Hypertension in Pregnancy

Stuart Shelton, MD
CFV Medical Center
May 2015

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.

Case #1
28-year-old P2002 at 21w4d transferred to CFVMC
because of elevated blood pressures
PMH:
Ob Hx:
Meds:

? chronic hypertension
2 uncomplicated term deliveries
labetalol 400mg 3x per day (recently started)

Prenatal course:
- 14-20 weeks:

BP = 114-120/70-78 (no meds)

urine: negative-trace

Exam:
BP: 145/70
Lungs:
clear
Abdomen: non-tender
Labs:
Platelets:
Creatinine:
SGOT/SGPT:
24 hour urine:

130,000
0.8 mg/dL
17/19
1082 mg

What is diagnosis?
A.
B.
C.
D.

Chronic hypertension
Chronic hypertension with superimposed preeclampsia
Preeclampsia without severe features
Preeclampsia with severe features

What is your management?

Case #2
32-year-old P0 at 36w0d sent from office to L&D for
preeclampsia evaluation.
BP:
Urine:
SGOT:
SGPT:
Platelets:
Fetus:

150/100, 155/105
4+ protein
45 (normal 15-37)
82 (normal 12-78)
107,000
EFW: 10th percentile

What is the diagnosis?

Does she require delivery now?
Is magnesium sulfate required?

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%)

Infection (11 %)

Unknown (2.1%)
Embolism (18%)
PE (10%)
AFE (8%)

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

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
- with severe features (severe preeclampsia)
4. Chronic hypertension with superimposed preeclampsia
- without severe features
- with severe features

Classification
Avoid use of term mild preeclampsia
replace with preeclampsia without severe features
Severe preeclampsia = preeclampsia with severe features
PIH should not be used
- ACOG recommended against use in 2000
- recommendation made 15 years ago

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
Diagnostic 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 persistent DBP > 105
Quality of evidence:
Recommendation:

Moderate
Strong

BP goals with treatment:

120-159/80-105

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
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 < 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 (? 28-32 weeks)

Quality of evidence:
Recommendation:

Low
Qualified

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 artery Doppler

Quality of evidence:
Recommendation:

Moderate
Strong

Chronic Hypertension:
Delivery
No other additional maternal/fetal complications
- delivery < 38w0d not recommended
(i.e. wait until > 38w0d)

Quality of evidence:
Recommendation:

Moderate
Strong

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 movement (daily)
- serial measurement of BP
- 2x per week in office
or - 1x per week in office and 1x 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 NOT be given

Quality of Evidence:
Recommendation:

Moderate
Qualified

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 evidence:
Recommendation:

Low
Qualified

If patients develops severe features magnesium

Gestational Hypertension:
Delivery
Gestational hypertension and < 37w0d
- expectant management until 37w0d
- deliver sooner if other indications arise

Quality of evidence:
Recommendation:

Low
Qualified

Gestational Hypertension:
Delivery
Gestational hypertension
Diagnosis made > 37w0d
- deliver

Quality of evidence:
Recommendation:

Moderate
Qualified

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:
- proteinuria
- absence of severe features

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

Lungs
CNS
Fetus

New classification

Severe preeclampsia
Preeclampsia with severe features
BP > 160 or > 110 (6 hr) BP > 160 or > 110 (4 hrs apart)
< 100,000
< 100,000
increased LFTs increased LFTs
RUQ/epigastric pain
RUQ/epigastric pain
creatinine not used
creatinine > 1.1 mg or doubling
oliguria
not used
> 5000 mg protein
not used
pulmonary edema
pulmonary edema
persistent HA
persistent HA
visual changes
persistent visual changes
growth restriction
not used

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

Moderate
Qualified

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 recommended

Quality of Evidence:
Recommendation:

Moderate
Strong

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 Doppler

Quality of evidence:
Recommendation:

Moderate
Strong

Preeclampsia:
Delivery
Preeclampsia without severe features and < 37w0d
- deliver > 37w0d
- deliver sooner if other indications arise
Quality of evidence:
Recommendation:

Low
Qualified

PQCNC project (Feb 2014):

CMOP: Conservative Management of Preeclampsia

Preeclampsia:
Delivery
Preeclampsia without severe features
Diagnosis at > 37w0d
- deliver

Quality of evidence:
Recommendation:

Moderate
Qualified

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 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 < 100,000
- elevated LFTs
- EFW < 5th 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
> 34w0d
- deliver

Quality of evidence:
Recommendation:

Moderate
Strong

Preeclampsia:
Delivery
Preeclampsia with severe features
< 34w0d and stable maternal/fetal status
- expectant management at tertiary center

Quality of evidence:
Recommendation:

Moderate
Strong

Preeclampsia:
Expectant management*
Preeclampsia with severe features and 23w0d-33w6d
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 of evidence:
Recommendation:

Low
Qualified

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 evidence:
Recommendation:

High
Strong

If Cesarean continue magnesium intraoperatively

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 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
- delivery > 37w0d

Quality of evidence:
Recommendation:

Low
Qualified

CHTN with Superimposed Preeclampsia:

Delivery
With severe features
< 34w0d 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
> 34w0d
- deliver

Quality of evidence:
Recommendation:

Moderate
Strong

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

Summary
- preeclampsia w/o severe features 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
- proteinuria not used to determine delivery timing
- fetal growth restriction removed
- oliguria removed
- elevated creatinine defined (> 1.1 mg/dL)

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
- delivery:
- CHTN:
- GHTN:
- Preeclampsia, w/o severe
- Preeclampsia, w/ severe

> 38w0d
> 37w0d
> 37w0d
varies; 34w0d latest

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 1st trimester

References
Hypertension in Pregnancy: Report of the American College of Obstetricians
and Gynecologists Task Force on Hypertension in Pregnancy. ACOG, 2013.

Lockwood, CJ. ACOG task force on hypertension in pregnancy (editorial).

Contemporary Ob/Gyn. December 2013.
Altman, D et al. Magpie Trial Collaboration Group. Do women with
preeclampsia, and their babies, benefit from magnesium sulphate? The
Magpie Trial: a randomised placebo-controlled trial. Lancet.
2002;349:1877-1890.

Seizure Risk
- Some authorities still recommend magnesium sulfate for
patients with preeclampsia without severe features (i.e. mild)
- Cochrane review: magnesium for non-severe preeclampsia
- reduced eclampsia by 56%
- reduced abruption by 36%
- number needed to treat to prevent 1 seizure:
- number needed to treat to prevent 1 abruption:

100
100

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 hospital
- equivalent outpatient surveillance
- Repeat BP assessment 7-10 days postpartum
- Repeat BP earlier in women with symptoms
Quality of evidence:
Recommendation:

Moderate
Qualified

Prevention
Women with history of:
- early-onset preeclampsia and PTD < 34w0d
- 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 preeclampsia
- diabetes
Needed to treat to prevent 1 case preeclampsia: 50

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

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