Transcript Hypertension in Pregnancy: Clinical Update

Hypertension in
Pregnancy:
Clinical Update
Meredith Birsner MD
Robert Atlas MD
On behalf of Maryland Maternal Mortality Review
Committee
No disclosures
Abbreviations
O ACEi: ACE (angiotensin
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O gHTN: gestational
converting enzyme) inhibitor
ARB: angiotension receptor O
blocker
BMI: body mass index
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BP: blood pressure
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BPP: biophysical profile
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cHTN: chronic hypertension O
DBP: diastolic blood pressure O
FGR: fetal growth restriction O
GA: gestational age
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hypertension
HELLP: hemolysis, elevated
liver enzymes, low platelets
HTN: hypertension
NST: non-stress test
PEC: preeclampsia
PTD: preterm delivery
ROM: rupture of membranes
SBP: systolic blood pressure
UA: umbilical artery
(Dopplers)
Background: local
O Action item from 2012 review
O Preeclampsia: leading cause of pregnancy-
associated deaths 2007-2012
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12 deaths
Mean age: 31.6
Race: AA (5), Caucasian (4), Hisp (2), Asian (1)
5 primigravidas
3 with late or no prenatal care
Mean PPD: 4.6
Mechanism of death: ICH (6), Hemorrhage/DIC (2),
cardiomyopathy/PE (2), hypertensive cardiovascular
disease (1), liver capsule rupture/DIC (1)
2007-2012 PEC deaths
O Committee focus:
O Delay in recognition/diagnosis
O Variation in treatment
O Lack of recognition postpartum
Background: national
O ACOG Task Force on
Hypertension in
Pregnancy
O Obstet Gynecol. 2013
Nov;122(5):1122-31
Evidence evaluation: GRADE
O Grading of Recommendations Assessment,
Development and Evaluation Working group
O Approach: function of expert task forces and
working groups is to evaluate available evidence
regarding a clinical decision that, because of
limited time and resources, would be difficult for
the average health care provider to accomplish;
then, makes recommendations consistent with
typical pt values and preferences
O Evidence quality: very low, low, moderate, high
Strength of recommendations
O Strong: so well supported that it would be
the approach for virtually all patients
O Could be the basis for health care policy
O Qualified: appropriate for most patients but
might not be optimal for some patients
O Provider and patient are encouraged to work
together to arrive at a decision based on
values and judgment and underlying health
condition of a particular patient in a
particular situation
Summary of strength and
quality of recommendations
• There are no recommendations supported by very
low evidence in this document
• All high quality evidence in this document is given
strong recommendation (6)
• All low quality recommendations are qualified (23)
• Comprises the majority of recommendations (23)
Strong recommendations based
on high-quality evidence (6)
1. Administration of vitamin C or E to prevent
PEC is not recommended
2. For women with eclampsia, magnesium is
recommended
3. For women with PEC with severe features,
magnesium is recommended to prevent
eclampsia intra- and postpartum
Strong recommendations based
on high-quality evidence (6)
For women with PEC with severe features
receiving expectant management at ≤34
weeks, administration of corticosteroids
for lung maturity is recommended
5. For women with superimposed PEC
receiving expectant management at ≤34
weeks, administration of corticosteroids
for lung maturity is recommended
6. For women with previable HELLP, deliver
shortly after initial maternal stabilization
4.
Document highlights by
chapter
Document breakdown
O Chapter 1: Classification of hypertensive disorders
O Chapter 2: Establishing the diagnosis of preeclampsia and
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eclampsia
Chapter 3: Prediction of preeclampsia (1)
Chapter 4: Prevention of preeclampsia (4)
Chapter 5: Management of preeclampsia and HELLP syndrome (30)
Chapter 6: Management of women with prior preeclampsia (1)
Chapter 7: Chronic hypertension in pregnancy and superimposed
preeclampsia (22)
Chapter 8: Later-life cardiovascular disease in women with prior
preeclampsia (1)
Chapter 9: Patient education (1)
Chapter 10: State of the science and research recommendations
Chapter 1: Classification of
hypertensive disorders
Definition of preeclampsia
O Eliminated dependence on proteinuria for
diagnosis of PEC
O PEC defined as HTN plus
O Thrombocytopenia (platelets <100K)
O Impaired liver function (2x normal)
O New onset renal insufficiency (Cr >1.1 or doubled
in the absence of other renal disease)
O Pulmonary edema
O New-onset cerebral or visual disturbances
O Why is this important?
O Can diagnose PEC without proteinuria!
Classification of hypertensive
disorders of pregnancy
O Preeclampsia-Eclampsia
O Gestational hypertension
O BP elevation after 20 weeks gestation in the
absence of proteinuria or systemic findings
O Chronic hypertension
O Hypertension that predates pregnancy
O Chronic hypertension with superimposed
preeclampsia
Diagnosis of proteinuria
O Urine protein/creatinine ratio of ≥ 0.3
diagnostic of proteinuria
O Important because can speed diagnosis &
eliminate 24h study
O 24h study still has some clinical utility in
equivocal situations
O Dipsticks discouraged unless other methods
not available
O Remain useful for office-based screening
Chapter 2: Establishing the
diagnosis of preeclampsia and
eclampsia
Technique of BP measurement
O Comfortably seated, legs uncrossed, back & arm
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supported
Middle of cuff on upper arm is at level of R atrium
(midpoint of sternum)
Instruct pt to relax and not talk during measurement
5 mins should elapse before 1st reading is taken
If need to retake, allow “several minutes” to elapse
L lateral positioning discouraged b/c will falsely lower
BP readings (cuff will be above heart)
Diagnosis
O Eliminates “mild PEC” and“severe PEC”
O Renames the former as “PEC” and the latter
as “PEC with severe features”
O 5g protein/24h and fetal growth restriction
no longer diagnostic of “severe”
O Why? Minimal relationship between quantity
of proteinuria and pregnancy outcome
O Also because FGR is managed similarly in
pregnant women with and without
preeclampsia
Chapter 3: Prediction of
Preeclampsia
Risk factors
Screening to predict PEC beyond history to
evaluate for risk factors is not recommended.
Chapter 4: Prevention of
preeclampsia
Aspirin
O Late first trimester initiation of daily low-
dose (60-80mg) aspirin for women with hx
early-onset PEC and PTD <34 weeks or PEC
in >1 pregnancy
O Appears to be safe with no major adverse
effects
O No guidance on specific GA to start other
than late first trimester
Chapter 5: Management of
preeclampsia and HELLP
syndrome
Maternal surveillance for gHTN
or PEC without severe features
O Daily kick counts
O Twice weekly blood pressure
O Labs at least once weekly
O Monitor gHTN weekly for proteinuria until
diagnosed
O Review warning symptoms at dx and every
visit
Fetal surveillance in gHTN or
PEC without severe features
O Growth ultrasounds q3 weeks
O AFI at least once weekly
O NST once weekly for gHTN (twice weekly for
PEC without severe features)
O Frequency not defined in the executive
summary but reads: “for PEC without severe
features, use of ultrasonography to assess
fetal growth and antenatal testing to assess
fetal status is suggested”
Delivery indications for gHTN
or PEC without severe features
O 37 weeks or more
O Suspected abruption
O 34 weeks plus
O Progressive labor or ROM
O Estimated fetal weight <5%ile
O Oligohydramnios (persistent AFI <5cm)
O Persistent BPP 6/10 or less
Other points of management
for PEC and HELLP
O Blood pressure: don’t treat gHTN for SBP
<160 or DBP <110
O Strict bedrest should not be prescribed for
gHTN or PEC without severe features
O Big push nationally against bedrest
Other points of management
for PEC and HELLP
O Use growth ultrasounds for PEC: if FGR
found, UA Dopplers are recommended
O Deliver gHTN and PEC without severe
features after 37w
Other points of management
for PEC and HELLP
O Magnesium not recommended universally
for PEC with SBP <160, DBP <110, and no
maternal symptoms
O But treat preeclampsia with severe features
O Treat severe HTN (SBP >160, DBP >110)
Other points of management
for PEC and HELLP
O For PEC, delivery decisions should not be
based on amount of or change in proteinuria
O No worse outcomes
O Do not hold magnesium intraoperatively
O Long half life (5h)
O Expectant management: daily NST and kick
counts, BPP 2x/week, serial growth q2
weeks
Management of preeclampsia
with severe features <34 weeks
O Observe in Labor and Delivery for first 24-48
hours
O Corticosteroids, magnesium sulfate
prophylaxis, and antihypertensive
medications
O Ultrasonography, monitoring of fetal heart
rate, symptoms, and laboratory tests
Maternal contraindications to
expectant management
, DIC, or partial
HELLP
Fetal contraindications to
expectant management
What constitutes appropriate
expectant management?
O Facilities with adequate maternal and
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neonatal intensive care resources
Fetal viability-33 weeks 6 days gestation
Inpatient only and stop magnesium sulfate
Daily maternal-fetal tests
Vital signs, symptoms, and blood tests
Oral anti-hypertensive drugs
Postpartum surveillance
O For gHTN, PEC, or superimposed PEC,
monitor blood pressure in hospital (or
equivalent outpatient surveillance) for at
least 72h postpartum and again 7-10d
postpartum (earlier if symptoms)
Discharge instructions
O All postpartum women should receive
discharge instructions which include
information about PEC signs and symptoms
and importance of prompt reporting to
provider
Postpartum hypertension
O Give magnesium for postpartum women
with new-onset HTN with headaches, blurred
vision, or PEC with severe HTN
O Stricter criteria for treating persistent
postpartum HTN
O SBP ≥ 150, DBP ≥ 100, 2 occasions at least
4-6h apart
O Treat persistent SBP ≥ 160 or DBP ≥ 110
within 1h
Chapter 6: management of
women with prior
preeclampsia
Prior preeclampsia
O Preconception counseling and assessment
suggested for women with PEC in prior
preeclampsia
Evaluation and management
of women at risk of
preeclampsia recurrence:
preconception and by
trimester
Preconception
O Identify risk factors (type 2 diabetes
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mellitus, obesity, HTN, family history)
Review outcome of previous pregnancy
(abruption, fetal death, fetal growth
restriction, gestational age at delivery)
Perform baseline metabolic profile and
urinalysis
Optimize maternal health
Supplement with folic acid
First trimester
O Perform the following:
O Ultrasonography for gestational age and fetal
number
O Baseline metabolic profile and complete blood count
O Baseline urinalysis
O Continue folic acid supplementation
O Offer first-trimester combined screening
O Offer low-dose aspirin initiation
O For women with prior preeclampsia that led to
delivery <34 weeks gestation or occurring in ≥ 1
pregnancy
O In late first trimester
Second trimester
O Counsel patients about signs and symptoms of
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preeclampsia beginning at 20 weeks of
gestation; reinforce this with printed handouts
Monitor for signs and symptoms of preeclampsia
Monitor BP at prenatal visits, with nursing
contacts, or home
Perform ultrasonography at 18-22 weeks for
fetal anomaly evaluation
Hospitalize for severe gestational hypertension,
severe fetal growth restriction, or recurrent
preeclampsia
Third trimester
O Monitor for signs and symptoms of preeclampsia
O Monitor BP at prenatal visits, with nursing
contacts, or home
O Perform the following as indicated by clinical
situation:
O Laboratory testing
O Serial ultrasonography for fetal growth and
amniotic fluid assessment
O Umbilical artery Doppler with nonstress test, BPP,
or both
O Hospitalize for severe gestational hypertension
or recurrent preeclampsia
Chapter 7: Chronic
hypertension in pregnancy
and superimposed
preeclampsia
Home/ambulatory monitoring
O Home BP monitoring for women with cHTN
and poorly controlled BP
O Ambulatory BP monitoring for women with
suspected white coat HTN to confirm
diagnosis before initiating anti-hypertensive
therapy
BP treatment
O Treat pregnant women with persistent cHTN
with SBP ≥ 160 or DBP ≥105
O Don’t treat for less if no end-organ damage
O Goal 120-160/80-105
Antihypertensive agents
Choice of medications
• Theoretical concern of combined use of nifedipine
and IV magnesium sulfate resulting in hypotension
and neuromuscular blockade (both are calcium
antagonists)
One review concluded that combined use does not
increase such risks
• Plausible so careful monitoring of women receiving
both is advisable
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• Choice/route should be primarily based on physician
familiarity and experience, adverse effects and
contraindications, local availability, and cost.
• Labetalol, nifedipine, or methyldopa recommended
above all other anti-hypertensive drugs
Contraindicated medications
O For (nonpregnant) women of reproductive
age with cHTN, use of ACEi, ARBs, renin
inhibitors, and mineralocorticoid receptor
antagonists NOT recommended unless
compelling reason (ex. proteinuric renal
disease)
Aspirin
O Late first trimester initiation of daily low-
dose (60-80mg) aspirin for women with
cHTN at greatly increased risk of adverse
outcomes (hx early onset PEC and PTD at
<34 weeks or PEC in >1 pregnancy)
Delivery considerations for
cHTN
O Do not deliver cHTN with no additional maternal
or fetal complications <38w
O Isolated, uncomplicated chronic hypertension
without superimposed preeclampsia
O Give magnesium (intra- and postpartum) for
cHTN with superimposed PEC with severe
features
O For superimposed PEC without severe features,
and stable maternal and fetal conditions,
expectant management until 37 weeks
Diagnosis of superimposed
preeclampsia LIKELY
O Sudden increase in BP that was previously
well-controlled, or escalation of
antihypertensive medications to control BP
O New onset of proteinuria or a sudden
increase in proteinuria in a woman with
known proteinuria before or early in
pregnancy
Diagnosis of superimposed
preeclampsia ESTABLISHED
O Severe-range BP despite escalation of
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antihypertensive therapy
Thrombocytopenia (platelets <100K)
Elevated liver transaminases (two times the
upper limit of normal concentration for a
particular laboratory)
New-onset and worsening renal insufficiency
Pulmonary edema
Persistent cerebral or visual disturbances
Chapter 8: Later-life
cardiovascular disease in
women with prior
preeclampsia
Later-life considerations
O For women with history of PEC who delivered
<37 weeks or recurrent PEC: yearly
assessment of blood pressure, lipids, fasting
blood glucose, BMI
Chapter 9: Patient
education
Thank you!
Please contact us with any questions:
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http://phpa.dhmh.maryland.gov/mch/SitePages/mmr.aspx