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Hypertensive Disorders of Pregnancy
Linda Fonseca, MDMaternal-Fetal Medicine
Objectives
➧ To review the maternal morbidity and mortality associated with hypertensive disorders of pregnancy➧ Discuss the criteria used to differentiate various
hypertensive disorders in pregnancy➧ Understand when pharmacotherapy is indicated for
hypertension in pregnancy and preferred agents to use➧ Identify when delivery is indicated in the setting of
different hypertensive disorders.
Background
➧ Incidence 10% of pregnancies worldwide
➧ Incidence increased by 25% in US in past 20 years
➧ 50-60,000 pre-eclampsia-related deaths worldwide per year
➧ For every preeclampsia-related death in US, there are 50-100 other women with “near miss” significant maternal morbidity
Preeclampsia/Eclampsia deaths➧ United Kingdom: 2/3 of deaths in 2003-2005 due to CVA
C antw ell R , e ta l. B JO G 2011;118(supp l 1):-203
➧ US: 40% deaths in 1979-2002 due to CVAM acK ay A P , e t a l. O bste t G yneco l 2001;97:533-538
➧ California: 2/3 of deaths in 2002-2004 due to CVA
C alifo rn ia M aterna l Q ua lity C are C o llabora tive , 2013 h ttps://w w w . cm qcc.org
https://www.cdc.gov/mmwr
6
Maternal
AbruptionPulmonary edemaAcute renal failureLiver hemorrhage or failureDICEclampsia
Fetal growth restrictionOligohydramniosPreterm DeliveryPerinatal death
Complications
Fetal
1. Preeclampsia-Eclampsia2. Chronic Hypertension3. Chronic Hypertension with superimposed preeclampsia4. Gestational Hypertension
ACOG Task Force on Hypertension in Pregnancy, 2013
NEW CONSIDERATIONS
• Massive proteinuria (>5 gm) eliminated from consideration of preeclampsia as severe
• Intrauterine growth restriction eliminated
• “Mild preeclampsia” = preeclampsia withoutsevere features
• “Severe preeclampsia” = preeclampsia withsevere features
• Dynamic process -> appropriate management mandates frequent reevaluation for severe features
ACOG Task Force on Hypertension in Pregnancy, 2013
ACOG Task Force on Hypertension in Pregnancy, 2013
Cerebral or visual disturbances
Pulmonary edemaEpigastric/RUQ pain↑ liver enzymes
serum Cr > 1.1 mg/dL
SBP > 160/DBP > 110Thrombocytopenia
Severe Features of Preeclampsia
Eclampsia
➧ NEW ONSET seizures in absence of other causative conditions
➧ Incidence is 1 in 1,000 deliveries in U.S.
➧ Mortality § 1% in the developed world§ 15% in the developing world
Ghulmiyyah L, Sabai BM . Semin Perinatol 2012;36:56-59.
Eclampsia
➧ 1 in 5 without proteinuria➧ 1 in 4 without hypertension➧ 30% occurred postpartum, more than half after 48
hr ppSibai BM. Am J Obstet Gynecol Sept 1990
➧ Most common prodromal neurological symptoms § Headaches (80%) § Visual disturbance (45%),
➧ 20% of women with eclampsia reported no neurologic symptoms before the seizure
Cooray SD et al. Obstetrics & Gynecology, Vol 118(5):1000-1004, November 2011.
HELLP Syndrome
Superimposed preeclampsia
➧ A sudden increase in BP that was previously well controlled or an escalation of antihypertensive medications to control BP
➧ New onset of proteinuria or sudden increase in proteinuria in a women with known proteinuria before or early in pregnancy
➧ Severe-range BP despite escalation of antihypertensive therapy
➧ Thrombocytopenia (platelet <100,000/ml)
➧ Elevated liver transaminases (2x upper normal)
➧ New-onset and worsening renal insufficiency
➧ Pulmonary edema➧ Persistent cerebral or visual
disturbances
Superimposed preeclampsia with severe features
Chronic Hypertension- hypertension <20 wks
ACOG Task Force on Hypertension in Pregnancy, 2013
Gestational Hypertension
➧ SBP 140 or more or DBP 160 or more on at least 2 occasions at least 4 hours apart after 20 wks➧ Absence of proteinuria and severe features
➧ 25-50% develop preeclampsia § Sibai BM Stella CL. Am J Obstet Gynecol 2009
➧ If severe range BPs developà preeclampsia with severe features
Management
➧ Control blood pressures➧ Prevent seizures➧ Delivery: 34 wks vs 37 wks➧ Postpartum surveillance
GHTN, Preeclampsia w/o SF, Superimposed Preeclampsia w/o SF➧ <37 wks
§ Expectant management with maternal and fetal monitoring
➧ ≥37 wks or at diagnosis after 37 wks§ Deliver
ACOG Task Force on Hypertension in Pregnancy, 2013
Management of Gestational HTN, preeclampsia and superimposed preeclampsia without SF
Expectant managementInpatient vs outpatient
Antenatal corticosteroidsMaternal: Daily assessment of symptoms, kick counts, BP monitoring 2 x/week, weekly labsFetal: US fetal growth Q3-4 wks, weekly AFI,
antenatal testing 1-2x/wk
<37 wks≥37 wks
or≥ 34 wks with:Labor or ROM
Abnormal maternal-fetal test resultsEFW <5th%ile
Suspected abruption
Delivery• MOD based on fetal gestational age, fetal
presentation, cervical status, and maternal and fetal conditions
• MgS04 is not suggested if SBP <160 or DBP <110 and absence of maternal symptoms
Yes
Severe Features
➧ <34 wks§ Expectant management prolongs pregnancy by 1-2 wks
Continued pregnancy observation be undertaken only at facilities with adequate maternal and neonatal intensive care resources
Magee LA. Hypertens Pregnancy 2009 ACOG Task Force on Hypertension in Pregnancy, 2013
Management of suspected preeclampsia with SF <34 wksAdmit to L&D for 24-48 hours
• Maternal: Monitor symptoms, labs, vitals• Fetal: Continuous EFM, ultrasound • Initiate antihypertensive medications for severe HTN• MgS04 for seizure prophylaxis• Antenatal corticosteroids
Contraindications to expectant managementUncontrollable severe HTN
EclampsiaPulmonary edema
Abruption placentaeDIC
Non-reassuring fetal statusStroke/MI
Pre-viable fetus, demise, or condition with poor prognosis
Delivery after maternal stabilization
PPROM/laborThrombocytopenia
Elevated Liver Enzymes (>2x normal)IUGR <5%
Severe oligohydramnios New or worsening renal dysfunctionPersistent Reverse End Diastolic Flow
Persistent Symptoms
Delay Delivery for 48hYes
Yes
No
Inpatient Expectant Management• Facility with adequate maternal and
neonatal intensive care resources• Stop MgS04• Antepartum ward• Maternal assessment of symptoms,
vitals, labs, antihypertensive therapy• Daily assessment of fetal well-being• Ultrasound for growth and AFI
New-onset contraindications to
expectant management
Delivery
34 wksYes
Acute-Onset Severe Hypertension➧ Hypertensive emergency: acute-onset, severe HTN that
persists >15 minutes
➧ Severe HTN → central nervous system injury
➧ Most important predictor of cerebral injury/infarction = degree of systolic hypertension
➧ Case series of 28 women with severe preeclampsia and stroke:§ All but 1 woman had severe systolic hypertension just
before hemorrhagic stroke; 54% died§ Only 13% had severe diastolic hypertension in hours
preceding stroke
ACOG CO Emergent Therapy for Severe Hypertension #767 February 2019Martin JN Jr, et al. Obstet Gynecol 2005;105:246–54
➧ The critical initial step in decreasing maternal morbidity and mortality is to administer anti-hypertensive medications within 60 minutes of documentation of persistent BP ≥160 systolic, and/or >110 diastolic
➧ Treatment for ALL:➧GHTN, preeclampsia, superimposed preE➧ Antepartum, intrapartum, postpartum
Initial Critical Step: Treatment of Severe Hypertension
INITIAL CRITICAL STEP: HYPERTENSION TREATMENT
➧ Hypertensive Emergency
➧ Severe HTN (≥160 or≥ 110) persistent for 15 min
➧ Begin treatment as soon as possible within 30-60 min
ACOG Committee Opinion No 767. Obstet Gynecol. 2019 Feb;133(2):174-80
Notify MD if SBP ≥160 or DBP ≥110
Institute fetal surveillance if undelivered and fetus viable
If severe BP perisists x 15 or more*, administer
immediate –release nifedipine capsules 10 mg
orally
If either BP exceeds threshold, administer
labetalol 20 mg and consult with MFM, IM, anesthesia or
critical care subspecialists
If either BP exceeds threshold, administer
immediate-release nifedipinecapsules 20 mg orally. If BP is below threshold, continue to
monitor BP.
If either BP exceeds threshold, administer
immediate-release nifedipinecapsules 20 mg orally. If BP is below threshold, continue to
monitor BP.
20 min
20 min
20 min
Oral Nifedipine Algorithm
Once BP control achieved:√BP every 10 min x 1 hour√BP every 15 min x 1 hour√BP every 30 min x 1 hour√BP every hour x 4 hrs
Give additional antihypertensive medication per specific order
Institute additional BP monitoring per specific order
Notify MD if SBP ≥160 or DBP ≥110
Institute fetal surveillance if undelivered and fetus viable
If severe BP persists x 15 or more *, administer labetalol
20 mg IV for >2 minutes
10 min
If either BP exceeds threshold, administer
labetalol 40 mg IV for > 2 min. If BP is below threshold,
continue to monitor BP.
If either BP exceeds threshold, administer
labetalol 80 mg IV for > 2 min. If BP is below threshold,
continue to monitor BP.
10 min
10 min
If either BP exceeds threshold, administer
hydralazine 10 mg IV for > 2 min. If BP is below threshold,
continue to monitor BP.
20 min
If either BP exceeds threshold, obtain emergency consultation from MFM, IM,
anesthesiologist or critical care
Give additional hypertensive medication per specific order
Labetalol Algorithm
Once BP control achieved:√BP every 10 min x 1 hour√BP every 15 min x 1 hour√BP every 30 min x 1 hour√BP every hour x 4 hrs
Institute additional BP monitoring per specific order
Notify MD if SBP ≥160 or DBP ≥110
Institute fetal surveillance if undelivered and fetus viable
If severe BP persists x 15 or more, administer hydralazine 5 or 10 mg IV for >2 minutes
If either BP is still exceeded, administer hydralazine10 mg
IV for >2 minutes. If BP is below threshold, continue to
monitor BP.
20 min20 min
If either BP is still exceeded, administer labetalol 20 mg IV for >2 minutes. If BP is below
threshold, continue to monitor BP.
10 min
If either BP is still exceeded, administer labetalol 40 mg IV
for >2 minutes and obtain emergency consultation with MFM, IM, anesthesiologist or
critical care.
Give additional hypertensive medication per specific order
Hydralazine Algorithm
Institute additional BP monitoring per specific order
Once BP control achieved:√BP every 10 min x 1 hour√BP every 15 min x 1 hour√BP every 30 min x 1 hour√BP every hour x 4 hrs
➧ If no IV access:
➧ First line: Oral nifedipine algorithm ➧ Onset of action 5-10 minutes
➧ Second line: Oral labetalol 200 mg (repeat dose in 30 min if needed)
➧ Onset of action 20 min-2 hours
Initial Critical Step: Treatment of Severe Hypertension
ACOG Committee Opinion No 767. Obstet Gynecol. 2019 Feb;133(2):174-80
Emergency consultation• Maternal Fetal Medicine, Internal
Medicine, Anesthesiology, Critical Care, or Emergency Medicine
• Second line:• Nicardipine or esmolol infusion pump• Sodium nitroprusside for extreme
emergencies
Treatment of Resistant Hypertension
ACOG Committee Opinion No 767. Obstet Gynecol. 2019 Feb;133(2):174-80
Drug Dosage Comments
Labetalol 200- 2,400 mg/d orally in two or three divided doses
Well toleratedPotential bronchoconstriction Avoid in patients with asthma and CHF
Nifedipine 30-120 mg/d orally of slow-release preparation
Do not use sublingual form
Methyldopa 0.5- 3g/d orally in two or three divided doses
Childhood safety data up to 7 years
Common Oral Antihypertensive Agents in Pregnancy
Magnesium Sulfate for treatment and prevention of Eclampsia
• Drug of choice for seizure prophylaxis• More effective than phenytoin, diazepam or nimodipine
• Cochrane Database of Systematic Review 2010• MgS04 vs placebo
• MgS04 ↓ seizures, abruption and maternal death (NS)
• Should NOT be considered antihypertensive medicationBelfort M , Allred J, Dildy G. Hypertens Pregnancy. 2008;27(4):315-27.
32
Recommended Use➧ Initial evaluation period
before expectant management
➧ Prophylaxis with severe features
➧ Postpartum with severe features
➧ Treatment of eclampsia
➧ NOT recommended for preeclampsia without severe features
Timing of Administration➧ Intrapartum
➧ Intraoperatively in women undergoing cesarean delivery
➧ Continued at least 24 hours:§ After delivery (if diagnosed before
delivery)§ After last convulsion§ From diagnosis (if diagnosed
postpartum)
ACOG Task Force on Hypertension in Pregnancy, 2013
Magnesium Sulfate for the Treatment and Prevention of Eclampsia
Alternatives1. Lorazepam 2-4 mg IV x1, may repeat after 10-15 minutes2. Diazepam 5-10 mg IV every 5-10 minutes to max dose 30 mg3. Phenytoin 15-20 mg/kg IV x1, may repeat 10 mg/kg IV after 20 min if no response (avoid with
hypotension, may cause cardiac arrhythmias4. Keppra 500mg IV or orally, may repeat in 12 hours. Dose adjustment for renal impairment
• Therapeutic goal is 4-8 mEQ /L
Postpartum
➧ MgS04 is recommended for 24 hr after delivery.
➧ Antihypertensive therapy if persistent SBP of 150 mm HG or 100 mm Hg diastolic or higher on at least 2 occasions at least 4-6 hours apart.
➧ Persistent SBP ≥ 160 or DBP ≥ 110 should be treated within 1 hour.
MMWR 2019
Postpartum
➧ BP monitoring in hospital or equivalent outpatient surveillance be performed for at least 72 hours pp and again at 7-10 days or sooner with symptoms
➧ New-onset HTN with HA or blurred vision or preeclampsia with severe hypertension,§ Administer MgS04 and treat with
antihypertensive therapy as needed
ACOG Task Force on Hypertension in Pregnancy, 2013
PoSTPARTUM
➧ Discharge instructions FOR ALL§ Information about signs and symptoms of preeclampsia
and prompt reporting
➧ Counseling regarding long term cardiovascular disease risk
➧ Counseling regarding recurrence risk of preeclampsia§ Low dose aspirin ACOG Task Force on Hypertension in Pregnancy, 2013
www.preeclampsia.org/market-place
Risk Reduction
➧ Introducing standardized, evidence-based clinical guidelines for management of patients with preeclampsia-eclampsia reduces incidence of adverse maternal outcomes
➧ United Kingdom pregnancy hypertension guidelines -> decreased maternal mortality rates due to reduction in cerebral and respiratory complications
ACOG Committee Opinion No 623. Obstet Gynecol. 2015 Feb;125(2):521-5
Preeclampsia Toolkits and Bundles
➧ ACOG District II Safe Motherhood Initiative (New York)
➧ California Maternal Quality Care Collaborative (CMQCC)
For More Information and
to Download the
Toolkit➧ Visit our website:
www.cmqcc.org➧ Or contact us:
Available online at www.cmqcc.org
73
Conclusion➧ Hypertension in pregnancy is one of the leading causes of maternal mortality
➧ Stroke from hypertension is a leading cause of death in preeclampsia-eclampsia
➧ Proteinuria is no longer required for the diagnosis of preeclampsia
➧ Timely recognition and management of preeclampsia leads to improved outcomes
➧ Standardized, evidence-based clinical guidelines reduce preeclampsia-eclampsia related adverse maternal outcomes
Discussion/thanks