9/18/2019

1

Hypertension in PregnancyELIZABETH BALDWIN, MD

MPO 45TH ANNUAL FALL CONFERENCE

SEPT 19, 2019

Disclosure

I am employed by Minnesota Perinatal Physicians, a part of Allina Health.

Minnesota Perinatal Physicians is a financial sponsor of the conference today.

Hypertension in

pregnancy-

What’s the big deal?

9/18/2019

2

Maternal Mortality

� In MN, there are 20-35 maternal

deaths per year, 60% of which are

preventable

� 3,000 women per year experience

serious pregnancy associated

morbidity, often with permanent

sequelae

� The leading cause of maternal deaths

in the US is obstetric complications,

which includes hemorrhage,

hypertension and infection

Maternal Morbidity and Mortality

� The California Pregnancy-Associated Mortality Review evaluated preeclampsia associated maternal mortalities from 2002-2007

� Among 54 deaths, 33 were attributed to stroke with SBP >160 in 96% and DBP >110 in 65% of cases

� Only 48% of women received antihypertensive treatment

� They estimated that 66% of outcomes were preventable, with delayed response to clinical warning signs present in 91% of cases and ineffective treatment in 76%

Can we make a difference?

� California Department of Public Health: Maternal, Child and Adolescent Health Division launched the California Pregnancy-Associated Mortality Review (CA-PAMR) project to identify pregnancy-related deaths, causation and contributing factors, and then make recommendations on quality improvements to maternity care.

� Since 2006, California has seen maternal mortality decline by 55 percent between 2006 to 2013, from 16.9 deaths per 100,000 live births to 7.3 deaths per 100,000 live births. In contrast, the U.S. national maternal mortality rate continued to rise.

9/18/2019

3

Updated

diagnosis and

management guidelines

What is hypertension?

� Updated guidelines for diagnosis

and management of hypertension

released in 2017 by the ACC, AHA

and 9 other professional health

organizations

� Widely increased the population

meeting criteria for diagnosis as well

as lowered BP threshold for

surveillance and treatment

What is hypertension (if you’re

pregnant?)

� ACOG continues to advocate using a BP >140/90 at

least 4 hours apart to define hypertension during

pregnancy

� “The effect of the ACC/AHA changes on diagnosis of

hypertension… for pregnant women is unknown.”

� “…a blood pressure in this range [SBP 130-139 or DBP

80-89 mm Hg] would not require initiation of

antihypertensive medication. However, a

conservative approach or higher degree of

observation may be warranted.”

9/18/2019

4

Assessing Risk

Risk for Preeclampsia

� All pregnant women are at risk and should be educated about preeclampsia

� Individualized risk level should be assessed and discussed early in pregnancy

� Consider obtaining baseline Pr/Cr and HELLP labs in women at greatest risk (history of hypertension, pre-pregnancy diabetes, renal or autoimmune disease)

Mitigation of Risk for Preeclampsia

� Low dose aspirin is only intervention

found to be effective in prevention

of preeclampsia

� May be more effective in preventing

preterm preeclampsia than term

preeclampsia

� Should be started in second

trimester, earlier is better (ideally

around 12 weeks)

9/18/2019

5

Managing

Chronic

Hypertension in Pregnancy

Chronic Hypertension in Pregnancy

� Counseling

� Pregnancy risks & long term complications

� Signs/Symptoms of preeclampsia

� Testing/Monitoring

� Baseline HELLP labs and Pr/Cr; Consider baseline EKG

� Consider detailed anatomical survey

� Serial growth U/S beginning at 24-26 weeks

� Weekly antenatal testing beginning at 32 weeks

Medications for CHTN in Pregnancy

� Start low dose aspirin at 12 weeks

� Antihypertensive agents

� Assess previously prescribed agents

� If BP <120/60, consider discontinuing early in pregnancy

� Avoid ACE inhibitors, angiotensin receptor blockers, atenolol

� Switch to preferred OB agents (i.e. labetalol, nifedipine XL)

� Begin new oral hypertensive regimen (or adjust current regimen) for persistent hypertension in

mid 150s/mid 100s

9/18/2019

6

Common Oral Antihypertensive in

Pregnancy

Worsening HTN in Pregnancy

� Blood pressure typically decreases early in pregnancy and nadirs mid-

trimester, then increases through late second and third trimester

� Recommend triage or inpatient evaluation

� New persistent severe hypertension (>160/110), goal of treatment within 1 hour

� Any concern for superimposed preeclampsia (rapid acceleration of HTN, new

symptoms, abnormal labs or increased proteinuria)

� Delivery at 38 weeks if well controlled (on or off medication), earlier

delivery if not well controlled or superimposed preeclampsia

� Consider MFM consult if difficult to control or questions regarding

superimposed preeclampsia

Managing New

Onset

Hypertension

9/18/2019

7

What are the hypertensive disorders of

pregnancy?

� Gestational hypertension

� Preeclampsia

� Preeclampsia without severe features

� Preeclampsia with severe features

� Chronic hypertension with superimposed preeclampsia

� HELLP syndrome

� Eclampsia

Updated Preeclampsia Diagnosis

� Reclassify nomenclature- no

longer called mild/severe, now

with/without severe features

� Remove degree of proteinuria

and IUGR from classification as

severe features

� Preeclampsia may be diagnosed

even in absence of proteinuria

Preeclampsia Management

� Gestational hypertension and preeclampsia without severe features are managed similarly

� Outpatient management with close surveillance (1-2 x/week)

� Bedrest and antihypertensive therapy are NOT indicated

� Delivery by 37 weeks (or at diagnosis if >37 weeks)

� Severe gestational hypertension, preeclampsia with severe features and HELLP are managed similarly

� Inpatient management until delivery

� Antihypertensive therapy

� Delivery at diagnosis if >34 weeks; in stable early preterm patients expectant management may be considered

� Magnesium seizure prophylaxis during/after delivery

9/18/2019

8

Management of Severe Hypertension

� BP >160/110 that is sustained for 15 min or more at any time in pregnancy or postpartum should be treated immediately (within 1 hour or less)

� Severe hypertension that persists despite appropriate escalation may require beta blocker or calcium channel blocker drip (in ICU)

� Longer acting oral medications may be used antepartum/intrapartum to prevent recurrent severe hypertension

� Plan should be made regarding management-delivery, transfer, expectant management with treatment and ongoing close surveillance

Delivery is the

cure, right?

Not really…

Postpartum Hypertension

� Blood pressure typically peaks at 3-5 days after delivery

� Management of hypertension may be more aggressive as there is no risk of placental hypoperfusion (risk of abruption, fetal hypoxia)

� Immediate treatment with acute agent for severe hypertension (>160/110)

� Consider oral anti-hypertensives for mild hypertension (140-150s/90-100s)

� All patients should be evaluated at 1-3 days and again at 5-7 days post discharge

� Patients with severe hypertension who are discharged prior to 72 hours postpartum should be evaluated within 24 hrs of discharge

� If hypertension persists for more than 6-12 weeks postpartum, ongoing management should be transitioned to primary care or cardiology

9/18/2019

9

Common Oral Antihypertensive for

Postpartum Period

Postpartum Preeclampsia

� Educate all women on warning signs of postpartum preeclampsia

� Instruct women to tell medical professionals that they are postpartum

� All new onset hypertension up to 6-12 weeks postpartum should be evaluated by an obstetric care provider (history, exam, labs)

� If hypertension is severe or symptomatic, recommend admission and magnesium seizure prophylaxis

Long Term

Cardiovascular

Risk Association

9/18/2019

10

Pregnancy as Window to Future

Health

� Multiple studies have shown an increased risk of cardiovascular disease in

women who have preeclampsia during pregnancy

� Liklihood of dying from ischemic heart disease, heart failure or stroke is more

than doubled

� Risk for venous thromboembolism or peripheral artery disease is 1.8 times higher

� Women with preterm delivery due to preeclampsia are at even greater risk

Risks to future cardiovascular health

Threshold Theory

9/18/2019

11

Risk Reduction

� Statistical modeling studies have estimated that changes in lifestyle modifications alone may decrease the risk of mortality from cardiovascular causes by between 4-13%

� Early identification and treatment of cardiovascular disease decreases morbidity and mortality

� Counseling regarding importance of preventative care and following with a primary care physician (cardiology for those at highest risk) is paramount in optimizing future health.

Questions before I conclude?

Wrap Up

� Hypertension in pregnancy is an increasingly frequent problem and

leading cause of maternal morbidity and mortality, but we CAN make a

difference!

� ACOG Practice Bulletins are great, concise resources

� Using “toolkits” can make evaluation, diagnosis and management

standardized, easy to understand and to implement

� California Maternal Quality Care Collaborative (CMQCC)

� MPO’s Minnesota Perinatal Quality Collaborative is developing similar resources

for use in Minnesota

� Providing counseling and ongoing preventative care to women with

hypertension during pregnancy is critical

9/18/2019

12

Thank you!

References

� ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical PracticeGuidelines. J Am CollCardiol 2018;71:e127-e248.

� Chronic hypertension in pregnancy. ACOG Practice Bulletin No. 203. American College of Obstetricians and Gynecologists. Obstet Gynecol2019;133:e26–50.

� California Maternal Quality Care Collaborative. Data from the California Pregnancy-Associated Mortality Review Project. Access available at https://www.cmqcc.org/research/ca-pamr-maternal-mortality-review. Accessibility verified September 11, 2019.

� Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. ACOG Committee Opinion No. 767. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e174–80.

� Gestational hypertension and preeclampsia. ACOG Practice Bulletin No. 202. American College of Obstetricians and Gynecologists. Obstet Gynecol2019;133:e1-25.

� Leslie MS, Briggs LA. Preeclampsia Foundation position paper: Preeclampsia and Future Cardiovascular Disease. 2019.

� Low-dose aspirin use during pregnancy. ACOG Committee Opinion No. 743. American College of Obstetricians and Gynecologists. Obstet Gynecol2018;132:e44–52.

� Minnesota Department of Health. Report on Maternal Morbidity and Mortality. 2019.

� Pregnancy and heart disease. ACOG Practice Bulletin No. 212. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e320–56.

� Judy, AE, McCain, CL, Lawton, ES, Morton, CH, Main, EK, & Druzin, ML. "Systolic Hypertension, Preeclampsia-Related Mortality, and Stroke in California." Obstetrics & Gynecology. 2019; 1.

� Morton, CH, Seacrist, MJ, VanOtterloo, LR, & Main, EK. "Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Preeclampsia/Eclampsia." Journal of Obstetric, Gynecologic & Neonatal Nursing. 48(3), 275-287.