The ACOG Task force on hypertension in pregnancy

Report
Important Teaching Points for Medical Students from:
THE ACOG TASK FORCE ON
HYPERTENSION IN PREGNANCY
Background on Preeclampsia
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
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
What causes preeclampsia?
 Multifactorial
 We are not 100% certain of the pathogenesis
Gabbe: Obstetrics: Normal and Problem Pregnancies, 6th ed, Elsevier 2012.
Classification of Hypertension
in Pregnancy
Classification of
hypertension in pregnancy
1. Preeclampsia-eclampsia
1.
Hypertension in association with thrombocytopenia,
impaired liver function, the new development of renal
insufficiency, pulmonary edema, or new-onset cerebral or
visual disturbances
2. Gestational hypertension
1.
Blood pressure elevation after 20 weeks of gestation in
the absence of proteinuria or the aforementioned
systemic findings
3. Chronic hypertension
1.
Hypertension that predates pregnancy
4. Superimposed preeclampsia
1.
Chronic hypertension in association with preeclampsia
Diagnosis of Preeclampsia
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
Diagnosis of preeclampsia
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
Diagnosis of preeclampsia
with severe features
Diagnosis of preeclampsia
with severe features
 HELLP syndrome is a form of “preeclampsia
with severe features” (previously known as
severe preeclampsia)
Prediction and prevention
Prediction of preeclampsia
 Screening beyond obtaining an appropriate
medical history to evaluate for risk factors is
NOT recommended
Risk factors for
preeclampsia
Gabbe: Obstetrics: Normal and Problem Pregnancies, 6th ed, Elsevier 2012
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
Management: Gestational
Hypertension
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
Management: Preeclampsia
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
Management of Preeclampsia with
Severe Features
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
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
Management of preeclampsia
with severe features
 Before 24 0/7 weeks (ie before viability),
deliver them immediately
 The baby will likely not survive
Management of preeclampsia
with severe features
 Delivery is recommended at 34 0/7 weeks
 Always give magnesium sulfate for seizure
prophylaxis
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
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
No
BTMZ
Only if delivery
<34wks for
another
indication
Only if delivery
<34wks for
another
indication
Yes
Only if delivery
<34wks for
another
indication
Inpatient
monitoring at
tertiary hospital
No
No
Yes
No
PO antihypertensives
Only if >160/110
persistently
No
Only if >160/110
persistently
Only if >160/110
persistently
Management: simplified
High blood
pressure in
pregnancy
Onset <20wks
gestation
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
Gestational
hypertension
Preeclampsia
Deliver when pt is
in labor
Deliver at 37
0/7wks
Stable patient
Unstable patient
Inpatient
monitoring.
Delivery at 34
0/7wks.
Delivery ASAP
after BTMZ
Preeclampsia with
severe features
Stable patient
Unstable patient
Inpatient
monitoring.
Delivery at 34
0/7wks
Delivery ASAP
after BTMZ
Delivery recommendations
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
Postpartum
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
Later in life
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
Source
 Roberts, JR et al. “Executive Summary.”
Hypertension in Pregnancy. The ACOG Task
Force on Hypertension in Pregnancy.
American Congress of Obstetricians and
Gynecologists, 2013. Pages 1-11.

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