PQCNC CMOP March 2014 Webinar

8/12/2019 PQCNC CMOP March 2014 Webinar

1/23

Hypertension in Pregnancy

Stuart Shelton, MD

CFV Medical Center


2/23

Cape Fear Valley Medical Center

February Data

Diagnosis n Incorrect

Gestational hypertension 16 1 labeled PIH

Preeclampsia w/ severe 14

Preeclampsia w/o severe 5 1 (proteinuria)

CHTN with superimposed 1 .

TOTAL 36 2


3/23


February Data

Magnesium sulfate for preeclampsia w/ severe features:

Patients (n) Magnesium No Magnesium

14 10 4


4/23


February Data

Magnesium sulfate during Cesarean (w/ severe):

Patients (n) Magnesium No Magnesium

5 3 2


5/23

Hypertension in Pregnancy

ACOG Task Force (Nov 2013)

Classification

DiagnosisManagement

Prevention

Future Implications


6/23

Task Force Recommendations

Strong- well supported by evidence- appropriate for virtually all patients- recommended

Qualified- appropriate for most patients

- suggested

____________________________________________

Evidence quality:

- low

- moderate

- high


7/23

Classification

1. Chronic hypertension

2. Gestational hypertension3. Preeclampsia

- without severe features

- with severe features (severe preeclampsia)

4. Chronic hypertension with superimposed preeclampsia

- without severe features

- with severe features


8/23

Classification

PIH

should not be used- ACOG recommended against use in 2000

- recommendation made 14 years ago

PIH


9/23

Classification

Avoid use of term mild preeclampsia

replace with preeclampsia without severe features

Severe preeclampsia = preeclampsia with severe features


10/23

Diagnosis: Hypertension

Hypertension (either):SBP > 140

DBP > 90

Severe hypertension (either):

SBP > 160

DBP > 110

BP > 4 hours apart


11/23

Diagnosis: Hypertension

it is recommended that a diagnosis of

hypertension require at least 2 determinations at

least 4 hours apart, although on occasion,

especially when faced with severe hypertension,the diagnosis can be confirmed within a short

interval (even minutes) to facilitate timely

antihypertensive therapy.


12/23

Diagnosis: Proteinuria

Definition:

- 24 hour* > 300 mg

- timed (i.e. 12hr) > 300 mg (extrapolated)

- P/C ratio > 0.3- urine dipstick** > 1+

* 24 urine is preferred method

** urine dipstick used only if no other available


13/23

Chronic Hypertension:

Definition

Hypertension and either of the following:

- present prior to pregnancy

- present prior to 20 weeks

Diagnosis dilemmas:

- women with little care before pregnancy- women presenting after 20 weeks


14/23

Gestational Hypertension:

Definition

Hypertension (onset > 20 weeks) and all of following:

- absence of proteinuria

- absence of severe features


15/23

Preeclampsia: Definition

1. HTN (new onset > 20 weeks) + proteinuriaOR

2.* HTN (new onset > 20 wks) + multisystemic signs

- CNS- pulmonary edema

- renal dysfunction

- liver impairment

- thrombocytopenia

* Proteinuria is not required for diagnosis


16/23

Preeclampsia with Severe Features

Hypertension (onset > 20 weeks) and any of following:- SBP > 160 or DBP > 110

- platelets < 100,000

- increased LFTs (2x normal)

- severe, persistent RUQ/epigastric pain

- new renal insufficiency

- creatinine > 1.1 mg/dL

- doubling of creatinine- pulmonary edema

- new onset cerebral or visual disturbances


17/23

Old classification New classification

Name Severe preeclampsia Preeclampsia with severe featuresBP BP > 160 or > 110 (6 hr) BP > 160 or > 110 (4 hrs apart)

Platelets < 100,000 < 100,000

Liver increased LFTs increased LFTs

RUQ/epigastric pain RUQ/epigastric painRenal creatinine not used creatinine > 1.1 mg or doubling

oliguria not used

> 5000 mg protein not used

Lungs pulmonary edema pulmonary edemaCNS persistent HA persistent HA

visual changes persistent visual changes

Fetus growth restriction not used


18/23

Chronic Hypertension with

Superimposed Preeclampsia

Hypertension (onset < 20 weeks) and new findings:

Without severe features:- hypertension and proteinuria only

- proteinuria: new onset or worsening

With severe features

- hypertension +/- proteinuria + severe features


19/23


20/23

Seizure Prophylaxis

Gestational hypertensionPreeclampsia without severe features:

- magnesium is NOT universally needed

Quality of evidence: Low

Recommendation: Qualified

If patients develops severe features magnesium


21/23

Preeclampsia:

Seizure Prophylaxis

Preeclampsia with severe features or eclampsia

- magnesium sulfate

Quality of evidence: High

Recommendation: Strong

If Cesarean continue magnesium intraoperatively


22/23

CHTN with Superimposed Preeclampsia:

Seizure Prophylaxis

Without severe features

- magnesium sulfate is not necessary

With severe features

- magnesium sulfate is recommended

Quality of evidence: Moderate

Recommendation: Strong


23/23

Questions?

Documents

PQCNC CMOP March 2014 Webinar