hypertensive disorders of pregnancy · 2019-09-03 · hypertensive disorders of pregnancy linda...

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

https://www/

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



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


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


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


immediate-release nifedipinecapsules 20 mg orally. If BP is below threshold, continue to

monitor BP.


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



If severe BP persists x 15 or more *, administer labetalol

20 mg IV for >2 minutes

10 min


labetalol 40 mg IV for > 2 min. If BP is below threshold,

continue to monitor BP.


labetalol 80 mg IV for > 2 min. If BP is below threshold,


10 min

10 min


hydralazine 10 mg IV for > 2 min. If BP is below threshold,


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





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



➧ 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


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


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)


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


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


http://www.preeclampsia.org/market-place

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:

[email protected]

Available online at www.cmqcc.org

73

http://www.cmqcc.org/

mailto:[email protected]

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

hypertensive disorders of pregnancy · 2019-09-03 · hypertensive disorders of pregnancy linda...

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