ACOG Preeclampsia Guidelines: Antenatal Management and Timing of Delivery
SUMMARY:
Recommendations for prenatal assessment and perinatal management, including delivery, are included in the ACOG preeclampsia and gestational hypertension guidelines.
Inpatient vs Outpatient Management
Ambulatory management (outpatient) appropriate for the following
Gestational hypertension without severe features or
Preeclampsia without severe features
Inpatient management appropriate for the following
Severe preeclampsia or
Poor adherence to monitoring recommendations
How to Measure BP
Recommended technique for BP monitoring
Appropriate cuff size: 1.5 times upper arm circumference
Avoid tobacco or caffeine: Use in the 30 minutes preceding the measurement may lead to temporary rise in blood pressure
Patient should be upright after a 10-minute rest period
Inpatient setting: Measurement may be taken either
Sitting up or
Left lateral recumbent with arm at the level of the heart
Fetal and Maternal Assessment (Outpatient – No Severe Features)
Fetal Assessment
Fetal growth assessment every 3-4 weeks
Amniotic fluid assessment weekly
Antenatal testing 1-2 times per week
Maternal Assessment
Labs weekly (more frequently if concern that patient status is deteriorating)
Serum creatinine | Liver enzymes | Platelet count
Gestational hypertension: Include proteinuria
Note: If proteinuria is present, additional proteinuria measurements are not necessary
Clinical evaluation: At least one visit per week in-clinic
Obtain BP and evaluate for severe features (see ‘Related ObG Topics’ below)
Combination ambulatory and in-clinic assessment
BP and symptom assessment are recommended “serially”, using a combination of in-clinic and ambulatory approaches, with at least one visit per week in-clinic
sFlt-1/PlGF ratio to predict progression to preeclampsia with severe features
FDA approved | Studied in population of hospitalized patients between 23 and 35 weeks
ACOG states
There are insufficient data to recommend management strategies after a positive or negative test result
The sFlt-1:PlGF ratio alone should not replace current clinical criteria for diagnosing or excluding a diagnosis of preeclampsia with severe features
KEY POINTS:
Delivery vs Expectant Management
Decision regarding management based on gestational age and results from the following evaluation
Maternal: CBC | Creatinine | LDH, AST, ALT | Proteinuria | Uric acid if superimposed preeclampsia suspected
ACOG Guidance: Emergency Treatment for Severe Hypertension in Pregnancy
Summary:
Severe hypertension can be a life-threatening event during pregnancy and requires special vigilance in the postpartum period, particularly following hospital discharge. The goal of treatment is to control hypertension and prevent seizures. Uncontrolled hypertension can lead to heart failure, myocardial ischemia, renal injury and stroke.
When to Treat:
Urgently treat acute onset severe hypertension in pregnancy or postpartum period
SBP ≥160 and and/or DBP ≥110 mm Hg persisting for 15 minutes
systolic BP a predictor of maternal morbidity/mortality
Note: ACOG states that “any of these agents can be used to treat acute severe hypertension in pregnancy” | An approach detailed in ACOG guidance uses “an initial regimen of labetalol at 200 mg orally every 12 hours and increase the dose up to 800 mg orally every 8–12 hours as needed (maximum total 2,400 mg/d). If the maximum dose is inadequate to achieve the desired blood pressure goal, or the dosage is limited by adverse effect, then short-acting oral nifedipine can be added gradually”
Seizure Prophylaxis: Magnesium Sulfate
Remains drug of choice for seizure prophylaxis
Magnesium sulfate should not be used to reduce blood pressure
See more on magnesium sulfate in ‘Related ObG Topics’
When to Use
Severe features of preeclampsia
Administer to all women
No severe features of preeclampsia and systolic BP > 140 and < 160 mm Hg or diastolic BP > 90 and < 110 mm Hg
There is no consensus on this matter as prophylaxis will reduce eclampsia but 1 in 100 to 129 women need to be treated and side effects (although not life threatening) will increase
ACOG states that the decision to use magnesium sulfate when severe features are not present should be the decision of the “physician or institution, considering patient values or preferences, and the unique risk-benefit trade-off of each strategy”
Delivery and Postpartum
Vaginal delivery
Continue infusion 24 hours postpartum
Cesarean
Begin infusion (if not yet running) before surgery and continue 24 hours postpartum
Discontinuing prior to operative vaginal birth or cesarean section to avoid uterine atony or anesthetic drug interactions is not recommended
Administration
Loading dose of 4 to 6 g administered per infusion pump over 20 to 30 minutes (i.e., slowly) followed by a maintenance dose of 1 to 2 g per hour as a continuous intravenous infusion
IM option if IV access limited
10 g initially as a loading dose (5 g IM in each buttock) followed by 5 g every 4 hours
Diagnosing Preeclampsia – Key Definitions and ACOG Guidelines
WHAT IS IT?
Preeclampsia is a pregnancy specific hypertensive disease with multi-system involvement. It usually occurs after 20 weeks of gestation and can be superimposed on another hypertensive disorder. While preeclampsia was historically defined by the new onset of hypertension in combination with proteinuria, some women will present with hypertension and multisystemic signs in the absence of proteinuria. The presence of multisystemic signs is an indication of disease severity.
SUMMARY:
Diagnostic Criteria
Blood Pressure Criteria
Hypertension – systolic BP > 140 mm hg or diastolic BP > 90 mm hg or both
On two occasions at least 4 hours apart after 20 weeks gestations with previously normal BP
Considered ‘mild’ until diastolic BP > 110mm hg or systolic BP ≥160 mm Hg
Severe Hypertension – systolic BP > 160 mm hg or diastolic BP > 110 mm hg or both
Can confirm using a short time interval (e.g., minutes) to facilitate timely antihypertensive therapy
Note: Gestational Hypertension
ACOG defines gestational hypertension as “hypertension without proteinuria or severe features develops after 20 weeks of gestation and blood pressure levels return to normal in the postpartum period”
Caution and close follow-up is warranted as up to a half of women with gestational hypertension will go on to manifest signs an symptoms consistent with preeclampsia
Women with severe gestational hypertension, even in the absence of proteinuria should be managed similar to women with severe preeclampsia
ACOG states
Women with gestational hypertension with severe range blood pressures (a systolic blood pressure of 160 mm Hg or higher, or diastolic blood pressure of 110 mm Hg or higher) should be diagnosed with preeclampsia with severe features.
Proteinuria Criteria
24 hour urine collection >300 mg protein or
Single voided urine protein/creatinine ratio ≥0.3
Dipstick reading of 2+ (use only if other quantitative methods not available)
Preeclampsia Definitions
Preeclampsia
Hypertension and proteinuria or
In absence of proteinuria, new-onset hypertension with the new onset of any of the following
Thrombocytopenia: Platelets <100 x 109/L
Renal insufficiency: serum creatinine >1.1 mg/dl or doubling of serum creatinine in the absence of other renal disease
Impaired liver function: Elevated blood concentrations of liver transaminases to twice normal concentration
Pulmonary edema
Neuro: Unexplained new-onset headache unresponsive to medication (without an alternative diagnosis) or visual symptoms
Preeclampsia with severe features
Preeclampsia diagnosis, above, with any of the following
Severe hypertension
On two occasions at least 4 hours apart while on bed rest (unless already on antihypertensive therapy)
Thrombocytopenia: Platelets <100 x 109/L
Impaired liver function (without an alternative diagnosis): Elevated liver transaminases greater than twice upper limit of normal or severe persistent right upper quadrant or epigastric pain not responsive to medications
Progressive renal insufficiency: serum creatinine >1.1 mg/dl or doubling of serum creatinine in the absence of other renal disease
Pulmonary edema
Neuro: Unexplained new-onset headache unresponsive to medication (without an alternative diagnosis) or visual symptoms
Note: The following are not diagnostic criteria for the diagnosis of preeclampsia or preeclampsia with severe features
Clinically evident edema
Rapid weight gain
Massive proteinuria
Does not qualify as a ‘severe feature’
Fetal growth restriction
ACOG states that while it is important to monitor fetal status, FGR in the setting of all other fetal assessment being within normal limits (e.g., AFV, Doppler), expectant management ‘may be reasonable’ if mother and fetus appear stable and no other clinical indication is present that would indicate the need for early delivery
Uric acid
Hyperuricemia in hypertensive pregnancy is not a diagnostic marker, but is an important finding as a risk factor for adverse maternal and fetal outcomes
Small for gestational age (SGA) infant
Prematurity
Risk for adverse maternal outcomes if include patients with preeclampsia and risks increase with increasing concentration of uric acid
May be warranted in the setting of ‘diagnostic dilemmas’ such as diagnosing superimposed preeclampsia in the setting of chronic hypertension
OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.
Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Disclaimer
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
Jointly provided by
NOT ENOUGH CME HOURS
It appears you don't have enough CME Hours to take this Post-Test. Feel free to buy additional CME hours or upgrade your current CME subscription plan
You are now leaving the ObG website and on your way to PRIORITY at UCSF, an independent website. Therefore, we are not responsible for the content or availability of this site
