Hypertension in Pregnancy 2013 Update to ACOG Guidelines

Hypertension in Pregnancy 2013 Update to ACOG Guidelines

Major Changes • Simplified – four categories – Pre-eclampsia/eclampsia – Chronic hypertension (any cause) – Chronic hypertension with superimposed preeclampsia – Gestational hypertension • Proteinuria no longer required for diagnosis • Early delivery preferred – 37 0/7 wks • Emphasis on postpartum pre-eclampsia

Pre-eclampsia Diagnosis • BP criteria unchanged: – Mild hypertension: 140 -159/90 -109 – Severe hypertension: >160/>110 – At least 2 determinations 4 hours apart • Pre-eclampsia = hypertension plus EITHER – Proteinuria: 24 hr >300 mg OR pro/creat ratio >0. 3 (>1+ dipstick nonpreferred) – Thrombocytopenia: PLT <100 K – Impaired liver function: LFTs >2 x nl – New renal insufficiency: creatinine >1. 1 OR doubled w/o other cause – Pulmonary edema – New-onset visual/cerebral disturbance

Severe Pre-eclampsia Diagnosis • Pre-eclampsia plus – Blood pressure >160 or >110 or – Thrombocytopenia or – Severe persistent RUQ pain – Progressive renal insufficiency – Pulmonary edema – New-onset cerebral/visual disturbances • NEW: Proteinuria does not predict severity • NEW: IUGR does not predict severity

Management • NEW: Timing of delivery: – Without severe features: 37 0/7 weeks • Quality of evidence: moderate • Strength of recommendation: qualified – With severe features: depends on stability • “only at facilities with adequate maternal and NICU resources” • 34 0/7 weeks has strong recommendations for delivery decisions • NEW: BP treatment – Chronic HTN/pre-eclampsia: might not treat below 160/105 (low/qualified) – Goal BP: 120 -160/80 -105 (low/qualified) – Meds: labetalol, nifedipine or methyldopa (moderate/strong)

Management • Postpartum: – Gestational HTN, pre-eclampsia, chronic HTN with superimposed pre-eclampsia: • Monitor BP in hospital or outpatient equivalent (moderate/qualified) – 1 st 72 hours – Again 7 -10 days postpartum • If patient presents with new onset HTN plus headache or blurred vision, or with pre-eclampsia with severe HTN, admit, give Mg sulfate (low/qualified) – Avoid NSAIDs for pain if HTN persists >24 hours