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Hypertension in Pregnancy

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.

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Hypertension in Pregnancy

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  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.

  3. Hypertension in PregnancyWhy worry? Common: ~ 10% of pregnancies Morbidity: fetus: 12% of preterm deliveries mother: stroke, CHF, renal injury Mortality: 12-13% of maternal mortality

  4. 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

  5. Hypertension in PregnancyACOG Task Force (Nov 2013) Classification Diagnosis Management Prevention Future Implications

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

  7. 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

  8. Classification 1. Chronic hypertension Gestational hypertension 3. Preeclampsia - without severe features - with severe features (severe preeclampsia) 4. Chronic hypertension with superimposed preeclampsia - without severe features - with severe features

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

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

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

  12. 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.”

  13. 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

  14. 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

  15. 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

  16. 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

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

  18. Anti-hypertensive Therapy MedicationDoseComments 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

  19. 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

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

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

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

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

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

  25. 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

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

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

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

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

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

  31. 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

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

  33. 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

  34. Old classificationNew 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

  35. 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

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

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

  38. 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

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

  40. 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

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

  42. 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

  43. 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

  44. 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

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

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

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