Hypertension in Pregnancy and PostpartumPierce County Quality Collaborative

December 9, 2019

Objectives

• Recognize hypertension as a preventable cause of maternal morbidity and mortality as well as preterm birth

• Define hypertension, gestational hypertension, preeclampsia and preeclampsia with severe features

• Identify signs and symptoms related to hypertensive disorders of pregnancy

• Describe treatments and surveillance for hypertensive disorders of pregnancy

Josie May

Deaths from Preeclampsia are Highly Preventable

Washington Mortality Review Panel2014-2016

Washington State Maternal Mortality Review Panel: Maternal Deaths 2014-2016. (2019). https://www.doh.wa.gov/Portals/1/Documents/Pubs/141-010-MMRPMaternalDeathReport2014-2016.pdf

• Systemic lupus erythematosus

• Pre-pregnancy BMI > 30• Antiphospholipid antibody

syndrome• 35+ years old• Kidney disease• Assisted reproductive

technology

• Nulliparity• Multifetal gestations• History of preeclampsia• Chronic hypertension• Diabetes (pre- and

gestational)• Thrombophilia• Obstructive sleep apnea

Risk Factors for Preeclampsia

Definitions

• Chronic (preexisting) hypertension – Chronic hypertension is defined as hypertension present before pregnancy, is present before the 20th week of pregnancy, or persists longer than 12 weeks postpartum.

• Gestational hypertension – Elevated blood pressure after 20 weeks of gestation in the absence of proteinuria or other diagnostic features of preeclampsia.

• Preeclampsia & eclampsia –New onset of hypertension and proteinuria or new onset of hypertension and end-organ dysfunction with or without proteinuria, after 20 weeks of gestation. Eclampsia is diagnosed when seizures have occurred.

Gestational Hypertension

Preeclampsia Preeclampsia with Severe Features

New onset after 20 weeks’ gestation

New onset after 20 weeks’ gestation

Same as for Preeclampsia with any of the following severe features:

SBP ≥ 140 or DBP ≥ 90, on 2 occasions, at least 4 hours apart

SBP ≥ 140 or DBP ≥ 90, on 2 occasions, at least 4 hours apart

SBP ≥ 160 OR DBP ≥ 110, on 2 occasions, at least 15 mins apart

Proteinuria• >300 mg in 24hr• Protein/creatinine ratio >

0.3

Symptoms indicating possible cerebral or neurologic involvement• Headache or visual changes

Any severe feature Impaired liver function• AST or ALT 70 units/L• Twice the normal concentration

Renal insufficiency:• Serum creatinine 1.1 mg/dL• Doubled from baseline values

Pulmonary edema

Thrombocytopenia • <100,000/microliter

Or

Intrapartum Management

• Generally recommend elective delivery at/around 37 weeks

• Increased maternal/fetal assessment• Anti-hypertensives- target ≈ 135/85–Oral medications for maintenance – IV medications for severe hypertension

• Seizure prophylaxis–Magnesium sulfate

Severe Hypertension is an Emergency

Systolic BP ≥ 160 OR

Diastolic BP ≥ 110

Early treatment of severe hypertension mandatorywithin 30-60 minutes

(After confirming threshold BP within 15 mins)

The Face of HELLP

Postpartum Surveillance

• Effective discharge education for patient and family• Medication therapy as indicated• Home BP monitoring if possible• BP check in 3-10 days and continue frequent

surveillance until normotensive• Schedule appointment with primary care, monitor

increased risk for cardiovascular disease

Going home! 3 lb. 15oz

2017

Readmissions

2018 Jan-June 2019

Accurate Measurement is Important

• The patient should have feet on the ground and legs uncrossed or in a semi-reclining position with her back supported

• Allow the patient to rest for 5 minutes• The arm should be supported and at heart level• Use an appropriately sized cuff

And Most Importantly…

Thank youJenicaSandall@CHIFranciscan.org360-744-8089