The ACOG Task force on hypertension in pregnancy

1. Important Teaching Points for Medical Students from: The ACOG Task force on hypertension in pregnancy

2. Background on Preeclampsia

3. 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

4. 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

5. What causes preeclampsia? • Multifactorial • We are not 100% certain of the pathogenesis Gabbe: Obstetrics: Normal and Problem Pregnancies, 6thed, Elsevier 2012.

6. Classification of Hypertension in Pregnancy

7. Classification of hypertension in pregnancy • Preeclampsia-eclampsia • Hypertension in association with thrombocytopenia, impaired liver function, the new development of renal insufficiency, pulmonary edema, or new-onset cerebral or visual disturbances • Gestational hypertension • Blood pressure elevation after 20 weeks of gestation in the absence of proteinuria or the aforementioned systemic findings • Chronic hypertension • Hypertension that predates pregnancy • Superimposed preeclampsia • Chronic hypertension in association with preeclampsia

8. Diagnosis of Preeclampsia

9. 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 collectionOR • 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

10. Diagnosis of preeclampsia

11. 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

12. Diagnosis of preeclampsia with severe features

13. Diagnosis of preeclampsia with severe features • HELLP syndrome is a form of “preeclampsia with severe features” (previously known as severe preeclampsia)

14. Prediction and prevention

15. Prediction of preeclampsia • Screening beyond obtaining an appropriate medical history to evaluate for risk factors is NOT recommended

16. Risk factors for preeclampsia Gabbe: Obstetrics: Normal and Problem Pregnancies, 6thed, Elsevier 2012

17. 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

18. Management: Gestational Hypertension

19. 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

20. Management: Preeclampsia

21. 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 sulfatefor seizure prevention • If they develop severe features, the management changes

22. Management of Preeclampsia with Severe Features

23. 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

24. 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

25. Management of preeclampsia with severe features • Before 24 0/7 weeks (ie before viability), deliver them immediately • The baby will likely not survive

26. Management of preeclampsia with severe features • Delivery is recommended at 34 0/7 weeks • Always give magnesium sulfate for seizure prophylaxis

27. 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

28. Management summary

29. Management: simplified

30. Delivery recommendations

31. 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

32. Postpartum

33. 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

34. Later in life

35. 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

36. 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.