Diagnosis, Evaluation, and Management of the Hypertensive Disorders of Pregnancy: Executive Summary

Abstract

In this comprehensive new SOGC Guideline1.Magee L.A. Pels A. Helewa M. Rey E. von Dadelszen P. SOGC Hypertension Guideline Committee Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: executive summary. SOGC Clinical Practice Guideline No. 307, May 2014.J Obstet Gynaecol Can. 2014; 36: 416-438Abstract Full Text Full Text PDF PubMed Scopus (342) Google Scholar I was surprised to see that methyldopa and (to some extent) clonidine are recommended as “alternative” oral therapeutic agents for the treatment of severe hypertension. While the immediate-release nifedipine capsule has an onset of action approximately 20 minutes after administration and oral labetalol 20 minutes to two hours (peak effect 1 to 4 hours), the onset of action of oral methyldopa is four to six hours and immediate-release clonidine 30 minutes to one hour (peak effect 2 to 4 hours).2.Drug Information (Lexicomp). UpToDate. Waltham, MA. Available at: http://www.uptodate.com/home/drugs-drug-interaction. Accessed May 6, 2014.Google Scholar While this is the executive summary (23 pages!) and it does not contain discussion on treatment, it is widely recognized that severe hypertension (defined in this guideline as a systolic blood pressure>160 mmHg or a diastolic pressure>110 mmHg) is associated with an increased risk of severe morbidity and mortality and should be controlled rapidly. Given this, I question the wisdom of “recommending” treatment that may take up to six hours to have a clinical effect. I trust that the diagnostic criteria for severe hypertension will be more fully discussed in the main document, since at least one well-quoted case series reports four of 24 peripartum strokes occurring with maternal systolic blood pressures of between 155 and 160 mmHg.3.Martin Jr., J.N. Thigpen B.D. Moore R.C. Rose C.H. Cushman J. May W. Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure.Obstet Gynecol. 2005; 105: 246Crossref PubMed Scopus (361) Google Scholar Finally, I would like to suggest that in this electronic age future SOGC guidelines be circulated to the membership in draft form, so that all interested parties have a chance to review and comment before formal publication.