Hypertension in Pregnancy

Stuart Shelton, MD CFV Medical Center

Cape Fear Valley Medical Center February Data

Diagnosis Gestational hypertension Preeclampsia w/ severe Preeclampsia w/o severe CHTN with superimposed TOTAL n 16 14 5 1 36 Incorrect 1 labeled PIH 1 (proteinuria)
.

Cape Fear Valley Medical Center February Data

Magnesium sulfate for preeclampsia w/ severe features: Patients (n) 14 Magnesium 10 No Magnesium 4

Cape Fear Valley Medical Center February Data

Magnesium sulfate during Cesarean (w/ severe): Patients (n) 5 Magnesium 3 No Magnesium 2

Hypertension in Pregnancy ACOG Task Force (Nov 2013)

Classification Diagnosis Management Prevention Future Implications

Task Force Recommendations

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

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 - recommendation made 14 years ago

Classification

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

Diagnosis: Hypertension
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 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.

Diagnosis: Proteinuria
Definition: - 24 hour* > 300 mg - timed (i.e. 12hr) > 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 - present prior to 20 weeks Diagnosis dilemmas: - women with little care before pregnancy - women presenting after 20 weeks

Gestational Hypertension: Definition

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

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 with Severe Features

Hypertension (onset > 20 weeks) and any of following: SBP > 160 or DBP > 110 platelets < 100,000 increased LFTs (2x normal) severe, persistent RUQ/epigastric pain new renal insufficiency - creatinine > 1.1 mg/dL - doubling of creatinine - pulmonary edema - new onset cerebral or visual disturbances

Old classification
Name BP Platelets Liver Renal 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 not used pulmonary edema persistent HA persistent visual changes not used

Lungs CNS Fetus

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

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

If patients develops severe features ! magnesium

Preeclampsia: Seizure Prophylaxis

Preeclampsia with severe features or eclampsia - magnesium sulfate

Quality of evidence: Recommendation:

High Strong

If Cesarean ! continue magnesium intraoperatively

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

Questions?