Ob.gyns. will need to focus more on individualized care as they use the two new practice bulletins, one on chronic hypertension in pregnancy and one on gestational hypertension and preeclampsia, released by the American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins–Obstetrics.
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The bulletins will replace the 2013 ACOG hypertension in pregnancy task force report and are published in the January issue of Obstetrics & Gynecology.
“The task force was a tour de force in creating a comprehensive view of hypertensive diseases of pregnancy, including research,” Christian M. Pettker, MD, who helped develop both practice bulletins, stated in a press release. “The updated guidance provides clearer recommendations for the management of gestational hypertension with severe-range blood pressure, an emphasis on and instructions for timely treatment of acutely elevated blood pressures, and more defined recommendations for the management of pain in postoperative patients with hypertension.”
“Ob.gyns. will need to focus more on individualized care and may find it’s best to err on the side of caution because the appropriate treatment of hypertensive diseases in pregnancy may be the most important focus of our attempts to improve maternal mortality and morbidity in the United States,” he said.*
Gestational hypertension or preeclampsia
For women with gestational hypertension or preeclampsia at 37 weeks of gestation or later without severe features, the guidelines recommend delivery rather than expectant management.
Those patients with severe features of gestational hypertension or preeclampsia or eclampsia should receive magnesium sulfate to prevent or treat seizures.
Patients should receive low-dose aspirin (81 mg/day) for preeclampsia prophylaxis between 12 weeks and 28 weeks of gestation if they have high-risk factors of preeclampsia such as multifetal gestation, a previous pregnancy with preeclampsia, renal disease, autoimmune disease, type 1 or type 2 diabetes mellitus, chronic hypertension, or a previous pregnancy with preeclampsia; or more than one moderate risk factor such as a family history of preeclampsia, maternal age greater than 35 years, first pregnancy, body mass index greater than 30, personal history factors, or sociodemographic characteristics.
NSAIDs should continue to be used in preference to opioid analgesics.
The guidance also discusses mode of delivery, antihypertensive drugs and thresholds for treatment, management of acute complications for preeclampsia with HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome, the optimal treatment for eclampsia, and postpartum hypertension and headache.
Chronic hypertension
Pregnant women with chronic hypertension also should receive low-dose aspirin between 12 weeks and 28 weeks of gestation. Antihypertensive therapy should be initiated for women with persistent chronic hypertension at systolic pressure of 160 mm Hg or higher and/or diastolic pressure of 110 mm Hg or higher. Consider treating patients at lower blood pressure (BP) thresholds depending on comorbidities or underlying impaired renal function.
ACOG has recommended treating pregnant patients as chronically hypertensive according to recently changed criteria from the American College of Cardiology and the American Heart Association, which call for classifying blood pressure into the following categories:
- Normal. Systolic BP less than 120 mm Hg; diastolic BP less than 80 mm Hg.
- Elevated. Systolic BP greater than or equal to 120-129 mm Hg; diastolic BP greater than 80 mm Hg.
- Stage 1 hypertension. Systolic BP, 130-139 mm Hg; diastolic BP, 80-89 mm Hg.
- Stage 2 hypertension. Systolic BP greater than or equal to 140 mm Hg; diastolic BP greater than or equal to 90 mm Hg.