Hypertension in Pregnancy Stuart Shelton MD CFV Medical

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Hypertension in Pregnancy Stuart Shelton, MD CFV Medical Center January 2014

Hypertension in Pregnancy Stuart Shelton, MD CFV Medical Center January 2014

Disclosure I have no relevant financial relationships with the manufacturer of any commercial products

Disclosure I have no relevant financial relationships with the manufacturer of any commercial products and/or providers of commercial services discussed in this presentation. I do not intend to discuss any unapproved or investigative use of commercial products or devices.

Hypertension in Pregnancy Why worry? Common: ~ 10% of pregnancies Morbidity: fetus: 12% of

Hypertension in Pregnancy Why worry? Common: ~ 10% of pregnancies Morbidity: fetus: 12% of preterm deliveries mother: stroke, CHF, renal injury Mortality: 12 -13% of maternal mortality

Pregnancy-Related Mortality United States (1998 -2005) Anesthesia (1%) CVA (6%) Unknown (2. 1%) Embolism

Pregnancy-Related Mortality United States (1998 -2005) Anesthesia (1%) CVA (6%) Unknown (2. 1%) Embolism (18%) PE (10%) AFE (8%) Infection (11 %) Hemorrhage (12. 5%) Cardiomyopathy (11. 5%) Preeclampsia (12. 3%) Other medical conditions (13. 2%) Cardiovascular disease (12. 4%) Obstet Gynecol 2010

Hypertension in Pregnancy ACOG Task Force (Nov 2013) Classification Diagnosis Management Prevention Future Implications

Hypertension in Pregnancy ACOG Task Force (Nov 2013) Classification Diagnosis Management Prevention Future Implications

Hypertension in Pregnancy ACOG publications recently removed: - Chronic hypertension (Feb 2012) - Diagnosis

Hypertension in Pregnancy ACOG publications recently removed: - Chronic hypertension (Feb 2012) - Diagnosis and management of preeclampsia (2002) Updated publications pending

Task Force Recommendations Strong - well supported by evidence - appropriate for virtually all

Task Force Recommendations Strong - well supported by evidence - appropriate for virtually all patients - recommended Qualified - appropriate for most patients - suggested ______________________ Evidence quality: - low - moderate - high

Classification 1. Chronic hypertension 2. Gestational hypertension 3. Preeclampsia - without severe features -

Classification 1. Chronic hypertension 2. Gestational hypertension 3. Preeclampsia - without severe features - with severe features (severe preeclampsia) 4. Chronic hypertension with superimposed preeclampsia - without severe features - with severe features

Classification PIH “PIH” should not be used - ACOG recommended against use in 2000

Classification PIH “PIH” should not be used - ACOG recommended against use in 2000 - recommendation made 14 years ago

Classification Avoid use of term mild preeclampsia replace with preeclampsia without severe features Severe

Classification Avoid use of term mild preeclampsia replace with preeclampsia without severe features Severe preeclampsia = preeclampsia with severe features

Diagnosis: Hypertension (either): SBP > 140 DBP > 90 Severe hypertension (either): SBP >

Diagnosis: Hypertension (either): SBP > 140 DBP > 90 Severe hypertension (either): SBP > 160 DBP > 110 BP > 4 hours apart

Diagnosis: Hypertension “it is recommended that a diagnosis of hypertension require at least 2

Diagnosis: Hypertension “it is recommended that a diagnosis of hypertension require at least 2 determinations at least 4 hours apart, although on occasion, especially when faced with severe hypertension, the diagnosis can be confirmed within a short interval (even minutes) to facilitate timely antihypertensive therapy. ”

Blood Pressure: Technique Assessing BP (ideal): - seated, legs uncrossed, relaxed, quiet - back

Blood Pressure: Technique Assessing BP (ideal): - seated, legs uncrossed, relaxed, quiet - back and arm supported - middle of cuff at level of right atrium - wait 5 minutes before first reading Improper assessment: - left lateral using upper arm - gives falsely low values

Diagnosis: Proteinuria Definition: - 24 hour* > 300 mg - timed (i. e. 12

Diagnosis: Proteinuria Definition: - 24 hour* > 300 mg - timed (i. e. 12 hr) > 300 mg (extrapolated) - P/C ratio > 0. 3 - urine dipstick** > 1+ * 24 urine is preferred method ** urine dipstick used only if no other available

Chronic Hypertension: Definition Hypertension and either of the following: - present prior to pregnancy

Chronic Hypertension: Definition Hypertension and either of the following: - present prior to pregnancy - present prior to 20 weeks Diagnosis dilemmas: - women with little care before pregnancy - women presenting after 20 weeks

Chronic Hypertension: Anti-hypertensive Therapy Anti-hypertensive medication indicated: - persistent SBP > 160 - or

Chronic Hypertension: Anti-hypertensive Therapy Anti-hypertensive medication indicated: - persistent SBP > 160 - or persistent DBP > 105 Quality of evidence: Recommendation: Moderate Strong BP goals with treatment: 120 -160/80 -105

Chronic Hypertension: Anti-hypertensive Therapy Recommended medications: - labetalol - nifedipine - methyldopa Quality of

Chronic Hypertension: Anti-hypertensive Therapy Recommended medications: - labetalol - nifedipine - methyldopa Quality of evidence: Recommendation: Moderate Strong

Anti-hypertensive Therapy Medication Dose Comments Labetalol 200 -2400 mg/d (2 -3 doses) caution with

Anti-hypertensive Therapy Medication Dose Comments Labetalol 200 -2400 mg/d (2 -3 doses) caution with asthma, CHF Nifedipine 30 -120 mg/d (XL) avoid SL form Methyldopa 500 -3000 mg/d (2 -3 doses) may not be effective with severe HTN

Chronic Hypertension: Anti-hypertensive Therapy Anti-hypertensive medication not needed: - SBP < 160 and DBP

Chronic Hypertension: Anti-hypertensive Therapy Anti-hypertensive medication not needed: - SBP < 160 and DBP < 105 - no evidence for end-organ damage Quality of evidence: Recommendation: Low Qualified

Chronic Hypertension: Fetal Assessment Ultrasound: - screen for growth restriction - timing not specified

Chronic Hypertension: Fetal Assessment Ultrasound: - screen for growth restriction - timing not specified (? 28 -32 weeks) Quality of evidence: Recommendation: Low Qualified

Chronic Hypertension: Fetal Assessment Antenatal testing: - taking anti-hypertensive medication - other medical conditions

Chronic Hypertension: Fetal Assessment Antenatal testing: - taking anti-hypertensive medication - other medical conditions - superimposed preeclampsia Quality of evidence: Recommendation: Low Qualified

Chronic Hypertension: Fetal Assessment CHTN + fetal growth restriction: - antenatal testing - umbilical

Chronic Hypertension: Fetal Assessment CHTN + fetal growth restriction: - antenatal testing - umbilical artery Doppler Quality of evidence: Recommendation: Moderate Strong

Chronic Hypertension: Delivery No other additional maternal/fetal complications - delivery < 38 w 0

Chronic Hypertension: Delivery No other additional maternal/fetal complications - delivery < 38 w 0 d not recommended (i. e. wait until > 38 w 0 d) Quality of evidence: Recommendation: Moderate Strong

Gestational Hypertension: Definition Hypertension (onset > 20 weeks) and all of following: - absence

Gestational Hypertension: Definition Hypertension (onset > 20 weeks) and all of following: - absence of proteinuria - absence of severe features

Gestational Hypertension: Management - serial assessment for symptoms (daily) - serial assessment of fetal

Gestational Hypertension: Management - serial assessment for symptoms (daily) - serial assessment of fetal movement (daily) - serial measurement of BP - 2 x per week in office or - 1 x per week in office and 1 x at home - serial assessment for proteinuria (weekly) - platelets, LFTs, creatinine (weekly) Quality of Evidence: Recommendation: Moderate Qualified

Gestational Hypertension: Anti-hypertensive therapy SBP < 160 and DBP < 110 - BP medication

Gestational Hypertension: Anti-hypertensive therapy SBP < 160 and DBP < 110 - BP medication NOT be given Quality of Evidence: Recommendation: Moderate Qualified

Gestational Hypertension: Fetal Assessment - daily kick counts - ultrasound: assess growth every 3

Gestational Hypertension: Fetal Assessment - daily kick counts - ultrasound: assess growth every 3 weeks - NST once weekly with AFI

Gestational Hypertension: Seizure Prophylaxis Gestational hypertension - magnesium is NOT universally needed Quality of

Gestational Hypertension: Seizure Prophylaxis Gestational hypertension - magnesium is NOT universally needed Quality of evidence: Recommendation: Low Qualified If patients develops severe features magnesium

Gestational Hypertension: Delivery Gestational hypertension and < 37 w 0 d - expectant management

Gestational Hypertension: Delivery Gestational hypertension and < 37 w 0 d - expectant management until 37 w 0 d - deliver sooner if other indications arise Quality of evidence: Recommendation: Low Qualified

Gestational Hypertension: Delivery Gestational hypertension Diagnosis made > 37 w 0 d - deliver

Gestational Hypertension: Delivery Gestational hypertension Diagnosis made > 37 w 0 d - deliver Quality of evidence: Recommendation: Moderate Qualified

Preeclampsia: Definition 1. HTN (new onset > 20 weeks) + proteinuria OR 2. *

Preeclampsia: Definition 1. HTN (new onset > 20 weeks) + proteinuria OR 2. * HTN (new onset > 20 wks) + multisystemic signs - CNS - pulmonary edema - renal dysfunction - liver impairment - thrombocytopenia * Proteinuria is not required for diagnosis

Preeclampsia without Severe Features: Definition Hypertension (onset > 20 weeks) and all of following:

Preeclampsia without Severe Features: Definition Hypertension (onset > 20 weeks) and all of following: - proteinuria - absence of severe features

Preeclampsia with Severe Features Hypertension (onset > 20 weeks) and any of following: -

Preeclampsia with Severe Features Hypertension (onset > 20 weeks) and any of following: - SBP > 160 or DBP > 110 platelets < 100, 000 increased LFTs (2 x normal) severe, persistent RUQ/epigastric pain new renal insufficiency - creatinine > 1. 1 mg/d. L - doubling of creatinine - pulmonary edema - new onset cerebral or visual disturbances

Old classification Name BP Platelets Liver Renal Lungs CNS Fetus Severe preeclampsia BP >

Old classification Name BP Platelets Liver Renal Lungs CNS Fetus Severe preeclampsia BP > 160 or > 110 (6 hr) < 100, 000 increased LFTs RUQ/epigastric pain creatinine not used oliguria > 5000 mg protein pulmonary edema persistent HA visual changes growth restriction New classification Preeclampsia with severe features BP > 160 or > 110 (4 hrs apart) < 100, 000 increased LFTs RUQ/epigastric pain creatinine > 1. 1 mg or doubling not used pulmonary edema persistent HA persistent visual changes not used

Preeclampsia: Management Without severe features: - serial assessment for symptoms (daily) - serial assessment

Preeclampsia: Management Without severe features: - serial assessment for symptoms (daily) - serial assessment of fetal movement (daily) - serial measurement of BP (2 x per week) - platelets, LFTs, creatinine (weekly) Quality of Evidence: Recommendation: Moderate Qualified

Preeclampsia: Anti-hypertensive therapy SBP < 160 and DBP < 110 - BP medication NOT

Preeclampsia: Anti-hypertensive therapy SBP < 160 and DBP < 110 - BP medication NOT be given Quality of Evidence: Recommendation: Moderate Qualified

Preeclampsia: Anti-hypertensive therapy SBP > 160 or DBP > 110 - BP medication is

Preeclampsia: Anti-hypertensive therapy SBP > 160 or DBP > 110 - BP medication is recommended Quality of Evidence: Recommendation: Moderate Strong

Preeclampsia: Fetal Assessment Preeclampsia without severe features: - daily fetal kick counts - ultrasound

Preeclampsia: Fetal Assessment Preeclampsia without severe features: - daily fetal kick counts - ultrasound to assess growth (q 3 weeks) - antenatal testing twice weekly Quality of evidence: Recommendation: Moderate Qualified

Preeclampsia: Fetal Assessment Preeclampsia with fetal growth restriction: - antenatal testing - umbilical artery

Preeclampsia: Fetal Assessment Preeclampsia with fetal growth restriction: - antenatal testing - umbilical artery Doppler Quality of evidence: Recommendation: Moderate Strong

Preeclampsia: Delivery Preeclampsia without severe features and < 37 w 0 d - deliver

Preeclampsia: Delivery Preeclampsia without severe features and < 37 w 0 d - deliver > 37 w 0 d - deliver sooner if other indications arise Quality of evidence: Recommendation: Low Qualified New PQCNC project (Feb 2014) CMOP: Conservative Management of Preeclampsia

Preeclampsia: Delivery Preeclampsia without severe features Diagnosis at > 37 w 0 d -

Preeclampsia: Delivery Preeclampsia without severe features Diagnosis at > 37 w 0 d - deliver Quality of evidence: Recommendation: Moderate Qualified

Preeclampsia: Delivery Preeclampsia with severe features Prior to fetal viability (23 -24 weeks) -

Preeclampsia: Delivery Preeclampsia with severe features Prior to fetal viability (23 -24 weeks) - deliver (not candidates for expectant management) Quality of evidence: Recommendation: Moderate Strong

Preeclampsia: Delivery Deliver if any of following at any gestational age - uncontrollable severe

Preeclampsia: Delivery Deliver if any of following at any gestational age - uncontrollable severe hypertension - eclampsia - pulmonary edema - abruption - DIC - nonreassuring fetal status Quality of evidence: Recommendation: Moderate Qualified

Preeclampsia: Delivery Deliver in 48 hours (after steroids) if stable: - PROM - platelets

Preeclampsia: Delivery Deliver in 48 hours (after steroids) if stable: - PROM - platelets < 100, 000 - elevated LFTs - EFW < 5 th percentile - AFI < 5 cm - abnormal umbilical artery Doppler - new onset/worsening renal dysfunction Quality of evidence: Recommendation: Moderate Qualified

Preeclampsia: Delivery Preeclampsia with severe features > 34 w 0 d - deliver Quality

Preeclampsia: Delivery Preeclampsia with severe features > 34 w 0 d - deliver Quality of evidence: Recommendation: Moderate Strong

Preeclampsia: Delivery Preeclampsia with severe features < 34 w 0 d and stable maternal/fetal

Preeclampsia: Delivery Preeclampsia with severe features < 34 w 0 d and stable maternal/fetal status - expectant management at tertiary center Quality of evidence: Recommendation: Moderate Strong

Preeclampsia: Expectant management* Preeclampsia with severe features and 23 w 0 d-33 w 6

Preeclampsia: Expectant management* Preeclampsia with severe features and 23 w 0 d-33 w 6 d Expectant management candidates: - severe hypertension, if controllable - transient lab abnormalities (LFTs, platelets) * prior studies; not from Task Force recommendations

Preeclampsia: Seizure Prophylaxis Preeclampsia without severe features - magnesium is NOT universally needed Quality

Preeclampsia: Seizure Prophylaxis Preeclampsia without severe features - magnesium is NOT universally needed Quality of evidence: Recommendation: Low Qualified

Preeclampsia: Seizure Prophylaxis Preeclampsia without severe features - monitor closely during labor - magnesium

Preeclampsia: Seizure Prophylaxis Preeclampsia without severe features - monitor closely during labor - magnesium if progression to severe disease - BP > 160/110 - symptoms Some providers may elect to use magnesium for patients without severe features

Preeclampsia: Seizure Prophylaxis Preeclampsia with severe features or eclampsia - magnesium sulfate Quality of

Preeclampsia: Seizure Prophylaxis Preeclampsia with severe features or eclampsia - magnesium sulfate Quality of evidence: Recommendation: High Strong If Cesarean continue magnesium intraoperatively

Chronic Hypertension with Superimposed Preeclampsia Hypertension (onset < 20 weeks) and new findings: Without

Chronic Hypertension with Superimposed Preeclampsia Hypertension (onset < 20 weeks) and new findings: Without severe features: - hypertension and proteinuria only - proteinuria: new onset or worsening With severe features - hypertension +/- proteinuria + severe features

CHTN with Superimposed Preeclampsia: Seizure Prophylaxis Without severe features - magnesium sulfate is not

CHTN with Superimposed Preeclampsia: Seizure Prophylaxis Without severe features - magnesium sulfate is not necessary With severe features - magnesium sulfate is recommended Quality of evidence: Recommendation: Moderate Strong

CHTN with Superimposed Preeclampsia: Delivery Without severe features - stable maternal and fetal status

CHTN with Superimposed Preeclampsia: Delivery Without severe features - stable maternal and fetal status - delivery > 37 w 0 d Quality of evidence: Recommendation: Low Qualified

CHTN with Superimposed Preeclampsia: Delivery With severe features < 34 w 0 d and

CHTN with Superimposed Preeclampsia: Delivery With severe features < 34 w 0 d and stable maternal/fetal status - expectant management at tertiary center Quality of evidence: Recommendation: Moderate Strong

CHTN with Superimposed Preeclampsia: Delivery Preeclampsia with severe features > 34 w 0 d

CHTN with Superimposed Preeclampsia: Delivery Preeclampsia with severe features > 34 w 0 d - deliver Quality of evidence: Recommendation: Moderate Strong

CHTN with Superimposed Preeclampsia: Delivery Deliver if any of following at any gestational age

CHTN with Superimposed Preeclampsia: Delivery Deliver if any of following at any gestational age - uncontrollable severe hypertension - eclampsia - pulmonary edema - abruption - DIC - nonreassuring fetal status Quality of evidence: Recommendation: Moderate Qualified

Postpartum Preeclampsia: Seizure Prophylaxis Postpartum diagnosis - new onset hypertension with CNS symptoms -

Postpartum Preeclampsia: Seizure Prophylaxis Postpartum diagnosis - new onset hypertension with CNS symptoms - or preeclampsia with severe hypertension - magnesium sulfate (24 hr) Quality of evidence: Recommendation: Low Qualified

Management: Postpartum Gestational hypertension or preeclampsia - BP monitored for 72 hours - in

Management: Postpartum Gestational hypertension or preeclampsia - BP monitored for 72 hours - in hospital - equivalent outpatient surveillance - Repeat BP assessment 7 -10 days postpartum - Repeat BP earlier in women with symptoms Quality of evidence: Recommendation: Moderate Qualified

Management: Postpartum Persistent hypertension - SBP > 150 or DBP > 100 (2 readings

Management: Postpartum Persistent hypertension - SBP > 150 or DBP > 100 (2 readings > 4 hrs) - treat with anti-hypertensive - SBP > 160 or > 110 - treat within 1 hour Quality of evidence: Recommendation: Low Qualified

Prevention Women with history of: - early-onset preeclampsia and PTD < 34 w 0

Prevention Women with history of: - early-onset preeclampsia and PTD < 34 w 0 d - history preeclampsia in more than 1 pregnancy Treatment: - daily low-dose aspirin (60 -80 mg) - begin in late first trimester Quality evidence: Recommendation: Moderate Qualified

Prevention Consider for women with high-baseline risk (~20%) - chronic hypertension - previous preterm

Prevention Consider for women with high-baseline risk (~20%) - chronic hypertension - previous preterm preeclampsia - diabetes Needed to treat to prevent 1 case preeclampsia: 50

Prevention Not recommended: - vitamin C vitamin E salt restriction bed rest physical activity

Prevention Not recommended: - vitamin C vitamin E salt restriction bed rest physical activity restriction

Future Implications Preeclampsia in pregnancy - increased risk cardiovascular disease - overall: 2 x

Future Implications Preeclampsia in pregnancy - increased risk cardiovascular disease - overall: 2 x increase risk - < 34 week delivery: 8 -9 x increase risk

Future Implications What can be done to lower cardiovascular risk? Preterm birth < 37

Future Implications What can be done to lower cardiovascular risk? Preterm birth < 37 weeks from preeclampsia consider yearly assessment of: - BP - lipids - fasting glucose - BMI Quality of Evidence: Recommendation: Low Qualified

Summary - preeclampsia vs. gestational HTN: - presence of proteinuria - preeclampsia: - no

Summary - preeclampsia vs. gestational HTN: - presence of proteinuria - preeclampsia: - no longer use term “mild” preeclampsia - preeclampsia without severe features PIH

Summary - preeclampsia with severe features - proteinuria not used to define severe -

Summary - preeclampsia with severe features - proteinuria not used to define severe - proteinuria not used to determine delivery timing - fetal growth restriction removed - oliguria removed - elevated creatinine defined

Summary - CHTN with superimposed preeclampsia - Management similar to preeclampsia - depends on

Summary - CHTN with superimposed preeclampsia - Management similar to preeclampsia - depends on presence of severe features

Summary - magnesium sulfate recommended for: - preeclampsia with severe features - eclampsia -

Summary - magnesium sulfate recommended for: - preeclampsia with severe features - eclampsia - delivery: - CHTN: - GHTN: - Preeclampsia, w/o severe - Preeclampsia, w/ severe > 38 w 0 d > 37 w 0 d varies; 34 w 0 d latest

Summary Postpartum (GHTN and preeclampsia): - check BP for 72 hours - follow-up at

Summary Postpartum (GHTN and preeclampsia): - check BP for 72 hours - follow-up at 7 -10 days postpartum Prevention: - high-risk women - daily low dose aspirin starting late 1 st trimester

References Hypertension in Pregnancy: Report of the American College of Obstetricans and Gynecologists’ Task

References Hypertension in Pregnancy: Report of the American College of Obstetricans and Gynecologists’ Task Force on Hypertension in Pregnancy. ACOG, 2013. Chronic hypertension. Clinical management guidelines for obstetriciangynecologists. No. 125. February 2012 (no longer in circulation) Diagnosis and Management of Preeclampsia and Eclampsia. ACOG Practice Bulletin No. 33. January 2002 (no longer in circulation) Lockwood, CJ. ACOG task force on hypertension in pregnancy (editorial). Contemporary Ob/Gyn. December 2013.