Recent update to management of Hypertensive disorders of pregnancy based upon ACOG 2019 , ISSHP 2018 , CANADA 2018 guidelines

1. Assistant Lecturer
OB/GYN Department
Benha Faculty of Medicine
2019

2.  New concepts in an age-old disease is
needed ?!!!!
 Updated Classification
 Diagnosis
 Risk factor & Prediction
 Prevention
 Management
 Hypertensive Emergency : How to
manage?!
 Postpartum hypertension
Items to be discussed

4. Clinical picture is not always clear.
Multi-system disorder of unknown etiology.
Onset is unpredictable.
Nothing has changed…

5. Assessment of the severity/ prognosis is difficult.
Timely decision can be critical both for mother and
fetus, and surely brings Peace of mind for physicians
The therapy is ONLY symptomatic
Giving birth STILL REMAINS the only causal therapy.
Risk of post partum fits , HELLP still present , even
may be “ new – onset ‘’
Nothing has changed…
Efficient prevention and
screening are still missing

6. Among Top 3 Causes of
Maternal mortality

7. ALERT

9. 2013

10. PIH
Updated Classification of
Hypertensive disorders of
pregnancy ( ACOG,2013)
PIH

11. 2018

12. 2018

13. 2018

14. 2018

15. 2019

16. HDP is defined as hypertension in pregnancy.
Eclampsia was removed from the major
classification.
Chronic hypertension was added to the major
classification.
If pregnant women with new onset of hypertension
have either maternal organ dysfunction or
uteroplacental dysfunction, they should be
diagnosed with preeclampsia, even in the
absence of proteinuria.
PIH
Major changes of
new classification
PIH

17. The severity classification should be ‘severe’ when
hypertension is severe, or when hypertension is mild
but there is maternal organ dysfunction or uterine
placental dysfunction. The term ‘mild’ was
excluded from the criteria of HDP because it
can be misinterpreted to mean ‘not at high
risk’.
The definition of ‘early onset type’ is that which
appears earlier than 34 weeks gestation, in
accordance with international standards.
PIH
Major changes of
new classification
PIH

18. PIH
The New Vs. the Old
classifications
PIH
 Pre-eclampsia does not require the presence
of proteinuria for Dx.
 Pre-eclampsia may be diagnosed if HTN+
– Thrombocytopenia (PLTs<100k)
– Liver injury (ALT/AST > x2 UNL)
– Renal dysfunction (SCr>1.1 or x2 from baseline)
– Pulmonary edema
– New onset cerebral or visual disturbances

20.  systolic BP ≥140 and/or diastolic BP ≥90 mm Hg.
 Repeated to confirm true hypertension.
 Severe BP (systolic BP ≥160/110 mm Hg), then the BP should
be confirmed within 15 minutes
 Less severe BP, repeated within a few hours.
 Use a liquid crystal sphygmomanometer .If unavailable,
validated calibrated automated device.
 confirmed by 24-hour ABPM or home BP monitoring
Hypertension

21.  not required for a diagnosis of preeclampsia.
assessed initially by automated dipstick urinalysis, if
not available, careful visual dipstick urinalysis
If positive (≥1+, 30 mg/dL), then spot urine
protein/creatinine (PCr) ratio
PCr ratio ≥30 mg/mmol (0.3 mg/mg) is abnormal.
 Negative dipstick accepted, not require PCr.
 24hr urine collection still gold standard
Urine albumin/creatinine ratio (UACR) Quantifies
urine albumin Steps toward standardization
Massive proteinuria (>5 g/24 h) is associated with
more severe neonatal outcomes
Proteinuria

22. high BP predating the pregnancy or recognized at
<20 weeks’ gestation.
often diagnosed at the first or early booking visits.
should be confirmed by 24-hour ABPM or home
BP monitoring, or at minimum, after repeated
measurements over hours at the same visit
The majority because of essential hypertension
White-coat hypertension not an entirely benign
condition..
Masked hypertension more difficult to diagnose
1.Chronic Hypertension

23. Persistent de novo hypertension that develop at or
after 20 weeks’ gestation in the absence of features
of preeclampsia
Of women with apparent gestational hypertension,
about ⅓ develop preeclampsia
maternal and fetal outcomes are usually normal
High risk of chronic hypertension later in life
2.Gestational Hypertension

24. 3.Preeclampsia

25. Develop in 25 % of women with chronic hypertension
higher in women with underlying renal disease.
Experience a sudden exacerbation of hypertension
(not sufficient alone)
Develop maternal organ dysfunction
New-onset proteinuria
Increase in proteinuria in proteinuric renal disease
4. Chronic Hypertension with Superimposed
Preeclampsia ( CHSP)
Diagnosis

26. Severe Preeclampsia

27.  Eclampsia
 HELLP syndrome
 Pulmonary Edema
 Placental Abruption
 Cerebral Hemorrhage
 Cortical Blindness
 DIC
 Acute Renal Failure
 Hepatic Rupture
Crises in Preeclampsia

28. Early Vs. Late Preeclampsia

30. No single test or set of tests can reliably
predict the development of preeclampsia
the routine clinical use of rule-in or rule-out tests
not recommended
PlGF or sFlt-1 [soluble fms-like tyrosine kinase-
1]/PlGF ratio for preeclampsia continue to be evaluated
Prediction

31.  History of preeclampsia,
especially when accompanied
by an adverse outcome
 Multifetal gestation
 Chronic hypertension
 Type 1 or 2 diabetes
 Renal disease
 Autoimmune disease
( SLE, antiphospholipid
syndrome)
Risk Factors ( ACOG, 2019)
High
 Nulliparity
 Obesity (BMI > 30)
 Family history of preeclampsia
(mother or sister)
 Sociodemographic
characteristics (African American
race, low socioeconomic status)
 Age 35 years or older
 Personal history factors
(LBW, SGA, Previous adverse pregnancy
outcome, > 10-year pregnancy interval)
moderate

32. supplemental calcium (1.2–2.5g/d)
Low molecular weight heparin is not indicated
exercise during pregnancy
low salt diet
low-dose aspirin ( preferred dose 81 - 150 mg)
High risk patient
Ideally before 16 weeks but definitely
before20 weeks to prevent preterm but not
term preeclampsia.
Prevention
Aspirin prophylaxis

33. Prevention ( ACOG , 2019)

35. To maintain BP in the range 110-140/80-85 mmHg.
Home BP monitoring adjunct to clinic visits
Home device accuracy against a sphygmomanometer
Monitor for developing preeclampsia using
urinalysis at each visit with clinical assessment
Blood tests at 28 and 34 weeks as a minimum.
Indications for delivery similar to preeclampsia
if superimposed
No such indication, delivery at 39 weeks
Chronic Hypertension

36. Chronic Hypertension

37. White-Coat Hypertension

38. Gestational hypertension
Preeclampsia without severe features
ACOG,2019 Level A Recommendation

39. Gestational Hypertension

40. Preeclampsia

41.  Uncontrolled severe BP
( not responsive to antihypertensive )
 Persistent refractory headaches
 Epigastric pain or right upper pain Persistent
 Visual disturbances, motor deficit or altered sensorium
 Stroke
 Myocardial infarction
 HELLP syndrome
 New or worsening renal dysfunction
 Pulmonary edema
 Eclampsia
 Suspected acute placental abruption or
vaginal bleeding in the absence of placenta previa
NO Expectant Management (ACOG,2019)
Abnormal fetal
testing
 Fetal death
 Fetus without
expectation for
survival at the time of
maternal diagnosis
( lethal anomaly,
extreme prematurity)
 Persistent reversed
end-diastolic flow in
the umbilical artery
FetalMaternal

42. Severe Preeclampsia

43. At 1st Dx of PE Fetal biometry , EFW, AFI
assessment, and fetal Doppler waveform performed
In confirmed preeclampsia serial evaluation of
fetal growth, AFI and UA Doppler 24 weeks’ gestation
Fetal growth no more than at 2 WK intervals.
More frequent ultrasound measurements if there is
high UA RI or absent or reversed end-diastolic flow.
Prenatal corticosteroids for fetal lung maturation
given between 24+0 and 34+0 weeks
Multiple steroid courses not recommended.
MgSO4 for fetal neuroprotection should be
administered in gestations before 32 weeks.
Fetal Monitoring and Management

44. started with BP ≥ 150/100 mm Hg.
 The medical provider must be familiar with the dose , the
onset of action, and potential side effects
Nifedipine should not be given sublingually.
ACEi & Ag receptor blockers contraindicated
Chronic hypertensive women should be switched to
safer antihypertensive during pregnancy
Antihypertensive therapy

45. Antihypertensive therapy

46. Antihypertensive therapy

47. Labetalol ( 1st Line Drug )

48.  24 hours for complete action.
 May needs to be taken three or four times daily
 Common side effects are postural hypotension,
constipation, galactorrhea, postpartum depression
and altered sleep pattern.
 It also causes headache, which can be confused with
impending eclampsia
 Hematological manifestations include hemolysis and
thrombocytopenia on blood smear and false positive Coomb’s test in
10% cases.
 It causes falsely non-assuring fetal heart patterns
 Alpha-methyldopa accumulates in renal failure,
which can sometimes complicate preeclampsia
ALPHA-METHYLDOPA why not 1st ?!

49. Labetalol : why 1st ?!

50. Management 2018

52. Hypertensive Emergency
(1st Line Therapy)

53. Antihypertensive for
Urgent BP Control

54. Hypertensive Emergency
(2nd Line Therapy)

55. Hypertensive Emergency
(Monitoring)

56. Hypertensive Emergency
(Manage once patient stabilized)

57. Hypertensive Emergency
(Documentation Guidelines)

59. Postpartum care (INPATIENT)

60. Postpartum care (Discharge)

61. Postpartum care (Post Discharge)

62. 09- Jul-18 Dr Shashwat Jani.
+919909944160. 63