HYPERTENSION IN PREGNANCY HYPERTENSION IN PREGNANCY HYPERTENSION IN PREGNANCY Hypertension in Pregnancy was developed by the Task Force on Hypertension in Pregnancy. The information in Hypertension in Pregnancy should not be viewed as a body of rigid rules. The guidelines are general and intended to be adapted to many different situations, taking into account the needs and resources particular to the locality, the institution, or the type of practice. Variations and innovations that improve the quality of patient care are to be encouraged rather than restricted. The purpose of these guidelines will be well served if they provide a firm basis on which local norms may be built. Library of Congress Cataloging-in-Publication Data American College of Obstetricians and Gynecologists. Task Force on Hypertension in Pregnancy, author. Hypertension in pregnancy / developed by the Task Force on Hypertension in Pregnancy. p. ; cm. Includes bibliographical references. ISBN 978-1-934984-28-4 I. American College of Obstetricians and Gynecologists, issuing body. II. Title. [DNLM: 1. Hypertension, Pregnancy-Induced—Practice Guideline. WQ 244] RG575.5 618.3'6132—dc23 2013022521 Copyright 2013 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by an means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. 12345/76543 Contents Task Force on Hypertension in Pregnancy v Endorsements vii Foreword ix Executive Summary 1 Chapter 1: Classification of Hypertensive Disorders 13 Preeclampsia–Eclampsia 13 Chronic Hypertension 14 Chronic Hypertension With Superimposed Preeclampsia 14 Gestational Hypertension 14 Postpartum Hypertension 15 Chapter 2: Establishing the Diagnosis of Preeclampsia and Eclampsia 17 Preeclampsia 17 Eclampsia 19 Chapter 3: Prediction of Preeclampsia 21 Definition of an Ideal Predictive Test 21 Epidemiology of and Risk Factors for Preeclampsia 21 Prediction of Preeclampsia Using Uterine Artery Doppler Velocimetry 22 Prediction of Preeclampsia Using Biomarkers 22 Prediction of Adverse Outcomes in Patients With Gestational Hypertension and Preeclampsia 23 Clinical Considerations 23 Chapter 4: Prevention of Preeclampsia 27 Antiplatelet Agents 27 Antioxidant Supplementation With Vitamin C and Vitamin E 28 Other Nutritional Interventions 28 iii iv CONTENTS Dietary Salt Intake 29 Lifestyle Modifications 29 Chapter 5: Management of Preeclampsia and HELLP Syndrome 31 Antepartum Management 31 Intrapartum Management 34 Severe Preeclampsia 36 Route of Delivery in Preeclampsia 40 Eclampsia 40 HELLP Syndrome 41 Anesthetic Considerations 42 Postpartum Hypertension and Preeclampsia 43 Chapter 6: Management of Women With Prior Preeclampsia 47 Preconception Management 47 Antepartum Management 49 Chapter 7: Chronic Hypertension in Pregnancy and Superimposed Preeclampsia 51 Chronic Hypertension in Pregnancy 51 Superimposed Preeclampsia 61 Management of Women With Chronic Hypertension in the Postpartum Period 65 Chapter 8: Later-Life Cardiovascular Disease in Women With Prior Preeclampsia 71 Chapter 9: Patient Education 73 Importance of Patient Education 73 Patient Education Strategies 74 Patient Education Barriers 75 Chapter 10: State of the Science and Research Recommendations 79 Fundamental Advances in the Understanding of Preeclampsia 79 Summary of Fundamental Research Recommendations by the Task Force 83 Task Force on Hypertension in Pregnancy James M. Roberts, MD, Chair Maurice Druzin, MD Investigator Magee-Womens Research Institute Professor of Obstetrics and Gynecology and Professor, Department of Obstetrics, Gynecology and Maternal-Fetal Medicine Reproductive Sciences, Epidemiology and Clinical Stanford University Translational Research Stanford, CA University of Pittsburgh Robert R. Gaiser, MD Pittsburgh, PA Professor of Anesthesiology and Critical Care Phyllis A. August, MD, MPH University of Pennsylvania Professor of Medicine in Obstetrics and Gynecology Philadelphia, PA New York Presbyterian Joey P. Granger, PhD Weill Cornell Physicians Billy S. Guyton Distinguished Professor New York, NY Professor of Physiology and Medicine George Bakris, MD Director, Center for Excellence in Cardiovascular- Professor of Medicine Renal Research Director, Comprehensive Hypertension Center Dean, School of Graduate Studies in Health Sciences University of Chicago University of Mississippi Medical Center Chicago, IL Jackson, MS John R. Barton, MD Arun Jeyabalan, MD, MS Director, Maternal-Fetal Medicine Associate Professor, Department of Obstetrics, Baptist Health Lexington Gynecology and Reproductive Sciences Lexington, KY University of Pittsburgh Pittsburgh, PA Ira M. Bernstein, MD John VanSicklen Maeck Professor and Chair Donna D. Johnson, MD Department of Obstetrics, Gynecology and Lawrence L. Hester Professor and Chair Reproductive Sciences Department of Obstetrics and Gynecology Senior Associate Dean for Research Medical University of South Carolina University of Vermont Charleston, SC Burlington, VT v vi TASK FORCE ON HYPERTENSION IN PREGNANCY S. Ananth Karumanchi, MD Catherine Y. Spong, MD Associate Professor of Medicine Director, Extramural Research Beth Israel Deaconess Medical Center Eunice Kennedy Shriver National Institute of Child Harvard Medical School Health and Human Development, National Boston, MA Institutes of Health Bethesda, MD Marshall D. Lindheimer, MD Professor Emeritus, Departments of Obstetrics & Eleni Tsigas Gynecology, Medicine, and Committee on Clinical Executive Director Pharmacology and Pharmacogenomics Preeclampsia Foundation University of Chicago Melbourne, FL Chicago, IL James N. Martin Jr, MD Michelle Y. Owens, MD, MS Ex Officio Task Force Member Associate Professor Past President, American College of Obstetricians Vice-Chair of Obstetrics and Gynecology and Gynecologists and American Congress of University of Mississippi Medical Center Obstetricians and Gynecologists (2011–2012) Jackson, MS Vice Chair, Research and Academic Development Director, Division of Maternal-Fetal Medicine George R. Saade, MD University of Mississippi Medical Center Professor, Department of Obstetrics and Gynecology Jackson, MS Director, Division of Maternal-Fetal Medicine University of Texas Medical Branch American College of Obstetricians and Gynecologists Galveston, TX Staff Gerald F. Joseph Jr, MD, Vice President of Practice Baha M. Sibai, MD Activities Professor, Department of Obstetrics, Gynecology and Nancy O’Reilly, MHS Reproductive Sciences Alyssa Politzer University of Texas Health Science Center Sarah Son, MPH Houston, TX Karina Ngaiza Conflict of Interest Disclosures The following task force members reported no financial relationships or potential conflicts of interest to disclose: James M. Roberts, MD; Ira M. Bernstein, MD; Maurice Druzin, MD; Robert R. Gaiser, MD; Joey P. Granger, PhD; Arun Jeyabalan, MD; Donna D. Johnson, MD; Marshall Lindheimer, MD; Michelle Y. Owens, MD, MS; George R. Saade, MD; Catherine Y. Spong, MD; and Eleni Tsigas. George Bakris, MD, has Investigator Initiated grants from Takeda and CVRx paid directly to the University of Chicago. He received a salary for being National Clinical Trial Principal Investigator for Medtronic (15%), Relypsa (15%) (the percentage is salary support.) He is a consultant for Takeda, Abbott, CVRx, Johnson& Johnson, Eli Lilly, Daichi-Sankyo, Boerhinger-Ingelheim, and the U.S. Food and Drug Administration. He is an editor for the American Journal of Nephrology and the Hypertension section of UpToDate, and an associate editor for Diabetes Care and Nephrology Dialysis and Transplantation. John R. Barton, MD, provides research support to Alere and Beckman Coulter. S. Ananth Karumanchi, MD, has served as consultant to Beckman Coulter, Roche and Siemens; has a financial interest in Aggamin Therapeutics LLC, Co; and is an inventor on patents related to preeclampsia biomarkers held by Beth Israel Deaconess Medical Center. Baha M. Sibai, MD, is a consultant for Alere Women’s Health who is investigating a biomarker for preeclampsia. Endorsements The following professional organizations have reviewed, endorsed, and support this report: American Academy of Physician Assistants American Academy of Neurology* American College of Occupational and Environmental Medicine American Optometric Association American Osteopathic Association American Society of Hypertension Preeclampsia Foundation Society for Maternal-Fetal Medicine * The American Academy of Neurology has affirmed the value of this report. Please see the American Academy of Neurology Guideline Endorsement Policy for further information. vii Foreword Hypertensive disorders of pregnancy, including pre- • Preeclampsia is a risk factor for future cardiovascu- eclampsia, complicate up to 10% of pregnancies lar disease and metabolic disease in women. worldwide, constituting one of the greatest causes of • Despite considerable research, the etiology of pre- maternal and perinatal morbidity and mortality eclampsia remains unclear. worldwide. In early 2011, as the 62nd President Elect of the American College of Obstetricians and Gyne- • Within the past 10 years, substantial advances in cologists (the College) and the American Congress of the understanding of preeclampsia pathophysiology Obstetricians and Gynecologists, I decided to make as well as increased efforts to obtain evidence to