6/15/2017 Disclosures • Winn Lab Funded by: – NIH – Stanford Children’s Health Research Institute Preeclampsia Delivered – Stanford Cardiovascular Institute Now What? – Stanford Department of Obstetrics and Gynecology • Spouse employee of Merck Virginia D. Winn, MD, PhD Associate Professor Stanford University Department of Obstetrics and Gynecology Director of Perinatal Biology AIM Conference June 15 th , 2017 Hypertension in Pregnancy Objectives ACOG Task Force Report 2013 • Update in Definitions – • Update on current diagnosis and management of Gestational hypertension • Elevated BP (140/90) on 2 occasions 4 hr. apart after 20 weeks – Chronic hypertension preeclampsia with emphasis following delivery • Elevated BP (140/90) predates pregnancy (before 20 weeks) – Preeclampsia/Eclampsia • Understand risk of later cardiovascular disease (CVD) with • Elevated BP (140/90) with proteinuria (300mg /24 hr or PCR 0.3) OR severe feature – Preeclampsia with severe features (HELLP syndrome) • history of preeclampsia BP 160/110 2 occasions 4 hr apart • 5 gm proteinuria in 24 hour urine • Identify cardiovascular risk factors and know recommended • <100k plt, AST/ALT 2x normal, Cr >1.1, • pulmonary edema, cerebral or visual disturbances • IUGR interventions – Eclampsia • Seizure in pregnancy, not epilepsy • Be able to provide long-term health plan for patients with – Chronic hypertension with superimposed preeclampsia • Preeclampsia in woman with CHR HTN history of preeclampsia • DISCONTINUE USE OF PIH- Pregnancy Induced Hypertension • Discourage use of “mild” preeclampsia 1
6/15/2017 Management Case • Gestational HTN or Preeclampsia without Severe features – Daily symptoms and fetal movement • 35 yo AA G1P0 at 36 weeks by LMP and first – BP twice weekly – Labs weekly trimester U/S. – NST/AFI (1-2x week) and growth scan (q2-3 weeks) – Delivery at 37 weeks BMI 30 and Fx of HTN • Preeclampsia with Severe features • BP 145/92, UPC 0.32, – BMZ(<34 weeks) – Delivery by 34 weeks, sooner for certain maternal or fetal status • Labs normal, • Expectant following BMZ if BP well controlled and none of the below (occur at hospital with adequate maternal and fetal resources) • • SVE Closed/long/firm Don’t delay following BMZ (uncontrolled BP, eclampsia, pulmonary edema, abruption DIC, non-reassuring fetal status, IUFD) • Can delay 48 hr if stable but then deliver (PPROM, labor, low plt, elevated AST/ALT, IUGR, oligo, abnl Dopplers, • Ultrasound, EFW 65%, normal fluid increasing renal dysfunction) for HELLP 24-48 hr delay – Treat BP 160/110 * – MgSO4 (maintain through delivery even if C/S) ARQ#2 What is your management? ARQ #1 What is your Diagnosis? A. Gestational HTN A. Plan Induction at 37 weeks 69% B. Plan Induction at 38 weeks B. Preeclampsia without severe features 97% C. Plan Induction at 39 weeks C. Preeclampsia with severe features D. Expectant Management ‘til spontaneous D. Chronic Hypertension 26% labor but induce by 40 weeks E. Superimposed Preeclampsia 3% 1% 1% 2% 1% 0% Gestational HTN Superimposed Preeclampsia Preeclampsia without sever... Chronic Hypertension Preeclampsia with severe fe... s s s k k k . e e e . e e e . l w w w i t 7 8 9 ‘ t 3 3 3 n e t t t a a a m n n n e o o o g i i i a t t t n c c c u u u a M d d d n n n t I I I n n n n a a a a t l l l c P P P e p x E 2
6/15/2017 In labor her BP rise to 164/110 ARQ#4: What is your management? ARQ#3 Now what is the Diagnosis? A. Severe Gestational HTN A. Start IV MgSO4 76% 90% B. Preeclampsia with Severe Features B. Treat with IV labetalol C. Preeclampsia without Severe Features C. Prep for LTCS D. Chronic Hypertension D. A and B 10% E. A, B and C 0% 0% 9% 7% 4% 3% N n . o T . . H . . . i e r s e l F n a v e e e n t r S r o e t e t i v p 4 l S B C u O o C a e y d d t S o a l T s h H S n n g t L e h t e a a G i c M r t w i b o A B i n e w a f a o V l , r r p A e a i I V s h t e v s i p C r I r e p m a h P S m t t a S i a w c l l c e t e a e e r e P r r P T Management Postpartum: Management at 6 week Postpartum Visit What has changed? • Measure BP and adjust Dx if still elevated • Monitor BPs for at least 72 hrs and again at 7-10 – Chronic hypertension +/- preeclampsia days PP • Educate about risk of subsequent preeclampsia – Extend inpatient or arrange for outpatient monitoring – Educate women to start baby ASA at 12 weeks in subsequent • Avoid NSAIDs particularly in pregnancy – Severe preeclampsia • Lose weight if elevated BMI – Chronic hypertension • Screen BP and assess CVD risks starting at 6-12 months – BP remains elevated after first 24hr and then annually particularly for preterm or recurrent • Educate all patients regarding warning symptoms for preeclampsia – BP, lipids, fasting glucose, BMI preeclampsia that can develop after delivery 3
6/15/2017 Background: ASCVD in Women HDP increase risk diabetes and HTN • Danish registry based cohort • Leading cause of death among women in US • Median 16.4 years follow up – 1 in 4 deaths attributable to CAD • 782,287 women ages 15-50 with first singleton pregnancy without – 1 in 2 deaths for all forms of CVD previous CVD • Heart disease: Diabetes Hypertension − Second-leading cause of death for women 45 to 64 years HR(95% CI) HR(95% CI) − Third-leading cause of death for women age 25 to 44 No HDP 1 (ref) 1 (ref) years Gestational HTN 3.12 (2.63-3.70) 5.31 (4.9-5.75) • CVD kills almost twice as many women as all forms Mild preeclampsia 3.53 (3.23-3.85) 3.61 (3.43-3.80) of cancer combined Severe preeclampsia 3.68 (3.04-4.46) 6.07 (5.45-6.77) Lykke et al., Hypertension 2009 Preeclampsia: future risk CVD 2011 CVD prevention Systematic Review and Meta-analysis CVD RR 95% CI Studies Mean follow-up Outcome included Hypertension 3.70 2.70-5.05 14 14 years CHD (fatal/nonfatal) 2.16 1.86-2.52 8 11.7 years Pregnancy provides a unique opportunity to estimate a woman ’ s lifetime Stroke (fatal/nonfatal) 1.81 1.45-2.27 4 10.4 years • VTE 1.19 1.37-2.33 3 10.4 years risk • - Recurrent preeclampsia: 7-fold increased risk for HTN Referral to primary care provider or cardiologist so risk factors can be -Preeclampsia before 37 wks carefully monitored and controlled. • -8-fold increased risk for CHD (2 studies) History of preeclampsia, GDM, Gestational HTN is considered major risk -5-fold increased risk for stroke factor Bellamy, L. et al. BMJ 2007 Mosca et al., Circulation 2011 Brown et al. 2013; Wu et al, 2017 4
6/15/2017 ASCVD Risk Calculator from ACA 2014 stroke prevention http://tools.acc.org/ascvd-risk-estimator/ • Several smart phone apps available Variable Value 1 Age 35 (40) Sex F Race AA Total Cholesterol 200 10-year Lifetime LifetimeW ASCVD ASCVD ith PreE HDL Cholesterol 45 Risk Risk Hx • Consider evaluating all women starting 6 months to 1 year post partum, as well as those SBP 120 Actual NA (0.8%) 27% 54% who are past childbearing age, for a history of preeclampsia/eclampsia and document Risk (27%) their history of preeclampsia/eclampsia as a risk factor Treatment for HTN N Risk with NA (0.4%) 8% 16% • DM N Clinicians are not aware of the association between adverse pregnancy outcomes and Optimal (8%) Factors CVD and stroke. Smoker N * Assumes LDL-C 70-189 mg/dL Definition of Heart Failure Risk Reduction Options AMERICAN COLLEGE OF CARDIOLOGY/AMERICAN HEART ASSOCIATION • Stage A: At least one condition strongly associated with heart failure (HF) • Quit smoking – No identified structural or functional – no signs or symptoms of HF • Work toward BMI<25 • Stage B: – no known signs or symptoms • DASH diet/ AHA diet – LV concentric remodeling, LV hypertrophy, mildly impaired systolic function • Regular Exercise (EF<55%) or valvular disease • Stage C: – Current or prior symptoms of HF • Breastfeeding (Schwarz et al 2009, Rajaei et al. 2016) – underlying structural heart disease. • Baby ASA • Stage D: – Advanced structural heart disease, • Statins – marked symptoms of HF at rest despite maximal medical therapy. 5
6/15/2017 Heart Failure Risk Reduction Hx of Preeclampsia • Exercise 20 to 45 minutes several times a week and • Ace inhibitors/ ARB Prehypertension • Beta blocker Have Highest OR for HF Class B • BNP to monitor HF Ghossein-Doha, C. et al 2017 Ghossein-Doha, C. et al 2017 Breetveld et al, 2017 Risk factors that overlap for preeclampsia and Is it the chicken or the egg? CVD • Is increased future CVD risk due to underlying • Chronic hypertension biologic traits of the mother or exposures • Diabetes during pregnancy? • Obesity • Perhaps both • Insulin resistance • Dyslipidemia • Systemic inflammation Bushnell, C et al., Stroke Research and Treatment 2011 Powe et al., Circulation 2011 6
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