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) Unknown (2.1%) Anesthesia (1%) CVA (6%) 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 Gestational hypertension 3. Preeclampsia - without severe features - with severe features (severe preeclampsia) 4. Chronic hypertension with superimposed preeclampsia - with severe features

PIH Classification “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* > 300 mg - timed (i.e. 12hr) > 300 mg (extrapolated) - P/C ratio > 0.3 - urine dipstick** > 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: Moderate Recommendation: Strong BP goals with treatment: 120-160/80-105

Chronic Hypertension: Anti-hypertensive Therapy Recommended medications: - labetalol - nifedipine - methyldopa Quality of evidence: Moderate Recommendation: 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: Low Recommendation: Qualified

Chronic Hypertension: Fetal Assessment Ultrasound: - screen for growth restriction - timing not specified (? 28-32 weeks) Quality of evidence: Low Recommendation: Qualified

Chronic Hypertension: Fetal Assessment Antenatal testing: - taking anti-hypertensive medication - other medical conditions - superimposed preeclampsia Quality of evidence: Low Recommendation: Qualified

Chronic Hypertension: Fetal Assessment CHTN + fetal growth restriction: - antenatal testing - umbilical artery Doppler Quality of evidence: Moderate Recommendation: Strong

Chronic Hypertension: Delivery No other additional maternal/fetal complications - delivery < 38w0d not recommended (i.e. wait until > 38w0d) Quality of evidence: Moderate Recommendation: 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: Moderate Recommendation: Qualified

Gestational Hypertension: Anti-hypertensive therapy SBP < 160 and DBP < 110 - BP medication NOT be given Quality of Evidence: Moderate Recommendation: Qualified

Gestational Hypertension: Fetal Assessment daily kick counts ultrasound: assess growth every 3 weeks NST once weekly with AFI

Gestational Hypertension: Seizure Prophylaxis - magnesium is NOT universally needed Quality of evidence: Low Recommendation: 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: Low Recommendation: Qualified

Gestational Hypertension: Delivery Diagnosis made > 37w0d - deliver Quality of evidence: Moderate Recommendation: Qualified

Preeclampsia: Definition 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 New classification Name Severe preeclampsia Preeclampsia with severe features BP BP > 160 or > 110 (6 hr) BP > 160 or > 110 (4 hrs apart) Platelets < 100,000 < 100,000 Liver increased LFTs increased LFTs RUQ/epigastric pain RUQ/epigastric pain Renal creatinine not used creatinine > 1.1 mg or doubling oliguria not used > 5000 mg protein not used Lungs pulmonary edema pulmonary edema CNS persistent HA persistent HA visual changes persistent visual changes Fetus growth restriction 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: Moderate Recommendation: Qualified

Preeclampsia: Anti-hypertensive therapy SBP < 160 and DBP < 110 - BP medication NOT be given Quality of Evidence: Moderate Recommendation: Qualified

Preeclampsia: Anti-hypertensive therapy SBP > 160 or DBP > 110 - BP medication is recommended Quality of Evidence: Moderate Recommendation: 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: Moderate Recommendation: Qualified

Preeclampsia: Fetal Assessment Preeclampsia with fetal growth restriction: - antenatal testing - umbilical artery Doppler Quality of evidence: Moderate Recommendation: Strong

Preeclampsia: Delivery Preeclampsia without severe features and < 37w0d - deliver > 37w0d - deliver sooner if other indications arise Quality of evidence: Low Recommendation: Qualified New PQCNC project (Feb 2014) CMOP: Conservative Management of Preeclampsia

Preeclampsia: Delivery Preeclampsia without severe features Diagnosis at > 37w0d - deliver Quality of evidence: Moderate Recommendation: Qualified

Preeclampsia: Delivery Preeclampsia with severe features Prior to fetal viability (23-24 weeks) - deliver (not candidates for expectant management) Quality of evidence: Moderate Recommendation: 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: Moderate Recommendation: 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: Moderate Recommendation: Qualified

Preeclampsia: Delivery Preeclampsia with severe features > 34w0d - deliver Quality of evidence: Moderate Recommendation: Strong

Preeclampsia: Delivery Preeclampsia with severe features < 34w0d and stable maternal/fetal status - expectant management at tertiary center Quality of evidence: Moderate Recommendation: 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: Low Recommendation: 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: High Recommendation: 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: Moderate Recommendation: Strong

CHTN with Superimposed Preeclampsia: Delivery Without severe features - stable maternal and fetal status - delivery > 37w0d Quality of evidence: Low Recommendation: Qualified

CHTN with Superimposed Preeclampsia: Delivery With severe features < 34w0d and stable maternal/fetal status - expectant management at tertiary center Quality of evidence: Moderate Recommendation: Strong

CHTN with Superimposed Preeclampsia: Delivery Preeclampsia with severe features > 34w0d - deliver Quality of evidence: Moderate Recommendation: 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: Moderate Recommendation: 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: Low Recommendation: 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: Moderate Recommendation: 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: Low Recommendation: 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: Moderate Recommendation: 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: Low Recommendation: Qualified

Summary preeclampsia vs. gestational HTN: presence of proteinuria 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: > 38w0d GHTN: > 37w0d Preeclampsia, w/o severe > 37w0d Preeclampsia, w/ severe 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 obstetrician-gynecologists. 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.