1. Hypertension in Pregnancy
2013 Update to ACOG Guidelines

2. Major Changes Simplified – four categories
Pre-eclampsia/eclampsia
Chronic hypertension (any cause)
Chronic hypertension with superimposed pre-eclampsia
Gestational hypertension
Proteinuria no longer required for diagnosis
Early delivery preferred – 37 0/7 wks
Emphasis on postpartum pre-eclampsia

3. Pre-eclampsia Diagnosis
BP criteria unchanged:
Mild hypertension: /90-109
Severe hypertension: >160/>110
At least 2 determinations 4 hours apart
Pre-eclampsia = hypertension plus EITHER
Proteinuria: 24 hr >300mg OR pro/creat ratio >0.3 (>1+ dipstick nonpreferred)
Thrombocytopenia: PLT <100K
Impaired liver function: LFTs >2x nl
New renal insufficiency: creatinine >1.1 OR doubled w/o other cause
Pulmonary edema
New-onset visual/cerebral disturbance

4. Severe Pre-eclampsia Diagnosis
Pre-eclampsia plus
Blood pressure >160 or >110 or
Thrombocytopenia or
Severe persistent RUQ pain
Progressive renal insufficiency
Pulmonary edema
New-onset cerebral/visual disturbances
NEW: Proteinuria does not predict severity
NEW: IUGR does not predict severity

5. Management NEW: Timing of delivery: NEW: BP treatment
Without severe features: 37 0/7 weeks
Quality of evidence: moderate
Strength of recommendation: qualified
With severe features: depends on stability
“only at facilities with adequate maternal and NICU resources”
34 0/7 weeks has strong recommendations for delivery decisions
NEW: BP treatment
Chronic HTN/pre-eclampsia: might not treat below 160/105 (low/qualified)
Goal BP: / (low/qualified)
Meds: labetalol, nifedipine or methyldopa (moderate/strong)

6. Management Postpartum:
Gestational HTN, pre-eclampsia, chronic HTN with superimposed pre-eclampsia:
Monitor BP in hospital or outpatient equivalent (moderate/qualified)
1st 72 hours
Again 7-10 days postpartum
If patient presents with new onset HTN plus headache or blurred vision, or with pre-eclampsia with severe HTN, admit, give Mg sulfate (low/qualified)
Avoid NSAIDs for pain if HTN persists >24 hours