10/27/2016 DISCLOSURES H YPERTENSION I N P REGNANCY • None TIME TO GET “ HIP ” October 27, 2016 Obstetrics & Gynecology Update: What Does The Evidence Tell Us? Lena H. Kim, MD UCSF Assistant Clinical Professor HYPERTENSIVE DISORDERS OF LEARNING OBJECTIVES PREGNANCY • Define hypertensive disorders of pregnancy • Preeclampsia • Identify associated morbidity and mortality • Gestational HTN • Review current guidelines for management • Chronic (preexisting) HTN • Discuss specific patient cases • Superimposed preeclampsia 1
10/27/2016 PREECLAMPSIA GESTATIONAL HTN • BP ≥ 140/90 x 2 • Proteinuria • HTN > 20 weeks GA – > 4 hours apart – ≥ 300 mg in 24 hours but – Protein:creatinine ≥ 0.3 • If BP ≥ 160/110 • No proteinuria – Dipstick 1+ – Minutes apart • No other features of preeclampsia • PLT < 100,000 • GA > 20 wks • CR > 1.1 or doubling • No preexisting cHTN • AST or ALT > 2X normal • Pulmonary edema and any 1 of these � • HA or visual symptoms CHRONIC HTN SUPERIMPOSED PREECLAMPSIA • BP ≥ 140/90 at one of the following times • History of cHTN – pre-pregnancy and – GA < 20 weeks • Worsening HTN in pregnancy > 20 weeks GA – > 12 weeks postpartum with • New onset proteinuria or • Other features of preeclampsia 2
10/27/2016 HIP: MORBIDITY CDC: CAUSES OF MATERNAL MORTALITY • IUGR • Placental abruption • Preterm birth #7 • Maternal seizure (eclampsia) • CVA PREGNANCY RELATED MORTALITY CDC: MATERNAL MORTALITY TRENDS • Death during pregnancy/100,000 live births – Or within 1 year of delivery if related to pregnancy – Not accidents or incidental causes • Rising maternal mortality – Doubled from 1987 to 2012 – 1987 7.2/100,000 – 2012 15.9/100,000 • 2006 CDC vital statistics – Black population maternal mortality 3.4Xs > white 3
10/27/2016 COUNTRY SPECIFIC MATERNAL GLOBAL MATERNAL MORTALITY DATA MORTALITY DATA 2015 • 1990 � 2015 Country Deaths/100,000 live births – Global maternal mortality ↓44% United States 14 – But still ~830 pregnancy related deaths/day in 2015 Uganda 343 • 2015 Maternal mortality data Canada 7 – Developed countries 12/100,000 live births United Kingdom 9 – Developing countries 239/100,000 live births – Causes: PPH, infection, preeclampsia, unsafe Mexico 38 abortions, delivery complications Guatemala 88 • 2030 Sustainable Development Agenda Goal South Korea 11 – Global maternal mortality <70/100,000 live births WHO 2015 WHO 2015 HIP GUIDELINES HIGHLIGHTS OF THE HIP GUIDELINES • Obstetrics & Gynecology • Magnesium sulfate seizure prophylaxis – November 2013; 122(5):1122-1131 – NOT for preeclampsia without severe features – Do not turn off magnesium during cesarean • ACOG task force on HTN in pregnancy • Proteinuria >5grams/24hrs – “HTN in pregnancy” 99 page document – ACOG HIP Executive Summary 10 pages – Not diagnostic of severe • Maurice Druzin, MD, Stanford • IUGR – Not diagnostic of severe • Catherine Spong, MD, NICHD • Baha Sibai, MD, UT Houston Obstet & Gynecol 2013; 122(5):1122-1131 4
10/27/2016 DIAGNOSIS OF SEVERE PREECLAMPSIA HIP: INDICATED IMMEDIATE DELIVERY • INDEPENDENT of proteinuria if ≥ 1 of: • Do NOT delay delivery regardless of BMZ if: – PLT < 100,000 – Uncontrollable severe BP – LFTs > 2x NL – Eclampsia – CR > 1.1 – Pulmonary edema – Pulmonary edema – Placental abruption – HA/visual disturbances – DIC – Abdominal pain – NRFHT Obstet & Gynecol 2013; 122(5):1122-1131 Obstet & Gynecol 2013; 122(5):1122-1131 HIP: EXPECTANT MANAGMENT HIP: GESTATIONAL HTN • You can expectantly manage until after BMZ if: • Management is the SAME as preeclampsia without severe features – PLT < 100,000 – Deliver at 37 weeks – LFTs > 2x NL – IUGR – Oligohydramnios – UA AEDF/REDF – Renal dysfunction Obstet & Gynecol 2013; 122(5):1122-1131 Obstet & Gynecol 2013; 122(5):1122-1131 5
10/27/2016 HIP: CHRONIC HTN HYPITAT • Hyp ertension and preeclampsia i ntervention t rial • Antihypertensive medication if BP >160/105 a t t erm • Goal BP when on medication 120-160/80-105 – Dutch multicenter trial, 2005-8 • Delivery at 38 weeks – Singletons 36-41 wks – N=377 IOL v. 379 expectant management – 31% v 44% poor maternal outcome • RR 0.71 (95% CI 0.59-0.86) – IOL ≥ 37 weeks GA if gHTN or preeclampsia without severe features had better maternal outcomes compared to expectant management Koopmans et al. Lancet . 2009;374(9694):979. Obstet & Gynecol 2013; 122(5):1122-1131 TREATMENT: METHYLDOPA TREATMENT: LABETALOL • β but also α-blockade • Central α-adrenergic stimulator – α1 vascular receptors � vasoconstriction • ↓Sympathe�c ou�low to heart, kidneys, vessels – β1 renal receptors � RAA system activation • Pros – β1 cardiac receptors � inotrope • Pros – Long term safety data – More uteroplacental blood flow preservation than atenolol • Cons – Faster onset of action than methyldopa (2 hrs) – Can be given IV for acute severe HTN – Slow onset of action (3-6 hrs) • Cons – Many failures – Hepatotoxicity – TID dosing – Sedative at high doses 6
10/27/2016 TREATMENT: MORE RARE MEDS TREATMENT: OTHER COMMON MEDS • Nifedipine XL • Thiazide diuretics – Pros: long acting for QD or BID dosing – Not first line – Cons: less long term data – OK to continue in cHTN patients • Fluid loss occurs in 1 st 2 weeks of treatment • Hydralazine • Clonidine – Pros: rapid IV action for acute HTN treatment – Similar mechanism as methyldopa – Cons: unpredictable hypotension, oral side effects – Pros: transdermal patch if cannot take PO • Reflex tachycardia and fluid retention – Cons: rebound HTN if stopped CONTRAINDICATED TREATMENTS TREATMENT: BREASTFEEDING • Beta blockers • ACE inhibitors – Propranolol, metoprolol, labetalol • Angiotensin II receptor blockers (ARBs) • Low transfer to breast milk (<2%) • Direct renin inhibitors – Atenolol • Fetal cardiac anomalies 1 st trimester • High transfer to breast milk with infant β-blockade • Fetal renal toxicity 2 nd and 3rd trimester • Calcium channel blockers – Low transfer to breast milk (<2%) • ACEI likely safe but risk of newborn hypotension • Diure�cs likely safe but risk of milk volume ↓ 7
10/27/2016 OTHER ACUTE TREATMENTS ALGORITHM: ACUTE SEVERE HTN Rx • Labetalol IV push over 2min, q10 min • Nifedipine 10mg PO q20min • 20 mg � 40 � 80 � 80 � 80 (max 300 mg) • NTG IV 5mcg/min � q3-5 min – Max 100 mcg/min • Lasts 3-6hrs • Hydralazine IV push over 1-2min, q20 min • 5-10 mg � 20 (max 30 mg) • Lasts 2-4hrs HIP: POSTPARTUM CARE HIP: POSTPARTUM CARE • Serial outpatient BP follow-up checks • Counseling – 72 hours – Increased risk of CV disease 2x - 9x – 7-10 days • If PTD or recurrent preE regardless of GA: – L&D triage v. OB clinic workflows needed – Annual BP, lipids, fasting glucose, BMI • Indications for PP anti-HTN medication – Baby ASA in next pregnancy 12 to 36 weeks GA – BP > 150/100 2x > 4-6 hrs apart – Treat BP > 160/110 within one hour • Readmit if BP > 160/110 and/or neuro symptoms – Magnesium x 24 hrs Obstet & Gynecol 2013; 122(5):1122-1131 Obstet & Gynecol 2013; 122(5):1122-1131 8
10/27/2016 USPSTF 2014 Ann Intern Med USPSTF • Grade B: For women at high-risk of preeclampsia • Aspirin if 2 or more moderate risk factors – Aspirin 81mg after 12 weeks GA – Nulliparity – Obesity (BMI >30) • “High-risk” if 1 or more risk factors – Family history of 1 st degree relative – History of preeclampsia, especially if adverse outcome – Low SES – Multifetal gestation – African-American – Chronic HTN – Age ≥ 35yo – Type 1 or 2 DM – >10yr pregnancy interval – Renal disease – Personal history IUGR or adverse pregnancy outcome – Autoimmune disease (SLE, APS) USPSTF Ann Intern Med 2014;161:819-826 ASPIRIN FOR PREVENTION ACOG ENDORSES USPSTF • Who? • New ACOG practice advisory July 11, 2016 – HIP guidelines v. USPSTF • Aspirin and prevention of preeclampsia • Dosing? – Low dose better than regular dose – Updated recommendations – Prostacyclin (vasodilator) > thromboxane A2 (vasoconstrictor) • ACOG endorsed the USPSTF “high-risk” list – But which low dose? 81mg v. 150mg • Timing? – Baby aspirin 81 mg daily initiated 12-28 weeks – qHS timing thought to be more effective than AM – “Moderate-risk” list • Preventing what? • Not enough data to recommend – Preeclampsia – Other adverse outcomes such as IUGR? 9
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