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