Hypertensive Disorders in Pregnancy Part 1: ACOG Management Recommendations

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Learn about ACOG recommentations  for the diagnosis and management of different types of hypertension in pregnancy.

Background 

From Preeclampsia.org:

“Preeclampsia (pre-e-CLAMP-si-a) is a condition unique to human pregnancy. It is diagnosed by the elevation of the expectant mother’s blood pressure usually after the twentieth week of pregnancy combined with the appearance of excessive protein in her urine. Important symptoms that may suggest preeclampsia are headaches, abdominal pain, shortness of breath or burning behind the sternum, nausea and vomiting, confusion, heightened state of anxiety and/or visual disturbances such as oversensitivity to light, blurred vision, seeing flashing spots or auras. Preeclampsia and related hypertensive disorders of pregnancy impact 5-8% of all births in the United States.

Most women with preeclampsia will deliver a healthy baby and fully recover. However, some women will experience complications, several of which may be life-threatening to mother and/or baby. A woman’s condition can go from a mild form of preeclampsia to severe preeclampsia very quickly.

Preeclampsia and other hypertensive disorders of pregnancy can be devastating diseases, made worse by delays in diagnosis or management, seriously impacting or even killing both women and their babies before, during or after birth.”

This review will focus on the American College of Obstetricians and Gynecologists (ACOG) task force report on the management of hypertensive disorders in pregnancy. These include Chronic Hypertension (CHTN), Gestational Hypertension (GHTN), Preeclampsia (preE), and Chronic Hypertension with superimposed preeclampsia (CHTN with superimposed preE). The task force released their recommendations in 2013 after finding special issues in the management of these diseases that warrant extra attention.

Hypertension in Pregnancy

The American College of Obstetricians and Gynecologists. Hypertension in Pregnancy. Obstetrics and Gynecology, 2013;122:1122-1131

Classification of Hypertensive Disorders in Pregnancy

  • PreE: BP>140/90 x 2 at least 4 hours apart. The task force has eliminated dependence on proteinuria for diagnosis if signs of other organ involvement occur (see diagnosis of severe preE). Proteinuria is defined as >300mg of protein in a 24hr urine collection, or a protein/creatinine ratio >0.3. Dipstick measurement of protein is discouraged.
  • CHTN: hypertension that predates pregnancy
  • CHTN w/ superimposed preE: preE that develops on top of CHTN
  • GHTN: BP elevation after 20 weeks without proteinuria or systemic findings

Establishing the Diagnosis of Severe Preeclampsia

  • Systolic BP >160 or diastolic BP >110 x 2 at least 4 hours apart while the patient is on bedrest
  • Thrombocytopenia (platelet count <100,000)
  • Impaired liver function (elevated liver enzymes, severe persistent right upper quadrant or epigastric pain)
  • Progressive renal insufficiency (serum creatinine >1.1)
  • Pulmonary edema
  • New onset cerebral or visual disturbances

*Massive proteinuria >5g has been removed from the requirements of diagnosis of severe preE, as has fetal growth restriction

Prevention of Preeclampsia

  • Antioxidants C and E are ineffective
  • Calcium may be useful to reduce the severity in populations with low calcium intake, but this is not relevant in the US
  • There is no evidence that bed rest or salt restriction reduce preE risk
  • Low dose aspirin (60-80mg) appears to slightly reduce preE and adverse outcomes, especially in high risk women (those with early onset preE and preterm delivery at <34 wks, preE in more than 1 prior pregnancy). Begin administration in the late first trimester.

Management of PreE and HELLP Syndrome

Reviews of data show that deaths could be prevented if healthcare providers remained alert to the likelihood that preE will progress. Intervention in acutely ill women is sometimes delayed because of the absence of proteinuria. The amount of proteinuria found has no prediction of maternal or fetal outcome. For these reasons, proteinuria has been removed as a requirement for diagnosis as well as monitoring the severity of preE.

  • For GHTN or preE without severe features, it is suggested:
    1. daily fetal kick counts, 2x/wk BP checks, and weekly platelet and liver enzyme checks
    2. Persistent BP <160/110, antihypertensive medications should not be administered
    3. Strict bed rest should not be prescribed
    4. Use of ultrasound to assess fetal growth and antenatal testing [nonstress test or biophysical profile] is suggested
    5. If evidence of growth restriction, umbilical artery Doppler velocimetry is recommended
    6. Expectant management is recommended prior to 37 weeks with maternal and fetal monitoring if no indication for delivery
    7. Delivery at 37 weeks is recommended rather than expectant management
    8. For BP <160/110 and no maternal symptoms, magnesium sulfate should not be universally administered
  • For Severe PreE:
    1. Those >34 weeks, delivery soon after maternal stabilization is recommended
    2. Antihypertensive therapy is recommended for sustained BP >160/110
    3. Delivery decision SHOULD NOT be based on the amount of proteinuria or a change in the amount of proteinuria
    4. Before fetal viability, delivery after maternal stabilization is recommended. Expectant management is not recommended.
    5. Corticosteroids should be administered and delivery DELAYED for 48 hrs if STABLE and a viable fetus at <34 weeks with any of the following:
      • Preterm premature rupture of membranes
      • Labor
      • Platelet count <100,000
      • Abnormal liver enzymes
      • Fetal growth restriction <5%tile
      • Severe oligohydramnios (AFI <5cm)
      • Reverse end diastolic flow on umbilical artery Doppler
      • Renal dysfunction
      • HELLP syndrome
    6. Corticosteroids should be administered if fetus is viable and <34 wks, but delivery SHOULD NOT BE DELAYED after initial maternal stabilization REGARDLESS OF GESTATIONAL AGE for severe preE complicated further by:
      1. Uncontrollable severe HTN
      2. Eclampsia
      3. Pulmonary edema
      4. Placental abruption
      5. Disseminated intravascular coagulation
      6. Nonreassuring fetal status
      7. Fetal demise
    7. Administration of intrapartum magnesium sulfate is recommended
    8. Magnesium should be continued in a woman undergoing cesarean delivery
    9. Epidural or spinal anesthesia is recommended
  • Postpartum
    1. BP should be monitored in the hospital for 72 hours and again at 7-10 days or earlier in women with symptoms
    2. All women (not just those with preE) should be educated prior to discharge about the signs and symptoms of preE
    3. Women who present postpartum with new onset HTN associated with headaches or blurred vision, administration of IV magnesium sulfate is recommended
    4. Antihypertensive therapy is recommended with persistent postpartum BP >150/100 x 2 at least 4 hours apart

Chronic Hypertension and Superimposed Preeclampsia

  1. For pregnant women with Chronic Hypertension:
    1. For pregnant women with CHTN and poorly controlled BP, the use of home monitoring is suggested
    2. Weight loss and low sodium diets should NOT be used to manage CHTN in pregnancy
    3. Antihypertensive medication should be started with persistent BP >160/110. BP should be maintained between 120-160/80-105.
    4. BP <160/110 and NO evidence of end organ damage, antihypertensive medication is NOT recommended
    5. Recommended medications for BP management in pregnancy are labetalol, nifedipine, and methyldopa
    6. Those with CHTN who are at increased risk of preE (history of early onset preE and preterm delivery at <34 weeks, or preE in more than 1 prior pregnancy) should be started on daily low dose aspirin (60-80mg) in the late first trimester
    7. Use of ultrasound to screen for fetal growth restriction is recommended. If evidence of growth restriction, umbilical artery dopplers should be done
    8. Antenatal testing should be started in those with CHTN complicated by need for medication, other underlying medical conditions, fetal growth restriction, or superimposed preE
    9. Delivery is NOT recommended before 38 weeks as long as there are no additional maternal or fetal complications
  2. Pregnant women with Chronic Hypertension with Superimposed Preeclampsia
    1. See Severe PreE recommendations

Later in Life Cardiovascular Disease

  1. PreE places women at increased risk of cardiovascular (CV) disease later in life
  2. Pregnancy history should be part of the evaluation of CV risk in women
  3. For women with a history of preE requiring delivery <37 weeks, or who have a history of recurrent preE, yearly assessment of BP, lipids, fasting blood glucose, and BMI is suggested

 

For me, the biggest “take aways” are:

  1. Proteinuria is no longer required for the diagnosis of severe preeclampsia. It can aid in differentiating mild preE from GHTN in an otherwise asymptomatic woman. Protein can be negative but the woman can still have severe preeclampsia if she is showing other symptoms of organ involvement.
  2. Steroids are recommended for babies <34 weeks to help mature the lungs in patients with preE
  3. Delivery is recommended at 37 weeks if a patient is stable with preE
  4. Low dose aspirin should be started at the end of the first trimester for women at high risk of developing preE
  5. Growth ultrasounds and antenatal testing (nonstress tests or biophysical profiles) are recommended for all classes of hypertensive disorders in pregnancy

Please keep in mind if you are pregnant that these are recommendations put forth by ACOG. Preeclampsia is very serious, and can progress quickly. That being said, no one can force you to do something that you are not comfortable with. Your plan of care must be individualized between you and your care provider, and you ultimately have the final say.

2 thoughts on “Hypertensive Disorders in Pregnancy Part 1: ACOG Management Recommendations”

  1. Hi! I have a question for a friend of mine who is pregnant with previous BP problems. Her BP went up to about 130ish/100-ish and has gone back down for the most part after drinking turmeric and cinnamon tea. Her OB said the baby is growing fine for dates, yet he wants to do 2 ultrasounds a week from here on out and induce at 38 weeks and has already scheduled it. So my question is, why so many ultrasounds when I constantly read about how they are inaccurate in determining fetal size and weight and amount of fluid in the third trimester? I know it’s ACOG recommended, but why? It never says how many should be conducted or how often, either. I’m so confused and no one can show me scientific evidence to support this plan of care.

    1. I can’t speak for the other provider, but my guess would be that the ultrasounds they’re doing twice a week are biophysical profiles (BPPs) or an amniotic fluid index (AFI). These measure fluid and look at other measurements like practice breathing and tone. They are not measuring growth. Growth US are usually done every 3-4 weeks. While there are some inaccuracies, they give a general idea of fetal wellbeing. Hope that helps!

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