PIH HDP PEC PET PE Pre-E PIH I dont. The Joint Comm... - - PowerPoint PPT Presentation

Update on Hypertension in Pregnancy

June 13, 2019 Christian Pettker, MD

Chief of Obstetrics Associate Chief Quality Officer Yale-New Haven Hospital and Yale School of Medicine

@cmpettker christian.pettker@yale.edu

Objectives & Disclosure

− Participants will be able to: − Describe the latest guidelines for classification and diagnosis of preeclampsia − Explain details of the management of preeclampsia and chronic hypertension − Discuss specific cases related to hypertensive disorders in pregnancy − I have nothing to disclose.

How do you abbreviate preeclampsia?

• A. PEC
• B. PET
• C. PE
• D. Pre-E
• E. PIH
• F. I don’t. The Joint

Commission is here.

PEC PET PE Pre-E PIH I don’t. The Joint Comm...

9% 4% 12% 14% 58% 2%

History

− 1972: ACOG Committee on Terminology − “Pregnancy induced hypertension” (PIH) − 1999-2000: National High Blood Pressure Education Program Working Group (NHBPEP) − 2000: ACOG recommends against use of “PIH” − 19 years ago!!!

PIH

“HDP”

2013: ACOG Hypertension in Pregnancy Task Force

− “With severe features” − Urine protein/creatinine ratio − Outpatient mgmt. of GHTN + PEC − Gest HTN: deliver 37w − CHTN: deliver 38w (or later) − PEC with severe features: − 105 mm Hg diastolic − BP 4 hours apart − Serum creat ≥1.1 (or 2x nl) − FGR not in criteria − Magnesium not universally needed − Low dose ASA for prevention − No NSAIDs!

January 2019

6

“HDP”: A leading cause of morbidity/mortality

− Preeclampsia: 2-8% of pregnancies globally − 25% increase in US from 1987 to 2004 − Chronic HTN: 0.9-1.5% of pregnancies − 67% increase from 2000 to 2009 − 16-18% of all maternal deaths in US − 15% of premature births in industrialized countries − $2.18 billion estimated cost in US for 12 months after delivery ($1.03 billion maternal cost)

“HDP”: A quality of care problem

− A leading cause of morbidity/mortality − Approximately 50% of mortalities are considered preventable − Delays in presenting for care − Missed or misinterpreted clinical information − Delays in diagnosis − Often misidentified signs/symptoms or other evidence − Delays in therapy

Patient #1

Your new OB patient for the day is a cardiology fellow. She is 8 weeks of gestation and she tells you she has a history

• f stage I hypertension. She reports her blood pressures

were as high as 130s/80s last year, when she was diagnosed, and that she started on labetalol 100mg BID, as she was planning a pregnancy. Her blood pressure at intake is 134/82. − What are your thoughts about her blood pressures and their impact on pregnancy?

What about elevated BP & stage 1 CHTN?

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Stage 1 Hypertension (ACC/AHA)

− Men + women with BP 130-139 SBP or 80-89 DBP have modifiable long-term cardiovascular risk − These patients will now be treated; we may see more pregnancies treated as hypertensive − Sutton et al ONG 2018 − Higher risk of preeclampsia, gestational diabetes, indicated preterm birth − ASA does not appear to reduce this risk

Stage 1 Hypertension (ACC/AHA)

Keep her on her medications?

• A. Yes
• B. No
• What type of baseline tests?
• Surveillance?

Yes No

5% 95%

Patient #2

You are following a patient who you diagnosed with gestational hypertension at 32 weeks of gestation. You have been following her with weekly visits, NSTs, and laboratory evaluation. Today, at 35 1/7 weeks of gestation, she had a blood pressure of 162/100 and was referred to the triage unit for further evaluation, revealing − Repeat blood pressures 164/90 − ‘Normal’ creatinine, LFTs, platelets − Urine P/C ratio 0.05 − What is your management plan?

2013 Classification System

1. Chronic hypertension 2. Gestational hypertension 3. Preeclampsia

• without severe features
• with severe features

4. Chronic hypertension with superimposed preeclampsia

• without severe features
• with severe features

Gestational Hypertension, with “severe range” BPs

− Point 1: Treat the blood pressure.

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Gestational Hypertension, with “severe range” BPs

− Point 2: Treat as preeclampsia with severe features − Magnesium? − Delivery planning? − Mode of delivery?

Patient #3

Your patient with essential chronic hypertension has been managed with labetalol her entire pregnancy. She started

• n 200mg BID but at 28 weeks her blood pressures were

rising above 160/110 and her labetalol increased steadily

• ver time.

Today, she is 36 4/7 weeks of gestation and her blood pressure is 180/115. How do tell if this is preeclampsia?

Diagnosing Superimposed Preeclampsia

− Importance of baseline screening − Baseline creatinine − Baseline proteinuria − Consider pathophysiology of hypertension − SLE? Primary Renal? Intoxication? − Other labs? − Uric Acid − Hematocrit − Response to treatment

Patient #4

Your patient with chronic hypertension on labetalol 200mg TID presents is referred by your colleague at 36 3/7 for elevated blood pressures. In triage, BP is 165/95 and when repeated is 155/90. In the first trimester her 24 hour urine showed 100mg of protein. Given her rise in blood pressure, you send laboratory tests, including a urine protein/creatinineratio. UPC comes back at 0.29. What is the utility of this test? Is this preeclampsia?

What is the utility of urine protein/creatinine ratio?

− Protein/creatinine ratio is a spot urine test − Protein excretion varies during the day − With activity − Especially during pregnancy − < 0.13 to 0.15 very sensitive to rule out preeclampsia − Papanna et al ONG 2008 (90-98% sensitivity) − Morris et al BMH 2012 (85-93% sensitivity)

Patient #5

Your 33 year old nulliparous patient with chronic hypertension is 34 weeks of gestation and seeing you for a routine prenatal visit. Her blood pressure has been well controlled on labetalol 200mg BID her whole pregnancy. Her baseline studies (EKG, urine protein, serology/hematology) were all normal. She has been having normal weekly testing and fetal ultrasounds, including She is asking about her delivery plan. When do you deliver?

• A. 37 weeks
• B. 38 weeks
• C. 39 weeks
• D. 40 weeks?

3 7 w e e k s 3 8 w e e k s 3 9 w e e k s 4 w e e k s ?

12% 0% 43% 45%

Controlled CHTN: delivery at 37w, 38w, or 39w?

ACOG CO 764

Controlled CHTN: delivery at 37w, 38w, or 39w?

− Planned delivery prior to 39w is associated with a lower risk of developing preeclampsia with severe features − 10% v. 1% absolute risk (adj OR 0.07, 95%CI 0.01-0.5)

− Harper LM. ONG 2016 (retrospect cohort)

− Routine induction 38w vs. 39w lowers risk of superimposed PEC and eclampsia, with no increased risk

• f CD

− Ram M. ONG 2018 (retrospective cohort)

Patient #6 Your patient has just delivered by cesarean. She had two prior cesareans and was 35 weeks of gestation, with preeclampsia with severe features. She is on magnesium for seizure prophylaxis. Your nurse is asking what you would like to give for pain control. What is your approach?

• A. Routine (NSAIDs/Tylenol/Oxycodone)
• B. Anything but NSAIDs

R

• u

t i n e ( N S A I D s / T y l e n

• .

. . A n y t h i n g b u t N S A I D s

38% 62%

“I can’t give my patient NSAIDs?”

ACOG Task Force (2013)

“Overall, data support the safe use of NSAIDs in postpartum patients with blood pressure issues.”

− RCT of ibuprofen v. acetaminophen in preeclampsia with severe features: no prolongation of severe-range blood pressures

(Blue NR et al. AJOG 2018)

− Cohort study of 399 patients with preeclampsia with severe features; no difference in hypertensive episodes, renal injury, ICU admission, pulmonary edema

(Viteri OA et al ONG 2017)

− Cohort study of postpartum patients on magnesium for preeclampsia; no increased antihypertensive requirements.

(Wasden SW et al Pregnancy Hypertens 2014)

http://tmedweb.tulane.edu/pharmwiki/doku.php/nsaid_side_effects

ACOG PB 203 (2019)

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