Preeclampsia- The New Guidelines And Recommendations For .

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014PreeclampsiaThe new guidelines andrecommendations for managementRobert S. Egerman, MD1

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014Impact of high normal blood pressure on the risk ofcardiovascular diseaseChobanian, Hypertension 2003Benefits of Rx hypertension25%40% 50%Neal, Lancet 20002

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014JNC VIII Age 18 – 59GOALS:Systolic 140 mm HgDiastolic 90 mm Hg - demonstrable benefitCompletenessAge 60Systolic 150 mm HgDiastolic 90 mm HgJAMA 20143

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014Causes of hypertension Chronic kidney disease or obstructive uropathyRenovascular hypertensionCoarctation of the aortaDrug-induced or drug-relatedCushing syndrome and other glucocorticoid excessstates including chronic steroid therapyPheochromocytomaPrimary aldosteronism and other mineralocorticoidexcess statesSleep apneaThyroid or parathyroid disease4

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014At a minimum Why is the patient hypertensive?– History Prior medical history, alcohol, smoking, drugs– Physical Look at the patient (proptosis, nervous, Cushingoid) BP in both arms Chest, Abdominal bruits, Edema, Pulses– Lab CMP, TSH, Urinalysis, Protein/CreatinineLearning objectives Contrast new guidelines from priorcategorizations of preeclampsia Determine appropriate delivery timing forthose diagnosed with preeclampsia Review treatment of hypertension andhypertensive urgencies during pregnancy Construct plans for future cardiovascular riskreduction in women affected withpreeclampsia5

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014Overview Perspective New changes in definitions and management– Preeclampsia– Gestational hypertension– Chronic hypertension and superimposedpreeclampsia Managing hypertensive emergencies Prevention of preeclampsia Reducing long term cardiovascular riskHYPERTENSIONINPREGNANCY6

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014 The American College of OB/GYN sponsored atask force through 2011 and 2012 to addresshypertensive disease in pregnancy with 17experts from various specialtiesCase 1 40 yo caucasian female at 33 weeksNo antecedent hypertensionBP 157/98No proteinuriaCreatinine 1 mg/dL, AST 60 U/LEFW 1480 grams ( 5%), normal dopplerDiagnosis and Management?When would you deliver?7

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014Case 2 31 yo African American female at 35 weeksNo antecedent hypertensionBP 156/100Protein/Creatinine 370Creatinine 0.9 mg/dL, AST 45 U/LNormal fetal growth and testingDiagnosis and Management?When would you deliver?The new guidelines “You’ll be exhilarated”“You find hope where before none”“You’ll ride the emotional roller coaster”“You’ll laugh, you’ll cry”“You’ll learn some things”“You’ll realize some of the advice is good (andsome probably not so good)”8

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014The new guidelines“There is enough poor advice here to have thewhole thing rescinded, refined and re-releasedalong with the entirety of the new ASCCPguidelines.”Perspective Incidence of preeclampsia has increased by25% in the past 20 years Preeclampsia causes an estimated 60,000maternal deaths yearly worldwide A rigid diagnosis is not helpful There are 50 –100 near misses for everymaternal death Preeclampsia is a risk for future cardiovasculardisease9

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014A Re-namingNo more mild preeclampsiaOnly preeclampsiawith severe featuresor withoutThe skinny on this Preeclampsia is hypertension with either––––– Thrombocytopenia ( 100,000 /mL)Transaminases 2 fold higher than normalDoubling of creatinine or 1.1 mg/dLPulmonary edemaNew onset cerebral or visual disturbancesAND proteinuria is not necessary for the diagnosisGestational hypertension is the absence of aboveChronic hypertensionChronic hypertension with superimposed preeclampsia10

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014Proteinuria 300 mg in a 24 hour period or Protein/creatinine 0.3 (mg/dL/mg/dL) The old 5 grams of protein has gone away . . . Dipsticks are discouraged [1 could be used]Hypertension Systolic 140 mm Hg or higher orDiastolic 90 mm Hg or higherSystolic 160 mm Hg or higher orDiastolic 110 mm Hg or higherOn two caissons 4 hours apart on bed restUnless treatment before this time11

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014Fetal growth restrictionAntenatal assessment Preeclampsia without severe features– Weekly liver and platelet assessment– Twice weekly BP assessment– Daily fetal movement counts/symptoms– No Rx unless severe range 160 syst or 110 dias Gestational hypertension– Weekly BP and protein assessment– No Rx unless severe range 160 syst or 110 dias– Bed rest not needed for either group12

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014Antenatal assessment Sonography for fetal growth is recommendedand umbilical doppler assessment if there isgrowth restrictionAntenatal steroids Defer delivery for 48 hours if 33 6/7 weeksand severe preeclampsia and any of:– pPROM– Thrombocytopenia– Abnormal transaminases or creatinine– Growth restriction ( 5%)– Reversed end diastolic flow on umbilical dopplerGestational hypertension– Oligohydramnios (AFI 5 cm)13

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014Antenatal steroids No delay for delivery after steroids if 33 6/7weeks and severe preeclampsia and any of:– Uncontrolled hypertension– Eclampsia– Pulmonary edema– Abruptio placenta– Disseminated intravascular coagulation– Non reassuring fetal status– Fetal demiseMagnesium sulfate “For women with systolic BP of less than 160mm Hg and a diastolic BP less than 110 mm Hgand no maternal symptoms, it is suggested thatmagnesium sulfate not be administereduniversally for the prevention of eclampsia.”Quality of evidence: Low When using magnesium sulfate continueintraoperatively if a cesarean section isperformed14

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014Magnesium sulfate AlternativesAntihypertensives15

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014Delivery 37 weeks without severe features ofpreeclampsia (including gestationalhypertension) 34 weeks or if unstable maternal or fetalcondition, earlier in those withpreeclampsia with severe features This includes HELLP syndrome (& noexpectant management if below viability)Delivery: fetal conditions with severe preeclampsia 34 weeksAFI 5 or maximal pocket 2 cmIUGR 5%Reversal diastolic flowRecurrent variable or late decelerationsBPP 4/10 on at least 2 occasions 6 hoursapart16

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014Hypertension Systolic 160 mm Hg or higher or Diastolic 110 mm Hg or higher Use an antihypertensive agentCourtesy of Anthony Gregg, MD17

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014How Do Women Die Of Preeclampsia in CA?CA-PAMR Final Cause of Death AmongPreeclampsia Cases, 2002-2004 (n 25)Final Cause of otic16142Hepatic (liver) Failure416.0%Cardiac Failure28.0%Hemorrhage/DIC14.0%Multi-organ rs Contributing to PregnancyRelated Deaths, CA-PAMR 2002-2004Contributing FactorPreeclampsiaTOTALN (%)N (%)OVERALL25 (100%)129 (89%)PATIENT FACTORS16 (64%)104 (72%)(at least one factor probably ordefinitely contributed)Underlying significant medical conditions8 (50%)40 (39%)Delay or failure to seek care10 (63%)27 (26%)Lack of understanding the importance of ahealth event9 (56%)16 (15%)HEALTHCARE PROFESSIONALS24 (96%)115 (79%)Delay in diagnosis22 (92%)62 (54%)Use of ineffective treatment19 (79%)48 (42%)Misdiagnosis13 (54%)36 (31%)Failure to refer or seek consultation6 (25%)26 (23%)HEALTHCARE FACILITY12 (48%)72 (50%)3818

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014Preeclampsia, BP, Stroke28 pts, 12 antepartum, 8 eclampsia, 53% deathMartin, Obstet Gynecol 2005Preeclampsia, BP, StrokeMartin, Obstet Gynecol 200519

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014Postpartum Recognize NSAIDs contribute to hypertension Avoid these if bp is elevated 1 day postpartum With either preeclampsia, gestationalhypertension or superimposed preeclampsia:– BP monitoring 72 hours after delivery in thehospital or at home– Reassess in the office in 7-10 days– Earlier in patients with symptoms20

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014Postpartum New onset hypertension associated withheadache or blurred vision or preeclampsia,parenteral magnesium is suggested Treat persistent BP over 150 mm Hg Syst or 100mm Hg Diastolic. Persistent BP over 160 mm HgSyst or 110 mm Hg Diast should be treatedwithin 1 hourPostpartum Dischargeinstructions shouldinclude awareness ofthe signs orsymptoms ofpreeclampsia21

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014Chronic hypertension Treat if persistent BP over 160 mm Hg Syst or 105mm Hg Diastolic unless end organ involvement Sonography for fetal growth (and umbilical dopplerassessment if there is growth restriction) Delivery not before 38 weeks unless problems Delivery at 37 weeks if superimposed preeclampsia(SIP) and no severe features and 34 weeks withsevere features Use intrapartum magnesium sulfate if SIPChronic hypertensionAnkumah, Obstet Gynecol 201422

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014Chronic hypertensionAnkumah, Obstet Gynecol 2014Chronic hypertensionAnkumah, Obstet Gynecol 201423

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014Chronic hypertension with SIP Development of proteinuria after 20 weeks gestation Sudden exacerbation of hypertension or need toescalate therapy when previously well controlled Manifestation of signs symptoms or increased liverenzymes Decreased platelet count less than 100,000 /mL Right upper quadrant pain, headaches Pulmonary edema or congestion Renal insufficiency Sudden substantial and sustained increases in proteinPostpartum and beyond If preeclampsia then yearly:– BP– Lipids– Fasting glucose– Assessment of body mass index24

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014 Long term risk for CVD–––––––––Hypertension increased6 foldIschemic heart disease2 foldCerebrovascular disease2 foldDiabetes2 foldHypothyroidismEnd stage renal diseaseAbove risks are on the low endEarlier onset of preeclampsia the greater riskMechanism-? Vascular damage, dyslipidemiaCharlton, Heart Lung Circulation 201325

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014Charlton, Heart Lung Circulation 2013Age,Gender,BP systolic,Total Cholesterol,HDL,Smoker,Rx for BP26

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014Keaney, N Engl J Med 2014Prevention of preeclampsia USPHTF15 RCT high risk patients6 RCT and 2 observational average riskLow dose asa beginning in 2nd trimesterPreeclampsia RR 0.76 [95% CI, 0.62-0.95]IUGRRR 0.80 [95% CI, 0.66-0.99]Henderson, Ann Int Med 2014 {Chronic hypertension, diabetes, renal disease,prior preeclampsia, autoimmune, multiples Less risk is obesity and AMA}27

FHA HEN / FPQC OB Hot Topics – ImprovingSafety for OB PatientsAugust 7, 2014Hospital efforts Recognition in Ob triage areas– Admission– Discharge Timely treatment of hypertension Recognition when treatment is not adequate Post partum management– Before discharge– Discharge– Readmission Patient information and follow up28

Preeclampsia is a risk for future cardiovascular disease . FHA HEN / FPQC OB Hot Topics – Improving Safety for OB Patients August 7, 2014 10 A Re-naming No more mild preeclampsia Only preeclampsia with severe features or without The skinny on this