should hypertensive disorders of pregnancy be considered ...€¦ · pregnancy-induced hypertension...

Should hypertensive disorders of pregnancy be

considered as a prehypertension state ?

Pr. Jacques Blacher

Paris-Descartes University ; AP-HP ; Unité HTA, prévention et

thérapeutique cardio-vasculaires, Centre de diagnostic et de thérapeutique,

Hôtel-Dieu, Paris, France

February 2018

Disclosures of Jacques Blacher:

- No financial interest in the capital of a drug

company.

- No lasting connection with a business related to

drugs (employment contract, regular pay...).

- Off interventions related businesses related to

drugs (clinical trials, scientific research, scientific

committees, expert reports, conferences,

seminars, training, participation in various

symposia, writing brochures ...) and, if applicable,

fee billing; and this with the majority of

companies selling cardiovascular medicines and

other products related to my areas of specialty

(Amgen, Astra-Zeneca, Bayer, Boehringer

Ingelheim, Bouchara, Daiichi Sankyo, Egis,

Ferring, Ipsen, Lilly, Le Quotidien du Médecin,

Medtronic, Menarini, MSD, Novartis,

Pharmalliance, Pierre Fabre, Pileje, Quantum

genomics, Sanofi Aventis, Saint Jude, Servier,

Takeda).

- HAS, ANSM, CNAM, MGEN



• Prehypertension : – Stroke risk factor ?

– CHD risk factor ?

– CV mortality risk factor - all-cause mortality risk factor ?

– Which patients ?

• Hypertensive disorders of pregnancy (pre-eclampsia) :– Hypertension and renal risk factor ?

– Stroke and CHD risk factor ?

• One more guideline : why ?

• Conclusion

Prehypertension and risk of stroke

• Huang Y et al. Prehypertension and the risk of

stroke. Neurology 2014 ; 82 : 1153-61.

• Pooled data included the results of 762,393 participants from 19

prospective cohort studies. Prehypertension increased the risk of stroke

(RR 1.66; 95% CI 1.51–1.81) compared with optimal blood pressure

(<120/80 mm Hg).

• After adjusting for multiple cardiovascular risk factors, prehypertension

is associated with stroke morbidity. Although the increased risk is

largely driven by high-range prehypertension, the risk is also increased

in people with low-range prehypertension.










• Conclusion

Definitions of hypertension during pregnancy

Pregnancy-related

hypertension

SBP ≥140 mmHg or DBP ≥90 mmHg

Mild to moderate

hypertension

SBP 140-159 mmHg or DBP 90-109 mmHg

Severe

hypertension

SBP ≥160 mmHg or DBP ≥110 mmHg

Pregnancy-induced hypertension can present as

one of the following:

• Chronic hypertension (preexisting or diagnosed

before 20 weeks gestation)

• Gestational hypertension (onset after 20 weeks

gestation) with no proteinuria

• Preeclampsia defined as onset of hypertension

(controlled or not) associated with significant

proteinuria after 20 weeks gestation.

Severe preeclampsia is associated with at

least one of the following:

• severe hypertension,

• target organ damage defined by one or more of the

following:

– oliguria <500 mL per 24 hours, or creatininemia >135

µmol/L, or proteinuria >3 g per 24 hours,

– pulmonary edema,

– persistent epigastric or right upper quadrant abdominal

pain,

– HELLP syndrome (intravascular hemolysis, hepatic

cytolysis and thrombocytopenia),

– Persistent neurological symptoms (visual disturbances,

headache, hyperactive deep-tendon reflexes, seizures),

– Retro-placental hematoma.

RECOMMENDATION N°20 - (Grade C - Class 2)

• It is suggested that a dedicated consultation

focusing on patient information and announcement

of the diagnosis of hypertension should be

programed some time after the birth for all patients

who experienced hypertension during their

pregnancy. The objectives would be:

– to explain the links between hypertension during

pregnancy and the risk of cardiovascular and renal

disease;

– to underline the importance of a coordinated

multidisciplinary care-plan, and to ensure that preventive

measures are set up, targeting lifestyle measures and the

control of cardiovascular and renal risk factors.

RECOMMENDATION N°21 (Grade B - Class 1)

• It is recommended that women who experienced

hypertension during a pregnancy should be offered:

– BP-, creatininemia- and proteinuria-monitoring;

– An assessment of the etiology of the disease;

– Evaluation and management of other cardiovascular and renal

risk factors;

– Long-term BP monitoring, even for patients whose BP returns to

normal after delivery, because of the persistently elevated risk

of cardiovascular and renal outcomes;

– Adjustment of their antihypertensive treatment if necessary.


• It is suggested that women with chronic hypertension or a

history of gestational hypertension in a previous pregnancy

should be offered a preconception checkup with a view to:

– assessing and advising the woman about the risks associated with a

new pregnancy (recurrence of hypertension or preeclampsia or intra-

uterine growth retardation, or premature birth);

– discussing the possibility of researching a possible etiology of the

patient’s hypertension before beginning a new pregnancy;

– postponing a new pregnancy in a women with severe hypertension

until the disease is controlled;

– adjusting the antihypertensive drug therapy to the potential new

pregnancy;

– suggesting a specific coordinated care-plan for a new pregnancy;

– informing the patient whether she needs to take aspirin.










• Conclusion

Conclusion

• Prehypertension : cerebrovascular and coronary risk factor

• Limited to those who will develop hypertension ?

• Hypertensive disorders of pregnancy (pre-eclampsia) :

cerebrovascular, coronary and renal risk factor

• Both situation partly neglected

Eclampsia

• Eclampsia is characterized by the occurrence

of convulsions or generalized tonic-clonic

seizures in a setting of pregnancy-induced

hypertension.

Recommendation N°1

• It is recommended that BP should be measured with the

patient seated, in a medical setting, after at least 5 minutes

rest, using an approved electronic brachial blood pressure

measuring device. (Grade A - Class 1)

• For office-measured mild to moderately high BP, hypertension

should be confirmed by measurements taken outside the

physician’s office (HBPM following the ‘rule of 3’ or daily

average of 24-hour ABPM) to exclude any possible white-coat

effect (Grade B - Class 1) (29). SBP ≥135 mmHg or DBP ≥85

mmHg, outside the physician’s office, is considered

pathological. (Grade C - Class 2)

Recommendation N°2 - (Grade B - Class 1)

• It is recommended that proteinuria should be measured at

least once a month in all pregnant women by urine collection

or by dipstick.

• A dipstick result greater than 1+ proteinuria requires

laboratory confirmation on a morning urine sample or a 24-

hour urine collection.

• Proteinuria >300 mg/24h or a proteinuria/creatininuria ratio

≥30 mg/mmol (or ≥300 mg/g) are reliable indicators of disease.

If onset occurs after the 20th week of gestation, it defines

preeclampsia in a hypertensive patient, regardless of whether

hypertension is controlled.

RECOMMENDATION N°3 - (Grade A - Class 1)

• It is recommended that treatment for severe

hypertension (SBP ≥160 mmHg or DBP ≥110

mmHg) should be initiated without delay.


• Office-measured mild to moderate hypertension

(SBP, 140-159 mmHg or DBP, 90-109 mmHg),

confirmed by HBPM or by the daytime average of

ABPM measurements (SBP ≥135 or DBP ≥85 mmHg),

a history of cardiovascular disease, pregestational

diabetes, chronic renal disease or high

cardiovascular risk in primary prevention, are all

situations where initiation of antihypertensive

treatment should be considered.

RECOMMENDATION N°5 (Grade A - Class 1)

• It is recommended that when antihypertensive

medication is prescribed, target office BP levels

should be DBP between 85 mmHg and 100 mmHg

and SBP <160 mmHg.

RECOMMENDATION N°6 - (Grade B - Class 2)

• During pregnancy, it is suggested that any one of the

following antihypertensive medications should be

used first line (presented in alphabetical order):

alpha-methyldopa, labetalol, nicardipine, or

nifedipine.

RECOMMENDATION N°7 - (Grade A - Class 1)

• Angiotensin converting enzyme (ACE) inhibitors,

angiotensin II receptor blockers (ARB) and aliskiren

must not be used at any time-point of pregnancy and

are contraindicated in the 2nd and 3rd trimesters.


• It is suggested that a Personal Pregnancy Care-Plan

notebook should be used in patients with

hypertension to ensure the best possible use is

made of the coordinated healthcare pathway (general

practitioner, hypertension specialist, obstetrics team,

and pharmacist).

RECOMMENDATION N°15

• To prevent the onset of preeclampsia, it is

recommended that low-dose (75-160 mg) aspirin

should only be prescribed to patients with a history

of preeclampsia. This treatment should be initiated

before 20 weeks gestation, ideally at the end of the

first trimester. (Grade A - Class 1)

• It is suggested that treatment with aspirin should be

continued until at least 35 weeks gestation. (Grade C

- Class 2)


• Low-dose aspirin is not currently recommended for

the prevention of preeclampsia in other high risk

populations, i.e., patients with chronic hypertension,

obesity, pregestational diabetes, chronic kidney

disease, abnormal uterine artery Doppler scan, or

those having undergone medically assisted

procreation, or screening by different biomarkers

during the first trimester.

RECOMMENDATION N° 17 - (Grade A - Class 3)

• Low molecular weight heparin, nitric oxide

(NO) donors, antioxidants (Vitamins C and E)

or physical exercise are not recommended for

the prevention of preeclampsia.


• It is suggested that the following

antihypertensive agents should be selected

for women who are breastfeeding:

– β-blockers: labetalol, propranolol;

– Calcium channel blockers: nicardipine, nifedipine;

– Alpha-methyldopa;

– ACE inhibitors: benazepril, captopril, enalapril or

quinapril, except for mothers of premature infants

or those with renal failure.

RECOMMENDATION N°19

• It is recommended that combined hormonal contraceptives

should not be prescribed prior to six weeks post-partum

because of the elevated risk of venous or arterial

thromboembolic disease. (Grade B - Class 1)

• It is recommended that non-hormonal contraceptive methods

should be prescribed for hypertensive patients with

inadequate BP control despite appropriate treatment. (Grade

B - Class 1)

• For women who rapidly become normotensive after the birth,

progestin-only contraception can be prescribed (pill, implant

or intrauterine device). (Grade B - Class 2)

• For patients who wish to use an intrauterine device, it is

recommended that this should be fitted at the post-natal visit.

(Grade B – Class 2)


• It is suggested that a dedicated consultation

focusing on patient information and announcement

of the diagnosis of hypertension should be

programed some time after the birth for all patients

who experienced hypertension during their

pregnancy. The objectives would be:

– to explain the links between hypertension during

pregnancy and the risk of cardiovascular and renal

disease;

– to underline the importance of a coordinated

multidisciplinary care-plan, and to ensure that preventive

measures are set up, targeting lifestyle measures and the

control of cardiovascular and renal risk factors.

Corinne DAVID (39 ans)

Tél. : 07 86 12 35 76 [email protected]

31, Boulevard de Valmy 92700 Colombes

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should hypertensive disorders of pregnancy be considered ...€¦ · pregnancy-induced hypertension...

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