A summary of the 2023 Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) hypertension in pregnancy guidelines

To the Editor: The recently updated Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) hypertension in pregnancy guidelines have highlighted clinical characteristics of women considered to be at increased risk of hypertensive disorders in pregnancy (HDP) and discussed the future implementation of combined first trimester screening tools.1 We note two factors worthy of mention regarding HDP.

First, in Australia, about 50% of women begin pregnancy overweight or obese and 3% have gestational hypertension,2 increasing the likelihood of having metabolic dysfunction‐associated steatotic liver disease (MASLD) in the first trimester of pregnancy. MASLD is prospectively associated with HDP.3 Although there are currently insufficient data to recommend screening for MASLD in pregnancy, the new Australian consensus statement for assessment of metabolic dysfunction‐associated fatty liver disease (MAFLD) recommends liver ultrasound examination for MASLD and assessment for associated cardiometabolic risk factors in adults who are obese.4 For the current purpose, the diagnostic labels MASLD and MAFLD can be used interchangeably. About 30% of overweight and 55–75% of obese adults have MASLD, and the prevalence in Australia is rising in parallel with obesity, particularly in women.4 It is therefore reasonable to consider women with pre‐pregnancy and early pregnancy obesity and MASLD to also be at increased risk of cardiometabolic disorders such as HDP. Despite these associations, the current SOMANZ guidelines do not include MASLD as a potential risk factor for HDP.

Second, although the guidelines rightly encourage exercise to reduce the risk of HDP, healthy nutrition has not been promoted. A Mediterranean diet, for example, is safe in pregnancy, improves cardiometabolic risk factors, may reduce arterial stiffness and blood pressure,5 and is commonly recommended as a treatment for MASLD.

Pregnancy characteristics provide a window to identify risk factors for future maternal cardiometabolic health. Although it is premature to recommend screening for MASLD in pregnancy, we consider it appropriate to consider MASLD in early pregnancy as a relevant and potentially modifiable risk factor for HDP. Early intervention by initiating exercise and nutrition modification for at‐risk women is as appropriate during as outside of pregnancy.