Precepting the Prenatal Patient: A Curriculum for Non OB Family Medicine Physicians

ACGME Requirements  "Whenever residents are performing clinical duties in the FMC, there must be an appropriate number of family physician faculty who, without other obligations, are engaged in active teaching and supervision of the residents.”(PR – V.B.2.b)

 Model I: Hypertensive Disorders of Pregnancy

 Define the hypertensive disorders of pregnancy  Identify the new recommendations in the definition  Identify and teach the management of hypertensive disorders of pregnancy Lecture Objectives

 Pre-eclampsia/eclampsia  With severe features  Without severe features  Chronic Hypertension  Chronic Hypertension with super-imposed pre- Eclampsia  Gestational hypertension Categories

A 27-year-old woman who is 30 weeks pregnant presents to her OB for routine follow up and has a blood pressure of 150/105 mm Hg. She was previously normotensive. Urinalysis reveals a specific gravity of with 1+ proteinuria and no cells. Serum uric acid level is 5.0 mg/dL. Platelet count and liver function tests are normal. Analysis of a 24-hour urine collection shows 1.1 g of protein. Which of the following does this patient most likely have? (A) Chronic hypertension (B) Gestational hypertension (C) Normal blood pressure for pregnancy (D) Preeclampsia

Incidence has increased 25% over 20 years 50-60K maternal and perinatal deaths yearly, worldwide For every death, “near- misses” with morbidity Correct diagnosis continues to challenge clinicians Pre-Eclampsia

Elevated blood pressure 140/90 After 20 th week of pregnancy Proteinuria 300 mg/24 hour OR Protein/cr ratio >0.3 OR 1+ on dipstick Pre-eclampsia Diagnosis: Old Criteria

Elevated blood pressure 140/90 After 20 th week of pregnancy Proteinuria 300 mg/24 hour OR Protein/cr ratio >0.3 OR 1+ on dipstick Pre-eclampsia Diagnosis: New Criteria

Elevated blood pressure 140/90 New onset after 20 th week of pregnancy Pulmonary Edema New cerebral or visual changes Platelets <100K Liver enzymes 2x normal New renal insufficiency Cr > 1.1 OR Doubling of Cr New Pre-eclampsia diagnosis in the absence of Proteinuria

New pre-eclampsia diagnosis: No longer depends solely on presence of proteinuria

 Avoid use of term mild preeclampsia  Replaced with preeclampsia without severe features  Severe preeclampsia = preeclampsia with severe features New Jargon

Platelets <100K Liver enzymes 2x normal New renal insufficiency Cr> 1.1 Pulmonary edema New cerebral or visual disturbances Systolic BP >160 Diastolic BP > 110 Persistent RUQ quadrant pain Epigastric pain not responsive to medication Pre-Eclampsia with Severe Features

Pre-eclampsia with severe features no longer requires Massive proteinuria (> 5g) Fetal growth restriction removed as indication of pre-eclampsia with severe features

Current maternal mortality data: More deaths could be avoided!!!!!

Huge Change in Pre-Eclampsia Management!! Suggest delivery at or beyond 37 0/7 weeks  For pre-eclampsia without severe features and gestational hypertension

New-onset BP elevation after 20wks of pregnancy in absence of proteinuria Outcomes are generally good Requires advance surveillance even with mild BP elevations May be a sign of future chronic HTN Gestational Hypertension

Expectant management with maternal and fetal monitoring What to do when your patient has gestational hypertension or pre-eclampsia without severe features at less than 37 weeks?

Maternal symptoms & fetal movement daily Check BP twice weekly Platelet counts and liver enzymes weekly Proteinuria assessments weekly Task Force Recommendations: Gestational HTN & Preeclampsia

Suggest ultrasound for fetal growth Suggest antenatal testing for fetal well- being Suggest umbilical artery Doppler velocimetry if growth restriction US surveillance

No antihypertensives if SBP <160 & DBP < 110 No bed rest No delivery decision based on amount of proteinuria or change in proteinuria Task Force Recommendations: Gestational HTN & Preeclampsia

 High blood pressure which is known to pre-date conception or is detected before 20 weeks gestation  Incidence of pre-eclampsia 4-5x higher for women with chronic hypertension Chronic Hypertension

 Home blood pressure monitoring if poorly controlled  Antihypertensives for SBP > 160 and DBP >105  Recommended medications:  - methyldopa - labetalol - nifedipine  Quality of evidence:Moderate  Antenatal testing:  if BP meds needed, if growth restriction, if other medical conditions Chronic Hypertension

 Women with chronic HTN who are accustomed to exercising, with controlled BP, it is recommended that moderate exercise be continued during pregnancy  The use of ACEI, ARBs, renin inhibitors, and mineralocorticoid receptor antagonists is not recommended in women of reproductive age unless there is compelling reason as proteinuric renal disease Chronic Hypertension

 Delivery before 38 weeks is not recommended for women with chronic hypertension with no maternal/fetal complications Chronic Hypertension

 For women with a medical history of early-onset pre-eclampsia and preterm delivery at less than 34wks or preeclampsia in 2 or more pregnancies, ASA low dose beginning in late first trimester is suggested– not beneficial to low risk patients  GRADE Recommendation: Qualified Important Facts

 The administration of vit c or E to prevent pre- eclampsia is not recommended  Pre-eclampsia with severe features at or beyond 34wks in those with unstable maternal and fetal conditions, delivery after maternal stability is recommended  GRADE Recommendation: Strong Important Facts

 Pre-eclampsia with severe features at less than 34wks with stable maternal and fetal conditions, recommended that pregnancy be continued at location with maternal and neonatal ICU  Pre-eclampsia with severe features receiving expectant management at 34wks or less, the administration of corticosteroids for fetal lung maturity benefit is recommended  GRADE Recommendation: Strong Important Facts

 Expedite delivery at 37 weeks for gestational hypertension and preeclampsia without severe features  Proteinuria no longer necessary for diagnosis of preeclampsia if other clinical criteria present  No delivery before 38 weeks for women with chronic hypertension and no maternal/fetal complications Summary of Biggest Changes

 The Task Force Report on Hypertension in Pregnancy, 2013  “Emergent Therapy for Acute-Onset, Severe Hypertension With Preeclampsia or Eclampsia.” 2011 “Emergent Therapy for Acute-Onset, Severe Hypertension With Preeclampsia or Eclampsia    Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol. 2000;183(1):S1–S22.  ACOG Committee on Practice Bulletins. ACOG Practice Bulletin. Chronic hypertension in pregnancy. Obstet Gynecol. 2001;98(1 suppl):177–185. References