Hypertension in Pregnancy
Stuart Shelton, MD
CFV Medical Center
January 2014
Disclosure
I have no relevant financial relationships with the manufacturer of any
commercial products and/or providers of commercial services discussed in
this presentation.
I do not intend to discuss any unapproved or investigative use of
commercial products or devices.
Hypertension in Pregnancy
Why worry?
Common:
~ 10% of pregnancies
Morbidity:
fetus: 12% of preterm deliveries
mother: stroke, CHF, renal injury
Mortality:
12-13% of maternal mortality
Pregnancy-Related Mortality
United States (1998-2005)
Anesthesia (1%)
CVA (6%)
Unknown (2.1%)
Embolism (18%)
PE (10%)
AFE (8%)
Infection (11 %)
Hemorrhage (12.5%)
Cardiomyopathy (11.5%)
Preeclampsia (12.3%)
Other medical conditions (13.2%)
Cardiovascular disease (12.4%)
Obstet Gynecol 2010
Hypertension in Pregnancy
ACOG Task Force (Nov 2013)
Classification
Diagnosis
Management
Prevention
Future Implications
Hypertension in Pregnancy
ACOG publications recently removed:
- Chronic hypertension (Feb 2012)
- Diagnosis and management of preeclampsia (2002)
Updated publications pending
Task Force Recommendations
Strong
- well supported by evidence
- appropriate for virtually all patients
- recommended
Qualified
- appropriate for most patients
- suggested
____________________________________________
Evidence quality:
- low
- moderate
- high
Classification
1. Chronic hypertension
2. Gestational hypertension
3. Preeclampsia
- without severe features
- with severe features (severe preeclampsia)
4. Chronic hypertension with superimposed preeclampsia
- without severe features
- with severe features
Classification
PIH
“PIH” should not be used
- ACOG recommended against use in 2000
- recommendation made 14 years ago
Classification
Avoid use of term mild preeclampsia
replace with preeclampsia without severe features
Severe preeclampsia = preeclampsia with severe features
Diagnosis: Hypertension
Hypertension (either):
SBP > 140
DBP > 90
Severe hypertension (either):
SBP > 160
DBP > 110
BP > 4 hours apart
Diagnosis: Hypertension
“it is recommended that a diagnosis of
hypertension require at least 2 determinations at
least 4 hours apart, although on occasion,
especially when faced with severe hypertension,
the diagnosis can be confirmed within a short
interval (even minutes) to facilitate timely
antihypertensive therapy.”
Blood Pressure: Technique
Assessing BP (ideal):
- seated, legs uncrossed, relaxed, quiet
- back and arm supported
- middle of cuff at level of right atrium
- wait 5 minutes before first reading
Improper assessment:
- left lateral using upper arm
- gives falsely low values
Diagnosis: Proteinuria
Definition:
- 24 hour*
- timed (i.e. 12hr)
- P/C ratio
- urine dipstick**
> 300 mg
> 300 mg (extrapolated)
> 0.3
> 1+
* 24 urine is preferred method
** urine dipstick used only if no other available
Chronic Hypertension:
Definition
Hypertension and either of the following:
- present prior to pregnancy
- present prior to 20 weeks
Diagnosis dilemmas:
- women with little care before pregnancy
- women presenting after 20 weeks
Chronic Hypertension:
Anti-hypertensive Therapy
Anti-hypertensive medication indicated:
- persistent SBP > 160
- or persistent DBP > 105
Quality of evidence:
Recommendation:
Moderate
Strong
BP goals with treatment:
120-160/80-105
Chronic Hypertension:
Anti-hypertensive Therapy
Recommended medications:
- labetalol
- nifedipine
- methyldopa
Quality of evidence:
Recommendation:
Moderate
Strong
Anti-hypertensive Therapy
Medication
Dose
Comments
Labetalol
200-2400 mg/d (2-3 doses)
caution with
asthma, CHF
Nifedipine
30-120 mg/d (XL)
avoid SL form
Methyldopa
500-3000 mg/d (2-3 doses)
may not be
effective with
severe HTN
Chronic Hypertension:
Anti-hypertensive Therapy
Anti-hypertensive medication not needed:
- SBP < 160 and DBP < 105
- no evidence for end-organ damage
Quality of evidence:
Recommendation:
Low
Qualified
Chronic Hypertension:
Fetal Assessment
Ultrasound:
- screen for growth restriction
- timing not specified (? 28-32 weeks)
Quality of evidence:
Recommendation:
Low
Qualified
Chronic Hypertension:
Fetal Assessment
Antenatal testing:
- taking anti-hypertensive medication
- other medical conditions
- superimposed preeclampsia
Quality of evidence:
Recommendation:
Low
Qualified
Chronic Hypertension:
Fetal Assessment
CHTN + fetal growth restriction:
- antenatal testing
- umbilical artery Doppler
Quality of evidence:
Recommendation:
Moderate
Strong
Chronic Hypertension:
Delivery
No other additional maternal/fetal complications
- delivery < 38w0d not recommended
(i.e. wait until > 38w0d)
Quality of evidence:
Recommendation:
Moderate
Strong
Gestational Hypertension:
Definition
Hypertension (onset > 20 weeks) and all of following:
- absence of proteinuria
- absence of severe features
Gestational Hypertension:
Management
- serial assessment for symptoms (daily)
- serial assessment of fetal movement (daily)
- serial measurement of BP
- 2x per week in office
or - 1x per week in office and 1x at home
- serial assessment for proteinuria (weekly)
- platelets, LFTs, creatinine (weekly)
Quality of Evidence:
Recommendation:
Moderate
Qualified
Gestational Hypertension:
Anti-hypertensive therapy
SBP < 160 and DBP < 110
- BP medication NOT be given
Quality of Evidence:
Recommendation:
Moderate
Qualified
Gestational Hypertension:
Fetal Assessment
- daily kick counts
- ultrasound: assess growth every 3 weeks
- NST once weekly with AFI
Gestational Hypertension:
Seizure Prophylaxis
Gestational hypertension
- magnesium is NOT universally needed
Quality of evidence:
Recommendation:
Low
Qualified
If patients develops severe features  magnesium
Gestational Hypertension:
Delivery
Gestational hypertension and < 37w0d
- expectant management until 37w0d
- deliver sooner if other indications arise
Quality of evidence:
Recommendation:
Low
Qualified
Gestational Hypertension:
Delivery
Gestational hypertension
Diagnosis made > 37w0d
- deliver
Quality of evidence:
Recommendation:
Moderate
Qualified
Preeclampsia: Definition
1. HTN (new onset > 20 weeks) + proteinuria
OR
2.* HTN (new onset > 20 wks) + multisystemic signs
- CNS
- pulmonary edema
- renal dysfunction
- liver impairment
- thrombocytopenia
* Proteinuria is not required for diagnosis
Preeclampsia without Severe Features:
Definition
Hypertension (onset > 20 weeks) and all of following:
- proteinuria
- absence of severe features
Preeclampsia with Severe Features
Hypertension (onset > 20 weeks) and any of following:
-
SBP > 160 or DBP > 110
platelets < 100,000
increased LFTs (2x normal)
severe, persistent RUQ/epigastric pain
new renal insufficiency
- creatinine > 1.1 mg/dL
- doubling of creatinine
- pulmonary edema
- new onset cerebral or visual disturbances
Old classification
Name
BP
Platelets
Liver
Renal
Lungs
CNS
Fetus
Severe preeclampsia
BP > 160 or > 110 (6 hr)
< 100,000
increased LFTs
RUQ/epigastric pain
creatinine not used
oliguria
> 5000 mg protein
pulmonary edema
persistent HA
visual changes
growth restriction
New classification
Preeclampsia with severe features
BP > 160 or > 110 (4 hrs apart)
< 100,000
increased LFTs
RUQ/epigastric pain
creatinine > 1.1 mg or doubling
not used
not used
pulmonary edema
persistent HA
persistent visual changes
not used
Preeclampsia:
Management
Without severe features:
- serial assessment for symptoms (daily)
- serial assessment of fetal movement (daily)
- serial measurement of BP (2x per week)
- platelets, LFTs, creatinine (weekly)
Quality of Evidence:
Recommendation:
Moderate
Qualified
Preeclampsia:
Anti-hypertensive therapy
SBP < 160 and DBP < 110
- BP medication NOT be given
Quality of Evidence:
Recommendation:
Moderate
Qualified
Preeclampsia:
Anti-hypertensive therapy
SBP > 160 or DBP > 110
- BP medication is recommended
Quality of Evidence:
Recommendation:
Moderate
Strong
Preeclampsia:
Fetal Assessment
Preeclampsia without severe features:
- daily fetal kick counts
- ultrasound to assess growth (q 3 weeks)
- antenatal testing twice weekly
Quality of evidence:
Recommendation:
Moderate
Qualified
Preeclampsia:
Fetal Assessment
Preeclampsia with fetal growth restriction:
- antenatal testing
- umbilical artery Doppler
Quality of evidence:
Recommendation:
Moderate
Strong
Preeclampsia:
Delivery
Preeclampsia without severe features and < 37w0d
- deliver > 37w0d
- deliver sooner if other indications arise
Quality of evidence:
Recommendation:
Low
Qualified
New PQCNC project (Feb 2014)
CMOP: Conservative Management of Preeclampsia
Preeclampsia:
Delivery
Preeclampsia without severe features
Diagnosis at > 37w0d
- deliver
Quality of evidence:
Recommendation:
Moderate
Qualified
Preeclampsia:
Delivery
Preeclampsia with severe features
Prior to fetal viability (23-24 weeks)
- deliver
(not candidates for expectant management)
Quality of evidence:
Recommendation:
Moderate
Strong
Preeclampsia:
Delivery
Deliver if any of following at any gestational age
- uncontrollable severe hypertension
- eclampsia
- pulmonary edema
- abruption
- DIC
- nonreassuring fetal status
Quality of evidence:
Recommendation:
Moderate
Qualified
Preeclampsia:
Delivery
Deliver in 48 hours (after steroids) if stable:
- PROM
- platelets < 100,000
- elevated LFTs
- EFW < 5th percentile
- AFI < 5 cm
- abnormal umbilical artery Doppler
- new onset/worsening renal dysfunction
Quality of evidence:
Recommendation:
Moderate
Qualified
Preeclampsia:
Delivery
Preeclampsia with severe features
> 34w0d
- deliver
Quality of evidence:
Recommendation:
Moderate
Strong
Preeclampsia:
Delivery
Preeclampsia with severe features
< 34w0d and stable maternal/fetal status
- expectant management at tertiary center
Quality of evidence:
Recommendation:
Moderate
Strong
Preeclampsia:
Expectant management*
Preeclampsia with severe features and 23w0d-33w6d
Expectant management candidates:
- severe hypertension, if controllable
- transient lab abnormalities (LFTs, platelets)
* prior studies; not from Task Force recommendations
Preeclampsia:
Seizure Prophylaxis
Preeclampsia without severe features
- magnesium is NOT universally needed
Quality of evidence:
Recommendation:
Low
Qualified
Preeclampsia:
Seizure Prophylaxis
Preeclampsia without severe features
- monitor closely during labor
- magnesium if progression to severe disease
- BP > 160/110
- symptoms
Some providers may elect to use magnesium for
patients without severe features
Preeclampsia:
Seizure Prophylaxis
Preeclampsia with severe features or eclampsia
- magnesium sulfate
Quality of evidence:
Recommendation:
High
Strong
If Cesarean  continue magnesium intraoperatively
Chronic Hypertension with
Superimposed Preeclampsia
Hypertension (onset < 20 weeks) and new findings:
Without severe features:
- hypertension and proteinuria only
- proteinuria: new onset or worsening
With severe features
- hypertension +/- proteinuria + severe features
CHTN with Superimposed Preeclampsia:
Seizure Prophylaxis
Without severe features
- magnesium sulfate is not necessary
With severe features
- magnesium sulfate is recommended
Quality of evidence:
Recommendation:
Moderate
Strong
CHTN with Superimposed Preeclampsia:
Delivery
Without severe features
- stable maternal and fetal status
- delivery > 37w0d
Quality of evidence:
Recommendation:
Low
Qualified
CHTN with Superimposed Preeclampsia:
Delivery
With severe features
< 34w0d and stable maternal/fetal status
- expectant management at tertiary center
Quality of evidence:
Recommendation:
Moderate
Strong
CHTN with Superimposed Preeclampsia:
Delivery
Preeclampsia with severe features
> 34w0d
- deliver
Quality of evidence:
Recommendation:
Moderate
Strong
CHTN with Superimposed Preeclampsia:
Delivery
Deliver if any of following at any gestational age
- uncontrollable severe hypertension
- eclampsia
- pulmonary edema
- abruption
- DIC
- nonreassuring fetal status
Quality of evidence:
Recommendation:
Moderate
Qualified
Postpartum Preeclampsia:
Seizure Prophylaxis
Postpartum diagnosis
- new onset hypertension with CNS symptoms
- or preeclampsia with severe hypertension
- magnesium sulfate (24 hr)
Quality of evidence:
Recommendation:
Low
Qualified
Management: Postpartum
Gestational hypertension or preeclampsia
- BP monitored for 72 hours
- in hospital
- equivalent outpatient surveillance
- Repeat BP assessment 7-10 days postpartum
- Repeat BP earlier in women with symptoms
Quality of evidence:
Recommendation:
Moderate
Qualified
Management: Postpartum
Persistent hypertension
- SBP > 150 or DBP > 100 (2 readings > 4 hrs)
- treat with anti-hypertensive
- SBP > 160 or > 110
- treat within 1 hour
Quality of evidence:
Recommendation:
Low
Qualified
Prevention
Women with history of:
- early-onset preeclampsia and PTD < 34w0d
- history preeclampsia in more than 1 pregnancy
Treatment:
- daily low-dose aspirin (60-80 mg)
- begin in late first trimester
Quality evidence:
Recommendation:
Moderate
Qualified
Prevention
Consider for women with high-baseline risk (~20%)
- chronic hypertension
- previous preterm preeclampsia
- diabetes
Needed to treat to prevent 1 case preeclampsia: 50
Prevention
Not recommended:
-
vitamin C
vitamin E
salt restriction
bed rest
physical activity restriction
Future Implications
Preeclampsia in pregnancy
- increased risk cardiovascular disease
- overall:
2x increase risk
- < 34 week delivery: 8-9x increase risk
Future Implications
What can be done to lower cardiovascular risk?
Preterm birth < 37 weeks from preeclampsia
consider yearly assessment of:
- BP
- lipids
- fasting glucose
- BMI
Quality of Evidence:
Recommendation:
Low
Qualified
Summary
- preeclampsia vs. gestational HTN:
- presence of proteinuria
- preeclampsia:
- no longer use term “mild” preeclampsia
- preeclampsia without severe features
PIH
Summary
- preeclampsia with severe features
- proteinuria not used to define severe
- proteinuria not used to determine delivery timing
- fetal growth restriction removed
- oliguria removed
- elevated creatinine defined
Summary
- CHTN with superimposed preeclampsia
- Management similar to preeclampsia
- depends on presence of severe features
Summary
- magnesium sulfate recommended for:
- preeclampsia with severe features
- eclampsia
- delivery:
- CHTN:
- GHTN:
- Preeclampsia, w/o severe
- Preeclampsia, w/ severe
> 38w0d
> 37w0d
> 37w0d
varies; 34w0d latest
Summary
Postpartum (GHTN and preeclampsia):
- check BP for 72 hours
- follow-up at 7-10 days postpartum
Prevention:
- high-risk women
- daily low dose aspirin starting late 1st trimester
References
Hypertension in Pregnancy: Report of the American College of Obstetricans
and Gynecologists’ Task Force on Hypertension in Pregnancy. ACOG,
2013.
Chronic hypertension. Clinical management guidelines for obstetriciangynecologists. No. 125. February 2012 (no longer in circulation)
Diagnosis and Management of Preeclampsia and Eclampsia. ACOG Practice
Bulletin No. 33. January 2002 (no longer in circulation)
Lockwood, CJ. ACOG task force on hypertension in pregnancy (editorial).
Contemporary Ob/Gyn. December 2013.