Blog | Monday, February 10, 2014

QD: News Every Day--Stroke guideline focus on women's specific needs

Women now have their own set of stroke guidelines that focus on their unique needs, including prevention of preeclampsia and taking blood pressure measurement before the start of hormonal contraception.

The guidelines appeared online Feb. 6 in Stroke.

Prevention of preeclampsia
• Women with chronic primary or secondary hypertension or previous pregnancy-related hypertension should take low-dose aspirin from the 12th week of gestation until delivery (Class I; Level of Evidence A).
• Consider oral calcium supplementation of 1 g/d or more for women with dietary intake of less than 600 mg/d to prevent preeclampsia (Class I; Level of Evidence A).

Hypertension during pregnancy and post-partum
• Severe hypertension in pregnancy should be treated with safe and effective antihypertensive medications, such as methyldopa, labetalol, and nifedipine;
• Moderate hypertension in pregnancy may be treated with antihypertensive medications, (Class IIa; Level of Evidence B).
• Atenolol, angiotensin receptor blockers, and direct renin inhibitors are contraindicated in pregnancy and should not be used (Class III; Level of Evidence C).
• Women with postpartum chronic hypertension should continue on their antihypertensive regimen, with dose adjustments to reflect the decrease in volume of distribution and glomerular filtration rate that occurs after delivery, and should also be monitored carefully for postpartum preeclampsia (Class IIa; Level of Evidence C).

Preventing stroke in women with a history of preeclampsia
• Consider evaluating all women for hypertension and stroke starting 6 months to 1 year post-partum, as well as those who are past childbearing age, for a history of preeclampsia/ eclampsia and document their history as a risk factor. Evaluate and treat for cardiovascular risk factors such as hypertension, obesity, smoking and dyslipidemia (Class IIa; Level of Evidence C).

Oral contraception
• Oral contraceptives may be harmful in women with additional risk factors such as cigarette smoking or prior thromboembolic events (Class III; Level of Evidence B).
• Aggressive therapy of stroke risk factors may be reasonable (Class IIb; Level of Evidence C).
• It is not useful to routinely screen for prothrombotic mutations before starting hormonal contraception (Class III; Level of Evidence A).
• Measure blood pressure before starting hormonal contraception (Class I; Level of Evidence B).

Because there are no data from large, well-controlled, randomized controlled trials directly comparing specific antihypertensive agents in pregnancy, the choice of blood pressure-lowering medications before pregnancy should be made based on a woman’s plan for future pregnancy, based on the risks particular to each drug category:
• Methyldopa has been extensively used in pregnancy and appears to be safe;
• β-blockers in pregnancy decreased the risk of progression to severe hypertension but may have increased risk for fetal growth restriction, although this may have been confounded by including trials that included the use of atenolol;
• Pindolol and metoprolol appear to be safe during pregnancy;
• Calcium channel blockers appear to be safe in pregnancy, with the most commonly used being nifedipine;
• There was a small increase in the risk for preeclampsia with the use of calcium-channel blockers versus no therapy; and
• Diuretics, predominantly thiazide-type, have been indicated to be safe in pregnancy, and women taking thiazides before pregnancy do not need to stop them.