SUMMARY ACOG HYPERTENSION IN PREGNANCYMAY 2014

SPARROW HOSPITAL DEPARTMENT OBGYN

GESTATIONAL HYPERTENSION (GHTN)Diagnosis:

≥140 systolic or ≥90 diastolic on two occasions at least 4 hours apart: New onset hypertension after 20 weeks, and returns to normal by 6-12 weeks postpartum

24 hr urine protein < 300 mg, no severe features, no FGR

Management: No bed rest No antihypertensive unless persistent severe range blood pressures (≥160 systolic

and/or ≥110 diastolic) Daily kick counts Once weekly AFI and CBC, AST, creatinine ± ALT/LDH Once weekly NST with BP check and urine dipstick in office One additional BP obtained each week in office or at home

Delivery Criteria: 37-39 weeks if no evidence of preeclampsia or other indication for delivery

Management Preeclampsia Without Severe Features (Previously called Mild preeclampsia)

No bed rest, regular diet with no salt restriction No antihypertensive medication unless persistent severe range blood pressures (≥160

systolic and/or ≥110 diastolic) Daily kick counts Growth ultrasound every 2-3 weeks

o If there is evidence of fetal growth restriction, obtain umbilical artery Doppler velocimetry

Weekly or twice weekly AFI Twice weekly NST with BP check Once weekly CBC, AST, ALT, creatinine Instruct woman to report symptoms of severe preeclampsia such as severe headache,

visual changes, epigastric pain or shortness of breath If woman reports decreased fetal movement or fundal height is found to be less than 3 cm

of expected, prompt evaluation with NST and AFI is indicated Magnesium Sulfate for seizure prophylaxis is optional and should not be given universally

Hospitalization Criteria: Development of features of severe preeclampsia or evidence of fetal growth restriction

are indications for immediate hospitalization

Delivery Criteria: > 37 weeks > 34 weeks plus any of the following:

o Progressive labor or rupture of membraneso Ultrasound estimate of fetal weight less than fifth percentile

o Oligohydramnios (persistent AFI less than 5cm or MVP < 2 cm)o Persistent BPP 6/10 or lesso Suspected abruption

Management of Severe Preeclampsia

Admit to L&D If > 34 0/7 weeks, deliver after maternal stabilization If diagnosed before fetal viability, deliver after maternal stabilization

If between viability and 34 weeks, expectant management for 24-48 hours unless contraindicated by one or more of the following (if present, do not delay delivery, deliver after maternal stabilization):

o Eclampsiao Pulmonary edemao DICo Uncontrollable severe hypertensiono Non-viable fetuso Abnormal fetal test results/evidence of non-reassuring fetal statuso Placental abruptiono Intrapartum fetal demiseo Renal failureo Severe thrombocytopenia

Expectant management for the first 24-48 hours after admission for severe preeclampsia includes:

o Corticosteroids o Magnesium sulfate o Daily labs (CBC, AST, ALT, & creatinine)o Ultrasound for fetal growth and presentation

Delivery may be delayed 48 hours to provide corticosteroid administration for the following complications:

o > 33 5/7 weekso Persistent symptomso HELLP or partial HELLP syndromeo Fetal growth restriction (less than 5th percentile)o Severe oligohydramnios (persistent AFI < 5cm or MVP < 2 cm)o Reverse end-diastolic flow (umbilical artery Doppler studies)o Labor or PROMo Significant renal dysfunction

Perinatology consultation recommended if < 34 weeks and/or immediate delivery not planned

Amount of proteinuria or change in the amount of proteinuria are NOT correlated with outcome and should not be used as a criteria for delivery in preterm patients

Acute control of severe HTN (≥160 systolic and/or ≥110 diastolic)o Option 1:

Administer labetalol (20 mg IV over 2 minutes). Repeat BP measurement in 10 minutes and record results. If either BP threshold is still exceeded, administer labetalol (40 mg IV over

2 minutes). If BP is below threshold, continue to monitor BP closely. Repeat BP measurement in 10 minutes and record results. If either BP threshold is still exceeded, administer labetalol (80 mg IV over

2 minutes). If BP is below threshold, continue to monitor BP closely. Repeat BP measurement in 10 minutes and record results. If either BP threshold is still exceeded, administer hydralazine (10 mg IV

over 2 minutes). If BP is below threshold, continue to monitor BP closely. Repeat BP measurement in 20 minutes and record results. If either BP threshold is still exceeded, obtain emergency consultation from

maternal–fetal medicine, internal medicine, anesthesia, or critical care specialists.

o Option 2: Administer hydralazine (5 mg or 10 mg IV over 2 minutes). Repeat BP measurement in 20 minutes and record results. If either BP threshold is still exceeded, administer hydralazine (10 mg IV

over 2 minutes). If BP is below threshold, continue to monitor BP closely. Repeat BP measurement in 20 minutes and record results. If either BP threshold is still exceeded, administer labetalol (20 mg IV over

2 minutes). If BP is below threshold, continue to monitor BP closely. Repeat BP measurement in 10 minutes and record results.

If either BP threshold is still exceeded, administer labetalol (40 mg IV over 2 minutes) and obtain emergency consultation from maternal–fetal medicine, internal medicine, anesthesia, or critical care specialists.

Option 3: if no IV accessLabetolol 200 mg orally or Nifedipine 10 mg orally (not sublingual)Repeat in 30 minutes if BP >160 systolic or > 110 diastolic

Once BP threshold is achieved check BPsEvery 10 minutes for 1 hourEvery 15 minutes for 1 hourEvery 30 minutes for 1 hourEvery 4 hours until discharge

Seizure Prophylaxis- Magnesium Sulfate 4 – 6 gm bolus over 20 minutes, then 1 - 2 gm/hr continuous

infusion (may need to reduce to 1 gm/hr if renal impairment and follow serum magnesium levels)

- Magnesium sulfate 5 mg IM each buttock (10 mg total) if no IV access- Anticonvulsant medications for recurrent seizures or when MGSO4

contraindicated (pulmonary edema, renal failure, myasthenia gravis) Lorazepam 2 – 4 mg IV x 1, may repeat x 1 after 10 minutes) Diazepam 5 – 10 mg IV every 5 – 10 minutes, max dose 30 mg Phenytoin 15 – 20 mg/kg IV x 1, may repeat 10 mg/kg IV after 20 minutes.

Avoid with hypotension; may cause cardiac arrythmias Keppra 500 mg IV or PO, may repeat in 12 hours, adjust dose

ECLAMPSIA

Diagnosis New-onset grand mal seizures in a woman with preeclampsia.

Management Control seizures and provide patient safety (Airway-Breathing-Circulation) Correction of hypoxia and acidosis Control severe hypertension Assess neurologic status If antepartum, deliver after maternal stabilization

Anticonvulsant Therapy: Initiate and maintain magnesium sulfate infusion for further seizure prevention when eclampsia is suspected.

Magnesium sulfate dosage: 4 to 6 grams IV loading dose over 20 minutes, followed by 2gm/hour as a continuous intravenous infusion as per severe preeclampsia

For women having a convulsion after receiving initial magnesium sulfate, give another IV bolus of 2 g magnesium sulfate.

If no IV magnesium sulfate 5 mg IM in each buttock (10 mg total) x 1 Continue magnesium sulfate for at least 24 hours after the last convulsion Anticonvulsant medications for recurrent seizures or when MGSO4 contraindicated

(pulmonary edema, renal failure, myasthenia gravis) Lorazepam 2 – 4 mg IV x 1, may repeat x 1 after 10 minutes) Diazepam 5 – 10 mg IV every 5 – 10 minutes, max dose 30 mg Phenytoin 15 – 20 mg/kg IV x 1, may repeat 10 mg/kg IV after 20 minutes.

Avoid with hypotension; may cause cardiac arrythmias

SUPERIMPOSED PREECLAMPSIADiagnosis:

In a woman with hypertension that had onset < 20 weeks with at least one of the following:

- New onset proteinuria (≥300 mg/24 hours, or Protein/creatinine ratio >0.3)- Increase in baseline proteinuria (double of baseline)- Sudden increase in BP that was previously well controlled- Escalation in BP meds- Headache, visual changes, epigastric pain – evaluate for preeclampsia- Severe features

Management and Delivery Criteria: • CHTN with Superimposed Preeclampsia without severe features should be delivered ≥ 37 weeks

If severe features develop, deliver as per severe preeclampsia guidelines

POSTPARTUM MANAGEMENT

Keep magnesium sulfate infusing 24 hours postpartum Monitor BP every 4 hours in hospital until discharge For women who present postpartum with new-onset hypertension associated with

headaches, blurred vision, or preeclampsia with severe hypertension, administer magnesium sulfate, regardless of proteinuria present

Anti-hypertensive therapy is suggested for women with persistent postpartum hypertension, systolic >150 mm Hg, or diastolic > 100 mm Hg, on 2 occasions, 4 hours apart. Persistent systolic > 160 or diastolic > 110 should be treated within 1 hour.

Avoid NSAIDs in patients with severe features, HELLP Syndrome, or clinical suspicion of worsening preeclampsia postpartum.

Brain imaging studies ifo Unremitting headacheo Focal signs or symptomso Lethargyo Confusiono Seizureso Abnormal neurologic examo Coagulopathy

Discharge planning: BP should be checked at 72 hours, in office if patient has been discharged prior to this

time Repeat BP in office 7 – 10 days postpartum or earlier if symptoms Provide patient with specific written discharge orders regarding headache, RUQ or chest

pain, visual impairment, and emergency numbers Refer to algorithm below

FLP, acute fatty liver of pregnancy; APAS, antiphospholipid antibody syndrome; HELLP, hemolysis, elevated liver enzymes, and low platelet; HUS, hemolytic uremic syndrome; RCVS, reversible cerebral vasoconstriction syndrome; TTP, thrombotic thrombocytopenic purpura.

REFERENCESSibai. Postpartum hypertension-preeclampsia. Am J Obstet Gynecol 2012.

ACOG Practice bulletin #33, 2012

ACOG. (2013). Hypertension in Pregnancy.

Summary of the Hypertension in Pregnancy Taskforce, ACOG Annual Meeting 2012

Peter von Dadelszen, et al, The Active Implementation of Pregnancy Hypertension Guidelines in British Columbia, OBGYN, VOL. 116, NO. 3, Sept 2010

Maternal Safety Bundle for Severe Hypertension in Pregnancy, ACOGDistrict II, January 2014

ACOG Committee Opinion #514. Dec 2011. Emergent Therapy for Acute-Onset, Severe Hypertension with Preeclampsia or Eclampsia

Magee, L, July 2008, OBGYN, Letters to the Editor pg 563, Re: Avoidance of NSAIDs in postpartum hypertensive patients