1. Hypertension in Pregnancy
Stuart Shelton, MD
CFV Medical Center
January 2014

2. 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.

4. Hypertension in Pregnancy Why worry?
Common: ~ 10% of pregnancies
Morbidity: fetus: 12% of preterm deliveries
mother: stroke, CHF, renal injury
Mortality: % of maternal mortality

5. 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

6. Hypertension in Pregnancy ACOG Task Force (Nov 2013)
Classification
Diagnosis
Management
Prevention
Future Implications

7. Hypertension in Pregnancy
ACOG publications recently removed:
- Chronic hypertension (Feb 2012)
- Diagnosis and management of preeclampsia (2002)
Updated publications pending

8. 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

9. 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

10. PIH Classification “PIH” should not be used
- ACOG recommended against use in 2000
- recommendation made 14 years ago

11. Classification Avoid use of term mild preeclampsia
replace with preeclampsia without severe features
Severe preeclampsia = preeclampsia with severe features

12. Diagnosis: Hypertension
Hypertension (either):
SBP > 140
DBP > 90
Severe hypertension (either):
SBP > 160
DBP > 110
BP > 4 hours apart

13. 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.”

14. 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

15. 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

17. 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

18. 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: /80-105

19. Chronic Hypertension: Anti-hypertensive Therapy
Recommended medications:
- labetalol
- nifedipine
- methyldopa
Quality of evidence: Moderate
Recommendation: Strong

20. Anti-hypertensive Therapy
Medication Dose Comments
Labetalol mg/d (2-3 doses) caution with
asthma, CHF
Nifedipine mg/d (XL) avoid SL form
Methyldopa mg/d (2-3 doses) may not be
effective with
severe HTN

21. 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

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

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

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

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

27. Gestational Hypertension: Definition
Hypertension (onset > 20 weeks) and all of following:
- absence of proteinuria
- absence of severe features

28. 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

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

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

31. Gestational Hypertension: Seizure Prophylaxis
- magnesium is NOT universally needed
Quality of evidence: Low
Recommendation: Qualified
If patients develops severe features  magnesium

32. Gestational Hypertension: Delivery
Gestational hypertension and < 37w0d
- expectant management until 37w0d
- deliver sooner if other indications arise
Quality of evidence: Low
Recommendation: Qualified

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

35. 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

36. Preeclampsia without Severe Features: Definition
Hypertension (onset > 20 weeks) and all of following:
- proteinuria
- absence of severe features

37. 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

38. 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, < 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

39. 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

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

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

42. 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

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

44. 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

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

46. 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

47. 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

48. 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

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

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

51. 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

52. Preeclampsia: Seizure Prophylaxis
Preeclampsia without severe features
- magnesium is NOT universally needed
Quality of evidence: Low
Recommendation: Qualified

53. 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

54. Preeclampsia: Seizure Prophylaxis
Preeclampsia with severe features or eclampsia
- magnesium sulfate
Quality of evidence: High
Recommendation: Strong
If Cesarean  continue magnesium intraoperatively

56. 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

57. 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

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

59. 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

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

61. 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

63. 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

64. 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

65. 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

67. 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

68. Prevention Consider for women with high-baseline risk (~20%)
- chronic hypertension
- previous preterm preeclampsia
- diabetes
Needed to treat to prevent 1 case preeclampsia: 50

69. Prevention Not recommended: - vitamin C - vitamin E - salt restriction
- bed rest
- physical activity restriction

71. Future Implications Preeclampsia in pregnancy
- increased risk cardiovascular disease
- overall: x increase risk
- < 34 week delivery: 8-9x increase risk

72. 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

74. Summary preeclampsia vs. gestational HTN: presence of proteinuria
no longer use term “mild” preeclampsia
- preeclampsia without severe features
PIH

75. 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

76. Summary CHTN with superimposed preeclampsia
Management similar to preeclampsia
depends on presence of severe features

77. 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

78. 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

80. 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 February 2012 (no longer in circulation)
Diagnosis and Management of Preeclampsia and Eclampsia. ACOG Practice Bulletin No January 2002 (no longer in circulation)
Lockwood, CJ. ACOG task force on hypertension in pregnancy (editorial). Contemporary Ob/Gyn. December 2013.