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Objective: This trial was undertaken to evaluate the effects of high-cocoa-content chocolate supplementation in pregnancy on several haematochemical and clinical parameters. The study had as reference population the pregnant women requesting an obstetric control at Outpatient Clinic of Obstetrics and Gynaecology of the S. Maria della Misericordia University Hospital, Perugia, Italy. Candidates who participated in this study were all Caucasian women aged 18-40 years, who had a single gestation pregnancy between 11th + 0 and 13th + 0 week gestational age. Methods: We conducted a single-center randomized controlled trial. The pregnant women selected were randomized into Group A, which received daily doses of 30 g of chocolate (70% cocoa), and Group B, which was free to increase their diet with other foods. Results: Ninety women were randomized. Significant difference was found between the two groups for diastolic blood pressure (p = 0.05), systolic (p < 0.0001) and levels of liver enzymes, with values lower in Group A than in Group B. Total cholesterol levels and weight gain in Group A did not increase more than in Group B. Conclusions: A modest daily intake of high-cocoa-content chocolate contributes to reduce blood pressure, glycemic and liver pattern during pregnancy without affecting the weight gain.
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The Journal of Maternal-Fetal and Neonatal Medicine, 2012; 25(10): 1860–1867
© 2012 Informa UK, Ltd.
ISSN 1476-7058 print/ISSN 1476-4954 online
DOI: 10.3109/14767058.2012.683085
Objective: This trial was undertaken to evaluate the effects
of high-cocoa-content chocolate supplementation in preg-
nancy on several haematochemical and clinical parameters.
The study had as reference population the pregnant women
requesting an obstetric control at Outpatient Clinic of Obstetrics
and Gynaecology of the S. Maria della Misericordia University
Hospital, Perugia, Italy. Candidates who participated in this
study were all Caucasian women aged 18–40 years, who had
a single gestation pregnancy between 11th + 0 and 13th + 0
week gestational age. Methods: We conducted a single-center
randomized controlled trial. The pregnant women selected were
randomized into Group A, which received daily doses of 30 g of
chocolate (70% cocoa), and Group B, which was free to increase
their diet with other foods. Results: Ninety women were random-
ized. Significant difference was found between the two groups
for diastolic blood pressure (p = 0.05), systolic (p < 0.0001) and
levels of liver enzymes, with values lower in Group A than in
Group B. Total cholesterol levels and weight gain in Group A did
not increase more than in Group B. Conclusions: A modest daily
intake of high-cocoa-content chocolate contributes to reduce
blood pressure, glycemic and liver pattern during pregnancy
without affecting the weight gain.
Keywords: Blood pressure, cocoa, high-cocoa-content chocolate,
pregnancy
Abbreviations: BMI: body mass index; BP: blood pressure; DBP:
diastolic blood pressure; GA: gestational age; GDM: gestational
diabetes mellitus; GH: gestational hypertension; NO: nitric oxide;
OGTT: oral glucose tolerance test; SBP: systolic blood pressure;
TAC: total antioxidant capacity
Introduction
Recent in vitro and in vivo investigations showed the impor-
tance of eobroma cacao phytocomplex for health in general
but particularly for the cardiovascular system [1–3]. Flavonoids,
belonging to the class of polyphenols, are compounds ubiquitous,
distributed in the plant kingdom, frequently present in dietary
constituents and widely present in cocoa. ey are also identi-
able in chocolate, although in variable amounts that depend
on numerous variables. e main avonoids found in cocoa
and chocolate, avan-3-ols and their oligomeric derivatives,
procyanidins, have a potent antioxidant activity as proved by in
vitro researches [4]. Food products derived from cocoa disclosed
the greatest antioxidant capacity among several other vegetables
[4]. It was demonstrated that cocoa avonoid molecules have
the following capacities: inducing enhancement in vascular
function; prevention of endothelial dysfunction and interrelated
diseases [5,6], reduction of insulin resistance [6], increase of
insulin sensitivity [6,7], inhibition of platelet aggregation [8,9]
and decrease of blood pressure (BP) [1,6,7,10]. Moreover cocoa
avonoids exhibited anti-inammatory eects [11,12], capacities
to improve plasma total antioxidant capacity (TAC) [13], inhibi-
tion of low-density lipoprotein (LDL) oxidation [14,15], increase
high density lipoprotein (HDL) concentrations [16,17], reduc-
tion of LDL cholesterol [15,16,17] and total plasmatic cholesterol
[18]. e above mentioned phytochemicals have been thought
to be main responsible for the positive health eects provided
by cocoa and chocolate. e extensive availability of scientic
sources about the eects of the cocoa and chocolate consumption
in general population contrasted with the scarce scientic litera-
ture available on chocolate consumption by pregnant women. To
this day, most of the studies on this particular population have
analysed maternal-fetal health impact of some specic cocoa
components and not the whole chocolate. us, the eects of
chocolate consumption in pregnancy have not been studied
extensively. We undertook a randomized controlled trial aimed
to evaluate the eects of chocolate supplementation (with a
cocoa content of 70%) in pregnancy on several haematochemical
and clinical parameters.
Methods
Participants
Enrollment began on February 1, 2008 and ended on
October 31, 2008. e study had as reference population the
pregnant women requesting an obstetric control at Outpatient
Clinic of the Department of Obstetrics and Gynaecology of the
S. Maria della Misericordia University Hospital, Perugia, Italy. All
Caucasian women of 18–40 year-olds, who had a single gestation
pregnancy between 11th + 0 and 13th + 0 week gestational age
(GA) (conrmed by rst trimester ultrasound), were candidated to
enter in this study. e exclusion criteria included: pre-gestational
metabolic disorders; previous history of hypertension and/
or gestational hypertension (GH) and/or preeclampsia and/
or eclampsia; chronic renal disease; conditions associated with
Potential effects of chocolate on human pregnancy: a randomized
controlled trial
Gian Carlo Di Renzo, Eleonora Brillo, Maila Romanelli, Giuseppina Porcaro, Federica Capanna, Tomi T. Kanninen,
Sandro Gerli & Graziano Clerici
Department of Obstetrics and Gynecology, Centre for Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
Correspondence: Gian Carlo Di Renzo, MD, PhD, FRCOG, Department of Obstetrics and Gynecology, Centre for Perinatal and Reproductive Medicine,
University of Perugia, S. Maria della Misericordia University Hospital, 06132 Perugia, Italy. Tel: +39 075 5783829; +39 075 5783231. Fax: +39 075 5783829.
E-mail: direnzo@unipg.it
e Journal of Maternal-Fetal and Neonatal Medicine
2012
25
10
1860
1867
© 2012 Informa UK, Ltd.
10.3109/14767058.2012.683085
1476-7058
1476-4954
16February2012
02April2012
Chocolate in pregnancy
G. C. Di Renzo et al.
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Chocolate in pregnancy 1861
©  Informa UK, Ltd.
thrombophilia; maternal obesity (prepregnant body mass index,
BMI ≥ 30 kg/m2); multiple gestation in the current pregnancy;
diabetes and/or hypertension recognized in the rst trimester of
the current pregnancy [19]; ongoing antihypertensive treatment
and/or ongoing antithrombosis prophylaxis; gastrointestinal
pathologies which can compromise the normal absorption process;
haemoglobin <11 g/dL at the baseline assessment; current or past
(<6 months from the conception) iron therapy and/or use of
antioxidant supplements and/or cigarette smoking, current or past
use (<6 months from the conception) of antioxidant supplements.
e presence of the eligibility criteria was assessed by anamnestic
evaluation, clinical, laboratory and instrumental examination.
Interventions
e study was designed as a prospective, randomized controlled
trial. e treatment allocation was not blinded to participants, but
it was blinded to those responsible for data retrieval, capture and
gathering, as well as those responsible for assessing the outcomes.
e study protocol and the informed consent form were reviewed
and approved on 04/06/2007 by our institutional ethics board,
Centre of Perinatal and Reproductive Medicine, University of
Perugia (No. 00081 003 0004). e present study was conducted
over the period from January 1, 2008 and October 30, 2009, inclu-
sive. An initial screening visit (between the 11th–13th week of GA)
was performed to assess the medical history of the subject and her
potential eligibility. e clinical assessments were subdivided into
three phases: the rst was unblended and conducted by gynaeco-
logists. e second consisting of an assessment of selected clinical
data (BP, anthropometric data and the level of physical activity),
carried out by a blinded midwife observer. e third was conducted
by a dietician (blinded only to the screening visit data). A clinical
assessment was carried out at the screening visit and subsequently
aer each antenatal check, which was carried out every four weeks.
A program of nutrition education was implemented from the
screening visit and continued for the entire pregnancy.
e selected volunteers underwent blood sample collection
for baseline assessment of hematological and biochemical param-
eters. e patients selected were randomized into intervention
group (Group A) and control group (Group B). e women in
Group A received the chocolate supplement, while the women
in Group B were followed without any supplement. Group A
was instructed to ingest a daily chocolate dose (until delivery or
potential exclusion from the study), consisting of one bar of dark
chocolate which provided 161 kcal/day. e chocolates chemical
composition (Table I) was analysed by high performance liquid
chromatography (HPLC) at the Pernigotti Institute (Novi Ligure,
Italy) specically for this study. e women in the Group B were
free to increase their diet with other preferential foods and to
eat chocolate, in quantity and type, as before enrollment. All
the women in the groups received folic acid supplements (400
mcg/day) at the rst visit if not taken before and each of them
was discouraged from the use of other vitamin and antioxidant
supplements. Diagnosed iron deciency anemia (<11 g/dL)
an oral supplementation with ferrous sulfate complex started.
Subjects were free to withdraw from the study at any time.
Outcomes
Two primary outcomes were selected: systolic blood pressure
(SBD) and diastolic blood pressure (DBP) trends with gesta-
tion progress; number of women with diagnosis of anemia
executed aer the enrollment. Glycaemia, total cholesterol and
liver enzymes levels (alanine aminotransferase, ALT; aspartate
aminotransferase, AST; alkaline phosphatase, ALP) were adopted
as secondary outcomes. In these latters, weight gain, BMI, food
intake and amount of physical activity were included. Compliance
with treatment was estimated with a specic self-assessment and
anonymous questionnaire, which was administered to women at
around 37th week GA.
Dietary intake information was collected by a face to face
food frequency questionnaire and a standardized interview, both
structured to assess quali-quantitative food intake in the last 4
weeks. In order to conrm the kind and quantity of foods and
beverages taken daily, illustrations of dish, of cooked foods and
of common containers for liquids were shown to the interviewed.
Women were asked to specify a commonly used unit or portion
size for each food and beverage. Subjects were also asked to
report how oen they had consumed that amount of each food
and beverage. Nutrient intakes were computed by multiplying
the frequency response by the nutrient content of the specied
portion sizes. Chocolate consumption was investigated in both
groups by asking about the frequency (daily, weekly or monthly)
and the quantity of chocolate assumption. Subsequently an
average daily dose of chocolate consumed was calculated for each
subject. For each of them, the dietitian also checked up on the
type of chocolate mainly assumed between dark chocolate with
>60% cocoa, dark chocolate with <60% cocoa, milk chocolate or
white chocolate. In the phase of estimation of the predominant
Table I. Nutritional values per serving size (1 bar/30 g) of chocolate (70%
cocoa solids).
Components Va lues
Proteins (g) 2.4
Carbohydrates (g) 9.2
Ash (g) 0.7
Total lipid (fat) (g) 12.8
Stearic acid (C18:0) (%) 36
Oleic acid (C18:1 ω-9) (%) 35
Palmitic acid (C16:0) (%) 24
Linoleic acid (C18:2 ω-6) (%) 3
Arachidonic acid (C20:4 ω-6) (%) 1
Other fatty acids (%) 1
Cholesterol (mg) 1
Dietary bers (g) 3,3
Iron, Fe (mg) 7
Magnesium, Mg 60
Calcium, Ca (mg) 19
Phosphorus, P (mg) 85
Sodium, Na (mg) 7
Potassium, K (mg) 208
Zinc, Zn (mg) 0.9
Copper, Cu (mg) 0.5
Manganese, Mn (mg) 0.6
Folic acid (µg) 6
Vitamin E (α-tocopherol) (mg) 0.3
eobrominea (mg) 194
Caeine (mg) 24
Catechinsa (mg) 2.46
Epicatechinsa (mg) 10.14
Procyanidins B1a (mg) 3.54
Procyanidins B2a (mg) 13.26
Calories 161 kcal (674 kJ)
a Qualitative and quantitative analysis of phenolic constituents were performed with
high performance liquid chromatography (HPLC) system.
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1862 G. C. Di Renzo et al.
e Journal of Maternal-Fetal and Neonatal Medicine
chocolate type consumed it was given larger prominence to
the amount of chocolate with high cocoa content. Dietary and
chocolate intake information was collected at the screening
visit and then every four weeks until the last visit at the 37th. A
synthesis of the data collected was done for each trimester.
e women were categorized into three groups according
to their prepregnancy BMI: underweight (BMI < 18.5 Kg/m2);
normal weight (BMI = 18.5–24.9 Kg/m2); overweight (BMI =
25.0–29.9 Kg/m2). e BMI categories were exploited to detect
the appropriate range of weight gain for each woman [20,21].
Total daily physical activity was assessed by structured interview
of seven-day recall in order to measure physical activity levels and
to classify women in accordance with the criteria of the IOM. A
synthesis of the data collected was done for each trimester [22].
e 100-g three-hour Oral Glucose Tolerance Test (OGTT) was
conducted in all women to check the onset of gestational diabetes
mellitus (GDM). is was performed between 24th–26th weeks
GA with woman in fasting condition for at least ten hours before
having the test and following three days of diet containing at least
150 g of carbohydrates a day. Standard OGTT procedure recom-
mended by the American Diabetes Association was practiced [23].
e diagnostic criteria used for identication of the onset of
gestational hypertension and preeclampsia were based on those
described in the Report of the National High Blood Pressure
Education Program Working Group on High Blood Pressure in
Pregnancy [24] and Practice Bulletin Number 33 of the American
College of Obstetricians and Gynecologists (ACOG) [25].
Randomization
e unpredictable allocation sequence was generated, using
computer-generated random numbers, at the Department of
Internal Medicine of the S. Maria della Misericordia Hospital.
e assignment schedule was prepared by departmental sta not
involved with the study. e details of the series were unknown
to any of the investigators and these were concealed in sealed
envelopes, sequentially numbered, containing the intervention
assigned. Aer acceptance of the woman to participate in the
study and completion of the screening procedures, the appro-
priate envelope was opened to discover the group of allocation.
Statistical analysis
Data were analysed on an intention-to-treat basis.
Comparisons within and between the subject groups in the
two arms over time were performed using two-way ANOVA for
repeated measures, with Geisser-Greenhouse adjustment for non-
sphericity and Student t-test for independent and paired data.
Bonferroni’s post hoc correction was also applied. Before statis-
tical analysis, the Box-Cox transformation was used to normalize
approximately the skewed distributed variables (checked with
Shapiro–Wilk test). A p value < 0.05 was regarded as statisti-
cally signicant. All calculations were carried out with Predictive
Analytic Soware release 17.0.2, SPSS Inc., Chicago, USA, 2009.
Data are expressed as means and standard deviations.
Results
A total of 107 subjects were screened for inclusion in the study; of
these 90 pregnant women were enrolled and randomized into the
two groups: Group A (n = 46) and Group B (n = 44). e ow of
patients through the trial is depicted in the diagram in Figure 1.
Eighty women completed the entire protocol including the inter-
vention and all follow- up assessments. Indeed there were ten
Figure 1. Flow of subjects through the trial.
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Chocolate in pregnancy 1863
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deviations from the protocol (11.1%): ve in Group A (10.9%)
and ve in Group B (11.4%). Two subjects were excluded at the
26th week GA due to diagnosis of gestational diabetes: one in
Group A, one in Group B. Two women of the Group A withdrew
from the protocol (at 16th and at 30th week GA) and two of those
belonging to Group B (at 19th and 23rd week GA). A woman of
the group B had a miscarriage at 20th week GA. e available
follow-up data on subjects who withdrew from the protocol were
included in the statistical analysis; the same was done for data of
the three subjects who were excluded (one at the 20th and two at
the 26th week GA). Two subjects of the Group A (both at the 10th
week GA) and one of the Group B (at the 19th week GA) dropped
out of the treatment, but these three were however followed up for
the subsequent weeks GA. Altogether seven dropout cards were
lled in for the seven women of the sample who had deliberately
chosen to have a behaviour dierent from that prescribed by the
protocol (the cases of deviation from the protocol for free choice
and not for direction of the researchers).
Descriptive statistics were calculated for the original, untrans-
formed data. e mean GA at enrollment was 12.1 and 12.0 weeks in
Group A and in Group B, respectively. e baseline characteristics
of the women randomized in the two groups are reported in Table II.
As shown by t-test analysis, there were no signicant dierences
between the mean values analysed, made exception for baseline
glycemic levels, which resulted with values higher in Group B than
in Group A: t(88) = 3.248, p = 0.002. Additionally, there were no
statistically signicant dierences between the groups on women’s
parity status (χ2 with one degree of freedom = 0.002, p = 0.962).
When the sample was subdivided according to pre-pregnancy
BMI, 74 normal weight subjects (38 of the Group A and 36 of the
Group B) and 16 overweight (eight of the Group A and eight of
the Group B) were observed.
Participants were divided in four physical activity catego-
ries [22] for each trimester and the ndings are presented in
Table III. Physical activity level in both groups was low and
inclined to decrease with the increase of gestation trimesters, as
found by other studies [26,27]. e consumptions of chocolate
through the three trimesters are described in Table III.
Mean daily caloric intake was calculated as 2120 ± 150 kcal for
Group A and 2050 ± 170 kcal for Group B rising to 2380 ± 120
kcal and 2350 ± 130 kcal respectively at the end of pregnancy. In
the Group A, weight gain during the time study was similar to
that of the Group B (10.2 kg and 11.6 kg, respectively).
During the follow-up period, SBP values in Group A were
signicantly lower as compared to Group B (F1,594 = 31,60,
p < 0.0001); a weak but statistically signicant dierence was
found between the two groups for DBP levels (F1,594 = 4,13,
p = 0.0426). e resulting trend of SBP and DBP is depicted in
Figure 2.
e levels of liver enzymes in Group A remained signicantly
lower at any point of pregnancy than those in Group B
(p < 0.05). e ANOVA output has shown dierences statistically
signicant between the groups for levels of ALT (F1,340 = 20.12,
p < 0.0001), AST (F1,340 = 62.87, p < 0.0001) and ALP (F1,342 =
4.78, p=0.0294). Serum levels of ALT and AST are shown in
Figure 3; ALP data are not shown. Granted the existence of
the initial and signicant dierence in glycemic levels between
the groups (higher in Group B), the following glycemic values
acquired during follow-up were signicantly higher in Group
B (F1,340 = 21,07, p < 0.0001). Iron deciency anemia was
diagnosed in 30 women out of 90 (33.3%): 11 of those belonging to
Group A (23.9%) and 19 of Group B (43.2%). Despite an apparent
diversity in the occurrence of anemia, no statistically signicant
dierence between the two groups were been determined
(p = 0.053, x2; p = 0.074, Fisher’s test). No case of GH or
preeclampsia was detected in both groups. Starting from basal
levels of total cholesterol similar between groups (Group A 197.28
± 34.19 mg/dL vs Group B 191.57 ± 29.45 mg/dL), the nal values
detected at the 35th–37th week GA were lower in Group A than
in Group B (280.65 ± 35.46 mg/dL vs 304.65 ± 34.06 mg/dL
respectively), but not statistically signicant.
Discussion
is study was motivated by the recent investigations on the e-
cacy of cocoa in the reduction of BP (in the adult population) and
in the decrease of the risks of preeclampsia [28,29] and gestational
hypertension [29]. It was hypothesized that a regular consump-
tion of high-cocoa-content chocolate during pregnancy, could be
a valid dietary supplement during pregnancy to improve BP and
other biochemical parameters. It was thought that chocolate could
be a good iron source and that pregnant women could benet
from an iron rich food, particularly palatable. is hypothesis was
derived from an animal study that demonstrated that, in spite of
its anti-nutritional factors content, cocoa possess iron with high
bioavailability [30]. Clearly cocoa contains non-heme iron that is
not as well absorbed as heme iron, nevertheless a marked increase
in iron absorption occur during pregnancy beginning from the
second trimester. Besides, cocoa used in chocolate was submitted
to some manufacturing processes which decrease the amount of
some iron absorption inhibitors. Since the type and the portion
size of chocolate selected for the study did not bring more than
7 mg daily of iron, it was impossible to cover the increased iron
requirements of pregnancy with only this amount of additional
dietary iron. For this reason, an intervention of nutrition educa-
tion in conjunction with dietary counseling as implemented to
attempt to cover the remaining amount of iron not yet covered
(according to the quantity advised by the Institute of Medicine,
IOM) [20,31], through a careful selection of adequate foods.
Secondly, having considered the evidences which prove cocoa
intake ecacy in the improvement in insulin sensitivity [7] as
well as in the reduction of cholesterol and liver enzymes levels, it
was supposed that assumption of high-cocoa-content chocolate
could improve on glycemic, cholesterolemic and transaminases
levels of pregnant women as well.
Basal BP levels did not dier signicantly between the two
groups, but subsequently BP values were found to be lower in
women who consumed chocolate. e possible confounders
(maternal age, physical activity level, pre-pregnancy BMI, weight
gain during pregnancy, dietary characteristics, smoking habit)
were taken into account and they were not found dierent from
the two study groups. We cannot rule out the possibility of other
factors on modication of BP. e role played by the chocolate
intake in the BP decrement, could be explained through an action
of stimulation of endothelial cells by cocoa phenols, followed by
up regulation of nitric oxide synthase (NOS) transcription and
nitric oxide (NO) synthesis increase [5,10]. e activity of cocoa
avonoids could also be expressed through alternative or additional
mechanisms of BP control, as the inhibition of angiotensin-
converting enzyme (ACE) activity [32] and the insulin-resistance
reduction [6,7] with consequent improvement of insulin’s ability
to induce NO-mediated vasodilation. e possible mechanisms of
action are manifold and, moreover, they are not only attributable
to avonoid molecules but also to concomitant activities of
other cocoa components as methylxanthines (theobromine
in particular) [33] and magnesium, a mineral that is copiously
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1864 G. C. Di Renzo et al.
e Journal of Maternal-Fetal and Neonatal Medicine
Table II. Baseline characteristics of randomly assigned subjects according to group.
Var iab l e No. of subjects Mean (SD) Mean dierence and 95% CI
t-valuea
P value Sig. (2-tailed)a
Maternal age (y)
Group B 44 29.43 (5.07)
Group A 46 29.93 (4.91)
−0.503 −0.478
−2.592 to 1.586 0.634
BMI (kg/m2)
Group B 44 22.88 (2.45)
Group A 46 22.88 (3.49)
0.000 0.714
−0.0000476 to 0.0001009 0.477
SBP (mm Hg)
Group B 44 115.23 (13.12)
Group A 46 114.57 (9.59)
0.662 0.274
−4.137 to 5.461 0.785
DBP (mm Hg)
Group B 44 69.20 (8.76)
Group A 46 69.41 (7.91)
−0.208 −0.119
−3.700 to 3.283 −0.906
Haemoglobin (g/dL)
Group B 44 12.55 (0.55)
Group A 46 12.42 (0.68)
0.126 −0.968
−0.1325 to 0.3843 0.336
Glycaemia (mg/dL)
Group B 44 75.25 (10.18)
Group A 46 68.46 (9.66)
6.793 3.248b
2.637 to 10.950 0.002
AST (IU/L)
Group B 44 16.50 (4.60)
Group A 46 14.93 (3.47)
0.065 1.570
−0.017141 to 0.146264 0.120
ALT (IU/L)
Group B 44 14.82 (6.56)
Group A 46 13.54 (5.47)
0.041 1.129
−0.030849 to 0.112033 0.262
ALP (IU/L)
Group B 44 139.00 (59.82)
Group A 46 121.43 (24.67)
0.041 0.961
−0.043539 to 0.125091 0.339
Cholesterol, mg/dL
Group B 44 191.57 (29.45)
Group A 46 197.28 (34.19)
−0.046 −0.789
−0.1614 to 0.0697 0.432
Nulliparas
Group B 27 (61.4%)
Group A 28 (60.9%)
Primiparas and multiparas
Group B 17 (38.6%)
Group A 18 (39.1%)
ALP, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; BMI, body mass index; CI, condence interval; DBP, diastolic blood pressure; SBP,
systolic blood pressure; SD, standard deviation.
at test for independent groups of observations, comparing mean dierence for Group B and Group A. e 95% condence interval refers to the mean dierence; equal variance
assumed.
bSig. < 0.05.
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present in chocolate and whose decit has been correlated with
hypertension and other cardiovascular diseases [34–36].
A smaller incidence of iron deciency anemia during gesta-
tional period was registered in the Group A in comparison with
that of the Group B (23.9% vs 42.2% respectively), but a statistical
dierence was not found. With this study, we did not attempt to
administer the entire supplementary dose of iron required by
pregnancy during the second and third trimester. According to
the IOM suggestions, 9 mg daily of iron could be required for the
second and third trimester, in addition to 18 mg/day normally
necessary to women of fertile age [20,21,31]. erefore the 7 mg
of iron, introduced with the chocolate bar, could form a part of
the additional daily dose requested by the last two trimesters of
pregnancy (considering, moreover, that not even in ideal condi-
tions, the amount of iron absorbed is equal to that assumed). In
order to prevent iron deciency anemia in the pregnant women
of the Group A, it would have been necessary that each following
condition should be occurred: sucient pre-pregnancy deposits
of iron, assumption of the base quantity of 18 mg/day of iron
through diet [20,21,31], intake of the 7 mg/day of iron with the
chocolate bar, completion of the daily supplementary amount of
iron (of 9 mg/day) [20,21,31]. Evidently, one of those conditions
did not occur and this could explain why one fourth of women
of Group A was diagnosed with iron deciency anemia during
the study. But it could also be that the iron quantity derived from
chocolates contribution, whose good bioavailability has been
hypothesized (on the basis of an animal study) [30], were instead
scantly absorbed. In this case, a study on bioavailability of choc-
olate-derived iron in the human body is required. With regard to
the no statistically signicant result for the occurrence of anemia
between the groups, the reason could be found in a larger iron
intake through diet in Group B than in Group A. In the future
studies, it will be necessary a better system for the quantication
of the iron intake provided by the diet. e glucose challenge in
individuals consuming chocolate was in all cases normal and
moreover, signicantly lower basal glycemic levels were noted
in Group A in comparison with Group B. Nevertheless, a conr-
mation of these results is necessary through a similar study on
Table III. Physical activity through three trimesters of pregnancy, type of chocolate mainly assumed and calculated quantity of chocolate on average per day.
Var iab l e
1st trimester 2nd trimester 3rd trimester
Group AaGroup BbGroup AcGroup BbGroup AcGroup Bb
(n = 46) (n = 44) (n = 46) (n = 44) (n = 41) (n = 39)
Chocolate consumptiond
Darke (>60% cocoa) (n) 5 4 46 2 41 2
<5 g/day 130202
5–14 g/day 210000
15–30 g/day 2 0 46 0 41 0
>30 g/day 000000
Dark (<60% cocoa) (n) 10 10 2 10 2 9
<5 g/day 542525
5–14 g/day 440303
15–30 g/day 120201
>30 g/day 000000
Milk (n) 27 26 4 28 3 26
<5 g/day 9 11 4 13 3 12
5–14 g/day 13 11 0 9 0 8
15–30 g/day 430505
>30 g/day 110101
White (n) 441412
<5 g/day 211111
5–14 g/day 120201
15–30 g/day 010100
>30 g/day 100000
Physical activityf
Sedentaryg (n) 41 37 42 40 39 38
Low activeh (n) 443211
Activei (n) 030200
Ver y activej (n) 101010
aWomen in Group A began to take chocolate bars between the 11th and 13th week of gestation, therefore during the 1st trimester, but the column reserved for the 1st trimester was
used, for the Group A, to report information only relative to pre-enrollment behaviour.
be pregnant women in the Group B were free to eat chocolate (free in quantity and type) as before enrollment; for each of them it was assessed the type of chocolate mainly
assumed (giving larger prominence to the amount of chocolate with high cacao content).
cGroup A subjects allowed additional chocolate intake (excluding dark chocolate), not in excess of maximum dietary calorie intake (estimated according to the IOM recommenda-
tions) [20,21]. We only recommended them to do not consume additional dark chocolate and, above all, that containing >60% cocoa solids. From the 2nd trimester, for the Group
A, apart from the 30 g of chocolate containing 70% cocoa mass, it was reported potential additional intakes of chocolate (always specifying type and quantity).
dType of chocolate mainly assumed and calculated quantity of chocolate on average per day.
eDark chocolate: term used to indicate semi- and bitter-sweet chocolate, in any case a milk free chocolate.
fWomen in both groups were classied as sedentary, low active, active or very active, according to the criteria of the Institute of Medicine.
gSedentary: typical daily living activities (e.g. household tasks, walking to the bus).
hLow activity: typical daily living activities plus 30–60 min of daily moderate activity (e.g. walking at 5–7 km/h).
iActive: typical daily living activities plus at least 60 min of daily moderate activity.
jVery active: Typical daily living activities plus at least 60 min of daily moderate activity plus an additional 60 min of vigorous activity or 120 min of moderate activity.
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1866 G. C. Di Renzo et al.
e Journal of Maternal-Fetal and Neonatal Medicine
groups not having any signicant dierence in baseline glycemic
levels. e importance of the reduction of the liver enzymes levels
can be explained by further investigations.
In conclusion, a modest daily intake of high-cocoa-content choc-
olate contribute to reduce woman’s blood pressure during pregnancy
and does not aect weight gain. Also the glycemic and liver pattern
in pregnancy seems to be positively aected by chocolate contents.
e contribution of chocolate to the decrease of the cholesterol levels
and to the reduction of gestational anemia and GH, needs further
studies. A moderate amount of high-cocoa-content chocolate could
be a valuable supplemental food in pregnancy.
Acknowledgements
We are indebted to all the members of the “Prenatal Chocoteam
(authors not included): Adalberti Alberti, BSc, PhD, Zena
Baccaille, Res midwife, Nadia Belia, Res midwife, Giovanni
Cammardella, MD, Maria Pia Chiuchiù, Dietitian, Francesca
Incalza, MD, Alessia Rosati, MD, Vittorio Bini, MD, Statistician.
We would like to thank Mrs. Averna, CEO of Pernigotti SPA
(Novi Ligure, Italy), for kindly providing all the chocolate bars
used for this study. is paper is presented at the poster session
at the Pregnancy Meeting, Society for Maternal Fetal Medicine,
Hilton, Chicago, Chicago, USA, 1-6 February, 2010. Author
participation with the manuscript. Gian Carlo Di Renzo: design of
the study protocol; analysis and interpretation of data; draing of
the manuscript; critical revision of the manuscript for important
intellectual content. Eleonora Brillo: acquisition of data; analysis
and interpretation of data; draing of the manuscript; critical revi-
sion of the manuscript for important intellectual content. Maila
Romanelli: acquisition of data; analysis and interpretation of data.
Giuseppina Porcaro: acquisition of data; analysis and interpreta-
tion of data; draing of the manuscript. Federica Capanna: orga-
nization of data; draing of the manuscript. Tomi T. Kanninen:
analysis and interpretation of data; draing of the manuscript.
Sandro Gerli: analysis and interpretation of data; critical revision
of the manuscript for important intellectual content. Graziano
Clerici: analysis and interpretation of data; critical revision of the
manuscript for important intellectual content.
Declaration of Interest: e authors report no conicts of interest.
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... The combination of caffeine and theobromine as a derivative of methylxanthine contained in green tea for the basic ingredients of chocolate is believed to have beneficial effects without the side effects of caffeine [10]. The flavanoid molecule in green tea has the capacity to improve vascular function, prevent endothelial dysfunction and related diseases, and can also reduce blood pressure [11]. ...
... 13 Flav o noid contained in green tea is an antioxidant that is molecularly beneficial to improve vascular function, prevent endothelial dysfunction and related diseases, increase insensitivity , lower blood pressure , increase total capacity of antioxidant plasma, increase HDL concentration, reduce cholesterol LDL and total plasma cholesterol. 11 Langer et al tested zero flavo levels from 14 brands of green tea bars that were sold freely in the category of one brand type of white green tea , one brand type of milk green tea and 12 brands of type of green tea . Green tea samples contain 39 and 72% solid green tea (as indicated on the sample label), except for one brand of green tea containing 100% solid cacao. ...
... But no gestational hypertension was reported in either group. 11 Studies on the effect of preeclampsia especially green tea on PE cases are still limited. Most studies link cacao to hypertension cases in general, but this can be a preliminary study for PE cases. ...
... The available scientific evidence suggests that chocolate with a high cocoa content consumed daily in small quantities may properly fit into this nutritional strategy without entailing negative consequences in terms of weight during various trimesters. 124 Chocolate supplementation during pregnancy appears to reduce systolic and diastolic blood pressure during gestation, 124 (Figure 9.3) though this association was not found in all studies. 125 Considering the characteristics and risk factors of pre-eclampsia, including maternal hypertension, placental disease, endothelial dysfunction, oxidative stress, lack of NO, 126-128 the theoretical possibility of preventing pre-eclampsia by up-regulating NO availability due to antioxidant activity and the induction of NO-dependent vasodilatation by cocoa, it has been suggested that chocolate consumption could be a reasonable strategy for preventing this disease. ...
... The available scientific evidence suggests that chocolate with a high cocoa content consumed daily in small quantities may properly fit into this nutritional strategy without entailing negative consequences in terms of weight during various trimesters. 124 Chocolate supplementation during pregnancy appears to reduce systolic and diastolic blood pressure during gestation, 124 (Figure 9.3) though this association was not found in all studies. 125 Considering the characteristics and risk factors of pre-eclampsia, including maternal hypertension, placental disease, endothelial dysfunction, oxidative stress, lack of NO, 126-128 the theoretical possibility of preventing pre-eclampsia by up-regulating NO availability due to antioxidant activity and the induction of NO-dependent vasodilatation by cocoa, it has been suggested that chocolate consumption could be a reasonable strategy for preventing this disease. ...
... 130 Although not all of cocoa's potential health benefits for pregnant women have been clearly confirmed, chocolate consumption during pregnancy has shown to be positive in some accounts and harmless in others. 124 Overall, there is a natural female preference for chocolate that becomes markedly more apparent during pregnancy, with an increasing trend that follows the progress of gestation. 131 Chocolate in a balanced diet of a pregnant woman can instill psychological well-being to both the pregnant woman (typically during a time of high emotional lability) and the future child. ...
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Over the millennia, a multi-cultural following has developed around cocoa and chocolate, which appreciates its hedonic value as well as its health and therapeutic properties. Cocoa polyphenols can improve endothelial function, lipid pattern, insulin sensitivity and decrease platelet aggregation. They also have significant antioxidant, anti-inflammatory and neuro-protective properties. The female psyche is particularly susceptible to fascination with these products and the female gender is the most attracted to chocolate consumption, especially women suffering with premenstrual syndrome (PMS), seasonal affective disorder or disease (SAD) or depression. Chocolate carries sensorial stimulation and causes pleasure. These actions explain only a small part of the intimate connection between chocolate and sex. Among the various bioactive compounds of cocoa-based products, flavonoids and theobromine have been shown to positively influence the health, well-being and beauty of the woman, even in pregnancy and in menopause.
... Only two small clinical trials have explored this hypothesis in normal pregnant women. A non-placebo controlled, non-blinded trial indicated that a modest daily intake of high-cocoa content chocolate initiated between 11 and 13 weeks of gestation contributes to reducing BP (18). Our previous pilot randomized clinical trial did not reveal any variations in BP or endothelial function induced by the intake of high flavanol cocoa intake beginning at 21 weeks gestation (19). ...
... An To date, two trials have evaluated the effects of chocolate on BP regulation during pregnancy. Di Renzo et al. performed a randomized clinical trial on a group of 90 healthy women at 11-13 weeks gestational age with 30 g daily of dark chocolate (12.6 mg catechin and epicatechin) for the entire second and third trimesters of pregnancy (18). The authors found a significant decrease in systolic and diastolic BP in the treatment group compared to the group who received no intervention. ...
... There are limitations in this study that warrant a mention. The first is a large number of participants who discontinued the intervention and were lost to follow-up when compared to the only other clinical trial evaluating the impacts of HFHT in pregnancy women (18). Among the 131 women who were randomized in our trial, 8% were lost to follow-up and 14% discontinued the intervention compared to 7% of women lost to follow-up and 3% who discontinued intervention in Di Renzo et al. (2012). ...
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... Indeed, cocoa could reduce the rate and extent of macronutrient digestion by binding to and antagonizing digestive enzymes 35 which may help explain the previously reported inverse relation between chocolate intake and Type 2 Diabetes Mellitus (T2DM) incidence. 58,59 In general, the "timing" of chocolate intake resulted in differential changes in microbiota profiles and function as shown in Figure 6A. These differences were mostly marked by metabolites (SCFAs) produced by the microbiota, indicating that SCFAs might be a good biomarker to explain, at least in part, the differences found among conditions. ...
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... In 2006, Tabernero and collaborators [65] estimated for the Spanish diet that cocoa products account for 10% of the total antioxidant capacity of dietary intake. In addition, research conducted by Di Renzo and co-authors [66] reported the beneficial effects of the daily intake of 30 g of chocolate (70% cocoa) in pregnant women that showed reduced arterial pressure (diastolic and systolic). Moreover, the same authors highlighted a decrease in the risk of preclampsia, which is a major complication of pregnancy with cardiovascular manifestation that is related to chocolate consumption. ...
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Theobroma cacao provides precious products such as polyphenol-rich beans that are useful for nutraceutical purposes. The geographical area may influence the chemical composition of raw cocoa beans in terms of the polyphenols and biological qualities of the products. This work aimed to investigate the biological properties and the chemical composition of two different samples of Criollo var. cocoa raw beans coming from two areas (Indonesia; Peru). Beans underwent biphasic extraction obtaining lipophilic and hydroalcoholic extracts. The extracts were tested for antiradical, antimutagenic, and antigenotoxic effects. Cell viability inhibition toward breast, gastric/esophageal colorectal adenocarcinoma, and hepatoblastoma human cell lines was evaluated. Extracts were chemically investigated through UV-Vis spectroscopy and ultra-high-pressure liquid chromatography electrospray ionization quadrupole time-of-flight mass spectrometry (UHPLC-ESI-QqTOF MS/MS). Results showed that the Indonesian bean hydroalcoholic extracts were able to scavenge 2′-azino-bis (3-ethylbenzothiazoline-6-sulfonic acid) diammonium salt (ABTS) cation radical better than the Peruvian hydroalcoholic extracts (ECs50: 72.63 vs. 322.20 μg/mL). Extracts showed antimutagenic and antigenotoxic activity. The viability inhibitory effect on breast and hepatic cancer cells was reached only for the Indonesian hydroalcoholic extracts at hundreds of μg/mL. Phenylpropenoyl-L-amino acids, hydroxycinnamoyl aminoacids conjugates, and procyanidin compounds were found mainly in the hydroalcoholic extracts, whereas fatty acids and lyso-phospholipids were found mainly in lipophilic fractions. Fatty acid and (epi)catechins appeared to be affected by different environmental conditions of the geographical areas.
... Limmy (2012) Honduras (2004), Gupta et al. (1979), Khan (1997), Mans et al. (2004), and Bashir and Gilani (2008) Honduras (2014), Michel et al. (2006, 2007), and Di Renzo et al. (2012 Panamá (Duke 2000) Kuna Gupta et al. (1993), Duke (2000), Innes et al. (2003), and Ramiro et al. (2005) Costa Rica (2014) and Michel et al. (2006Michel et al. ( , 2007Michel et al. ( , 2012 Costa Rica Gupta et al. (1993) and Jimenez et al. (2001) Panamá ...
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Over the past 20 years, Central America (CA) has made considerable progress in improving the health status of its populations. However, in some countries, the overall health status remains below average with poor outcomes concentrated geographically among the poor and Indigenous populations. Although Indigenous people make up the second largest population in CA, these populations have less access to healthcare, and funding for initiatives to improve maternal health is scarce. In many communities across CA, women continue to rely heavily on plant-based medicines for health and well-being, and yet there is a paucity of information regarding the safety and efficacy of these therapies. Sourced from available academic, governmental, and gray literature, in both English and Spanish, this chapter reviews maternal health issues among the Indigenous, Ladino, and other ethnic women of CA, evaluates the role of traditional medicine practices and their influence on maternal health outcomes, and reviews the existing scientific evidence supporting the use of traditional (i.e., plant-based) medicines for pregnancy-related health conditions.
... Abstention from alcohol, smoking cessation, exercises for the maintenance of fitness, calcium supplementation, and stress reduction, among others, are recommended to prevent preeclampsia and its complications. Some researchers have found a significant reduction of BP with daily intake of chocolate, resulting in a reduced risk of gestational hypertension and preeclampsia [71,72]. Although previous researchers have found a positive influence of physical activity (PA) on pregnant women and their infants [73][74][75], there is a lack of clinically validated research aimed to determine the influence of exercise on the risk of hypertensive disorders. ...
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Background: Hypertensive disorders are the most common complications during pregnancy, occurring in 5% to 11% of pregnancies; gestational hypertension and preeclampsia are the leading causes of perinatal and maternal morbidity and mortality, especially in low- and middle-income countries (LMIC) where maternal and perinatal mortality ratios are still high. Pregnant women with hypertensive disorders could greatly benefit from mobile health (mHealth) solutions as a novel way to identify and control early symptoms, as shown in an increasing number of publications in the field. Such digital health solutions may overcome access limiting factors and the lack of skilled medical professionals and finances commonly presented in resource-poor environments. Objective: The aim of this study was to conduct a literature review of mHealth solutions used as support in hypertensive disorders during pregnancy, with the objective to identify the most relevant protocols and prototypes that could influence and improve current clinical practice. Methods: A methodological review following a scoping methodology was conducted. Manuscripts published in research journals reporting technical information of mHealth solutions for hypertensive disorders in pregnancy were included, categorizing articles in different groups: Diagnosis and Monitoring, mHealth Decision Support System, Education, and Health Promotion, and seven research questions were posed to study the manuscripts. Results: The search in electronic research databases yielded 327 articles. After removing duplicates, 230 articles were selected for screening. Finally, 11 articles met the inclusion criteria, and data were extracted from them. Very positive results in the improvement of maternal health and acceptability of solutions were found, although most of the studies involved a small number of participants, and none were complete clinical studies. Accordingly, none of the reported prototypes were integrated in the different health care systems. Only 4 studies used sensors for physiological measurements, and only 2 used blood pressure sensors despite the importance of this physiological parameter in the control of hypertension. The reported mHealth solutions have great potential to improve clinical practice in areas lacking skilled medical professionals or with a low health care budget, of special relevance in LMIC, although again, no extensive clinical validation has been carried out in these environments. Conclusions: mHealth solutions hold enormous potential to support hypertensive disorders during pregnancy and improve current clinical practice. Although very positive results have been reported in terms of usability and the improvement of maternal health, rigorous complete clinical trials are still necessary to support integration in health care systems. There is a clear need for simple mHealth solutions specifically developed for resource-poor environments that meet the United Nations Sustainable Development Goal (SDG); of enormous interest in LMIC.
... Dostępne dowody naukowe sugerują, że dzienne spożycie czekolady bogatej w kakao w niewielkich ilościach (30 g na dobę przez 24 tygodnie) może wpłynąć pozytywnie na przebieg ciąży poprzez m.in. stabilizację ciśnienia tętniczego krwi, bez dodatkowych negatywnych konsekwencji, takich jak wzrost masy ciała kobiety w poszczególnych trymestrach [60]. Czekoladę mogą spożywać kobiety w ciąży, ponieważ nie stwierdzono negatywnego wpływu na zdrowie matki i płodu, przeciwnie -badania ujawniają korzystne efekty dla matki oraz dziecka zarówno w okresie płodowym, jak i pourodzeniowym [7]. ...
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Ostatnie badania potwierdzają prozdrowotne właściwości czekolady, chociaż historia kakao jako leku sięga kilku tysięcy lat. Drzewo kakaowca rosnące w klimacie równikowym, w wierzeniach starożytnych Majów i Azteków, było boskim darem dla ludzkości zapewniającym mądrość i wiedzę uniwersalną. Z jego ziaren uzyskiwany jest proszek kakaowy służący do produkcji czekolady zawierającej wiele składników bioaktywnych, w tym witaminy, składniki mineralne, polifenole i kwasy tłuszczowe. Czekolada pozytywnie wpływa na nastrój, zmniejsza podatność na stany depresyjne oraz stres oksydacyjny. Spożycie czekolady w trakcie ciąży może poprawić stan psychiczny przyszłych matek i zmniejszyć negatywny wpływ matczynego stresu na niemowlę. Dzięki wysokiej zawartości flawanoli wykazuje właściwości przeciwzapalne, przeciwalergiczne, przeciwwirusowe oraz przeciwnowotworowe. Pozytywnie wpływa na pamięć i umiejętności poznawcze, może zmniejszyć ryzyko demencji. Regularne spożywanie produktów zawierających kakao zmniejsza ryzyko zgonu z przyczyn sercowo-naczyniowych, a zwłaszcza udaru mózgu, oraz może zmniejszyć obwodową oporność na insulinę u kobiet z cukrzycą typu 2. Działa pobudzająco po wysiłku psychicznym lub fizycznym. Zapewnia uczucie sytości, dlatego była dodawana do żołnierskich racji żywnościowych w czasie I wojny światowej. Należy jednak pamiętać, że spożycie czekolady podnosi poziom kwasu szczawianowego w moczu oraz może prowadzić do zaostrzenia objawów trądziku pospolitego. Jest toksyczna dla zwierząt. Czekolada zawiera również związki, których znaczenie dla zdrowia nie zostało szczegółowo poznane.
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Background: Flavonoids are polyphenolic compounds of plant origin with antioxidant effects. Flavonoids inhibit LDL oxidation and reduce thrombotic tendency in vitro. Little is known about how cocoa powder and dark chocolate, rich sources of polyphenols, affect these cardiovascular disease risk factors. Objective: We evaluated the effects of a diet high in cocoa powder and dark chocolate (CP-DC diet) on LDL oxidative susceptibility, serum total antioxidant capacity, and urinary prostaglandin concentrations. Design: We conducted a randomized, 2-period, crossover study in 23 healthy subjects fed 2 diets: an average American diet (AAD) controlled for fiber, caffeine, and theobromine and an AAD supplemented with 22 g cocoa powder and 16 g dark chocolate (CP-DC diet), providing ≈466 mg procyanidins/d. Results: LDL oxidation lag time was ≈8% greater (P = 0.01) after the CP-DC diet than after the AAD. Serum total antioxidant capacity measured by oxygen radical absorbance capacity was ≈4% greater (P = 0.04) after the CP-DC diet than after the AAD and was positively correlated with LDL oxidation lag time (r = 0.32, P = 0.03). HDL cholesterol was 4% greater after the CP-DC diet (P = 0.02) than after the AAD; however, LDL-HDL ratios were not significantly different. Twenty-four–hour urinary excretion of thromboxane B2 and 6-keto-prostaglandin F1α and the ratio of the 2 compounds were not significantly different between the 2 diets. Conclusion: Cocoa powder and dark chocolate may favorably affect cardiovascular disease risk status by modestly reducing LDL oxidation susceptibility, increasing serum total antioxidant capacity and HDL-cholesterol concentrations, and not adversely affecting prostaglandins.
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Hypertensive disease occurs in approximately 12-22% of pregnancies, and it is directly responsible for 17.6% of maternal deaths in the United States (1,2). However, there is confusion about the terminology and classification of these disorders. This bulletin will provide guidelines for the diagnosis and management of hypertensive disorders unique to pregnancy (ie, preeclampsia and eclampsia), as well as the various associated complications. Chronic hypertension has been discussed elsewhere (3).