Download - Pregnancy Hypertensive Disorders of
Hypertensive Disorders of Pregnancy
Robin Sautter MD Tacoma Family Medicine Rural/Obstetrics Fellow
March 26, 2021
DisclosuresNone
Thank YouMulticare OB/GYN
Swedish Family Medicine ResidencyTacoma Family Medicine Residency
Learning Objectives● Review the impact of hypertensive disorders of pregnancy on
maternal morbidity and mortality
● Assess maternal risk factors for hypertensive disorders of pregnancy
● Review updated guidelines for diagnosis and management of hypertensive disorders of pregnancy
Trends in Pregnancy-related Mortality in USA: 1987 - 2017
Centers for Disease Control and Prevention 2020
Pregnancy-Related Mortality Ratio by Race/Ethnicity: 2014-2017
Centers for Disease Control and Prevention 2020
Causes of Pregnancy - Related Death in USA: 2014-2017
Centers for Disease Control and Prevention 2020
Morbidity: Long Term Effects of Pre-eclampsia
ACOG Practice Bulletin No. 212 2019Bellamy et al 2007
Barrett 2020Kira et al 2018
Outcome Relative Risk (95% CI) Years of Observation
Chronic Hypertension 3.70 (2.7 - 5.05) 14
Ischemic heart disease 2.16 (1.86 - 2.52) 11.7
Stroke 1.81 (1.45 - 2.27) 10.4
Venous Thromboembolism 1.79 (37 - 2.33) 4.7
Chronic kidney disease 2.11 (1.45 - 2.27) 6-39 years
End stage renal disease 4.90 (3.56 - 6.74) 6-39 years
Long term cardiovascular morbidity of offspring
2.32 (1.15 - 4.67)*
*adjusted hazard ratio
Pregnancy with Systolic Blood Pressure > 140 or Diastolic BP > 90
YesNo
No Yes
> 20 Weeks Gestation
Gestational Hypertension Preeclampsia
New proteinuria or severe features
No Yes
Postpartum Preeclampsia or
Gestational Hypertension
Chronic Hypertension
Pregnant?
Case 1
31 yo G3P1011 at 35w4d with BMI of 33 was sent to L&D for a blood pressure reading of 148/90 in the office 4 hours ago. She is asymptomatic. No prior history of hypertension.
What type of lab work up would you like to do at this time?
Pregnancy with Systolic Blood Pressure > 140 or Diastolic BP > 90
No Yes
> 20 Weeks Gestation
Gestational Hypertension
Preeclampsia
New proteinuria or
severe features
Yes
Protein/Creatinine ratio 0.11 Cr 0.4 AST 20 ALT 22 Plts 211
What is her diagnosis?
gHTN with severe range pressures is managed similarly to preeclampsia with severe features
50% of women with gHTN will develop preeclampsia
“The notion that gHTN is intrinsically less concerning than preeclampsia is incorrect.”
ACOG Practice Bulletin No. 220 2020
Case 2
20 yo G1P0 at 32w4d with BMI of 29 was sent to L&D for severe headache with blurry vision. Initial BP 162/100, repeat 168/104.
What type of lab work up would you like to do at this time?
Pregnancy with Systolic Blood Pressure > 140 or Diastolic BP > 90
No Yes
> 20 Weeks Gestation
Gestational Hypertension Preeclampsia
New proteinuria or
severe features
Yes
Protein/Creatinine ratio 0.62 Cr 0.5 AST 24 ALT 30 Plts 176
What is her diagnosis?
Feta
l
Renal HepaticH
ematologic
Vascular
?
Risk Factor Relative Risk (95% CI)
Preeclampsia in a previous pregnancy 8.4 (7.1-9.9)
Chronic Hypertension 5.1 (4.0-6.5)
Pregestational diabetes 3.7 (3.1-4.3)
Multifetal gestations 2.9 (2.6-3.1)
Antiphospholipid Antibody Syndrome 2.8 (1.8-4.3)
Prepregnancy BMI >30 2.8 (2.6-3.1)
Systemic lupus erythematosus 2.5 (1.0-6.3)
Prior stillbirth 2.4 (1.7-3.4)
Nulliparity 2.1 (1.9-2.4)
Prepregnancy BMI >25 2.1 (2.0-2.2)
Prior placental abruption 2.0 (1.4-2.7)
Chronic kidney disease 1.8 (1.5-2.1)
Assisted reproductive technology 1.8 (1.6-2.1)
Maternal age > 40 years 1.5 (1.2-2.0)
Prior IUGR 1.4 (0.6-3.0)
Maternal age > 35 years 1.2 (1.1-1.3)
Genetic component? Obstructive sleep apnea?
Risk Factors for Preeclampsia
Brew 2016Bartsch 2016
Proteinuria● 300 mg or more per 24 hour urine collection (or this amount extrapolated from a
timed collection)
● Protein/creatinine ratio of 0.3 or more
● Dipstick reading of 2+ (only used if other quantitative methods not available)
ACOG Practice Bulletin No. 220 2020
Severe Features = ANY of the following WITH or WITHOUT proteinuria
Platelets <100,000/microliter
Serum creatinine >1.1 mg/dL or doubling of the serum creatinine in the absence of other rental disease
Elevated liver transaminases to twice normal concentration or severe persistent RUQ or epigastric pain unresponsive to medications
Pulmonary edema
New-onset headache unresponsive to medication and not accounted for by alternative diagnoses or visual symptoms
ACOG Practice Bulletin No. 220 2020
HELLP Syndrome● Hemolysis, Elevated Liver Enzymes,
and Low Platelet Count Syndrome
● 30% occur postpartum
● Increased rates of maternal morbidity and mortality
● Diagnosis○ LDH >600 IU/L○ AST and ALT >2x upper limit of
normal○ Platelet count
<100,000/microliter
Eclampsia● New onset tonic-clonic, focal, or
multifocal seizures in the absence of other causes
● 78-83% of cases preceded by premonitory signs of cerebral irritation
● 20-38% of cases do not demonstrate classic signs of preeclampsia
Now What?Gestational hypertension or preeclampsia without severe features
● Deliver at 37 0/7 weeks ● Serial US to assess fetal growth● Twice weekly antenatal testing● Close monitoring of BP● Weekly preeclampsia labs
Preeclampsia with severe features
● Deliver when diagnosed at or beyond 34 0/7 weeks ● Expectant management prior to 34 weeks if stable
maternal and fetal condition● Delivery should not be delayed for steroids
Medications for Preeclampsia with Severe FeaturesHydralazine
● Initial 5 mg IV or IM● 5-10 mg IV q 20-40 min● Max dose 20 mg
Labetalol
● Initial 10-20 mg IV ● 20-80 q 10-30 min● Max dose 300 mg
Nifedipine
● Initial 10-20 PO● 10-20 mg PO q20 min● Max dose 180 mg
Magnesium Sulfate
● 6 g loading dose IV followed by 1-2 g/hr (4 loading dose and 1 g/hr in renal disease; 2 g/hr in obese)
● Renally excreted● Goal magnesium level 5-9 ml/dl● Magnesium toxicity
Case 336 yo G5P3013 @ 15 weeks gestation presenting for a routine OB visit.
Initial prenatal BP: 142/86
Today’s BP: 145/82
Pregnancy with Systolic Blood Pressure > 140 or Diastolic BP > 90
No
> 20 Weeks
Gestation
No Yes
Chronic Hypertension
Pregnant?
1. What is her diagnosis?
1.2. What additional work up and
follow-up is recommended for this patient?
Postpartum Preeclampsia or
Gestational Hypertension
Chronic Hypertension ● 0.9-1.5% of pregnant women
● Increased by 67% from 2000-2009 with largest increase (87%) among African Americans
● 11% of women with chronic hypertension have proteinuria
● Hypertension persisting longer than 12 weeks after delivery may be re-classified as chronic
● 20-50% of women with cHTN may develop superimposed preeclampsia
ACOG Practice Bulletin No. 203 2019
Baseline Evaluation
● CMP (includes liver function tests)● CBC● Spot urine protein/creatinine ratio or 24 hour urine
for total protein and creatinine (to calculate creatinine clearance) as appropriate
● Electrocardiogram or echocardiogram as appropriate
● Urine drug screen as appropriate Uric Acid
Morris et al 2012
Common Medications
Drug Dosage CommentsLabetalol 200 - 2,400 mg/d PO Bronchoconstrictive
in 2-3 divided doses
Nifedipine 30 - 120 mg/d PO Immediate release extended release used for severe acutely elevated pressures
Methyldopa 500 - 3,000 mg/d PO Limited by side effectsin 2-4 divided doses
Hydrochlorothiazide 12.5-50 PO daily 2nd or 3rd line agent
ACOG Practice Bulletin No. 203 2019
Game Plan
No antihypertensives
● Deliver at 38 0/7 - 39 6/7 weeks ● Serial US to assess fetal growth● Twice weekly antenatal testing
starting at 36 weeks
On antihypertensive agent
● Deliver at 37 0/7 - 39 6/7 weeks ● Serial US to assess fetal growth● Twice weekly antenatal testing
starting at 32 weeks
ACOG Practice Bulletin No. 203 2019
Case 422 yo G2P2002 on PPD2 following NSVD with BPs 140s/90s. No history of hypertensive disorders. PreE labs notable for P/C ratio of 0.58.
Pregnancy with Systolic Blood Pressure > 140 or Diastolic BP > 90
No
> 20 Weeks
Gestation
No Yes
Chronic Hypertension
Pregnant?
1. What is her diagnosis?
1.2. Plans for follow up?
PostpartumPreeclampsia
Aspirin
Low dose aspirin (81 mg/day) initiated between 12 and 28 weeks (optimally before 16 weeks)
No increased risk of placental abruption, postpartum hemorrhage, mean blood loss, or adverse neonatal outcomes.
25% Risk of developing
preeclampsia
AJOG 2018 , 2020
Risk Level Risk Factors Recommendation
High History of preeclampsiaMultifetal gestationChronic hypertensionType 1 or 2 diabetesRenal diseaseAutoimmune disease
Recommend low dose aspirin if 1 or more of these high risk factors
Moderate NulliparityObesity (BMI >30)Family history of preeclampsia (1st deg)Age >35 yrsPrevious adverse preg outcomeLow birth weight or SGAMore than 10 yr pregnancy intervalAfrican American raceLow socioeconomic status
Consider low dose aspirin if patient has more than 1 of these moderate risk factors
Low Previous uncomplicated full-term delivery
Do not recommend aspirin
AJOG 2020
● Early screening for chronic hypertension and pre-eclampsia risk factors
● Low dose aspirin for the prevention of preeclampsia
● Monitor for long term effects of hypertensive disorders of pregnancy
Conclusions
References1. Pregnancy Mortality Surveillance System - CDC 2020
https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm
2. American College of Obstetrics and Gynecology ACOG Practice Bulletin No. 212: Pregnancy and Heart Disease. Obstet Gynecol 2019; 133(5) e320-e356..
3. Bellamy, L et al, Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis, 2007 BMJ Nov 10th, 335 (7677)
4. Barrett, P et al, Adverse Pregnancy Outcomes and Long-term Maternal Kidney Disease A Systematic Review and Meta-analysis, 2020, Feb 12th, JAMA JAMA Network Open. 2020;3(2):e1920964
5. Kira et al “Prenatal exposure to preeclampsia as an independent risk factor for long-term cardiovascular morbidity of the offspring” Pregnancy Hypertension 13 (2018) 181-186
6. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 220: Gestational Hypertension and Preeclampsia. Obstet Gynecol. 2020;135(6): e237-e260.
7. D. Williams “Pre-eclampsia and long-term maternal outcomes”. Obstetric Medicine 2012 Sep; 5(3): 98-104
8. Bartsch, et al “Clinical risk factors for preeclampsia determined in early pregnancy: systematic review and meta-analysis of large cohort studies” 2016 BMJ. 2016; 353: i1753. Published online 2016 Apr 19. doi: 10.1136/bmj.i1753: 10.1136/bmj.i1753
9. Brew, et al. “Comparison of Normal and Pre-Eclamptic Placental Gene Expression: A Systematic Review with Meta-Analysis” PLOS One 2016 DOI: 10.137/journal.pone.0161504
10. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 203: Chronic Hypertension in Pregnancy. Obstet Gynecol. 2019;133(1): e26-e50.
11. Morris RK, Riley RD, Doug M, Deeks JJ, Kilby MD. Diagnostic accuracy of spot urinary protein and albumin to creatinine ratios for detection of significant proteinuria or adverse pregnancy outcome in patients with suspected preeclampsia: systematic review and meta-analysis. BMJ 2012;345:e4342.
12. Society for Maternal-Fetal Medicine Special Statement: Checklists for preeclampsia risk-factor screening to guide recommendations for low-dose aspirin. Am J Obstet Gynecol. 2020. Vol. 223(3): pb7-b11
13. Roberge S., Bujold E., Nicolaides K.H. Aspirin for the prevention of preterm and term preeclampsia: systematic review and metaanalysis. Am J Obstet Gynecol. 2018; 218: 287-293.e1
14. Henderson JT, Whitlock EP, O’Connor E, Senger CA, Thompson JH, Rowland MG. Low-dose aspirin for prevention of morbidity and mortality from preeclampsia: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med 2014;160:695–703
References