Hypertension in Pregnancy

1. Hypertension in Pregnancy Updates: ACOG Task Force 2013

2. Reference • All Material taken from the ACOG task force report • Hypertension n pregnancy. American college of obstetricians and gynecologists. Obstetgynecol 2013,122:1122-31 • The Executive summary is concise and worth reading

3. Change • Much is the same • The experts listed came together to give guidance and remark upon level of evidence

4. Classification • Preeclampsia-eclampsia • Chronic hypertension • Chronic hypertension with superimposed preeclampsia • Gestational hypertension

5. 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

6. Diagnosis • Gestational Hypertension • Onset >20 weeks, no Proteinuria • Chronic Hypertension • Predates Pregnancy • Superimposed Preeclampsia • Chronic with new onset from previous lists

7. 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

8. Preeclampsia • There is NO LONGER a mild categorization, simply preeclampsia or not • With or without severe features

9. Prevention • Consider low dose aspirin – Evidence Moderate • Things not helpful: • Vitamin C/E • Bed Rest • Salt Restriction

10. 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

11. 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

12. Reasons to not Delay if <34 Weeks • Uncontrolled hypertension • Eclampsia • Pulmonary Edema • Abruptio Placenta • DIC • Non-reassuring Fetal Status • IUFD • HELLP – if rapidly worsening

13. Delivery Mode • VAGINAL DELIVERY unless indicated by: • Fetal gestational age • Presentation • Cervical status • Maternal fetal condition

14. 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

15. 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

16. 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