Hypertension

ACOG HTN in Pregnancy Handbook:

http://www.acog.org/Resources-And-Publications/Task-Force-and-Work-Group-Reports/Hypertension-in-Pregnancy

Hypertension Diagnosis and Management:

Gestational:

- New onset hypertension (systolic 140 or greater or diastolic 90 or greater) after 20 weeks gestation with absence of proteinuria.

- Becomes chronic hypertension if it persists postpartum.

- Manage the same as mild preeclampsia.

- If severe pressures requiring acute treatment are present, then manage as preeclampsia with severe features.

Antenatal: Once or twice weekly NSTs with once week AFI and growth US every 3 weeks (with dopplers if growth restriction is identified)..

- Weekly CBC, LFTs, creatinine, proteinuria check.

Chronic:

Hypertension that predates conception or presents before 20 weeks gestation.

Preclampsia without Severe Features:

At time of diagnosis, admit for observation for at least 24 hours (MFM-Cardoba prefers 48-72 hrs observation before allowing outpatient management).

Antenatal: Twice weekly NST with once week AFI and growth US every 3 weeks (with dopplers if growth restriction is identified).

- Weekly CBC, LFTs, creatinine, proteinuria check.

- Once proteinuria is confirmed, do not repeat with other labs.

- Delivery at 37 weeks.

Preeclampsia with Severe Features:

Antenatal: Twice weekly NST with once week AFI and growth US every 3 weeks (with dopplers if growth restriction is identified).

- Consider q6hr CBC, LFTs, creatinine.

- Once proteinuria is confirmed, do not repeat with other labs.

- Delivery at 34 weeks...consider earlier if features such as platelets decreasing significantly.

Spectrum MFM notes:

- Only treat with oral anti-hypertensives if inpatient or chronic hypertension.

- Never treat outpatient gHTN or PrE with orals - concern for masking worsening disease (Cardoba)

- At time of preeclampsia diagnosis consider 48-72 hr observation before discharge.

- Some attendings only start mag right before delivery, or only 24 hours pp, not before delivery.

- seizure risk is increased at time of and in first 24 hrs after delivery.

Box 1. Order Set for Severe Intrapartum or

Postpartum Hypertension Initial First-Line

Management With Labetalol* ⇦

• • Notify physician if systolic blood pressure (BP) measurement is greater than or equal to 160 mm Hg or if diastolic BP measurement is greater than or equal to 110 mm Hg.

  • Institute fetal surveillance if undelivered and fetus is viable.

  • If severe BP elevations persist for 15 minutes or more, administer labetalol (20 mg intravenously [IV] over 2 minutes).

  • Repeat BP measurement in 10 minutes and record results.

  • If either BP threshold is still exceeded, administer labetalol (40 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely.

  • Repeat BP measurement in 10 minutes and record results.

  • If either BP threshold is still exceeded, administer labetalol (80 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely.

  • Repeat BP measurement in 10 minutes and record results.

  • If either BP threshold is still exceeded, administer hydralazine (10 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely.

  • Repeat BP measurement in 20 minutes and record results.

  • If either BP threshold is still exceeded, obtain emergency consultation from maternal–fetal medicine, internal medicine, anesthesia, or critical care subspecialists.

  • Give additional antihypertensive medication per specific order.

  • Once the aforementioned BP thresholds are achieved, repeat BP measurement every 10 minutes for 1 hour, then every 15 minutes for 1 hour, then every 30 minutes for 1 hour, and then every hour for 4 hours.

Box 2. Order Set for Severe Intrapartum

or Postpartum Hypertension Initial First-

Line Management With Hydralazine* ⇦

• • Notify physician if systolic blood pressure (BP) is greater than or equal to 160 mm Hg or if diastolic BP is greater than or equal to 110 mm Hg.

  • Institute fetal surveillance if undelivered and fetus is viable.

  • If severe BP elevations persist for 15 minutes or more, administer hydralazine (5 mg or 10 mg intravenously [IV] over 2 minutes).

  • Repeat BP measurement in 20 minutes and record results.

  • If either BP threshold is still exceeded, administer hydralazine (10 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely.

  • Repeat BP measurement in 20 minutes and record results.

  • If either BP threshold is still exceeded, administer labetalol (20 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely.

  • Repeat BP measurement in 10 minutes and record results.

  • If either BP threshold is still exceeded, administer labetalol (40 mg IV over 2 minutes) and obtain emergency consultation from maternal–fetal medicine, internal medicine, anesthesia, or critical care subspecialists.

  • Give additional antihypertensive medication per specific order.

  • Once the aforementioned BP thresholds are achieved, repeat BP measurement every 10 minutes for 1 hour, then every 15 minutes for 1 hour, then every 30 minutes for 1 hour, and then every hour for 4 hours.

Box 3. Order Set for Severe Intrapartum

or Postpartum Hypertension Initial First-

Line Management With Oral Nifedipine* ⇦

• • Notify physician if systolic blood pressure (BP) is greater than or equal to 160 mm Hg or if diastolic BP is greater than or equal to 110 mm Hg.

  • Institute fetal surveillance if undelivered and fetus is viable.

  • If severe BP elevations persist for 15 minutes or more, administer nifedipine† (10 mg orally).

  • Repeat BP measurement in 20 minutes and record results.

  • If either BP threshold is still exceeded, administer nifedipine capsules (20 mg orally). If BP is below threshold, continue to monitor BP closely.

  • Repeat BP measurement in 20 minutes and record results.

  • If either BP threshold is still exceeded, administer nifedipine capsule (20 mg orally). If BP is below threshold, continue to monitor BP closely.

  • Repeat BP measurement in 20 minutes and record results.

  • If either BP threshold is still exceeded, administer labetalol (40 mg intravenously over 2 minutes) and obtain emergency consultation from maternal–fetal medicine, internal medicine, anesthesia, or critical care subspecialists.

  • Give additional antihypertensive medication per specific order.

  • Once the aforementioned BP thresholds are achieved, repeat BP measurement every 10 minutes for 1 hour, then every 15 minutes for 1 hour, then every 30 minutes for 1 hour, and then every hour for 4 hours.