Welcome to the Pregnancy Medical Home “First Tuesdays” Webinar: Management … ·...
Transcript of Welcome to the Pregnancy Medical Home “First Tuesdays” Webinar: Management … ·...
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Welcome to the Pregnancy
Medical Home “First Tuesdays”
Webinar: Management of
Hypertensive Disorders of
Pregnancy
Webinar will begin at 7:30am
Connect to audio by computer
Submit any questions through chat
Funding for this project is provided in part by The Duke Endowment
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PMH Care Pathways
CCNC network OB champions collaborate to create evidence-based
clinical guidance for maternity care providers, in order to promote best
practices and improve quality and outcomes.
Currently available PMH Care Pathways:
▪ Hypertensive Disorders of Pregnancy
▪ Induction of Labor in Nulliparous Patients
▪ Perinatal Tobacco Use
▪ Postpartum Care and the Transition to Well Woman Care
▪ Progesterone Treatment and Cervical Length Screening
▪ Substance Use in Pregnancy
https://www.communitycarenc.org/population-management/pregnancy-
home/pmh-pathways/
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Management of Hypertensive
Disorders of PregnancyLydia Wright, MDMedical Director, Wilmington Maternal Fetal Medicine
Medical Director of Obstetrics, New Hanover Regional Medical
Center
Funding for this project is provided in part by The Duke Endowment
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Learning Objectives
By the end of this session, participants will be able to:
1- List the 2 main goals of the ACOG Task Force
recommendations.
2- List the 3 categories of Hypertensive Disorders of
Pregnancy and give their definitions.
3- List general recommendations for timing of delivery for
each category of Hypertension in Pregnancy.
4- Know the critical BP that defines severe hypertension.
5- Be able to advise patients on the current
recommendations for future pregnancy.
4Funding for this project is provided in part by The Duke Endowment
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Background
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▪ Hypertensive disorders are the leading cause of
iatrogenic preterm birth
▪ Pregnancy Medical Home Care Pathway
incorporates ACOG Task Force 2012 guidance
▪ Two goals:
▪ Manage patients with gestational hypertension or
preeclampsia without severe features to 37 weeks in
absence of other complications
▪ Expectant management for patients with severe features
to 34 weeks with care in appropriate setting
Funding for this project is provided in part by The Duke Endowment
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Hypertensive Disorders of
Pregnancy
▪ Gestational hypertension*: Systolic BP ≥140 mmHg or
diastolic BP ≥ 90 mmHg taken on 2 occasions > 4 hours apart, in the
absence of proteinuria or severe features occurring after 20 weeks
gestation in a woman with previously normal blood pressure
▪ Preeclampsia (with or without severe features)*:Systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg taken on 2
occasions > 4 hours apart with new onset proteinuria or with severe
features (BP criteria SBP ≥ 160 or DBP ≥ 100 taken on 2 occasions > 4
hours apart.
▪ Chronic hypertension with superimposed
preeclampsia*: The onset of proteinuria in a woman with
preexisting hypertension, sudden increase in proteinuria if already
present in early gestation, sudden increase in hypertension or
development of severe features.
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Definitions
Proteinuria: >300mg of protein in a 24-hour timed urine
collection or protein/creatinine ratio ≥ 0.3mg/dL or dipstick
reading of 1+ if quantitative methods not available
Severe features:
▪ Severe hypertension: systolic BP ≥ 160mmHg or diastolic BP ≥ 110
mmHg taken on 2 occasions
▪ Thrombocytopenia: platelet count <100,000/mm3
▪ Impaired liver function: abnormally elevated liver enzymes (to twice
normal concentration).
▪ New onset renal insufficiency: serum creatinine > 1.1 mg/dL or doubling
of the serum creatinine from baseline
▪ Pulmonary edema
▪ New onset visual or cerebral disturbances
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Accurate BP
8Funding for this project is provided in part by The Duke Endowment
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Hypertensive Disorders of
Pregnancy
▪ Gestational hypertension*: Systolic BP ≥140 mmHg or
diastolic BP ≥ 90 mmHg taken on 2 occasions > 4 hours apart, in the
absence of proteinuria or severe features occurring after 20 weeks
gestation in a woman with previously normal blood pressure
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Management of Gestational
Hypertension
▪ Close monitoring for the development of
preeclampsia, particularly proteinuria
▪ Weekly NST or BPP
▪ Only use oral anti-hypertensive medications in those
with severe hypertension*
▪ Indication for delivery: Gestational age greater than
or equal to 37 0/7 weeks gestation
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Goals of ACOG Task Force
▪ Manage patients with gestational hypertension or
preeclampsia without severe features to 37 weeks in
absence of other complications
▪ Expectant management for patients with severe
features to 34 weeks with care in appropriate setting
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Hypertensive Disorders of
Pregnancy
▪ Preeclampsia without severe features: Systolic BP
≥ 140 mmHg or diastolic BP ≥ 90 mmHg taken on 2 occasions > 4
hours apart with new onset proteinuria.
▪Chronic hypertension with superimposed
preeclampsia*: The onset of proteinuria in a woman with
preexisting hypertension, sudden increase in proteinuria if already
present in early gestation, sudden increase in hypertension.
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Management of Preeclampsia
WITHOUT Severe Features
▪ Outpatient management with close follow-up or inpatient in a facility
with obstetrical services available
▪ Evaluation at least 2x/week for evidence of severe features by
measurement of blood pressure and review of symptoms
▪ Fetal testing: daily fetal kick counts and BPP or NST at least 2x/week
▪ Assessment of amniotic fluid volume weekly
▪ Ultrasound at 2-3 week intervals to evaluate fetal growth
▪ Laboratory testing at diagnosis and repeated with changes in clinical
characteristics or at least weekly
▪ *Timed urine collection not warranted once preeclampsia is
diagnosed
▪ *Use of oral antihypertensives only in those with severe hypertension
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Management of Preeclampsia
WITHOUT Severe Features
▪ Indications for delivery:
▪ Gestational age ≥ 37 weeks
▪ Nonreassuring fetal testing
▪ Consider consultation for any patient <37 0/7 weeks of gestation
with additional clinical complications, such as PPROM, fetal
growth restriction, suspected abruption
▪ Mode of delivery: vaginal preferred, cesarean only for
usual obstetric indications
▪ Seizure prophylaxis:
▪ Data unclear about use of magnesium sulfate for preeclampsia
without severe features (evidence solid for severe features)
▪ If used, continue 12-24 hours postpartum or until urine output is
at least 150ml/hour for 3 hours14
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Severe Hypertension
SBP 160 or higher
DBP 110 or higher
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Goals of ACOG Task Force
▪ Expectant management for patients with severe
features to 34 weeks with care in appropriate setting
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Management of Preeclampsia
WITH Severe Features
▪ Initial assessment (maternal) - inpatient
▪ Assess urine output, initiate 24 hour collection of urine for protein
▪ Laboratory evaluation: CBC with platelets, LFTs, creatinine
▪ Antihypertensive therapy indicated for sustained systolic BP ≥ 160mm
Hg or diastolic BP ≥ 110 mm Hg
▪ Magnesium sulfate for seizure prophylaxis
▪ Initial assessment (fetal)
▪ Continuous fetal monitoring as appropriate for gestational ages 24 0/7 –
33 6/7 weeks
▪ Ultrasound for estimated fetal weight and presentation
▪ Antenatal corticosteroids initiated prior to 34 0/7 weeks gestation
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Management of Preeclampsia
WITH Severe Features
▪ Gestational age ≥34 weeks: delivery at hospital with appropriate
levels of maternal and neonatal support
▪ Gestational age < 34 weeks: admit for evaluation
▪ Consider transfer to a center with appropriate level of maternal and
neonatal support, including Maternal-Fetal Medicine consultation
▪ Patient should be counseled about options: expectant management
vs. delivery
▪ Expectant management benefits the fetus by increasing gestational age
at delivery, and carries some risk to the mother
▪ Maternal risks (incidence): HELLP syndrome (20%), eclampsia (2%),
pulmonary edema (5%), acute renal failure (2%)
▪ Fetal risks (incidence): worsening fetal condition (40%), placental
abruption (rare), fetal death (rare)
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Management of Preeclampsia
WITH Severe Features
▪ Severe hypertension, controlled with antihypertensive
medication, is not an indication for delivery prior to 34
0/7 weeks
▪ If severe hypertension cannot be controlled with
antihypertensive medication, then delivery is indicated
▪ The amount of proteinuria by itself is not an indication
for delivery in women with early onset of
preeclampsia with severe features
▪ Fetal death is an absolute contraindication to
expectant management for severe disease in
singleton pregnancies
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Treat Severe Hypertension
SBP 160 or higher
DBP 110 or higher
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Treatment of Severe HTN
Number 623, February 2015
(Replaces Committee Opinion Number 514, December 2011)
Committee on Obstetric Practice
This document reflects emerging clinical and scientific advances as of the date issued and is
subject to change. The information should not be construed as dictating an exclusive course of
treatment or procedure to be followed.
Emergent Therapy for Acute-Onset, Severe
Hypertension During Pregnancy and the Postpartum
Period
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Treatment of severe range
BP’s
▪ IV labetalol
▪ IV hydralazine
▪ If IV access is not established, po nifedipine
Keep order sets simple and accessible!
Stress with the team rapid assessment and treatment!
Goal: SBP 140-159 *not normal range!
DBP 90-100
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Low Dose Aspirin
▪ Low-dose aspirin (81mg) for women at moderate or
high risk for preeclampsia.
▪ Initiate by 16 weeks of gestation, continue through 36 weeks.
▪ US Preventive Services Task Force: “high risk” (early onset,
prior adverse outcome, multifetal gestation, cHTN, T1DM,
T2DM, renal disease, autoimmune disease) vs moderate risk
factors: (nulliparity, BMI >30, family hx of preeclampsia,
“sociodemographic characteristics”, age 35 or older, personal
hx factors)
▪ USPSTF recommends treat women at high risk and consider
in women with “several” moderate risk factors.
▪ PMH pathway recommendation: treat if 2+ risk factors
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Low Dose Aspirin
▪ Decreases the risk for development of preeclampsia
in moderate and high risk women (intent to treat ~ 59-
167 to prevent 1 case)
▪ Decreases the risk for preterm birth (intent to treat ~
44-200 to prevent 1 case)
▪ Decreases the risk for perinatal death (intent to treat
~ 125- >10,000 to prevent 1 case)
▪ Stop aspirin 5-10 days prior to expected delivery
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Long term maternal
outcomes
Preeclampsia is a screening test for future health:
▪ Recurrent preeclampsia
▪ CHTN (4-fold)
▪ Ischemic heart disease (2-fold)
▪ CVA (2-fold)
▪ VTE (2-fold)
▪ All cause mortality (1.5-fold)
Barton, Sibai 2008
Craici 2008
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Learning Objectives
Participants can:
1- List the 2 main goals of the ACOG Task Force
recommendations.
2- List the 3 categories of Hypertensive Disorders of
Pregnancy and give their definitions.
3- List general recommendations for timing of delivery for
each category of Hypertension in Pregnancy.
4- Know the critical BP that defines severe hypertension.
5- Be able to advise patients on the current
recommendations for future pregnancy.
26Funding for this project is provided in part by The Duke Endowment
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References
1. Sibai BM. Evaluation and management of severe preeclampsia before 34
weeks’ gestation. SMFM Clinical Opinion. AJOG 2011; 205(3): 191-8.
2. Magee LA, et al. Expectant management of severe preeclampsia remote
from term: a structured systemic review. Hypertens Pregnancy 2009; 28(3):
312-47.
3. Sibai BM. Management of late preterm and early-term pregnancies
complicated by mild gestational hypertension/pre-eclampsia. Semin
Perinatol. 2011 Oct;35(5):292-6.
4. Task Force on Hypertension in Pregnancy. Hypertension in Pregnancy:
Report of the American College of Obstetricians and Gynecologists’ Task
Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122(5): 1122-
1131.
5. LeFevre, ML, on behalf of the U.S. Preventive Services Task Force. Low-
Dose Aspirin Use for the Prevention of Morbidity and Mortality From
Preeclampsia: U.S. Preventive Services Task Force Recommendation
Statement. Ann Intern Med. 2014;161:819-826. doi:10.7326/M14-1884
27Funding for this project is provided in part by The Duke Endowment
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Questions?
Lydia Wright, MD
Wilmington Maternal Fetal Medicine
Wilmington, NC
28Funding for this project is provided in part by The Duke Endowment