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Hypertension in Pregnancy: Clarifying What to Do and When to Do It

Guideline Watch |
November 21, 2013

Hypertension in Pregnancy: Clarifying What to Do and When to Do It

  1. Allison Bryant, MD, MPH

ACOG's Task Force on Hypertension in Pregnancy updates recommendations for diagnosis and management.

  1. Allison Bryant, MD, MPH

Sponsoring Organization: American College of Obstetricians and Gynecologists (ACOG)

Target Population: Obstetric care providers

Background and Objective

Guided by the latest evidence, ACOG's Task Force on Hypertension in Pregnancy has updated its diagnostic and therapeutic recommendations. The report includes clarifying points as well as paradigmatic shifts.

Key Points and Recommendations

Diagnosis and Classification

  • Hypertensive disorders remain classified as preeclampsia–eclampsia, chronic hypertension, chronic hypertension with superimposed preeclampsia, and gestational hypertension.

  • The requirement of proteinuria for diagnosing preeclampsia has been abandoned: Hypertension with associated laboratory abnormalities, pulmonary edema, or neurologic symptoms — even in the absence of proteinuria — should be considered indicative of preeclampsia.

  • A urinary protein:creatinine ratio ≥0.3 is a diagnostic criterion for preeclampsia.

  • No level of proteinuria should be used as a defining standard for severe preeclampsia.

Management of Chronic Hypertension

  • Blood pressures (BPs) persistently above 160/105 should be treated to goals between 120/80 and 160/105.

  • Ultrasound screening for fetal growth restriction is appropriate; antenatal fetal surveillance should be performed in women who require antihypertensive therapy or who have superimposed preeclampsia or fetal growth restriction.

Management of Preeclampsia

  • Antihypertensive medications should not be administered unless BPs are persistently above 160/110.

  • Women with mild gestational hypertension or with preeclampsia lacking severe features (the preferred terminology over “mild preeclampsia”) should be expectantly managed before 37 weeks' gestation.

  • For women with severe preeclampsia before 34 weeks and stable maternal and fetal status, expectant management in appropriate care settings can be pursued; for those with laboratory abnormalities, fetal growth restriction, or preterm labor, planned delivery should be delayed for 48 hours to permit a complete course of antenatal steroids; for those with maternal or fetal instability, delivery should be initiated without delay.

  • Expectant management is not recommended for women with severe preeclampsia preceding fetal viability.

  • Magnesium sulfate should be administered intrapartum–postpartum to women with severe preeclampsia.

  • When preeclampsia is diagnosed postpartum and is accompanied by neurologic symptoms or severe hypertension, magnesium sulfate should be administered.

  • In women with gestational hypertension and/or preeclampsia, BP should be monitored for at least 72 hours postpartum and again 7 to 10 days after delivery.

Prevention of Preeclampsia

  • Women with histories of preeclampsia that is recurrent or has previously developed before 34 weeks should be offered daily low-dose aspirin commencing at the end of the first trimester.

  • Bed rest is not recommended for prevention or treatment of preeclampsia.

Ongoing Healthcare for Women with Histories of Preeclampsia

  • Given their increased risk for cardiovascular disease, women who have experienced early or recurrent preeclampsia should have yearly assessments of BP, lipids, fasting glucose, and body-mass index.

What's Changed

  • Proteinuria is no longer required to make a diagnosis of preeclampsia when hypertension occurs with one or more severe features of this condition; however, when proteinuria is used among other diagnostic criteria for preeclampsia, a protein:creatinine ratio of at least 0.3 is sufficient.

  • Magnesium sulfate is now only recommended for women with preeclampsia with severe features.

Comment

Although the strength of some of these suggestions for managing hypertensive disorders during pregnancy is tempered by the quality of the evidence behind them, I believe that, overall, the American College of Obstetricians and Gynecologists has produced a thorough and practical document. Guidelines clarifying the role of proteinuria in diagnosing preeclampsia, opposing bed rest as a therapy, and specifying appropriate use of magnesium for seizure prophylaxis should alter the practices of many clinicians. The task force is to be lauded for recognizing pregnancy as a window to future health while making recommendations for women at risk for later cardiovascular complications.

  • Disclosures for Allison Bryant, MD, MPH at time of publication Nothing to disclose

Citation(s):

Reader Comments (5)

Robert Bone MD Physician, Surgery, General, Vanderbilt University,School of Medicine,Department of Surgery

Daughter with severe eclampsia with C section at 37 weeks yielding male infant with autism

moamin Physician

A recent task force from ACOG ( included high risk OB, anesthesiologists, nephrologists) in 2013 re-evaluated the definition and concept of using proteinuria in the diagnosis of pre-eclampsia. Proteinuria is not going to be considered a hard finding anymore for the diagnosis of pre-eclampsia. The ACOG felt that this would delay diagnosis in many cases. The entire report is found here.
Proteinuria seemed to have been down graded in many instances in the report.

Diagnosis:

BP criteria remained
Proteinuria over 5gm has been eliminated from the term of severe preclampsia.
Severe features of pre-eclampsia now include: BP changes, SBP>160mmHg, low platelets, impaired liver function, AKI, pul edema and new onset cerebral disturbances.

Some other changes:

Screening to predict preeclampsia beyond taking an appropriate medical history to evaluate for risk factors is not recommended.
Vitamin C or vitamin E to prevent preeclampsia is not recommended.
Daily low-dose aspirin to help prevent preeclampsia is suggested in very high-risk women with a history of preeclampsia and preterm delivery.
Antihypertensive medication is recommended for severe hypertension during pregnancy.
A decision to deliver should not be based on the amount of proteinuria or change in the amount of proteinuria.
The use of magnesium sulfate is recommended for severe preeclampsia, eclampsia, or HELLP syndrome.

Risk factors the task force came up with for pre-eclampsia:

Primiparity
Prior pre eclampsia
CKD
Chronic HTN
Thrombophilia history
Multi-fetal pregnancy
IVF
Family history
DM I or II
Obesity
SLE
Advanced maternal age ( >40)

Jurgen Mross Fellow-In-Training, Critical Care Medicine

Great summary, all at the finger tips

Mohamed Hassan Hatahet MD.CUEM.CNPH.FACE Physician, Endocrinology, King Abdulaziz Hospital. Al Ahsa.Saudi Arabia

review for a common problem that is practical and comprehensive

zhou feng Physician, Critical Care Medicine, suzhou

simple and clear

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