum management: [5]
❑ Postpartum hypertension until 12 weeks postpartum should be managed with medications that are safe for breastfeeding. | |||||||||||||||||||||||||||||||||
Dos[3]
- Pregnant woman with gestational hypertension should be advised to visit her health care provider regularly throughout the pregnancy.[3]
- Patient should be encouraged to take her blood pressure medication as prescribed.
- The health care provider should prescribe the safest medication at the most appropriate dose.
- Pregnant woman with gestational hypertension should stay active and follow her health care provider's recommendations for physical activity.
- Pregnant woman with gestational hypertension should have a healthy diet and if additional help is needed, she can speak with a nutritionist.
- Pregnant woman with gestational hypertension should talk to her health care provider before taking over-the-counter medications.
Don'ts
- Strength training and pure isometric exercise, such as lifting weights and aerobic exercise should be discouraged as it can acutely elevate blood pressure to severe levels. It can also increase the risk for adverse events such as stroke.[10]
- There is no evidence that suggests benefits in restricting sodium intake during pregnancy, thus it is not recommended to limit the intake in the prevention of preeclampsia.
- Pregnant woman should avoid alcohol,recreational drugs, smoking.[3]
References
- ↑ Kintiraki E, Papakatsika S, Kotronis G, Goulis DG, Kotsis V (2015). "Pregnancy-Induced hypertension". Hormones (Athens). 14 (2): 211–23. doi:10.14310/horm.2002.1582. PMID 26158653.
- ↑ Marik PE (2009). "Hypertensive disorders of pregnancy". Postgrad Med. 121 (2): 69–76. doi:10.3810/pgm.2009.03.1978. PMID 19332964.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 "Hypertension In Pregnancy - StatPearls - NCBI Bookshelf".
- ↑ Villar J, Carroli G, Wojdyla D, Abalos E, Giordano D, Ba'aqeel H, Farnot U, Bergsjø P, Bakketeig L, Lumbiganon P, Campodónico L, Al-Mazrou Y, Lindheimer M, Kramer M (April 2006). "Preeclampsia, gestational hypertension and intrauterine growth restriction, related or independent conditions?". Am J Obstet Gynecol. 194 (4): 921–31. doi:10.1016/j.ajog.2005.10.813. PMID 16580277.
- ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 Spiro L, Scemons D (2018). "Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners". Open Nurs J. 12: 180–183. doi:10.2174/1874434601812010180. PMC 6128013. PMID 30258507.
- ↑ 6.0 6.1 Portelli M, Baron B (2018). "Clinical Presentation of Preeclampsia and the Diagnostic Value of Proteins and Their Methylation Products as Biomarkers in Pregnant Women with Preeclampsia and Their Newborns". J Pregnancy. 2018: 2632637. doi:10.1155/2018/2632637. PMC 6046127. PMID 30050697.
- ↑ 7.0 7.1 7.2 Lo JO, Mission JF, Caughey AB (April 2013). "Hypertensive disease of pregnancy and maternal mortality". Curr Opin Obstet Gynecol. 25 (2): 124–32. doi:10.1097/GCO.0b013e32835e0ef5. PMID 23403779.
- ↑ Abdul Sultan A, West J, Tata LJ, Fleming KM, Nelson-Piercy C, Grainge MJ (November 2013). "Risk of first venous thromboembolism in pregnant women in hospital: population based cohort study from England". BMJ. 347: f6099. doi:10.1136/bmj.f6099. PMC 3898207. PMID 24201164.
- ↑ "Treatment Options for Gestational Hypertension".
- ↑ Yeo S, Steele NM, Chang MC, Leclaire SM, Ronis DL, Hayashi R (April 2000). "Effect of exercise on blood pressure in pregnant women with a high risk of gestational hypertensive disorders". J Reprod Med. 45 (4): 293–8. PMID 10804484.
[[Category:Up-to-date]