8/12/2019 PQCNC CMOP March 2014 Webinar
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Hypertension in Pregnancy
Stuart Shelton, MD
CFV Medical Center
8/12/2019 PQCNC CMOP March 2014 Webinar
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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
8/12/2019 PQCNC CMOP March 2014 Webinar
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Cape Fear Valley Medical Center
February Data
Magnesium sulfate for preeclampsia w/ severe features:
Patients (n) Magnesium No Magnesium
14 10 4
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Cape Fear Valley Medical Center
February Data
Magnesium sulfate during Cesarean (w/ severe):
Patients (n) Magnesium No Magnesium
5 3 2
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Hypertension in Pregnancy
ACOG Task Force (Nov 2013)
Classification
DiagnosisManagement
Prevention
Future Implications
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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
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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
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Classification
PIH
should not be used- ACOG recommended against use in 2000
- recommendation made 14 years ago
PIH
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Classification
Avoid use of term mild preeclampsia
replace with preeclampsia without severe features
Severe preeclampsia = preeclampsia with severe features
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Diagnosis: Hypertension
Hypertension (either):SBP > 140
DBP > 90
Severe hypertension (either):
SBP > 160
DBP > 110
BP > 4 hours apart
8/12/2019 PQCNC CMOP March 2014 Webinar
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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.
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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
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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
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Gestational Hypertension:
Definition
Hypertension (onset > 20 weeks) and all of following:
- absence of proteinuria
- absence of severe features
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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
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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
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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
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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
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Seizure Prophylaxis
Gestational hypertensionPreeclampsia without severe features:
- magnesium is NOT universally needed
Quality of evidence: Low
Recommendation: Qualified
If patients develops severe features magnesium
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Preeclampsia:
Seizure Prophylaxis
Preeclampsia with severe features or eclampsia
- magnesium sulfate
Quality of evidence: High
Recommendation: Strong
If Cesarean continue magnesium intraoperatively
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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
8/12/2019 PQCNC CMOP March 2014 Webinar
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Questions?
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