ANMC GUIDELINES FOR MANAGEMENT OF

HYPERTENSIVE DISORDERS IN PREGNANCY

# KEY POINTS

-Hypertensive disorders are the most common medical complications of
pregnancy with an incidence of 12-22% in pregnancy.

-The best screening test is a BP measured in the sitting position after
a 10 minute rest. The BP needs to be repeated in 6 hours for the
diagnosis. The patient should not use tobacco or caffeine for 30 minutes
preceding the measurement. Details below

-There is no good predictive test for preeclampsia, e.g., urine or blood
tests

-Urine dipstick testing has NO role in universal screening for
preeclampsia [in routine prenatal care]{.underline}, e.g., if BP \<
140/90 and asymptomatic

-Low dose aspirin therapy is indicated if the patient has had prior
severe preeclampsia, chronic hypertension, pre existing diabetes, or
significant renal disease. (Level I recommendation)

-It has been demonstrated that over 500 mild preeclamptic women have to
be treated to prevent one seizure. One in 30 severe preeclamptic women
may seize if untreated.

-There is, to date, no scientific evidence that antihypertensive therapy
will improve

perinatal outcome in chronic hypertension

-We do not use the term 'pregnancy induced hypertension' or 'PIH'
anymore. That term has been replaced with the term 'gestational
hypertension'. It involves hypertension without proteinuria.

-Reports have suggested that almost 90% of Alaska Native women had low
calcium intakes compared to a NHANES II control data, and calcium
supplementation appears to be beneficial for women at high risk of
gestational hypertension and in communities with low dietary calcium
intake.

**DEFINITIONS**

I. [Pre-eclampsia]{.underline}

## Screening

-Screening for preeclampsia is recommended for all pregnant women at the
first prenatal

visit and throughout the remainder of pregnancy.

-To screen for preeclampsia, measure an upright sitting blood pressure
after a 10 minute rest. The BP should be repeated in a similar manner
4-6 hours later to confirm the diagnosis. (see below)

-There is no role for universal urine dipstick testing to screen for
preeclampsia in routine

prenatal care.

[Method of measuring blood pressure in pregnancy]{.underline}

> The diastolic blood pressure is that pressure at which the sound
> disappears (Korotkoff phase V) .
>
> To reduce inaccurate readings, an appropriate size cuff should be used
> (length 1.5 times upper arm circumference or a cuff with a bladder
> that encircles 80% or more of the arm). The blood pressure level
> should be taken with the patient in an upright position, after a
> 10-minute or longer rest period.
>
> For patients in the hospital, the blood pressure can be taken with
> either the patient sitting up or in the left lateral recumbent
> position with the patient\'s arm at the level of the heart. The
> patient should not use tobacco or caffeine for 30 minutes preceding
> the measurement Although validated electronic devices can be used, a
> mercury sphygmomanometer is preferred because it is the most accurate
> device

## Routine prenatal care

-There is no role for universal urine dipstick testing to screen for
preeclampsia [in routine]{.underline}

[prenatal care.]{.underline}

-On the other hand, if a patient presents with a BP \> 140/90, CNS
symptoms of

preeclampsia, or signs/symptoms of a urinary tract infection, then a
urine sample should

be obtained for dipstick urine protein, 24 hour urine, or Total Protein
/ Creat, as

appropriate.

A. Mild

1.  Blood pressure of 140 mm Hg systolic or higher, or 90 mm Hg
    diastolic or higher, in an upright sitting blood pressure after a 10
    minute rest, that occurs after 20 weeks of gestation in a woman with
    previously normal blood pressure.

> The BP should be repeated in a similar manner 4-6 hours later to
> confirm the diagnosis.

2.  Proteinuria, defined as urinary excretion of 0.3 g protein or higher
    in a 24-hour urine specimen

3.  Note the diagnosis of proteinuria will be mis-diagnosed on
    contaminiated urine specimens. If necessary, repeat the test on a
    clean specimen, e.g., 0-1 squamous cells, or an a catheterized
    specimen.

4.  Other methods to document proteinuria may include: 3+ on two urine
    dipsticks 4° apart, or Total Protein / Creat \> 0.20 on CCUA.

B. Severe (Mild, plus one or more criteria)

1.  Blood pressure of 160 mm Hg systolic or higher or 110 mm Hg
    diastolic or higher on two occasions at least 6 hours apart while
    the patient is on bed rest

2.  Proteinuria of 5 g or higher in a 24-hour urine specimen or 3+ or
    greater on two random urine samples collected at least 4 hours apart

3.  Cerebral or visual disturbances

4.  Pulmonary edema or cyanosis

5.  Epigastric or right upper-quadrant pain

6.  Oliguria of less than 500 mL in 24 hours

7.  Impaired liver function

8.  Fetal growth restriction

9.  Thrombocytopenia, platelets \<100,000

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C.  HELLP syndrome ([H]{.underline}emolysis-abnormal peripheral smear,
    bilirubin, LDH, [E]{.underline}levated [L]{.underline}iver enzymes,
    [L]{.underline}ow [P]{.underline}latelets \<100,000)

> -This syndrome requires prompt delivery upon diagnosis

II\. [Eclampsia]{.underline}

A. New onset generalized seizures in pregnancy without CNS lesion.

III\. [Chronic Hypertension (CHTN)]{.underline}

-There is, to date, no scientific evidence that antihypertensive therapy
will improve

perinatal outcome

-Angiotensin--converting enzyme (ACE) inhibitors are contraindicated
during the second

and third trimesters of pregnancy.

A. Mild: Systolic blood pressure \>=140 mm Hg

> Diastolic blood pressure \>=90 mm Hg
>
> Severe: Systolic blood pressure \>=180 mm Hg
>
>    Diastolic blood pressure \>=110 mm Hg

B.  Use of antihypertensive medications before pregnancy

C.  Onset of hypertension before 20th week of gestation

D.  Persistence of hypertension beyond the usual postpartum period, 42
    days

-At risk for IUGR, PTL, abruptio placenta, renal failure, CHF, CVA, and
superimposed

pre-eclampsia.

-Women with mild hypertension (140--179 mmHg systolic or 90--109 mm Hg
diastolic pressure) generally do well during pregnancy and do not, as a
rule, require antihypertensive medication There is, to date, no
scientific evidence that antihypertensive therapy will improve perinatal
outcome

-A systematic review concluded that there are no conclusive data to
address either

the benefits or the harms of various monitoring strategies for pregnant
women with chronic hypertension. However, other studies have indicated
that most of the increased morbidity associated with this condition is
secondary to superimposed preeclampsia or IUGR

IV\. [Chronic Hypertension plus Superimposed Pre-eclampsia]{.underline}

> Chronic hypertension as defined above, and either
>
> -Mild superimposed preeclampsia: Proteinuria: 300 mg. on \>24° urine
> collection, or
>
> -Severe superimposed preeclampsia: see Severe preeclampsia criteria

V. [Gestational hypertension]{.underline}

[Definition]{.underline}: Blood pressure elevation unaccompanied by
proteinuria after 20 weeks GA

> One quarter of these women will go on to develop the preeclampsia
> syndrome and so more frequent monitoring is essential. If proteinuria
> does not develop these patients can be delivered at term.
>
> If blood pressure elevation persists beyond 3 months postpartum, the
> patient is diagnosed with chronic hypertension. In the absence of
> proteinuria, perinatal outcomes are good. Unlike typical
> preeclamptics, a significant number of these women will go on to
> develop essential hypertension later in life.

**[MANAGEMENT]{.underline}**

I. Pre-eclampsia

The BP should be repeated in 4-6 hours after the initial BP to confirm
the

diagnosis before a laboratory work up is initiated.\*

A. Mild

After diagnosis, 80% will show weight loss, diuresis, and improved BP\'s
following 48°

hospitalization.

Outpatient management of mild preeclampsia may be considered if medical
adherence

with home bed rest and follow-up guidelines assured.

> -\*baseline studies: CBC, platelets, ALT/AST, Creatinine, 24° urine
> for protein and Cr
>
> clearance, or Total Protein / Creat \> 0.20 on CCUA, Level I U/S,
> initial NST

-Regular diet, bed rest with bathroom privileges

-BP every 6° while awake, daily weight

-daily evaluation for CNS, GI sx, fetal movement, vaginal bleeding and
contractions

[Prenatal follow-up]{.underline}

Weekly provider visits

Check BP twice a week, e.g., once at NST visit and once at provider
visit, or as separate

Nurses Clinic visit

If symptomatic, then repeat: platelet count, renal, and liver studies

If no IUGR or oligohydramnios, then NST q week and daily fetal movements

IUGR or oligohydramnios rarely develops. If it does, then

-NST every 3-4 days, amniotic fluid assessment every week

-US q 3-4 weeks

If IUGR or oligohyramious, then see Severe Preeclampsia

-Transfer to ANMC at 37 wks GA, if undelivered.

[Delivery:]{.underline}

When to deliver: Mild preeclampsia at 38 weeks

If remote from term: then follow weekly till 38 weeks

Consider Magnesium Sulfate (see dose below)

Careful fluid management is necessary to prevent fluid overload (\<3,000
cc/24 hrs IV

and po combined)

[Postpartum]{.underline}

Avoid Methergine

Continue Magnesium Sulfate at least 4 hours postpartum if BP \< 140/90,
DTR's less

then 3+, and no CNS symptoms

-Depending on clinical condition concurrent Pitocin IV drip (20U/liter
LR at 25-

50cc/hr) needs to be given PP to counter Magnesium Sulfate induced
uterine atony

B. Severe

-Prompt ANMC OB consultation

-Transfer after stabilization (stretcher, medical escort)

### 

### Delivery

Severe Preeclampsia mandates prompt delivery

Initially infuse 1,000 cc Lactated Ringers IV initially to decrease
vasospasm

(not if SOB or sat \< 95%)

[Magnesium Sulfate prophylaxis]{.underline}

Magnesium Sulfate 40 gram / liter LR-intravenous route ideal, infusion
pump required

4-6g loading dose IV over 15 to 30 minutes

maintenance rate: 1 to 3gram / hour to depress, not eliminate reflexes

-insert Foley, strict I&O, monitor urine ouput to monitor renal
perfusion

-cardiovascular and respiratory depression unlikely if reflexes still
exist

-if Magnesium Sulfate overdose occurs, give 10% Calcium gluconate, 10cc,
IV

> slowly over 2 minutes

-Magnesium Sulfate may be administered IM, if IV access not available

> -50% Magnesium Sulfate 10-ml (5g) in each buttock (10g total)

-then 50% Magnesium Sulfate 10ml (5g) IM every 4°-6° depending on reflex

activity

-1 ml 1-% lidocaine should be added to each injection to minimize
inevitable

pain

-Fluid Restriction: Total fluid (IV and po) 3000cc/24º

-continuous fetal monitoring while hospitalized, then every 15-30
minutes during

transport

-BP every 15-30 minutes, I&O every hour

[Remote from term]{.underline}:

If IUGR or oligohydramnios develops

-NST every 3-4 days, amniotic fluid assessment every week

-US q 3-4 weeks

[If Systolic BP \> 160 or diastolic \> 110:]{.underline}

[and]{.underline} the patient has received an initial 1000 cc of
Lactated Ringers or equivalent IVF

[and]{.underline} the patient has received initial magnesium bolus and
drip

[Then]{.underline}

TREAT

Hydralazine 5-10 mg IV, repeat after 15 to 30 minutes prn.

Measure BP every 5 minutes following / avoid precipitous BP drop to
prevent maternal cerebral or placental hypoperfusion

Satisfactory BP 140-150 systolic, 90-100 diastolic

or

Labetalol: 20-mg intravenous bolus dose followed by 40 mg if not
effective within 10

minutes; then, 80 mg every 10 minutes to maximum total dose of 220 mg

[Postpartum]{.underline}

Avoid Methergine

(could cause vasospam and increase BP)

-Magnesium Sulfate is usually continued at least 24° PP

-Depending on clinical condition concurrent oxytocin IV drip (20U/liter
LR at 25-

50cc/hr) needs to be given PP to counter Magnesium Sulfate induced
uterine atony

[Next Pregnancy]{.underline}

-Give prophylactic low dose ASA 65-85 mg. po every day starting after 12
weeks GA

to reduce risk of pre-eclampsia or IUGR, if

-Chronic HTN

-Past severe preeclampsia

-Renal disease

-Pre-existing Diabetes

[Other preventive measure]{.underline}

Alaska Native pregnant women should take 1.25 g of supplemental Calcium
/ day,

especially if the patient is lactose intolerant, or has a known low
dietary calcium intake.

II\. Eclampsia

-Initiate Magnesium Sulfate as above, STAT IM/IV.

-If eclampsia recurs while on Magnesium Sulfate then re-bolus with 6 gm
and increase

drip to 3gm/hr IV

-be sure urine output is greater than 20cc/hr, Creatinine is \< 1.0, and
Sat \> 95 %

-mask 02 8 L/minute when seizures resolved

-tongue blade / airway available, but remember DO NOT HARM, most
eclamptic

seizures resolve spontaneously

-anticipate postictal non-reassuring fetal heart rate monitoring allow
in utero

resuscitation (with standard measures) if non-reassuring FHRT persists
after 20 to 30

minutes, stat OB consultation

-transport to tertiary care center [after]{.underline} stabilization
(stretcher, medical escort, magnesium

sulfate, 0~2~ IV Fluids)

III\. Chronic Hypertension (CHTN)

-Give prophylactic low dose ASA 65-85 mg. po every day starting after 12
weeks GA

to reduce risk of pre-eclampsia or IUGR, if

-CHTN

-Past severe preeclampsia

-Renal disease

-Pre-existing Diabetes

[Anti-hypertensive therapy]{.underline}

ACE inhibitors [contraindicated]{.underline} 2° fetal, neonatal
complications

Often best to stop all medications and recheck BP in one week

-Antihypertensive therapy could be reinstituted for women with blood
pressures exceeding:

> 150--160 mmHg systolic or 100--110 mmHg diastolic.
>
> -We have the most experience with alpha-methyldopa po 250-1000 mg 8 h
> po

[Monitoring]{.underline}

-Baseline ultrasonography be obtained at 18--20 weeks of gestation

> -Ultrasonography should be repeated at 28--32 weeks of gestation and
> monthly thereafter -If growth restriction is detected or suspected,
> fetal status should be monitored twice weekly with nonstress testing
>
> -If growth restriction is not present and superimposed preeclampsia is
> excluded, these tests are [not]{.underline} indicated

[Labs]{.underline}

-Baseline labs at initial prenatal visit-CBC, Cr, lytes, AST/ALT, 24°
urine

for protein and Creat clearance

-Pt. seen every 4 weeks in 1st and 2nd trimester, every 2 weeks after 32

weeks, if BP control satisfactory.

-Begin weekly antenatal testing-NST plus amniotic fluid assessment every
week starting

at 32 weeks.

-Increase NST to twice weekly if IUGR or oligohydramnios

-chronic hypertensive with severe hypertension and/or cardiac, renal, or
connective

tissue disorders generally have more complications. These patients
should be

co-managed with earlier OB consultation and referral to tertiary care
center.

IV. Chronic hypertension (CHTN) with superimposed pre-eclampsia

> [Prenatal course:]{.underline}

After 12 weeks GA consider prophylactic low dose ASA 65-85 mg po every
day to

prevent or decrease severe pre-eclampsia and/or IUGR. Indicated if

-CHTN

-Past severe preeclampsia

-Renal Disease

-Pre-existing diabetes

## Delivery

> There are no randomized clinical trials that specifically address the
> timing of delivery in women with chronic hypertension and superimposed
> preeclampsia.
>
> A. Delivery should be considered in women with:
>
> -superimposed severe preeclampsia at or beyond 28 weeks of gestation
> and in women
>
> -mild superimposed preeclampsia at or beyond 37 weeks of gestation
>
> B. If it is elected to continue the pregnancy:
>
> Women with superimposed severe preeclampsia should be monitored in a
> center with maternal and neonatal intensive care capability, e.g.,
> ANMC
>
> C. Delivery should be considered, even remote from term: Superimposed
> severe preeclampsia or HELLP syndrome.
>
> [Postpartum]{.underline}

-Rule out chronic hypertension postpartum

-with subsequent pregnancies:

\*monitor closely for recurrent pre-eclampsia

\*early baseline U/S to confirm dates, in case later suspected IUGR
develops.

-manage as previous mild or severe preeclampsia

V. Gestational hypertension

> [Prenatal course]{.underline}
>
> -A significant proportion of these women will go on to develop the
> preeclampsia syndrome and so more frequent monitoring is essential.
>
> -See CHTN management plan above, [except]{.underline} need for
> antenatal aspirin therapy
>
> -If proteinuria does not develop these patients can be delivered at
> term.
>
> -In the absence of proteinuria, perinatal outcomes are good.
>
> [Postpartum]{.underline}
>
> -If blood pressure elevation persists beyond 3 months postpartum, the
> patient is diagnosed with chronic hypertension.
>
> -Unlike typical preeclamptics, a significant number of these women
> will go on to develop essential hypertension later in life.

Do you want to learn about hypertensive disease in pregnancy and earn
free CME credit?

Try any of these 3 Perinatology Corner CME modules online.

[Mild Pre-Eclampsia]{.underline}

<http://www.ihs.gov/MedicalPrograms/MCH/M/HP01.cfm>

[Severe Pre-Eclampsia]{.underline}

<http://www.ihs.gov/MedicalPrograms/MCH/M/HP02.cfm>

[Gestational Hypertension and Chronic Hypertension in
Pregnancy]{.underline}

<http://www.ihs.gov/MedicalPrograms/MCH/M/HP03.cfm>

**ACOG Summary of Recommendations**

[**Preeclampsia**]{.underline}

***The following recommendations are based on good and consistent
scientific evidence (Level A):***

>  Magnesium sulfate should be used for the prevention and treatment of
> seizures in women with severe preeclampsia or eclampsia.
>
>  If analgesia/anesthesia is required, regional or neuraxial
> analgesia/anesthesia should be used because it is efficacious and safe
> for intrapartum management of women with severe preeclampsia in the
> absence of coagulopathy.
>
>  Low-dose aspirin has not been shown to prevent preeclampsia in women
> at low risk and, therefore, is not recommended.
>
>  Daily calcium supplementation has not been shown to prevent
> preeclampsia and, therefore, is not recommended.

***The following recommendations are based on limited or inconsistent
scientific evidence (Level B):***

 The management of a woman with severe preeclampsia remote from term is
best accomplished in a tertiary care setting or in consultation with an
obstetrician-gynecologist with training, experience, and demonstrated
competence in the management of high-risk pregnancies, such as a
maternal-fetal medicine subspecialist.

>  Practitioners should be aware that although various laboratory tests
> may be useful in the management of women with preeclampsia, to date
> there is no reliable predictive test for preeclampsia.
>
>  Invasive hemodynamic monitoring should be considered in preeclamptic
> women with severe cardiac disease, renal disease, refractory
> hypertension, pulmonary edema, or unexplained oliguria.

***The following recommendations are based primarily on consensus and
expert opinion (Level C):***

 Women should be considered as having severe preeclampsia if they have
blood pressure levels of 160 mm Hg systolic or higher or 110 mm Hg
diastolic or higher on two occasions at least 6 hours apart while the
patient is on bed rest, proteinuria of 5 g or higher in a 24-hour urine
specimen or 3+ or greater on two random urine samples collected at least
4 hours apart, oliguria of less than 500 mL in 24 hours, cerebral or
visual disturbances, pulmonary edema or cyanosis, epigastric or right
upper-quadrant pain, elevated liver enzymes, thrombocytopenia, or fetal
growth restriction.

>  Expectant management should be considered for women remote from term
> who have mild preeclampsia.
>
>  Antihypertensive therapy (with either hydralazine or labetalol)
> should be used for treatment of diastolic blood pressure levels of
> 105-110 mm Hg or higher.

**[Chronic Hypertension in pregnancy]{.underline}**

***The following recommendation is based on good and consistent
scientific evidence (Level A):***

>  Angiotensin-converting enzyme inhibitors are contraindicated during
> pregnancy and are associated with fetal and neonatal renal failure and
> death.
>
>  Aspirin therapy should be considered in women with historical risk
> factors to decrease superimposed preeclampsia, e.g., preexisting
> diabetes, chronic hypertension, previous severe preeclampsia, and
> renal disease.

***The following recommendations are based on limited or inconsistent
scientific evidence (Level B):***

>  Antihypertensive therapy should be used for pregnant women with
> severe hypertension for maternal benefit.
>
>  Methyldopa and labetalol are appropriate first-line antihypertensive
> therapies.
>
>  Treatment of women with uncomplicated mild chronic hypertension is
> not beneficial because it does not improve perinatal outcome.

 The beta-blocker atenolol may be associated with growth restriction
and is not recommended for use in pregnancy.

***The following recommendations are based primarily on consensus and
expert opinion (Level C):***

>  Women with chronic hypertension should be evaluated for potentially
> reversible etiologies, preferably prior to pregnancy.
>
>  Women with long-standing hypertension should be evaluated for
> end-organ disease, including cardiomegaly, renal insufficiency, and
> retinopathy, preferably prior to pregnancy.
>
>  When chronic hypertension is complicated by IUGR or preeclampsia,
> fetal surveillance is warranted.

#### References

Diagnosis and management of preeclampsia and eclampsia. ACOG Practice
Bulletin No. 33. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2002;99:159-167 (Level III)

[\<http://www.acog.com/publications/educational_bulletins/pb033.htm\>]{.underline}

Chronic Hypertension in Pregnancy. ACOG Practice Bulletin No. 29.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2001; 98:177-185 (Level III)

[\<http://www.acog.com/publications/educational_bulletins/pb029.htm\>]{.underline}

Aspirin for Prevention of Preeclampsia in Women with Historical Risk
Factors: A Systematic Review.

Coomarasamy A, et al Obstet Gynecol June 2003, Volume 101, Number 6:
1319 -- 1332 (Level I)

[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12798543&dopt=Abstract]{.underline}

*Management of Chronic Hypertension During Pregnancy*. Summary, Evidence
Report/Technology Assessment: Number 14. AHRQ Publication No. 00-E010,
August 2000. Agency for Healthcare Research and Quality, Rockville, MD.
(Level III)
[\<http://www.ahrq.gov/clinic/epcsums/pregsum.htm\>]{.underline}

[Screening for Preeclampsia Guide to Clinical Preventive
Services]{.underline}

Second Edition (1996) US Preventive Service Task Force. (Level III)

[\<http://www.ahrq.gov/clinic/2ndcps/preeclam.pdf\>]{.underline}

Etiology and pathogenesis of preeclampsia: Current concepts. Dekker GA,
Sibai BM. Am J Obstet Gynecol 1998; 179:1359-75. (Level III)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9822529&dopt=Abstract>

Primary, secondary, and tertiary prevention of preeclampsia. Dekker GA,
Sibai BM. Lancet 2001; 357:209-215. (Level III)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11213110&dopt=Abstract>

Report of the National High Blood Pressure Education Program Working
Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol 2000;
183:S1-S22. (Level III)

[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10920346&dopt=Abstract]{.underline}

[Obstetrics: Normal and Problem Pregnancies]{.underline}. Hypertension,
Chapter 28. Gabbe SG, Neibyl JR, Simpson JL (Eds.) 4th Edition.
Churchill Livingstone, New York, 2002. Pages 945-1004. (Level III)

[Williams Obstetrics]{.underline}. Hypertensive Disorders in Pregnancy,
21st Edition. Cunningham GF, et al (Eds.) Section 7, No. 24, pp.
567-618. McGraw-Hill, 2001. (Level III)

Chobanian AV, et al. The Seventh Report of the Joint National Committee
on Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure *JAMA.* 2003;289:2560-2571. (Level III)

<http://jama.ama-assn.org/cgi/content/full/289/19/2560>

Hofmeyr GJ, Atallah AN, Duley L. Calcium supplementation during
pregnancy for preventing hypertensive disorders and related problems
(Cochrane Review). In: The Cochrane Library, Issue 4, 2003. Chichester,
UK: John Wiley & Sons, Ltd.

<http://www.ihs.gov/generalweb/webapps/sitelink/site.asp?link=http://www.cochranelibrary.com/enter/>

Special thanks to Betsy Nobmann, PhD, Nutrition, former IHS Area
Nutrition Director for information on calcium intake in Alaska Native
women.

Written 1/19/94; reviewed 1/23/94; revised 1/24/95

Revised 1/20/04 njm