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    ACOGS NEW BEST PRACTICEGUIDELINES FOR PREECLAMPSIA:

    USING THEM TO MINIMIZEMORBIDITY & MORTALITY

    The University of Iowa & The Preeclampsia

    Foundation

    October 18, 2013James N. Martin Jr., MD, [email protected]

    62nd President ACOG 2010-2013

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    Preeclampsia

    Summarize the current

    state of knowledge

    Develop practiceguidelines and checklists

    for Best Practices

    Identify the mostcompelling areas for

    research

    ACOG Presidential Initiative 2011-2012

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    In the United States.. PRE either alone or superimposed on preexisting

    hypertension presents the major risk

    Maternal-fetal serious morbidity and mortality still

    occur, sometimes avoidable vs lessened

    Optimal managementclose observation for signsand early findingsdiagnosisbest time for

    delivery

    A continuing challenge: differentiate worseningchronic hypertension vs developing preeclampsia

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    Some Problem Areas Identified.

    Failure of care providers to appreciate the

    multisystemic nature of PRE, sometimes the fault

    of rigid criteria for diagnosis

    PRE is a dynamic and a progressive process

    Continuing reevaluation of thepatient required

    PRE can first present or worsen

    during the puerperium

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    ACOG Hypertension in Pregnancy

    Working Group 2011-2012

    Jim Roberts (Chair)

    Phyll is August (Internist)

    George Bakris (Internist)

    RR Gaiser (Anesthesia)

    SA Karumanchi (Renal)

    M Lindheimer (Renal)

    Joey P Granger (Physiol)

    Eleni Z Tsigas (Patient)

    Jim Martin (Ex Officio)

    John R Barton (MFM)

    Ira M Bernstein (MFM)

    Maury L Druzin (MFM)

    A Jeyabalan (MFM)

    Donna D Johnson (MFM)

    Michelle Y Owens (MFM)

    George R Saade (MFM)

    Baha M Sibai (MFM)

    Cathy Y Spong (MFM)

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    The ACOG HIP APPROACH. Working Group of experts: Obstetrics,

    Hypertension, Anesthesia, Consumer Advocate

    Review the data

    develop evidence-basedrecommendations (Level I desired)

    Assessment of evidence/implications/confidence in

    estimates of effect (very low, low, moderate or high)make a recommendation strategy developed by

    the GRADE group

    [http://www.gradeworkinggroup.org/]

    Develop the most appropriate course of action:

    Strong (all patients) Qualified (most patients)

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    The GRADE approach

    Grading of Recommendations Assessment, Development

    and Evaluation (GRADE)

    An approach used by many groups

    Evaluate and score evidence

    Very low, low, moderate, or high quality of evidence

    Make and rate recommendation

    Strong recommendation

    Qualified recommendation

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    Recommendations

    Strong: Astrongrecommendationisonethatissowellsupported

    that

    it

    would

    be

    the

    approach

    appropriate

    for

    virtually

    all

    patients.

    It

    could

    be

    the

    basis

    for

    health

    care

    policy.

    Qualified:Aqualifiedrecommendationisalsoonethatwouldbe

    judged

    as

    appropriate

    for

    most

    patients,

    but

    it

    might

    not

    be

    the

    optimalrecommendationforsomepatients(whosevaluesand

    preference

    differ,

    or

    who

    have

    a

    different

    attitude

    toward

    uncertaintyinestimatesofeffect).WhentheTaskForcehasmadea

    qualified

    recommendation,

    the

    health

    care

    provider

    and

    patient

    are

    encouragedtoworktogethertoarriveatadecisionbasedonthe

    values

    and

    judgment

    and

    underlying

    health

    condition

    of

    a

    particular

    patient

    in

    a

    particular

    situation.

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    MAKING THE DIAGNOSIS Maintain the classification scheme advanced by

    National Blood Pressure Education Program and

    ACOG in 1998: GH

    PRE

    CHTN with Superimposed PRE

    In recognition of the syndromic nature of PRE, we

    have eliminated the dependence of the diagnosisupon proteinuria..and made it proteinuria OR any

    evidence of maternal compromise to be listed soon

    Blood pressure criteria

    are same as prior

    recommendations

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    GESTATIONAL HYPERTENSIONESTATIONAL HYPERTENSION

    Development of hypertension after 20 wks Previously normotensive

    SBP > 140 mmHg

    OR (not and/or)

    DBP > 90 mmHg

    Persistent for 4 hrs

    BP returns to normal by 6 wks postpartum

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    Mild PREECLAMPSIA

    Its never mild

    Increased morbidity

    Increased mortality

    Rapid progression is possible

    Early onset

    Co-morbidities

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    MILD PREECLAMPSIA:

    THE PROBLEM.Preeclampsia is progressive

    Mild preeclampsia seems to result in a false senseof security

    As an attempt to avoid this the Task Forcerecommends:

    Preeclampsia without severe features

    (Preeclampsia)Preeclampsia with severe features (Severe

    Preeclampsia)

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    PROTEINURIA

    Preeclampsia is not just hypertension but a

    multisystemic syndrome.

    Proteinuria has been the traditional way to test thissyndromic nature.

    Not all eclamptics or sick preeclamptics have

    proteinuria.

    Amount of protein does not correlate with maternal

    or fetal outcome.Conclusion: Use other signs of syndromic nature

    (other systemic findings) for diagnosis.

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    PREECLAMPSIA

    REECLAMPSIA

    Proteinuria

    > 300 mg/day or

    Protein/Cr > 0.30

    Thrombocytopenia

    Impaired liver function

    Renal insufficiency

    Pulmonary edema

    Cerebral disturbances Visual impairment

    Gestational

    hypertension

    +new onset of

    any of the

    following:

    (dipstick 1+) (IUGR out)

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    Induction versus Expectant Management in

    Mild GHTNPreeclampsia after 36 wk

    (HYPITAT randomized trial)*

    Induction

    (n=377)

    Expectant

    (n=379)

    GA (wk) 38.4 (36-41) 38.6 (36-41)

    GHTN 65% 66%

    Preeclampsia 33% 32%

    Proteinuria 450 (300 -

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    HYPITAT Randomized Trial

    Maternal Outcome

    Induction

    n=377

    Expectant

    n=379

    RR

    (95% C.I.)Composite adverse outcome 31% 44% 0.71 (0.59-0.86)

    HELLP 1% 3%

    Pulmonary edema 0 1%

    Abruptio 0 0

    Eclampsia 0 0

    Maternal ICU 2% 4%

    Severe systolic HTN

    Cesarean delivery

    15%

    14%

    23%

    19%

    0.63 (0.46-0.86)

    0.75 (0.55-1.04)

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    HYPITAT Randomized Trial

    Neonatal Outcome

    Induction (%) Expectant

    (%)

    Composite adverse outcome 6 8

    Perinatal deaths 0 0

    Apgar < 7 at 5 min 2 2

    Cord PH < 7.05 3 6

    NICU admission 3 2

    RDS 0.25 0.25

    Koopmans et al, Lancet 2009

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    GHTN PRE Without Severe Features

    Maternal & Fetal Evaluation

    37 weeks gestation

    34 weeks gestation Labor, PPROM, FGR

    Suspected Abruptio

    Abnormal M/F testing

    Delivery

    Inpatient / outpatient

    Maternal / fetal testing

    Worsening M/F condition

    Labor / PPROM

    37 weeks gestation

    Yes

    No

    HYPITATD&D

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    MANAGEMENT OF

    ANAGEMENT OF

    PREECLAMPSIA WITH

    REECLAMPSIA WITH

    SEVERE

    EVERE

    FEATURES

    EATURES

    Term

    Delivery Remote from term

    Individualize

    Deliver

    >34Weeks

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    ACUTE CONTROL OF SEVERE HYPERTENSION

    Persistent (>15 min) SBP > 160 mmHg or

    Persistent DBP > 105 mmHg

    IV labetalol

    bolus doses 20-40 mg (max 300/hr) continuous IV infusion (1-2 mg/min)

    IV bolus doses ofhydralazine

    5, 10, 10 mg q 20 min (max 25 mg)

    Oral nifedipine

    10-20 mg q 20 min (max 60 mg) ACOG CO 514

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    PREVENTION OF SEIZURES

    Magnesium sulfate

    Intravenous regimen

    Loading dose: 4 or 6 g IV over 20 mins

    Maintenance: 2 g IV per hr

    If convulsions recur

    2 g dose of magnesium sulfate

    Treat: Eclampsia, Preeclampsia (sev), HELLP

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    MATERNAL-PERINATAL Outcome

    According to GA at Start of Expectant

    Management

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    FETAL DELIVERY GUIDELINES-

    preeclampsia w/severe features

    Expedited delivery (within 72 hrs)

    Fetal distress by FHR tracing or BPP 4

    Amniotic fluid index < 5 cm

    Ultrasound EFW < 5th percentile

    Reverse umbilical artery diastolic flow

    Labor / ROM > 34 weeks gestation

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    PROTEINURIA PREECLAMPSIA

    Does the amount matter

    No differences in outcomes (< 5 vs

    5 g)

    Renal function

    Latency

    Similar outcomes (< 5, 5-9.99,

    10 g/24h)

    Delivery decision should not be based on: Amount of proteinuria

    Change in amount of proteinuria

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    PRE < 34 wks WITH SEVERE FEATURES

    Admit to L&D: ? Expectant Management ?

    Corticosteroids, MgSO4 prophylaxis, antihypertensives

    Ultrasound, FHR monitoring, symptoms, laboratory tests

    Contraindications to continued expectant

    management after initial 24-48hrs?

    Eclampsia

    < 230/7 wks (may individualize)

    Pulmonary edema

    Abnormal fetal testing ARF/AKI, DIC

    Abruptio placentae

    Delivery

    *******

    No

    Yes

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    PRE < 34 wks with SEVERE FEATURES

    Offer continued expectant management after first 24-48hrs

    Inpatient only, D/C MgSO4

    Daily maternal / fetal testing, sxs, BP, labs (?biomarkers?)

    No Contraindication

    Additional complications present?

    Persistent symptoms

    HELLP / partial HELLP syndrome

    FGR (

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    MAGNESIUM SULFATE DURING

    CESAREAN DELIVERY

    Half-life of 5 hours

    Discontinuing magnesium

    will not change drug

    interactions DCing increases risk for

    seizure outside the

    operative suite

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    MANAGEMENT OF HELLP SYNDROME

    Refer to tertiary care facil ity (< 35 wks)Admit to labor & delivery area

    IV magnesium sulfate

    Antihypertensives if SBP 160; or DBP 105mmHg

    < 23 wks or 34 wks

    Fetal distress

    Maternal distress

    EclampsiaAbruptio placentae / DIC

    Renal failure

    Respiratory distress

    Suspect liver hematoma

    23-34 wks Complete steroid course

    24-48 hours latency

    DeliveryYes

    No

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    ManagementofHELLPSyndrome:MISSISSIPPIPROTOCOL

    Class1or

    2HELLP

    Syndrome?

    (PLT600

    AST/ALT>70,+Schistocytes,

    Ind.Bili>1.2)

    YES

    NO Eclampsia?

    NO

    YES

    Class3or

    Partial

    HELLPSyndrome?

    NO

    YES

    Severe

    EpigastricPain?YES

    NOEndOrganInjury(renal,

    hepatic,

    CVS,

    CNS)

    and/or

    abruptionDIC?

    NO

    YES

    ContinueCurrent

    Managementwithout

    IVDexamethasone

    INITIATEIV

    DEXAMETHASONE10mgIVq12HOURS

    CONSIDERIV

    DEXAMETHASONE

    10mgIVq12HOURS

    SevereHypertension

    DifficulttoControl,

    orCNSSymptoms?

    YESNO

    Hypertension in Pregnancy January 2012

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    HELLP SYNDROME: Best Practice Martin JN Jr. Milestones in the quest for best

    management of patients with HELLPsyndrome. Int J Gynaecol Obstet 2013

    March22 [PMID: 23528799]

    Martin JN Jr, Owens MY, Keiser SD, ParrishMF, Tam Tam KB, Brewer JM, Cushman JL,

    May WL. Hypertens Pregnancy [Level 2]

    2012;31(1):79-90. [PMID: 21219123]

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    Rate of Persistent Diastolic Hypertension

    Proteinuria in POSTPARTUM Period

    %

    Hypertension Proteinuria Hypertension Proteinuria

    3 Days 7 Days H Stepan et al.,J Hum Hypert 2006

    POSTPARTUM PREECLAMPSIA

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    POSTPARTUM PREECLAMPSIA:Points to Consider

    In reviewing morbidity and mortality figures several

    mistakes leading to mortality were evident.

    Care providers whose care resulted in bad

    outcomes:

    did not appreciate the progressive nature ofpreeclampsia (mild preeclampsia).

    Did not act in the absence of proteinuria despite other

    systemic signs (did not understand syndromic) Postpartum preeclampsia & severe hypertension were

    frequently seen in these cases

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    BP monitored a minimum 72 hours postpartum

    Repeat BP assessment 7-10 days postpartumOffice / clinic

    Home health

    Specific written discharge instructions

    Headache

    RUQ or chest painVision impairment

    Office and L&D telephone numbers

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    LONG TERM MATERNAL

    OUTCOME

    Recurrent preeclampsia+

    CHTN (4-fold*)

    Ischemic heart disease (2-fold*)

    Stroke (2-fold*

    ) Venous thromboembolism(2-fold*)

    All-cause mortality (1.5-fold*)

    Preeclampsia is a screening test for future health

    +

    Barton, Sibai 2008*Craici et al 2008

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    Primary

    Prevention

    of

    Preeclampsia

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    Preeclampsia Pharmacopoeia

    What works?

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    PREVENTION OF RECURRENT

    PREECLAMPSIA

    Pre-pregnancy

    Weight loss to ideal BMI

    Control of glucose in diabetes

    Control of BP in CHTN (diet, exercise)Low dose aspirin in select patients (from 12 wks)

    Not recommended

    Vitamins C & E

    Dietary salt restriction

    Anti-HTN therapy to prevent preeclampsia

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    PREDICTION OF PREECLAMPSIA?

    Encouraging but not yet ready for routine clinical

    use, alone or in combination:

    Identification of demographic factors Biochemical analytes

    Biophysical findings

    NO RECOMMENDATIONS