The ACOG Task force on hypertension in pregnancy
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Transcript of The ACOG Task force on hypertension in pregnancy
THE ACOG TASK FORCE ON HYPERTENSION IN PREGNANCY
Important Teaching Points for Medical Students from:
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 pregnancy1. 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 hypertension1. Blood pressure elevation after 20 weeks of gestation in
the absence of proteinuria or the aforementioned systemic findings
3. Chronic hypertension1. Hypertension that predates pregnancy
4. Superimposed preeclampsia1. 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 summaryGestational 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 anti-hypertensives
Only if >160/110 persistently
No Only if >160/110 persistently
Only if >160/110 persistently
Management: simplifiedHigh 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
Stable patient
Inpatient monitoring.
Delivery at 34 0/7wks
Unstable patient
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.