pregnancy hypertensive disorders of

Hypertensive Disorders of Pregnancy

Robin Sautter MD Tacoma Family Medicine Rural/Obstetrics Fellow

March 26, 2021

DisclosuresNone

Thank YouMulticare OB/GYN

Swedish Family Medicine ResidencyTacoma Family Medicine Residency

Learning Objectives● Review the impact of hypertensive disorders of pregnancy on

maternal morbidity and mortality

● Assess maternal risk factors for hypertensive disorders of pregnancy

● Review updated guidelines for diagnosis and management of hypertensive disorders of pregnancy

Trends in Pregnancy-related Mortality in USA: 1987 - 2017

Centers for Disease Control and Prevention 2020

Pregnancy-Related Mortality Ratio by Race/Ethnicity: 2014-2017


Causes of Pregnancy - Related Death in USA: 2014-2017


Morbidity: Long Term Effects of Pre-eclampsia

ACOG Practice Bulletin No. 212 2019Bellamy et al 2007

Barrett 2020Kira et al 2018

Outcome Relative Risk (95% CI) Years of Observation

Chronic Hypertension 3.70 (2.7 - 5.05) 14

Ischemic heart disease 2.16 (1.86 - 2.52) 11.7

Stroke 1.81 (1.45 - 2.27) 10.4

Venous Thromboembolism 1.79 (37 - 2.33) 4.7

Chronic kidney disease 2.11 (1.45 - 2.27) 6-39 years

End stage renal disease 4.90 (3.56 - 6.74) 6-39 years

Long term cardiovascular morbidity of offspring

2.32 (1.15 - 4.67)*

*adjusted hazard ratio

Pregnancy with Systolic Blood Pressure > 140 or Diastolic BP > 90

YesNo

No Yes

> 20 Weeks Gestation

Gestational Hypertension Preeclampsia

New proteinuria or severe features

No Yes

Postpartum Preeclampsia or

Gestational Hypertension

Chronic Hypertension

Pregnant?

Case 1

31 yo G3P1011 at 35w4d with BMI of 33 was sent to L&D for a blood pressure reading of 148/90 in the office 4 hours ago. She is asymptomatic. No prior history of hypertension.

What type of lab work up would you like to do at this time?


No Yes



Preeclampsia

New proteinuria or

severe features

Yes

Protein/Creatinine ratio 0.11 Cr 0.4 AST 20 ALT 22 Plts 211

What is her diagnosis?

gHTN with severe range pressures is managed similarly to preeclampsia with severe features

50% of women with gHTN will develop preeclampsia

“The notion that gHTN is intrinsically less concerning than preeclampsia is incorrect.”

ACOG Practice Bulletin No. 220 2020

Case 2

20 yo G1P0 at 32w4d with BMI of 29 was sent to L&D for severe headache with blurry vision. Initial BP 162/100, repeat 168/104.

What type of lab work up would you like to do at this time?


No Yes


Gestational Hypertension Preeclampsia

New proteinuria or

severe features

Yes

Protein/Creatinine ratio 0.62 Cr 0.5 AST 24 ALT 30 Plts 176

What is her diagnosis?

Feta

l

Renal HepaticH

ematologic

Vascular

?

Risk Factor Relative Risk (95% CI)

Preeclampsia in a previous pregnancy 8.4 (7.1-9.9)

Chronic Hypertension 5.1 (4.0-6.5)

Pregestational diabetes 3.7 (3.1-4.3)

Multifetal gestations 2.9 (2.6-3.1)

Antiphospholipid Antibody Syndrome 2.8 (1.8-4.3)

Prepregnancy BMI >30 2.8 (2.6-3.1)

Systemic lupus erythematosus 2.5 (1.0-6.3)

Prior stillbirth 2.4 (1.7-3.4)

Nulliparity 2.1 (1.9-2.4)

Prepregnancy BMI >25 2.1 (2.0-2.2)

Prior placental abruption 2.0 (1.4-2.7)

Chronic kidney disease 1.8 (1.5-2.1)

Assisted reproductive technology 1.8 (1.6-2.1)

Maternal age > 40 years 1.5 (1.2-2.0)

Prior IUGR 1.4 (0.6-3.0)

Maternal age > 35 years 1.2 (1.1-1.3)

Genetic component? Obstructive sleep apnea?

Risk Factors for Preeclampsia

Brew 2016Bartsch 2016

Proteinuria● 300 mg or more per 24 hour urine collection (or this amount extrapolated from a

timed collection)

● Protein/creatinine ratio of 0.3 or more

● Dipstick reading of 2+ (only used if other quantitative methods not available)


Severe Features = ANY of the following WITH or WITHOUT proteinuria

Platelets <100,000/microliter

Serum creatinine >1.1 mg/dL or doubling of the serum creatinine in the absence of other rental disease

Elevated liver transaminases to twice normal concentration or severe persistent RUQ or epigastric pain unresponsive to medications

Pulmonary edema

New-onset headache unresponsive to medication and not accounted for by alternative diagnoses or visual symptoms


HELLP Syndrome● Hemolysis, Elevated Liver Enzymes,

and Low Platelet Count Syndrome

● 30% occur postpartum

● Increased rates of maternal morbidity and mortality

● Diagnosis○ LDH >600 IU/L○ AST and ALT >2x upper limit of

normal○ Platelet count

<100,000/microliter

Eclampsia● New onset tonic-clonic, focal, or

multifocal seizures in the absence of other causes

● 78-83% of cases preceded by premonitory signs of cerebral irritation

● 20-38% of cases do not demonstrate classic signs of preeclampsia

Now What?Gestational hypertension or preeclampsia without severe features

● Deliver at 37 0/7 weeks ● Serial US to assess fetal growth● Twice weekly antenatal testing● Close monitoring of BP● Weekly preeclampsia labs

Preeclampsia with severe features

● Deliver when diagnosed at or beyond 34 0/7 weeks ● Expectant management prior to 34 weeks if stable

maternal and fetal condition● Delivery should not be delayed for steroids

Medications for Preeclampsia with Severe FeaturesHydralazine

● Initial 5 mg IV or IM● 5-10 mg IV q 20-40 min● Max dose 20 mg

Labetalol

● Initial 10-20 mg IV ● 20-80 q 10-30 min● Max dose 300 mg

Nifedipine

● Initial 10-20 PO● 10-20 mg PO q20 min● Max dose 180 mg

Magnesium Sulfate

● 6 g loading dose IV followed by 1-2 g/hr (4 loading dose and 1 g/hr in renal disease; 2 g/hr in obese)

● Renally excreted● Goal magnesium level 5-9 ml/dl● Magnesium toxicity

Case 336 yo G5P3013 @ 15 weeks gestation presenting for a routine OB visit.

Initial prenatal BP: 142/86

Today’s BP: 145/82


No

> 20 Weeks

Gestation

No Yes


Pregnant?

1. What is her diagnosis?

1.2. What additional work up and

follow-up is recommended for this patient?

Postpartum Preeclampsia or


Chronic Hypertension ● 0.9-1.5% of pregnant women

● Increased by 67% from 2000-2009 with largest increase (87%) among African Americans

● 11% of women with chronic hypertension have proteinuria

● Hypertension persisting longer than 12 weeks after delivery may be re-classified as chronic

● 20-50% of women with cHTN may develop superimposed preeclampsia


Baseline Evaluation

● CMP (includes liver function tests)● CBC● Spot urine protein/creatinine ratio or 24 hour urine

for total protein and creatinine (to calculate creatinine clearance) as appropriate

● Electrocardiogram or echocardiogram as appropriate

● Urine drug screen as appropriate Uric Acid

Morris et al 2012

Common Medications

Drug Dosage CommentsLabetalol 200 - 2,400 mg/d PO Bronchoconstrictive

in 2-3 divided doses

Nifedipine 30 - 120 mg/d PO Immediate release extended release used for severe acutely elevated pressures

Methyldopa 500 - 3,000 mg/d PO Limited by side effectsin 2-4 divided doses

Hydrochlorothiazide 12.5-50 PO daily 2nd or 3rd line agent


Game Plan

No antihypertensives

● Deliver at 38 0/7 - 39 6/7 weeks ● Serial US to assess fetal growth● Twice weekly antenatal testing

starting at 36 weeks

On antihypertensive agent

● Deliver at 37 0/7 - 39 6/7 weeks ● Serial US to assess fetal growth● Twice weekly antenatal testing

starting at 32 weeks


Case 422 yo G2P2002 on PPD2 following NSVD with BPs 140s/90s. No history of hypertensive disorders. PreE labs notable for P/C ratio of 0.58.


No

> 20 Weeks

Gestation

No Yes


Pregnant?

1. What is her diagnosis?

1.2. Plans for follow up?

PostpartumPreeclampsia

Aspirin

Low dose aspirin (81 mg/day) initiated between 12 and 28 weeks (optimally before 16 weeks)

No increased risk of placental abruption, postpartum hemorrhage, mean blood loss, or adverse neonatal outcomes.

25% Risk of developing

preeclampsia

AJOG 2018 , 2020

Risk Level Risk Factors Recommendation

High History of preeclampsiaMultifetal gestationChronic hypertensionType 1 or 2 diabetesRenal diseaseAutoimmune disease

Recommend low dose aspirin if 1 or more of these high risk factors

Moderate NulliparityObesity (BMI >30)Family history of preeclampsia (1st deg)Age >35 yrsPrevious adverse preg outcomeLow birth weight or SGAMore than 10 yr pregnancy intervalAfrican American raceLow socioeconomic status

Consider low dose aspirin if patient has more than 1 of these moderate risk factors

Low Previous uncomplicated full-term delivery

Do not recommend aspirin

AJOG 2020

● Early screening for chronic hypertension and pre-eclampsia risk factors

● Low dose aspirin for the prevention of preeclampsia

● Monitor for long term effects of hypertensive disorders of pregnancy

Conclusions

References1. Pregnancy Mortality Surveillance System - CDC 2020

https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm

2. American College of Obstetrics and Gynecology ACOG Practice Bulletin No. 212: Pregnancy and Heart Disease. Obstet Gynecol 2019; 133(5) e320-e356..

3. Bellamy, L et al, Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis, 2007 BMJ Nov 10th, 335 (7677)

4. Barrett, P et al, Adverse Pregnancy Outcomes and Long-term Maternal Kidney Disease A Systematic Review and Meta-analysis, 2020, Feb 12th, JAMA JAMA Network Open. 2020;3(2):e1920964

5. Kira et al “Prenatal exposure to preeclampsia as an independent risk factor for long-term cardiovascular morbidity of the offspring” Pregnancy Hypertension 13 (2018) 181-186

6. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 220: Gestational Hypertension and Preeclampsia. Obstet Gynecol. 2020;135(6): e237-e260.

7. D. Williams “Pre-eclampsia and long-term maternal outcomes”. Obstetric Medicine 2012 Sep; 5(3): 98-104

8. Bartsch, et al “Clinical risk factors for preeclampsia determined in early pregnancy: systematic review and meta-analysis of large cohort studies” 2016 BMJ. 2016; 353: i1753. Published online 2016 Apr 19. doi: 10.1136/bmj.i1753: 10.1136/bmj.i1753



https://www-ncbi-nlm-nih-gov.offcampus.lib.washington.edu/pmc/articles/PMC4837230/?report=printable#

9. Brew, et al. “Comparison of Normal and Pre-Eclamptic Placental Gene Expression: A Systematic Review with Meta-Analysis” PLOS One 2016 DOI: 10.137/journal.pone.0161504

10. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 203: Chronic Hypertension in Pregnancy. Obstet Gynecol. 2019;133(1): e26-e50.

11. Morris RK, Riley RD, Doug M, Deeks JJ, Kilby MD. Diagnostic accuracy of spot urinary protein and albumin to creatinine ratios for detection of significant proteinuria or adverse pregnancy outcome in patients with suspected preeclampsia: systematic review and meta-analysis. BMJ 2012;345:e4342.

12. Society for Maternal-Fetal Medicine Special Statement: Checklists for preeclampsia risk-factor screening to guide recommendations for low-dose aspirin. Am J Obstet Gynecol. 2020. Vol. 223(3): pb7-b11

13. Roberge S., Bujold E., Nicolaides K.H. Aspirin for the prevention of preterm and term preeclampsia: systematic review and metaanalysis. Am J Obstet Gynecol. 2018; 218: 287-293.e1

14. Henderson JT, Whitlock EP, O’Connor E, Senger CA, Thompson JH, Rowland MG. Low-dose aspirin for prevention of morbidity and mortality from preeclampsia: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med 2014;160:695–703

References

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