Hypertension in Pregnancy

Updates: ACOG Task Force 2013

Reference

• All Material taken from the ACOG task force report

• Hypertension n pregnancy. American college of obstetricians and gynecologists. Obstet gynecol 2013,122:1122-31

• The Executive summary is concise and worth reading

Change

• Much is the same

• The experts listed came together to give guidance and remark upon level of evidence

Classification

• Preeclampsia-eclampsia

• Chronic hypertension

• Chronic hypertension with superimposed preeclampsia

• Gestational hypertension

Diagnosis

• Much is the same for Preeclampsia• BP criteria remain the same 140 systolic/90 diastolic

• 300mg/dl in 24 hour Protein Quant or Protein/Creatinine Ratio 0.3

• Platelets <100,000/microliter

• Impaired liver function, twice normal blood level transaminases

• Ne renal insufficiency, 1.1/dL Creatinine

• Pulmonary Edema

• Cerebral/Visual disturbances

Diagnosis

• Gestational Hypertension• Onset >20 weeks, no Proteinuria

• Chronic Hypertension• Predates Pregnancy

• Superimposed Preeclampsia• Chronic with new onset from previous lists

Severe Preeclampsia

• Systolic of ≥160, Diastolic ≥110 on 2 occasions at least 4 hours apart

• Cerebral or visual disturbances including Headache

• Platelets <100,000/microliter

• Impaired liver function, twice normal blood level transaminases

• New renal insufficiency, 1.1/dL Creatinine

• Pulmonary Edema

Preeclampsia

• There is NO LONGER a mild categorization, simply preeclampsia or not

• With or without severe features

Prevention

• Consider low dose aspirin – Evidence Moderate

• Things not helpful:• Vitamin C/E

• Bed Rest

• Salt Restriction

Management

• Preeclampsia without Severe features• BP twice weekly, liver enzyme assessment once weekly

• If BP ≤ 160/110 antihypertensive medication not needed

• Delivery at 37 weeks

• Magnesium Sulfate not universally recommended

Management

• Preeclampsia with Severe Features• Deliver after 34 weeks

• If less than 34 weeks and stable maternal fetal condidtion give Corticosteriods

• Bp ≥ 160/110 give antihypertensives

Reasons to not Delay if <34 Weeks

• Uncontrolled hypertension

• Eclampsia

• Pulmonary Edema

• Abruptio Placenta

• DIC

• Non-reassuring Fetal Status

• IUFD

• HELLP – if rapidly worsening

Delivery Mode

• VAGINAL DELIVERY unless indicated by:• Fetal gestational age

• Presentation

• Cervical status

• Maternal fetal condition

Post Partum Management

• Magnesium Sulfate is suggested to be used if ANY Severe feature exists

• BP should be evaluated 7-10 days after delivery

• BP Monitoring should be considered for 72 hours post delivery

• BP ≥ 150/100 on two occasions 4-6 hours apart should have antihypertensive medications administered

• BP ≥ 160/110 should be treated within one hour

Chronic Hypertension

• Moderate exercise recommended

• If Bp ≥160/105 antihypertensive medications are suggested

• Optimal BP range 120-160/80-105

• Growth Ultrasounds, and Dopplers if growth restricted

• Unless other maternal/fetal complications exist delivery before 38 weeks NOT recommended

• If Superimposed Preeclampsia deliver after 37 weeks

• If Superimposed Preeclampsia with Severe features delivery after 34 weeks

Long term

• Patients who have preeclampsia before 37 weeks should have yearly assessments of:• BP

• Lipids

• Fasting Blood glucose

Evidence for screening is low only because it is not clear when to start