1. The ACOG Task force on hypertension in pregnancy
Important Teaching Points for Medical Students from:
The ACOG Task force on hypertension in pregnancy

2. Background on Preeclampsia

3. Why is preeclampsia important?
It can lead to serious maternal and neonatal morbidity
Maternal: seizure, stroke, DIC, bleeding, liver hematoma
Neonatal: growth restriction, distress/hypoxia in labor, preterm birth
It increases a woman’s risk of hypertension and cardiovascular disease later in life

4. Important points about preeclampsia
We don’t know exactly why it happens
It occurs only in association with pregnancy
ALMOST ALWAYS from 20 wks gestation until delivery
RARELY you can see preeclampsia ≤6wks postpartum or before 20wks gestation
It is progressive (worsens as pregnancy progresses)
It is multisystemic

5. What causes preeclampsia?
Multifactorial
We are not 100% certain of the pathogenesis
Gabbe: Obstetrics: Normal and Problem Pregnancies, 6th ed, Elsevier 2012.

6. Classification of Hypertension in Pregnancy

7. Classification of hypertension in pregnancy
Preeclampsia-eclampsia
Hypertension in association with thrombocytopenia, impaired liver function, the new development of renal insufficiency, pulmonary edema, or new-onset cerebral or visual disturbances
Gestational hypertension
Blood pressure elevation after 20 weeks of gestation in the absence of proteinuria or the aforementioned systemic findings
Chronic hypertension
Hypertension that predates pregnancy
Superimposed preeclampsia
Chronic hypertension in association with preeclampsia

8. Diagnosis of Preeclampsia

9. Diagnosis of preeclampsia
Blood pressure criteria:
SBP ≥140 mm Hg or DBP ≥90 mm Hg
Persistent for 4 hours (repeat blood pressure after at least 4 hours)
Plus one or both of the following:
Proteinuria
≥300mg protein or more in 24 hour urine collection OR
Urine protein:creatinine ratio of ≥0.3 mg/dL OR
1+ protein on urine dipstick (not preferred method)
Systemic findings
Thrombocytopenia
Renal insufficiency
Impaired liver function
Pulmonary edema
Cerebral or visual findings

10. Diagnosis of preeclampsia

11. Diagnosis of preeclampsia
Notice that proteinuria is no longer a necessary part of the diagnosis
Waiting to diagnose proteinuria can delay necessary treatment
The amount of proteinuria does not predict maternal or fetal outcome

12. Diagnosis of preeclampsia with severe features

13. Diagnosis of preeclampsia with severe features
HELLP syndrome is a form of “preeclampsia with severe features” (previously known as severe preeclampsia)

14. Prediction and prevention

15. Prediction of preeclampsia
Screening beyond obtaining an appropriate medical history to evaluate for risk factors is NOT recommended

16. Risk factors for preeclampsia
Gabbe: Obstetrics: Normal and Problem Pregnancies, 6th ed, Elsevier 2012

17. Prevention of preeclampsia
For women with:
A medical history of early onset preeclampsia and preterm delivery at less than 34 0/7 weeks gestation, or
Preeclampsia in more than one prior pregnancy
Give them low dose aspirin (81mg) daily beginning in the late first trimester
Dietary modifications do not work
Bedrest does not work

18. Management: Gestational Hypertension

19. Management of gestational hypertension
Management is expectant
Daily fetal kick counts
Twice weekly blood pressure measurements
Check for proteinuria at every office visit (urine dipstick)
Oral anti-hypertensives are not needed, unless SBP >160 mmHb and DBP >110 mmHg persistently
If they develop preeclampsia, the management changes

20. Management: Preeclampsia

21. Management of preeclampsia
For preeclampsia WITHOUT severe features (formerly known as mild preeclampsia), manage patients expectantly until 37 0/7 weeks:
Daily fetal kick counts
Twice weekly blood pressure measurement
Weekly labs (platelets, AST, ALT)
Do not give antihypertensive medications as long as pressures remain SBP <160 mmHb and DBP <110 mmHg
Monitor fetal growth with monthly ultrasounds
If fetal growth restriction is found, perform umbilical artery Dopplers
Delivery is recommended at 37 0/7 weeks
When they are being delivered, they probably don’t need magnesium sulfate for seizure prevention
If they develop severe features, the management changes

22. Management of Preeclampsia with Severe Features

23. Management of preeclampsia with severe features
From 24 0/7 wks- 34 0/7 wks you can manage them expectantly:
At a tertiary hospital (transfer if necessary)
Give BTMZ for fetal lung maturity
Treat with antihypertensive medications for sustained SBP ≥160 or DBP ≥110
A change in the amount of proteinuria should not affect management or dictate delivery

24. Management of preeclampsia with severe features
From 24 0/7-34 0/7 weeks (continued): If a patient is sick but stable, you can administer BTMZ and wait ≥48 hours
However, if a patient is unstable or has any of the following, give BTMZ and deliver them immediately:
Severe HTN not controlled by IV medications
Eclampsia
Pulmonary edema
Placental abruption
DIC
Nonreassuring fetal status
Fetal demise

25. Management of preeclampsia with severe features
Before 24 0/7 weeks (ie before viability), deliver them immediately
The baby will likely not survive

26. Management of preeclampsia with severe features
Delivery is recommended at 34 0/7 weeks
Always give magnesium sulfate for seizure prophylaxis

27. Chronic hypertension (cHTN)
Chronic hypertension with superimposed preeclampsia is managed the same as preeclampsia
If severe features develop, it is managed the same as preeclampsia with severe features

28. Management summary Gestational hypertension Preeclampsia
Preeclampsia with severe features
Chronic hypertension
Delivery
At the onset of labor
37 0/7 wks
34 0/7wks
38 0/7wks
Magnesium sulfate No
Maybe
Yes
BTMZ
Only if delivery <34wks for another indication
Inpatient monitoring at tertiary hospital
PO anti-hypertensives
Only if >160/110 persistently

29. Management: simplified
High blood pressure in pregnancy
Onset <20wks gestation
Chronic hypertension
Delivery at 38 0/7 wks
Pt develops superimposed preeclampsia
Delivery at 37 0/7wks
Pt develops superimposed preeclampsia with severe features
Stable patient
Inpatient monitoring. Delivery at 34 0/7wks.
Unstable patient
Delivery ASAP after BTMZ
Onset >20wks gestation
Gestational hypertension
Deliver when pt is in labor
Preeclampsia
Deliver at 37 0/7wks
Preeclampsia with severe features
Inpatient monitoring. Delivery at 34 0/7wks

30. Delivery recommendations

31. Delivery recommendations
Induction of labor is acceptable as long as maternal and fetal conditions are stable
Epidural and spinal anesthesia are acceptable as long as maternal and fetal conditions are stable
Magnesium sulfate seizure prophylaxis is recommended for:
Eclampsia
Preeclampsia with severe features
It can be considered in non-severe preeclampsia

32. Postpartum

33. Postpartum recommendations
Women with eclampsia and preeclampsia with severe features should get magnesium sulfate seizure prophylaxis for 24 hours postpartum
Blood pressures should be monitored postpartum inpatient for at least 72 hours
If postpartum blood pressures are persistently ≥160/≥110, oral antihypertensives should be started
Any woman who presents within 6 weeks postpartum with new-onset hypertension with severe features, consider administering magnesium sulfate

34. Later in life

35. Later in life For women with a history of:
Preeclampsia who gave birth at less than 37 0/7 weeks
Recurrent preeclampsia
They should have a yearly assessment of:
Blood pressure
Lipids
Fasting blood glucose
BMI

36. Source
Roberts, JR et al. “Executive Summary.” Hypertension in Pregnancy. The ACOG Task Force on Hypertension in Pregnancy. American Congress of Obstetricians and Gynecologists, Pages 1-11.