Hypertension in Pregnancy Updates: ACOG Task Force 2013

Reference All Material taken from the ACOG task force report Hypertension n pregnancy. American college of obstetricians and gynecologists. Obstet gynecol 2013,122: The Executive summary is concise and worth reading

Change Much is the same The experts listed came together to give guidance and remark upon level of evidence

Classification Preeclampsia-eclampsia Chronic hypertension Chronic hypertension with superimposed preeclampsia Gestational hypertension

Diagnosis Much is the same for Preeclampsia BP criteria remain the same 140 systolic/90 diastolic 300mg/dl in 24 hour Protein Quant or Protein/Creatinine Ratio 0.3 Platelets <100,000/microliter Impaired liver function, twice normal blood level transaminases Ne renal insufficiency, 1.1/dL Creatinine Pulmonary Edema Cerebral/Visual disturbances

Diagnosis Gestational Hypertension Onset >20 weeks, no Proteinuria Chronic Hypertension Predates Pregnancy Superimposed Preeclampsia Chronic with new onset from previous lists

Severe Preeclampsia Systolic of ≥160, Diastolic ≥110 on 2 occasions at least 4 hours apart Cerebral or visual disturbances including Headache Platelets <100,000/microliter Impaired liver function, twice normal blood level transaminases New renal insufficiency, 1.1/dL Creatinine Pulmonary Edema

Preeclampsia There is NO LONGER a mild categorization, simply preeclampsia or not With or without severe features

Prevention Consider low dose aspirin – Evidence Moderate Things not helpful: Vitamin C/E Bed Rest Salt Restriction

Management Preeclampsia without Severe features BP twice weekly, liver enzyme assessment once weekly If BP ≤ 160/110 antihypertensive medication not needed Delivery at 37 weeks Magnesium Sulfate not universally recommended

Management Preeclampsia with Severe Features Deliver after 34 weeks If less than 34 weeks and stable maternal fetal condidtion give Corticosteriods Bp ≥ 160/110 give antihypertensives

Reasons to not Delay if <34 Weeks Uncontrolled hypertension Eclampsia Pulmonary Edema Abruptio Placenta DIC Non-reassuring Fetal Status IUFD HELLP – if rapidly worsening

Delivery Mode VAGINAL DELIVERY unless indicated by: Fetal gestational age Presentation Cervical status Maternal fetal condition

Post Partum Management Magnesium Sulfate is suggested to be used if ANY Severe feature exists BP should be evaluated 7-10 days after delivery BP Monitoring should be considered for 72 hours post delivery BP ≥ 150/100 on two occasions 4-6 hours apart should have antihypertensive medications administered BP ≥ 160/110 should be treated within one hour

Chronic Hypertension Moderate exercise recommended If Bp ≥160/105 antihypertensive medications are suggested Optimal BP range / Growth Ultrasounds, and Dopplers if growth restricted Unless other maternal/fetal complications exist delivery before 38 weeks NOT recommended If Superimposed Preeclampsia deliver after 37 weeks If Superimposed Preeclampsia with Severe features delivery after 34 weeks

Long term Patients who have preeclampsia before 37 weeks should have yearly assessments of: BP Lipids Fasting Blood glucose Evidence for screening is low only because it is not clear when to start