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Hypertensive Disorders Of

Pregnancy

Kent D. Heyborne, MD

Chief of Obstetrics

Associate Director, Obstetrics and Gynecology

Denver Health Hospital

Associate Professor of Obstetrics and Gynecology

University of Colorado School of Medicine

Why we care?

• Increasing incidence

– Obesity

– Age

• Leading cause of maternal and perinatal mortality

• Lots of near misses for every death

• Leading cause of prematurity

• Implications for long-term health

• Clinical guidelines out of date

Ananth, BMJ 2013;347:f6564

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Are these deaths preventable?

• UK: 80% of maternal deaths due to preeclampsia

preventable

• Holland: 96% of maternal deaths due to

preeclampsia preventable

• US: Clark (HCA) 30% preventable

• Most cases associated with:

– Failure to appropriately treat severe hypertension

– Proteinuria attributed to UTI

– HELLP syndrome attributed to gastritis, gall stones, etc.

Preeclampsia:

Newborn Implications

• 15% of preterm births attributable to

preeclampsia

• Often accompanied by low birth weight,

worsening prognosis

– Perinatal morbidity and mortality attributable to

preeclampsia hard to determine but > 15%

• Recurrence of preterm preeclampsia can be

prevented in some cases

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2013 ACOG Task Force on

Hypertension in Pregnancy

• Classification

• Risk screening

• Prevention

• Diagnosis

• Diagnosis of severe disease

• Postpartum management

2013 ACOG Task Force

Classification

• Unchanged:

– Preeclampsia/eclampsia

– Chronic hypertension

– Chronic hypertension with superimposed

preeclampsia

– Gestational hypertension

2013 ACOG Task Force

Prediction

• Basic H&P with focus on any chronic hypertension or renal disease is the only recommended screening –M/S

• There are blood tests with some prognostic significance but no strategy to use these results to improve outcomes – M/S

• * “Baseline labs” of no value in patients with chronic hypertension or renal disease with possible exception of urine protein quantitation (P/C ratio) and SCr

• Quality of evidence Low/Moderate/High

• Strength of recommendation Strong/Qualified

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Risk factors preeclampsia

Risk of preeclampsia with

underlying medical illness

2013 ACOG Task Force

Prevention• “Antioxidants” (vitamins C & E) don’t work – H/S

• Calcium may lower severity in calcium deficient populations, not relevant in US

• No role for bed rest or salt restriction – L/Q

• Garlic, omega-3, vitamin D, etc. – not ready for prime time

• LDA lowers risk in large metaanalyses but effect very modest in most populations

• Current recommendation is to target women with h/o severe early-onset pre-e (or IUGR) requiring delivery < 34 weeks – M/Q

• *Does not work in twins (nulliparous or otherwise), IDDM or chronic hypertension

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LDA: NNT

Askie 2007 Lancet 369, 1791

High-risk due to multiple gestation

Study N Inclusion Control LDA p

Porreco 1993 90 Twins, P0 21.4 12.5 .07

NICHD 1998 678 Mult 16 12 NS

NICHD 1998 253 Twins, P0 25 19 .3

2013 ACOG Task Force

Education

• Education about s/s of preeclampsia should be given

to all prenatal and postpartum patients

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2013 ACOG Task Force

Diagnosis

Protein/Creatinine ratio

• “Spot” urine sample submitted, urine protein and

creatinine measured in mg/dL

• Ratio of the two = g of protein/24 hours

– .150 = .150 g = 150 mg/24 hours

– .6 = .6 g = 600 mg/24 hours

– 2.9 = 2.9 g/24 hours

• Results available immediately, much less nurse and

patient effort!

• New recommendations are to only use dipstick if P/C

or 24 hour urine not available

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• No more “mild or severe preeclampsia”

• Concern that “mild preeclampsia” misleading

• Now “preeclampsia with or without severe features”

• Note proteinuria > 5gms/24h and IUGR are gone!

2013 ACOG Task Force

Diagnosis – “Severe features”

Why is severe proteinuria

(5gm/24h) no longer a criteria?

• Studies have showed that increasing amounts of

proteinuria correlate with worse maternal and

perinatal outcomes

• However, the predictive values are poor

• Not studied is whether taking into account the

amount of proteinuria in patient management

decisions improves outcomes

• I think this recommendation may be premature

and warrants more study

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What do the new

recommendations say about IUGR?• IUGR ≠ Severe preeclampsia

• However:

– If you diagnose preeclampsia, assess fetal growth

– If IUGR, assess umbilical artery Dopplers

– Delivery decisions based on both severity of preeclampsia

and severity of IUGR

• Mild preeclampsia and mild IUGR -> expectant

• Mild preeclampsia and severe IUGR -> deliver

• Severe preeclampsia with or without IUGR -> deliver

• I think I agree with this???

2013 ACOG Task Force: Treatment

GHTN or pre-e w/o SF: (L-M/Q)

• GHTN: BP 2X/wk, P/C 1X/wk

• Pre-e: BP and sx review 2X/wk, daily FAD,

Plts/LFTs 1X/wk

• No anti-HTN, no strict bed rest

• US*, antenatal testing**, Dopplers if IUGR – M/S

• Deliver at 37 weeks

• No “routine” MgSO4– * at diagnosis then q 2-4 weeks

– ** twice weekly NST and weekly AFI

Treatment of mild-moderate HTN

in pregnancy

• Cochrane review

– 49 trials, 4723 women

– RR severe HTN 0.49

– RR preeclampsia 0.93, IUFD 0.71, PTB 0.96, SGA

0.97 – p = NS

– Beta-blockers and Ca++ channel blockers better

than methyldopa at preventing severe

hypertension

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Treatment of mild-moderate HTN

in pregnancy

• These findings form the basis of the

recommendations not to treat mild-moderate

HTN

• Theoretical concerns about

– Decreased uteroplacental perfusion

– Masking preeclampsia

• Most providers will treat above 150/105 or so

to give margin of safety

What about MgSO4?

• British RCT 1990

• 22 eclamptic patients randomized to MgSO4

vs. phenytoin

• Recurrent seizures in 0 vs. 4 patients

• This study motivated the subsequent RCTs

Br J Obstet Gynaecol. 1990 Feb;97(2):104-9.

What about MgSO4?

• NEJM Parkland study 1995

• 2138 women randomized to Mg vs. phenytoin

• Mg given IM!!

• Eclampsia 10 vs. 0, p=0.004

• Assuming phenytoin is equivalent to placebo,

risk of eclampsia around 1%

N Engl J Med 1995;333:201-5

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What about MgSO4?

Magpie trial

• 10141 women in international (33 countries)

randomized to MgSO3 vs. placebo

• >= 140/90 and >= 1+ protein AP or within 24

hours PP

• Risk of eclampsia (0.8 vs. 1.9, p<0.0001) and

maternal death (0.2 vs. 0.4, p=NS) cut in half

• No increased perinatal risks

Lancet 2002; 359: 1877–90

No routine MgSO4 for mild

preeclampsia

• Risk of eclampsia with mild disease 1/200

• MgSO4 does not prevent progression to

severe disease in RCT (12-14% with or

without)

• If MgSO4 cut risk of eclampsia in half

(hypothetical), NNT is 400

2013 ACOG Task Force: Treatment

Severe preeclampsia

• 34 weeks or beyond or “unstable”, deliver – M/S

• Viable, < 34 weeks

– Give betamethasone – H/S

– Expectant management inpatient at tertiary

center – M/S

• Treat SBP > 160 or DBP > 110 – M/S

• Don’t deliver for proteinuria – M/S

• Previable, deliver – M/S

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Expectant management

• SMFM Publication Committee 2011

• Two RCTs of expectant management vs. delivery after

steroids of severe preeclampsia prior to 34 weeks

• Gestational age, need for NICU admission, newborn

morbidity, birth weight all significantly improved with

expectant management

• Recent study from Latin American casts some doubt

on these findings so stay tuned…

• SMFM. Severe preeclampsia. Am J Obstet Gynecol 2011.

• Am J Obstet Gynecol. 2013 Nov;209(5):425.e1-8. doi:

10.1016/j.ajog.2013.08.016. Epub 2013 Aug 14

Indications for delivery with

expectant management– Persistent symptoms

– Eclampsia**

– Pulmonary edema**

– Persistent severe

hypertension despite

treatment**

– HELLP syndrome

• Significant renal

dysfunction

• Abruption**

• DIC**

• Non reassuring fetal

testing**

• Previable gestation

** = do not delay delivery for corticosteroids

2013 ACOG Task Force: Treatment

Preeclampsia

• Route of delivery based on fetal status,

presentation, cervical exam, etc.

– A or REDV on UA Dopplers -> C/S

• MgSO4 is drug of choice for eclampsia

• MgSO4 should be given to all women with

severe preeclampsia

• Do not stop MgSO4 intraoperatively during

C/S

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2013 ACOG Task Force: Treatment

Preeclampsia

• CLE or spinal preferred form of analgesia for

labor or C/S

– Corticosteroids can improve platelet count and

facilitate regional anesthesia

• No need for routine invasive hemodynamic

monitoring

Steroids and CLE

• 350 patients, historical cohort study

• Class I/II HELLP, dexamethasone 10 mg q 12 x

2 then 5 mg q12 x 2

• Successful induction of labor more common

with dex (44 vs 28% < 32 wks; 62% vs 50% >

32 wks)

• Plts > 75K 12% vs 29% (p=0.58), allowing

regional anesthesia

Obstet Gynecol. 2004 Nov;104(5 Pt 1):1011-4.

2013 ACOG Task Force: Treatment

Postpartum

• For any GHTN or preeclampsia, monitor BP

inpatient or outpatient for 72 after delivery

and again 7-10 days after delivery

• ALL postpartum women should receive

discharge instructions including s/s of

preeclampsia

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Postpartum Hypertension

• Incidence difficult to ascertain as most women

not seen until 2-6 weeks

• Most patients will be those with preexisting

gestational hypertension, preeclampsia or

chronic hypertension

• Preeclampsia can first present postpartum

• Need to keep other rarer causes in differential

if there are atypical features

Postpartum Hypertension

DDX

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2013 ACOG Task Force: Treatment

Postpartum

• New onset postpartum hypertension with

either CNS s/s or severe range BP should

receive MgSO4

• Treat 150/100 if persistent over 4-6 hours

– Threshold lower PP since no fetal concerns

• Treat 160/110 within one hour

Recurrence

Recurrence

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Risk of preeclampsia with

underlying medical illness

Recurrence

Preconception and Prenatal Care

• Preconception

– Counseling

– Amelioration of risk factors of possible (weight,

diabetes, etc.)

• Prenatal

– LDA if appropriate

– Heightened surveillance as appropriate

• Growth scans if previous IUGR

• Dip urine q visit

2013 ACOG Task Force: Treatment

Postpartum

• History of preeclampsia increases risk of

cardiovascular disease in later life

• This is true even if only one episode in first

pregnancy (slight)

• Risk increased much more if

– Recurrent preeclampsia

– Preeclampsia requiring preterm delivery

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2013 ACOG Task Force: Treatment

Postpartum

• For women with a history of PTB (< 37 weeks)

due to preeclampsia or a history of recurrent

preeclampsia, yearly assessment of

– BP

– Lipids

– Fasting BS

– BMI

Summary of Major Changes

• Proteinuria not required for dx of preeclampsia (plts,

LFTs, renal, CNS, pulm edema)

• Spot Pr/Cr used to diagnose proteinuria

• No more mild/severe -> preeclampsia with or

without severe features

• 5 gm/24h, IUGR ≠ severe preeclampsia

• Monitoring of PP HTN

• Health maintenance

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Case 1

• 25 yo para 0, 36 weeks, uncomplicated course

• BP 145/95, no symptoms or other findings

• Urine dips tr ptotein

• Does she have preeclampsia?

• Pr/Cr 0.45

• What’s next?

Case 1

• NST reactive, AFI 9

• US fetus 8th%

• What’s next?

– When to deliver?

– MgSO4?

Case 1

• Uncomplicated NSVD after IOL at 37 weeks

• PP day #2 BP 145/90, feels great

• Can she go home?

• What’s next

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Case 1

• She comes in 2 days later for her “72 hour” BP

check

• BP 170/120, severe headache

• What’s next?

– Admit

– STAT antihypertensive

– MgSO4

Case 2

• 36 yo G3P2 10 weeks

– History of chronic hypertension

– History of preeclampsia leading to delivery at 33

weeks last pregnancy

– No meds currently

– BP 140/90

• What’s next?

– Labs?

– Meds?

Case 2

• Pr/Cr 0.2, Cr 0.7, BP declines

• Taking LDA

• 32 weeks, BP 150/95, 2+ proteinuria

• What’s next?

• Pr/Cr 1.9, plts 95, LFTs 140’s

• What’s next?

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Case 2

• Admit

• MgSO4

• Beta

• Evaluate fetal status for route of delivery

• Deliver!!

I’m tired, it’s time for a nap!