Seguridad y efectividad de la reducción o retiro de la terapia antihipertensiva en gestantes con enfermedad vascular hipertensiva crónica
ilustraciones, gráficas, tablas
- Autores:
-
Hamon Pinilla, Catalina
Salamanca Téllez, Andrea Milena
- Tipo de recurso:
- Fecha de publicación:
- 2021
- Institución:
- Universidad Nacional de Colombia
- Repositorio:
- Universidad Nacional de Colombia
- Idioma:
- eng
- OAI Identifier:
- oai:repositorio.unal.edu.co:unal/80815
- Palabra clave:
- 610 - Medicina y salud::618 - Ginecología, obstetricia, pediatría, geriatría
Hypertension, Pregnancy-Induced
Antihypertensive Agents
Pregnancy Complications, Cardiovascular
Hipertensión Inducida en el Embarazo
Antihipertensivos
Complicaciones Cardiovasculares del Embarazo
Embarazo
Hipertensión
Antihipertensivos
Privación de Tratamiento
Pregnancy
Hypertension
Antihypertensive Agents
Withholding Treatment
- Rights
- openAccess
- License
- Atribución-NoComercial-CompartirIgual 4.0 Internacional
| id |
UNACIONAL2_efbdee033ead3adc933fc90f9c5c793f |
|---|---|
| oai_identifier_str |
oai:repositorio.unal.edu.co:unal/80815 |
| network_acronym_str |
UNACIONAL2 |
| network_name_str |
Universidad Nacional de Colombia |
| repository_id_str |
|
| dc.title.spa.fl_str_mv |
Seguridad y efectividad de la reducción o retiro de la terapia antihipertensiva en gestantes con enfermedad vascular hipertensiva crónica |
| dc.title.translated.eng.fl_str_mv |
Safety and effectiveness of the reduction or withdrawal of antihypertensive therapy in pregnant women with chronic hypertensive vascular disease |
| title |
Seguridad y efectividad de la reducción o retiro de la terapia antihipertensiva en gestantes con enfermedad vascular hipertensiva crónica |
| spellingShingle |
Seguridad y efectividad de la reducción o retiro de la terapia antihipertensiva en gestantes con enfermedad vascular hipertensiva crónica 610 - Medicina y salud::618 - Ginecología, obstetricia, pediatría, geriatría Hypertension, Pregnancy-Induced Antihypertensive Agents Pregnancy Complications, Cardiovascular Hipertensión Inducida en el Embarazo Antihipertensivos Complicaciones Cardiovasculares del Embarazo Embarazo Hipertensión Antihipertensivos Privación de Tratamiento Pregnancy Hypertension Antihypertensive Agents Withholding Treatment |
| title_short |
Seguridad y efectividad de la reducción o retiro de la terapia antihipertensiva en gestantes con enfermedad vascular hipertensiva crónica |
| title_full |
Seguridad y efectividad de la reducción o retiro de la terapia antihipertensiva en gestantes con enfermedad vascular hipertensiva crónica |
| title_fullStr |
Seguridad y efectividad de la reducción o retiro de la terapia antihipertensiva en gestantes con enfermedad vascular hipertensiva crónica |
| title_full_unstemmed |
Seguridad y efectividad de la reducción o retiro de la terapia antihipertensiva en gestantes con enfermedad vascular hipertensiva crónica |
| title_sort |
Seguridad y efectividad de la reducción o retiro de la terapia antihipertensiva en gestantes con enfermedad vascular hipertensiva crónica |
| dc.creator.fl_str_mv |
Hamon Pinilla, Catalina Salamanca Téllez, Andrea Milena |
| dc.contributor.advisor.spa.fl_str_mv |
Grillo Ardila, Carlos Fernando Rubio Romero, Jorge Andrés |
| dc.contributor.author.spa.fl_str_mv |
Hamon Pinilla, Catalina Salamanca Téllez, Andrea Milena |
| dc.subject.ddc.spa.fl_str_mv |
610 - Medicina y salud::618 - Ginecología, obstetricia, pediatría, geriatría |
| topic |
610 - Medicina y salud::618 - Ginecología, obstetricia, pediatría, geriatría Hypertension, Pregnancy-Induced Antihypertensive Agents Pregnancy Complications, Cardiovascular Hipertensión Inducida en el Embarazo Antihipertensivos Complicaciones Cardiovasculares del Embarazo Embarazo Hipertensión Antihipertensivos Privación de Tratamiento Pregnancy Hypertension Antihypertensive Agents Withholding Treatment |
| dc.subject.decs.eng.fl_str_mv |
Hypertension, Pregnancy-Induced Antihypertensive Agents Pregnancy Complications, Cardiovascular |
| dc.subject.decs.spa.fl_str_mv |
Hipertensión Inducida en el Embarazo Antihipertensivos Complicaciones Cardiovasculares del Embarazo |
| dc.subject.proposal.spa.fl_str_mv |
Embarazo Hipertensión Antihipertensivos Privación de Tratamiento |
| dc.subject.proposal.eng.fl_str_mv |
Pregnancy Hypertension Antihypertensive Agents Withholding Treatment |
| description |
ilustraciones, gráficas, tablas |
| publishDate |
2021 |
| dc.date.issued.none.fl_str_mv |
2021-12-15 |
| dc.date.accessioned.none.fl_str_mv |
2022-01-31T17:31:12Z |
| dc.date.available.none.fl_str_mv |
2022-01-31T17:31:12Z |
| dc.type.spa.fl_str_mv |
Trabajo de grado - Especialidad Médica |
| dc.type.driver.spa.fl_str_mv |
info:eu-repo/semantics/masterThesis |
| dc.type.version.spa.fl_str_mv |
info:eu-repo/semantics/acceptedVersion |
| dc.type.content.spa.fl_str_mv |
Text |
| dc.type.redcol.spa.fl_str_mv |
http://purl.org/redcol/resource_type/TM |
| status_str |
acceptedVersion |
| dc.identifier.uri.none.fl_str_mv |
https://repositorio.unal.edu.co/handle/unal/80815 |
| dc.identifier.instname.spa.fl_str_mv |
Universidad Nacional de Colombia |
| dc.identifier.reponame.spa.fl_str_mv |
Repositorio Institucional Universidad Nacional de Colombia |
| dc.identifier.repourl.spa.fl_str_mv |
https://repositorio.unal.edu.co/ |
| url |
https://repositorio.unal.edu.co/handle/unal/80815 https://repositorio.unal.edu.co/ |
| identifier_str_mv |
Universidad Nacional de Colombia Repositorio Institucional Universidad Nacional de Colombia |
| dc.language.iso.eng.fl_str_mv |
eng |
| language |
eng |
| dc.relation.references.spa.fl_str_mv |
Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. The Lancet. 2002 Dec 14;360(9349):1903–13 Whelton PK, Carey RM, Aronow WS, Casey DEJ, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018 Jun;71(6):1269–324. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). European Heart Journal. 2018 Aug 25;39(33):3021–104 ACOG Practice Bulletin No. 203: Chronic Hypertension in Pregnancy. Obstetrics & Gynecology. 2019 Jan;133(1):e26 Bateman BT, Bansil P, Hernandez-Diaz S, Mhyre JM, Callaghan WM, Kuklina EV. Prevalence, trends, and outcomes of chronic hypertension: a nationwide sample of delivery admissions. Am J Obstet Gynecol. 2012 Feb;206(2):134.e1-8 Gilbert WM, Young AL, Danielsen B. Pregnancy outcomes in women with chronic hypertension: a population-based study. J Reprod Med. 2007 Nov;52(11):1046–51 Zetterström K, Lindeberg SN, Haglund B, Hanson U. Maternal complications in women with chronic hypertension: a population-based cohort study. Acta Obstetricia et Gynecologica Scandinavica. 2005 May 1;84(5):419–24 Panaitescu AM, Syngelaki A, Prodan N, Akolekar R, Nicolaides KH. Chronic hypertension and adverse pregnancy outcome: a cohort study. Ultrasound in Obstetrics & Gynecology. 2017 Aug 1;50(2):228–35 Panaitescu AM, Baschat AA, Akolekar R, Syngelaki A, Nicolaides KH. Association of chronic hypertension with birth of small-for-gestational-age neonate. Ultrasound in Obstetrics & Gynecology. 2017 Sep 1;50(3):361–6. Vigil-De Gracia P, Lasso M, Montufar-Rueda C. Perinatal outcome in women with severe chronic hypertension during the second half of pregnancy. International Journal of Gynecology & Obstetrics. 2004 May 1;85(2):139–44. Ettehad D, Emdin CA, Kiran A, Anderson SG, Callender T, Emberson J, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. The Lancet. 2016 Mar 5;387(10022):957–67 Lonn EM, Bosch J, López-Jaramillo P, Zhu J, Liu L, Pais P, et al. Blood-Pressure Lowering in Intermediate-Risk Persons without Cardiovascular Disease. New England Journal of Medicine. 2016 May 26;374(21):2009–20 Dickinson HO, Mason JM, Nicolson DJ, Campbell F, Beyer FR, Cook JV, et al. Lifestyle interventions to reduce raised blood pressure: a systematic review of randomized controlled trials. Journal of Hypertension. 2006 Feb;24(2):215–33. Wald DS, Law M, Morris JK, Bestwick JP, Wald NJ. Combination Therapy Versus Monotherapy in Reducing Blood Pressure: Meta-analysis on 11,000 Participants from 42 Trials. The American Journal of Medicine. 2009 Mar 1;122(3):290–300. Musini VM, Gueyffier F, Puil L, Salzwedel DM, Wright JM. Pharmacotherapy for hypertension in adults aged 18 to 59 years. Cochrane Database of Systematic Reviews [Internet]. 2017 [cited 2020 Nov 5];(8). Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008276.pub2/references Reeve E, Jordan V, Thompson W, Sawan M, Todd A, Gammie TM, et al. Withdrawal of antihypertensive drugs in older people. Cochrane Database of Systematic Reviews [Internet]. 2020 [cited 2020 Nov 5];(6). Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012572.pub2/full National Guideline Alliance (UK). Hypertension in pregnancy: diagnosis and management [Internet]. London: National Institute for Health and Care Excellence (UK); 2019 [cited 2020 Oct 26]. (National Institute for Health and Care Excellence: Clinical Guidelines). Available from: http://www.ncbi.nlm.nih.gov/books/NBK546004 Eschenhagen T. Treatment of Hypertension. In: Brunton LL, Hilal-Dandan R, Knollmann BC, editors. Goodman & Gilman’s: The Pharmacological Basis of Therapeutics, 13e [Internet]. New York, NY: McGraw-Hill Education; 2017 [cited 2020 Jul 20]. Available from: accessmedicine.mhmedical.com/content.aspx?aid=1162538308 Katzung BG, Kruidering-Hall M, Trevor AJ. Drugs Used in Hypertension. In: Katzung & Trevor’s Pharmacology: Examination & Board Review, 12e [Internet]. New York, NY: McGraw-Hill Education; 2019 [cited 2020 Jul 20]. Available from: accessmedicine.mhmedical.com/content.aspx?aid=1156527882 Frishman WH, Alwarshetty M. β-Adrenergic Blockers in Systemic Hypertension. Clin Pharmacokinet. 2002 Jun 1;41(7):505–16. Mazkereth R, Maayan-Metzger A, Leibovitch L, Schushan-Eisen I, Morag I, Straus T. Short-Term Neonatal Outcome among Term Infants after In-Utero Exposure to Beta Blockers. Isr Med Assoc J. 2019 Nov;21(11):724–7 Duan L, Ng A, Chen W, Spencer HT, Lee M-S. Beta-blocker subtypes and risk of low birth weight in newborns. J Clin Hypertens (Greenwich). 2018;20(11):1603–9. Haria M, Wagstaff AJ. Amlodipine. Drugs. 1995 Sep 1;50(3):560–86 Maille N, Gokina N, Mandalà M, Colton I, Osol G. Mechanism of hydralazine-induced relaxation in resistance arteries during pregnancy: Hydralazine induces vasodilation via a prostacyclin pathway. Vascular Pharmacology. 2016 Mar 1;78:36–42 Antihypertensive drug therapy for mild to moderate hypertension during pregnancy - Abalos, E - 2018 | Cochrane Library [Internet]. [cited 2020 Nov 5]. Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002252.pub4/full Magee LA, von Dadelszen P, Rey E, Ross S, Asztalos E, Murphy KE, et al. Less-Tight versus Tight Control of Hypertension in Pregnancy. New England Journal of Medicine. 2015 Jan 29;372(5):407–17. Nakhai-Pour HR, Rey E, Bérard A. Discontinuation of antihypertensive drug use during the first trimester of pregnancy and the risk of preeclampsia and eclampsia among women with chronic hypertension. Am J Obstet Gynecol. 2009 Aug;201(2):180.e1-8 Magee LA, CHIPS Study Group, von Dadelszen P, Singer J, Lee T, Rey E, et al. Do labetalol and methyldopa have different effects on pregnancy outcome? Analysis of data from the Control of Hypertension In Pregnancy Study (CHIPS) trial. BJOG. 2016 Jun;123(7):1143–51 Rezk M, Emarh M, Masood A, Dawood R, El-Shamy E, Gamal A, et al. Methyldopa versus labetalol or no medication for treatment of mild and moderate chronic hypertension during pregnancy: a randomized clinical trial. Hypertens Pregnancy. 2020 Jul 22;1–6 Su C-Y, Lin H-C, Cheng H-C, Yen AM-F, Chen Y-H, Kao S. Pregnancy Outcomes of Anti-Hypertensives for Women with Chronic Hypertension: A Population-Based Study. PLOS ONE. 2013 Feb 6;8(2):e53844 Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A-B, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. The Lancet Global Health. 2014 Jun;2(6):e323–33. Samra K. The eye and visual system in pregnancy, what to expect? An in-depth review. Oman journal of ophthalmology. 2013 Mar 4;6:87–91. Zeeman GG. Obstetric critical care: a blueprint for improved outcomes. Crit Care Med. 2006 Sep;34(9 Suppl):S208-214. van der Wardt V, Harrison JK, Welsh T, Conroy S, Gladman J. Withdrawal of antihypertensive medication: a systematic review. J Hypertens. 2017 Sep;35(9):1742–9. Zupan J, Åhman E. Neonatal and perinatal mortality: country, regional and global estimates. Geneva: World Health Organization; 2006. 69 p Apgar V. A Proposal for a New Method of Evaluation of the Newborn Infant. Anesthesia & Analgesia. 1953 Aug;32(4):260–7. Bender J, Koestler D, Ombao H, McCourt M, Alskinis B, Rubin LP, et al. Neonatal Intensive Care Unit: Predictive Models for Length of Stay. J Perinatol. 2013 Feb;33(2):147–53. Criteria for Neonatal Transfer AND Neonatal NICU Admission Criteria | Tom Wade MD [Internet]. [cited 2020 Nov 5]. Available from: https://www.tomwademd.net/criteria-for-neonatal-transfer-and-neonatal-nicu-admission-criteria/ Committee Opinion No 700: Methods for Estimating the Due Date. Obstetrics & Gynecology. 2017 May;129(5):e150 Dowswell T, Middleton P, Weeks A. Antenatal day care units versus hospital admission for women with complicated pregnancy. Cochrane Database of Systematic Reviews [Internet]. 2009 [cited 2020 Nov 5];(4). Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001803.pub2/full Schmidt P, Skelly CL, Raines DA. Placental Abruption. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 [cited 2020 Nov 5]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK482335/ American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics and the Society forMaternal-FetalMedicin. ACOG Practice Bulletin No. 204: Fetal Growth Restriction. Obstet Gynecol. 2019;133(2):e97–109 WHO Recommendations on Interventions to Improve Preterm Birth Outcomes [Internet]. Geneva: World Health Organization; 2015 [cited 2020 Nov 5]. (WHO Guidelines Approved by the Guidelines Review Committee). Available from: http://www.ncbi.nlm.nih.gov/books/NBK321160 Douglas-Escobar M, Weiss MD. Hypoxic-Ischemic Encephalopathy: A Review for the Clinician. JAMA Pediatr. 2015 Apr 1;169(4):397–403 Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019 28;366:l4898 Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997 Sep 13;315(7109):629–34 Harbord RM, Egger M, Sterne JAC. A modified test for small-study effects in meta-analyses of controlled trials with binary endpoints. Stat Med. 2006 Oct 30;25(20):3443–57. Rolnik DL, Wright D, Poon LCY, Syngelaki A, O'Gorman N, de Paco Matallana C, Akolekar R, Cicero S, Janga D, Singh M, Molina FS, Persico N, Jani JC, Plasencia W, Papaioannou G, Tenenbaum-Gavish K, Nicolaides KH. ASPRE trial: performance of screening for preterm pre-eclampsia. Ultrasound Obstet Gynecol. 2017 Oct;50(4):492-495. |
| dc.rights.coar.fl_str_mv |
http://purl.org/coar/access_right/c_abf2 |
| dc.rights.license.spa.fl_str_mv |
Atribución-NoComercial-CompartirIgual 4.0 Internacional |
| dc.rights.uri.spa.fl_str_mv |
http://creativecommons.org/licenses/by-nc-sa/4.0/ |
| dc.rights.accessrights.spa.fl_str_mv |
info:eu-repo/semantics/openAccess |
| rights_invalid_str_mv |
Atribución-NoComercial-CompartirIgual 4.0 Internacional http://creativecommons.org/licenses/by-nc-sa/4.0/ http://purl.org/coar/access_right/c_abf2 |
| eu_rights_str_mv |
openAccess |
| dc.format.extent.spa.fl_str_mv |
98 páginas |
| dc.format.mimetype.spa.fl_str_mv |
application/pdf |
| dc.publisher.spa.fl_str_mv |
Universidad Nacional de Colombia |
| dc.publisher.program.spa.fl_str_mv |
Bogotá - Medicina - Especialidad en Obstetricia y Ginecología |
| dc.publisher.department.spa.fl_str_mv |
Departamento de Obstetricia y Ginecología |
| dc.publisher.faculty.spa.fl_str_mv |
Facultad de Medicina |
| dc.publisher.place.spa.fl_str_mv |
Bogotá, Colombia |
| dc.publisher.branch.spa.fl_str_mv |
Universidad Nacional de Colombia - Sede Bogotá |
| institution |
Universidad Nacional de Colombia |
| bitstream.url.fl_str_mv |
https://repositorio.unal.edu.co/bitstream/unal/80815/4/1032462967.2021.pdf https://repositorio.unal.edu.co/bitstream/unal/80815/6/license.txt https://repositorio.unal.edu.co/bitstream/unal/80815/7/1032462967%20%20Licencia%20y%20%20autorizaci%c3%b3n%20para%20publicaci%c3%b3n%20de%20obras%20en%20el%20repositorio%20institucional%20UN%20v3.pdf https://repositorio.unal.edu.co/bitstream/unal/80815/8/1032462967.2021.pdf.jpg |
| bitstream.checksum.fl_str_mv |
40037ec6688dd291bb7cb4f2e4a4c2b0 8153f7789df02f0a4c9e079953658ab2 111376d9a8f29218db0c42f01748f93d fe1cd71113aed6a99f73ee4053b96b61 |
| bitstream.checksumAlgorithm.fl_str_mv |
MD5 MD5 MD5 MD5 |
| repository.name.fl_str_mv |
Repositorio Institucional Universidad Nacional de Colombia |
| repository.mail.fl_str_mv |
repositorio_nal@unal.edu.co |
| _version_ |
1814089263739830272 |
| spelling |
Atribución-NoComercial-CompartirIgual 4.0 Internacionalhttp://creativecommons.org/licenses/by-nc-sa/4.0/info:eu-repo/semantics/openAccesshttp://purl.org/coar/access_right/c_abf2Grillo Ardila, Carlos Fernandof196db07eecd7b7df3564871fee8e2fe600Rubio Romero, Jorge Andrés11daa564f778e7827bf8c669ebcc5445600Hamon Pinilla, Catalina60b5cfcc1a44beb83ac99dd082af91e8Salamanca Téllez, Andrea Milena52291f91c4e0f14d4b44ce2f55062ddb2022-01-31T17:31:12Z2022-01-31T17:31:12Z2021-12-15https://repositorio.unal.edu.co/handle/unal/80815Universidad Nacional de ColombiaRepositorio Institucional Universidad Nacional de Colombiahttps://repositorio.unal.edu.co/ilustraciones, gráficas, tablasObjective: To estimate the security and effectivity of the reduction or retirement of antihypertensive medication in pregnant women with chronic hypertension. Methods: Randomized controlled trials that compared management with antihypertensive drugs vs. no antihypertensive, discontinuation of the drug, placebo, or other interventions were included. We searched CENTRAL, MEDLINE, LILACS, and ClinicalTrials. We also hand-searched conference proceedings (ACOG, FIGO, RCOG, FECOLSOG) and reference lists of retrieved studies. Two review authors independently assessed trials for inclusion, extracted data and assessed risk of bias. We resolved disagreements through consensus. We used the GRADE approach to assess the quality of evidence. Results: The search did not find any controlled clinical trial evaluating the reduction or withdrawal of antihypertensive therapy. When antihypertensive management was compared with placebo or no antihypertensive, we found that antihypertensive treatment was associated with reduction of probability of developing severe hypertension in pregnant women with chronic hypertension (OR 0,43 95% CI 0.26 to 0.70 ) and increased probability of adverse effects associated to antihypertensive management (aOR 8.52; 95% CI 1.05 to 69). We did not found differences in the probability of developing superimposed pre-eclampsia, preterm birth, placental abruption, small for gestational age, pregnancy loss, neonatal death, admission to the neonatal intensive care unit or low APGAR at birth. We did not found differences in gestational age at birth. Quality of the evidence was very low due to the presence of serious risk of bias, limitations in the applicability of results and the confidence interval. Conclusion: Very low-quality evidence suggest that probably antihypertensive therapy reduces the incidence of severe hypertension in pregnant women with chronic hypertension when compared with placebo or no antihypertensive.Objetivo: Estimar la seguridad y efectividad de la reducción o retiro de la medicación antihipertensiva en mujeres embarazadas con hipertensión crónica. Métodos: Se incluyeron ensayos controlados aleatorios que compararon el tratamiento con fármacos antihipertensivos versus ningún antihipertensivo, suspensión del fármaco, placebo u otras intervenciones. Se realizaron búsquedas en CENTRAL, MEDLINE, LILACS y ClinicalTrials. También se realizaron búsquedas manuales en las actas de congresos (ACOG, FIGO, RCOG, FECOLSOG). Dos autores de la revisión evaluaron de forma independiente los ensayos para su inclusión, extrajeron los datos y evaluaron el riesgo de sesgo. Los desacuerdos fueron resultos por consenso. Utilizamos el enfoque GRADE para evaluar la calidad de la evidencia. Resultados: La búsqueda no encontró ningún ensayo clínico controlado que evaluara la reducción o el retiro de la terapia antihipertensiva. Cuando se comparó el tratamiento antihipertensivo con placebo o ningún antihipertensivo, encontramos que el tratamiento antihipertensivo se asoció con una reducción de la probabilidad de desarrollar hipertensión grave en mujeres embarazadas con hipertensión crónica (OR 0,43; IC del 95%: 0,26 a 0,70) y una mayor probabilidad de efectos adversos. asociado al tratamiento antihipertensivo (ORa 8,52; IC del 95%: 1,05 a 69). No encontramos diferencias en la probabilidad de desarrollar preeclampsia superpuesta, parto prematuro, desprendimiento de placenta, pequeño para la edad gestacional, pérdida del embarazo, muerte neonatal, ingreso en la unidad de cuidados intensivos neonatales o APGAR bajo al nacer. No encontramos diferencias en la edad gestacional al nacer. La calidad de la evidencia fue muy baja debido a la presencia de un riesgo grave de sesgo, las limitaciones en la aplicabilidad de los resultados y el intervalo de confianza. Conclusión: La evidencia de muy baja calidad sugiere que probablemente la terapia antihipertensiva reduce la incidencia de hipertensión severa en mujeres embarazadas con hipertensión crónica en comparación con placebo o ningún antihipertensivo. (Texto tomado de la fuente).Texto en inglésRevisión sistemática con meta-análisisEspecialidades MédicasEspecialista en Obstetricia y GinecologíaMethods Criteria for including studies in this review Randomized controlled trials or non-randomized controlled trials, published, unpublished and ongoing. Types of participants Pregnant women with a diagnosis of chronic hypertensive vascular disease defined as: systolic blood pressure greater than 130 mm Hg or diastolic pressure greater than 80 mm Hg (2,3) on at least two occasions 4 hours apart, before pregnancy or before 20 weeks of pregnancy (4). Type of intervention Withdrawal of antihypertensive drugs defined as abrupt suspension of drug use, de-staging of the drug until the withdrawal is complete, or decrease in current drug dose (16); versus: 1. Continue usual antihypertensive therapy with one or more medications of the type: alpha 2 agonists, calcium antagonists, alpha and beta blockers, alpha adrenergic antagonists, angiotensin converting enzyme inhibitors, angiotensin II receptor antagonists, vasodilators, and diuretics. 2. Placebo. 3. Other interventions. Types of outcomes Primary Outcomes Maternal: Maternal death: Defined as the death of a woman due to direct or indirect obstetric causes during pregnancy or up to 42 days after its termination, regardless of the place in which it occurred or its duration (31). Severe preeclampsia: Defined as finding after week 20 of gestation up to 6 weeks postpartum of systolic blood pressure values greater than or equal to 160 mm Hg or diastolic blood pressure values greater than or equal to 110 mm Hg on two occasions separated by a short interval of time (5-15 minutes), or the finding of systolic blood pressure values greater than or equal to 140 mm Hg or diastolic blood pressure greater than or equal to 90 mm Hg on at least two occasions separated by four hours and associated with: thrombocytopenia (platelet count less than 100 x 109 / L); impaired liver function indicated by abnormal serum levels of liver enzymes (twice the higher level of reference); persistent severe pain in epigastrium or right upper quadrant not due to other diagnoses; renal failure (serum creatinine greater than 1.1 mg / dL or twice the baseline serum creatinine concentration in the absence of other kidney disease); pulmonary edema; recent-onset headache that does not respond to analgesic management and is not related to alternative diagnoses; hyperreflexia; visual disturbances such as photophobia, blurred vision, photopsia, scotomas, or blindness that are not related to alternative diagnoses (32); eclampsia defined as the sudden onset of focal or multifocal tonic-clonic seizures in the absence of other conditions that cause it such as epilepsy, cerebral ischemia or infarction, intracranial hemorrhage or use of medications; or HELLP syndrome defined as elevated lactic acid dehydrogenase (LDH) greater than or equal to 600 IU / L, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) greater than twice the upper limit of normality and platelets less than 100 x 109 / L (4). Admission to the Intensive Care Unit: defined as the requirement for care in intermediate or intensive care units (33). Adverse reactions: defined as adverse events caused by the withdrawal or use of antihypertensive medications, including palpitations, headache, joint pain, lower limb edema, orthostatic hypotension or rebound hypertension, in addition to changes in serum biochemistry, heart rate, pulse rate, kidney function, and left ventricular parameters (34). Fetal: Loss of pregnancy: Defined as abortion (death of the fruit of conception before week 20 or less than 500 g) or death (death of a fetus in utero after week 20 and greater than 500 g) (26). Neonatal Mortality: defined as those newborns who die before reaching 28 days of life (35). APGAR less than or equal to 5 at minute 5: defined by the Apgar scale that assesses the viability of a newborn according to five simple physio-anatomical parameters: muscle tone, respiratory effort, heart rate, reflexes and skin color, each parameter is assigned a score between 0 and 2 (36). Neonatal intensive care unit admission: defined as admission of a neonate to a neonatal intensive care unit for some neonatal condition that requires surveillance or monitoring (37). Among the causes of admission are: prematurity or birth weight less than 1500 g, gestational age less than 32 weeks, respiratory distress that requires ventilatory support (continuous positive pressure in the airway, mechanical ventilation), seizure syndrome; congenital abnormalities or inborn errors of metabolism, congenital heart disease or cardiac arrhythmias requiring cardiac management, hypoxic-ischemic encephalopathy, other conditions requiring neonatological consultation (severe hyperbilirubinemia, severe intrauterine growth restriction, birth weight between 1000 g 2000 g and gestational age between 32 and 36 weeks (38). Secondary outcomes Maternal Severe arterial hypertension: Defined as the finding of systolic blood pressure values greater than or equal to 160 mm Hg or diastolic blood pressure greater than or equal to 110 mm Hg on two occasions separated by a short time interval (minutes) (4). Gestational age at delivery: Defined as weeks from conception to the date of delivery. It will be calculated taking into account the gestational age reported in the first trimester ultrasound (up to week 13 6/7) or that of the subsequent trimesters if the first trimester is not provided. If the date of the last menstruation agrees with the gestational age obtained through the ultrasound of the first trimester or of the subsequent trimesters, it can be used (39). Hospitalization During Pregnancy: Defined as admission to a hospital during pregnancy (40) Renal compromise: Defined as serum creatinine greater than or equal to 1.1 mg / dL (4). Placental abruption: Defined as a process consisting of premature detachment of the placenta characterized by vaginal bleeding, uterine hypertonicity or unsatisfactory fetal status associated with direct visualization of retroplacental hemorrhage or hematoma (41). Fetal: Small for gestational age fetus: defined as a newborn whose weight is less than the 10th percentile for gestational age (42). Preterm delivery: Defined as delivery before 37 weeks of gestation (43). Hypoxic / Ischemic Encephalopathy: defined as the presence of neurological dysfunction in the form of neonatal encephalopathy, associated with depression of the level of consciousness, respiratory depression, alteration of muscle tone and seizures, associated with suggestive findings on brain MRI (44). Search methods for identification of studies Electronic searches A comprehensive search was conducted to identify as many relevant studies as possible in the electronic databases. A combination of controlled vocabulary was used (MeSH, Emtree terms, Health Sciences, and descriptors (DeCS). The following electronic databases were searched: - Cochrane Central Register of Controlled Trials (CENTRAL). - MEDLINE, PubMed - EMBASE Ovid - LILACS (Health Sciences of Latin America and the Caribbean). Search for other resources The following resources were sought for additional studies: • International Clinical Trials Registry Platform (ICTRP) https://apps.who.int/trialsearch/AdvSearch.aspx • Gray literature: a search was carried out in the information system for gray literature in Europe “OpenGrey”. Manual search Abstracts of the following conferences were hand searched: - International Federation of Gynecology and Obstetrics (FIGO) (www.figo.org). - American College of Obstetricians and Gynecologists (ACOG) (www.acog.org). - Royal College of Obstetricians and Gynecologists (RCOG) (www.rcog.org.uk). - Colombian Federation of Obstetrics and Gynecology. (https://www.fecolsog.org/) Data extraction and analysis The following methods were used when the reports were identified: Study selection Two reviewers independently assessed the inclusion of all potential studies that were identified as a result of the search strategy. Relevance and adherence to the inclusion criteria were evaluated. If studies did not meet the inclusion criteria, they were not included and the reasons for exclusion were wrote. Any disagreement was resolved through discussion or, if necessary, a third reviewer was consulted. Data extraction and management A form for data extraction was designed. For chosen studies, two reviewers extracted data using the agreed form. Discrepancies were resolved through discussion or, if necessary, a third reviewer was consulted. The data was entered into the RevMan 2019 software and verified for accuracy. When the information on any of the previous points was not clear, an attempt was made to contact the authors and editors of the original studies and the journals where they were published to provide more details. Assessment of risk of bias in included studies The risk of bias from randomized clinical trials was assessed using the criteria described in RoB 2.0 bias assessment tool (45). Any disagreement was resolved by discussion or involving a third reviewer. RoB 2.0 risk assessment of biases Assessment of the quality of evidence using the GRADE system The quality of evidence was evaluated using the GRADE system as specified in the GRADE manual so as to assess the quality of evidence related to the outcomes of the main comparison. Antihypertensive withdrawal was defined as abrupt discontinuation of drug use, de-escalation of the drug until complete withdrawal or tapering of the drug dose compared to continuing established antihypertensive therapy, Placebo and Other interventions. A summary of the effect of the intervention and of the quality measurement for each of the next outcomes was developed using the GRADE system (Annexed tables 1 and 2). Measurement of treatment effect Dichotomous data The results were reported as a probability ratio (OR) with a 95% confidence interval (CI). Continuous data The mean difference (MD) was used if the results are measured in the same way within the included studies and the standardized mean difference (SMD) was used to combine trials measuring the same outcome, but with different methods. Assessment of missing data An intention-to-treat analysis was performed, that is, an attempt was made to include all participants assigned to each analysis group and all participants who were analyzed in the group to which they were assigned, regardless of whether or not they received the assigned intervention. The impact of including studies with high levels of missing data in the overall evaluation of treatment effects was explored using a sensitivity analysis. Assessment of heterogeneity Statistical heterogeneity was assessed using I2 values and Chi square test values. Heterogeneity was considered substantial if the I2 statistical value was greater than 40% or if there was a low p-value (less than 0.10) in the Chi-square test. Assessment of reporting bias Publication bias was assessed when ten or more studies were retrieved through the evaluation of the asymmetry of the funnel plot and the formal tests. For continuous variables, the test proposed by Egger was used (46), and for dichotomous results the test proposed by Harbord was used (47). Subgroup analysis and investigation of heterogeneity We explored the following potential sources of heterogeneity where it was considered that the effect size may have changed based on their results using subgroup analysis. 1. Definition of chronic arterial hypertension. Chronic arterial hypertension defined as SBP greater than or equal to 130 and DBP greater than or equal to 80 vs. defined as SBP greater than or equal to 140 and DBP greater than or equal to 90. 2. Subgroup of type of antihypertensive. alpha 2 agonists, calcium antagonists, alpha blockers, beta blockers, alpha adrenergic antagonists, angiotensin converting enzyme inhibitors, angiotensin II receptor antagonists, vasodilators, and diuretics. 3. Etiology of hypertension. Primary hypertension vs. secondary hypertension. Data analysis Statistical analysis was performed using RevMan 2019, a fixed-effect meta-analysis was used to pool the data when it was reasonable to assume that the studies estimated the same underlying treatment effect, that is, when the studies examined the same intervention, and the populations and study methods were sufficiently similar. When there was sufficient clinical heterogeneity to have expected underlying treatment effects differed between studies or substantial statistical heterogeneity, a random effects meta-analysis was performed. The average effect of the random effects was assessed as the average range of possible treatment effects and the clinical implications of treatment effects that differed between trials was discussed. If the average effect was not clinically significant, the trials were not combined. If random effects analysis was used, the results were presented as the mean treatment effect and 95% confidence intervals and I2 estimates. Sensitivity analysis A sensitivity analysis was performed by type of studies and based on other aspects of the review that may had have an effect on the results, a sensitivity analysis was also performed to explore the inclusion of the effects of fixed or random effects analysis for the results with statistical heterogeneity.98 páginasapplication/pdfengUniversidad Nacional de ColombiaBogotá - Medicina - Especialidad en Obstetricia y GinecologíaDepartamento de Obstetricia y GinecologíaFacultad de MedicinaBogotá, ColombiaUniversidad Nacional de Colombia - Sede Bogotá610 - Medicina y salud::618 - Ginecología, obstetricia, pediatría, geriatríaHypertension, Pregnancy-InducedAntihypertensive AgentsPregnancy Complications, CardiovascularHipertensión Inducida en el EmbarazoAntihipertensivosComplicaciones Cardiovasculares del EmbarazoEmbarazoHipertensiónAntihipertensivosPrivación de TratamientoPregnancyHypertensionAntihypertensive AgentsWithholding TreatmentSeguridad y efectividad de la reducción o retiro de la terapia antihipertensiva en gestantes con enfermedad vascular hipertensiva crónicaSafety and effectiveness of the reduction or withdrawal of antihypertensive therapy in pregnant women with chronic hypertensive vascular diseaseTrabajo de grado - Especialidad Médicainfo:eu-repo/semantics/masterThesisinfo:eu-repo/semantics/acceptedVersionTexthttp://purl.org/redcol/resource_type/TMAge-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. The Lancet. 2002 Dec 14;360(9349):1903–13Whelton PK, Carey RM, Aronow WS, Casey DEJ, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018 Jun;71(6):1269–324.Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). European Heart Journal. 2018 Aug 25;39(33):3021–104ACOG Practice Bulletin No. 203: Chronic Hypertension in Pregnancy. Obstetrics & Gynecology. 2019 Jan;133(1):e26Bateman BT, Bansil P, Hernandez-Diaz S, Mhyre JM, Callaghan WM, Kuklina EV. Prevalence, trends, and outcomes of chronic hypertension: a nationwide sample of delivery admissions. Am J Obstet Gynecol. 2012 Feb;206(2):134.e1-8Gilbert WM, Young AL, Danielsen B. Pregnancy outcomes in women with chronic hypertension: a population-based study. J Reprod Med. 2007 Nov;52(11):1046–51Zetterström K, Lindeberg SN, Haglund B, Hanson U. Maternal complications in women with chronic hypertension: a population-based cohort study. Acta Obstetricia et Gynecologica Scandinavica. 2005 May 1;84(5):419–24Panaitescu AM, Syngelaki A, Prodan N, Akolekar R, Nicolaides KH. Chronic hypertension and adverse pregnancy outcome: a cohort study. Ultrasound in Obstetrics & Gynecology. 2017 Aug 1;50(2):228–35Panaitescu AM, Baschat AA, Akolekar R, Syngelaki A, Nicolaides KH. Association of chronic hypertension with birth of small-for-gestational-age neonate. Ultrasound in Obstetrics & Gynecology. 2017 Sep 1;50(3):361–6.Vigil-De Gracia P, Lasso M, Montufar-Rueda C. Perinatal outcome in women with severe chronic hypertension during the second half of pregnancy. International Journal of Gynecology & Obstetrics. 2004 May 1;85(2):139–44.Ettehad D, Emdin CA, Kiran A, Anderson SG, Callender T, Emberson J, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. The Lancet. 2016 Mar 5;387(10022):957–67Lonn EM, Bosch J, López-Jaramillo P, Zhu J, Liu L, Pais P, et al. Blood-Pressure Lowering in Intermediate-Risk Persons without Cardiovascular Disease. New England Journal of Medicine. 2016 May 26;374(21):2009–20Dickinson HO, Mason JM, Nicolson DJ, Campbell F, Beyer FR, Cook JV, et al. Lifestyle interventions to reduce raised blood pressure: a systematic review of randomized controlled trials. Journal of Hypertension. 2006 Feb;24(2):215–33.Wald DS, Law M, Morris JK, Bestwick JP, Wald NJ. Combination Therapy Versus Monotherapy in Reducing Blood Pressure: Meta-analysis on 11,000 Participants from 42 Trials. The American Journal of Medicine. 2009 Mar 1;122(3):290–300.Musini VM, Gueyffier F, Puil L, Salzwedel DM, Wright JM. Pharmacotherapy for hypertension in adults aged 18 to 59 years. Cochrane Database of Systematic Reviews [Internet]. 2017 [cited 2020 Nov 5];(8). Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008276.pub2/referencesReeve E, Jordan V, Thompson W, Sawan M, Todd A, Gammie TM, et al. Withdrawal of antihypertensive drugs in older people. Cochrane Database of Systematic Reviews [Internet]. 2020 [cited 2020 Nov 5];(6). Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012572.pub2/fullNational Guideline Alliance (UK). Hypertension in pregnancy: diagnosis and management [Internet]. London: National Institute for Health and Care Excellence (UK); 2019 [cited 2020 Oct 26]. (National Institute for Health and Care Excellence: Clinical Guidelines). Available from: http://www.ncbi.nlm.nih.gov/books/NBK546004Eschenhagen T. Treatment of Hypertension. In: Brunton LL, Hilal-Dandan R, Knollmann BC, editors. Goodman & Gilman’s: The Pharmacological Basis of Therapeutics, 13e [Internet]. New York, NY: McGraw-Hill Education; 2017 [cited 2020 Jul 20]. Available from: accessmedicine.mhmedical.com/content.aspx?aid=1162538308Katzung BG, Kruidering-Hall M, Trevor AJ. Drugs Used in Hypertension. In: Katzung & Trevor’s Pharmacology: Examination & Board Review, 12e [Internet]. New York, NY: McGraw-Hill Education; 2019 [cited 2020 Jul 20]. Available from: accessmedicine.mhmedical.com/content.aspx?aid=1156527882Frishman WH, Alwarshetty M. β-Adrenergic Blockers in Systemic Hypertension. Clin Pharmacokinet. 2002 Jun 1;41(7):505–16.Mazkereth R, Maayan-Metzger A, Leibovitch L, Schushan-Eisen I, Morag I, Straus T. Short-Term Neonatal Outcome among Term Infants after In-Utero Exposure to Beta Blockers. Isr Med Assoc J. 2019 Nov;21(11):724–7Duan L, Ng A, Chen W, Spencer HT, Lee M-S. Beta-blocker subtypes and risk of low birth weight in newborns. J Clin Hypertens (Greenwich). 2018;20(11):1603–9.Haria M, Wagstaff AJ. Amlodipine. Drugs. 1995 Sep 1;50(3):560–86Maille N, Gokina N, Mandalà M, Colton I, Osol G. Mechanism of hydralazine-induced relaxation in resistance arteries during pregnancy: Hydralazine induces vasodilation via a prostacyclin pathway. Vascular Pharmacology. 2016 Mar 1;78:36–42Antihypertensive drug therapy for mild to moderate hypertension during pregnancy - Abalos, E - 2018 | Cochrane Library [Internet]. [cited 2020 Nov 5]. Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002252.pub4/fullMagee LA, von Dadelszen P, Rey E, Ross S, Asztalos E, Murphy KE, et al. Less-Tight versus Tight Control of Hypertension in Pregnancy. New England Journal of Medicine. 2015 Jan 29;372(5):407–17.Nakhai-Pour HR, Rey E, Bérard A. Discontinuation of antihypertensive drug use during the first trimester of pregnancy and the risk of preeclampsia and eclampsia among women with chronic hypertension. Am J Obstet Gynecol. 2009 Aug;201(2):180.e1-8Magee LA, CHIPS Study Group, von Dadelszen P, Singer J, Lee T, Rey E, et al. Do labetalol and methyldopa have different effects on pregnancy outcome? Analysis of data from the Control of Hypertension In Pregnancy Study (CHIPS) trial. BJOG. 2016 Jun;123(7):1143–51Rezk M, Emarh M, Masood A, Dawood R, El-Shamy E, Gamal A, et al. Methyldopa versus labetalol or no medication for treatment of mild and moderate chronic hypertension during pregnancy: a randomized clinical trial. Hypertens Pregnancy. 2020 Jul 22;1–6Su C-Y, Lin H-C, Cheng H-C, Yen AM-F, Chen Y-H, Kao S. Pregnancy Outcomes of Anti-Hypertensives for Women with Chronic Hypertension: A Population-Based Study. PLOS ONE. 2013 Feb 6;8(2):e53844Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A-B, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. The Lancet Global Health. 2014 Jun;2(6):e323–33.Samra K. The eye and visual system in pregnancy, what to expect? An in-depth review. Oman journal of ophthalmology. 2013 Mar 4;6:87–91.Zeeman GG. Obstetric critical care: a blueprint for improved outcomes. Crit Care Med. 2006 Sep;34(9 Suppl):S208-214.van der Wardt V, Harrison JK, Welsh T, Conroy S, Gladman J. Withdrawal of antihypertensive medication: a systematic review. J Hypertens. 2017 Sep;35(9):1742–9.Zupan J, Åhman E. Neonatal and perinatal mortality: country, regional and global estimates. Geneva: World Health Organization; 2006. 69 pApgar V. A Proposal for a New Method of Evaluation of the Newborn Infant. Anesthesia & Analgesia. 1953 Aug;32(4):260–7.Bender J, Koestler D, Ombao H, McCourt M, Alskinis B, Rubin LP, et al. Neonatal Intensive Care Unit: Predictive Models for Length of Stay. J Perinatol. 2013 Feb;33(2):147–53.Criteria for Neonatal Transfer AND Neonatal NICU Admission Criteria | Tom Wade MD [Internet]. [cited 2020 Nov 5]. Available from: https://www.tomwademd.net/criteria-for-neonatal-transfer-and-neonatal-nicu-admission-criteria/Committee Opinion No 700: Methods for Estimating the Due Date. Obstetrics & Gynecology. 2017 May;129(5):e150Dowswell T, Middleton P, Weeks A. Antenatal day care units versus hospital admission for women with complicated pregnancy. Cochrane Database of Systematic Reviews [Internet]. 2009 [cited 2020 Nov 5];(4). Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001803.pub2/fullSchmidt P, Skelly CL, Raines DA. Placental Abruption. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 [cited 2020 Nov 5]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK482335/American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics and the Society forMaternal-FetalMedicin. ACOG Practice Bulletin No. 204: Fetal Growth Restriction. Obstet Gynecol. 2019;133(2):e97–109WHO Recommendations on Interventions to Improve Preterm Birth Outcomes [Internet]. Geneva: World Health Organization; 2015 [cited 2020 Nov 5]. (WHO Guidelines Approved by the Guidelines Review Committee). Available from: http://www.ncbi.nlm.nih.gov/books/NBK321160Douglas-Escobar M, Weiss MD. Hypoxic-Ischemic Encephalopathy: A Review for the Clinician. JAMA Pediatr. 2015 Apr 1;169(4):397–403Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019 28;366:l4898Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997 Sep 13;315(7109):629–34Harbord RM, Egger M, Sterne JAC. A modified test for small-study effects in meta-analyses of controlled trials with binary endpoints. Stat Med. 2006 Oct 30;25(20):3443–57.Rolnik DL, Wright D, Poon LCY, Syngelaki A, O'Gorman N, de Paco Matallana C, Akolekar R, Cicero S, Janga D, Singh M, Molina FS, Persico N, Jani JC, Plasencia W, Papaioannou G, Tenenbaum-Gavish K, Nicolaides KH. ASPRE trial: performance of screening for preterm pre-eclampsia. Ultrasound Obstet Gynecol. 2017 Oct;50(4):492-495.EstudiantesInvestigadoresMaestrosORIGINAL1032462967.2021.pdf1032462967.2021.pdfTesis de Especialidad en Obstetricia y Ginecologíaapplication/pdf3061420https://repositorio.unal.edu.co/bitstream/unal/80815/4/1032462967.2021.pdf40037ec6688dd291bb7cb4f2e4a4c2b0MD54LICENSElicense.txtlicense.txttext/plain; charset=utf-84074https://repositorio.unal.edu.co/bitstream/unal/80815/6/license.txt8153f7789df02f0a4c9e079953658ab2MD561032462967 Licencia y autorización para publicación de obras en el repositorio institucional UN v3.pdf1032462967 Licencia y autorización para publicación de obras en el repositorio institucional UN v3.pdfLicencia coautorapplication/pdf220505https://repositorio.unal.edu.co/bitstream/unal/80815/7/1032462967%20%20Licencia%20y%20%20autorizaci%c3%b3n%20para%20publicaci%c3%b3n%20de%20obras%20en%20el%20repositorio%20institucional%20UN%20v3.pdf111376d9a8f29218db0c42f01748f93dMD57THUMBNAIL1032462967.2021.pdf.jpg1032462967.2021.pdf.jpgGenerated Thumbnailimage/jpeg5496https://repositorio.unal.edu.co/bitstream/unal/80815/8/1032462967.2021.pdf.jpgfe1cd71113aed6a99f73ee4053b96b61MD58unal/80815oai:repositorio.unal.edu.co:unal/808152023-07-31 23:04:17.039Repositorio Institucional Universidad Nacional de Colombiarepositorio_nal@unal.edu.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 |