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

In reply: We thank Latino and Ayonrinde1 for raising an important discussion on the association between metabolic dysfunction‐associated steatotic liver disease (MASLD)/metabolic dysfunction‐associated fatty liver disease (MAFLD) and hypertensive disorders of pregnancy (HDP).

As highlighted by Latino and Ayonrinde, increasing rates of obesity and the associated MASLD/MAFLD are identifiable in women of childbearing age in Australia, with only 20% of MASLD/MAFLD cases occurring in people who are lean or non‐obese.2 In acknowledging obesity as the underlying metabolic issue, and in keeping with international guidelines, the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) HDP 2023 guideline recognises obesity as a risk factor for HDP and includes obesity in the HDP risk screening tool.3,4 There is insufficient evidence to support population screening for MASLD/MAFLD in pregnancy; however, known risk and associated factors for MASLD/MAFLD, such as obesity and glycaemic dysregulation, are currently used to screen for women at risk of HDP and will likely identify most women with underlying MASLD/MAFLD in early pregnancy.

We acknowledge obesity as an important modifiable risk factor for many complications in pregnancy and the importance of pre‐conception modification; however, this topic was out of the scope of the current version of the guideline. Nevertheless, the importance of metabolic risk modification is discussed in the postpartum section guideline. This section highlights the importance of addressing all modifiable risk factors, including obesity, in women with a history of HDP in minimising the risk of adverse outcomes in subsequent pregnancies and, importantly, their long term metabolic and cardiovascular risks.3,4,5

Latino and Ayonrinde also raised concerns regarding the lack of healthy nutrition promotion in the guideline. In accordance with the pre‐determined scope and population, intervention, comparison and outcomes (PICO) questions, the SOMANZ HDP 2023 guideline examined the efficacy of two non‐pharmacological interventions — physical activity and salt restriction — in minimising the risk of HDP in women who are at risk.4 Although a recommendation on general nutrition in pregnancy was out of the scope for the current version of the guideline, recommendations on healthy eating in pregnancy are covered in the Australian pregnancy care guidelines (https://app.magicapp.org/#/guideline/8469), which are the national guidelines for general pregnancy care in Australia. Nevertheless, with emerging data on the benefits of a Mediterranean diet, the addition of a PICO question in examining the maternal and obstetrics outcomes with the Mediterranean diet, specific to women who are at risk of developing HDP, will be considered in the next version of this guideline.

In summary, obesity remains the important underlying issue that significantly contributes towards the observed risk of HDP, MAFLD/MASLD, gestational diabetes mellitus and adverse maternal and obstetric outcomes, therefore necessitating a more holistic approach to obesity. Although the current version of the SOMANZ HDP 2023 guideline identifies obesity as a risk factor for HDP and discusses the importance of addressing this in the postpartum period, the SOMANZ HDP Guideline Group acknowledges future scopes for the next version of this guideline.