Perinatologist Jennifer Duffy, MD, defines the categories of hypertension in pregnancy, providing criteria for diagnosis and monitoring – as well as the nuanced distinctions that inform management decision-making. She explains HELLP syndrome (which signifies the need for speedy intervention) and offers an online tool to help providers decide whether a patient with pre-eclampsia requires hospitalization.
mm. Um So my only disclosure actually is that my spouse works for johnson and johnson. He works in medical device marketing. And his work has nothing to do with obstetrics and nothing to do with anything I'm talking about. And I actually don't know anything more about his job than that. But there you have it as my disclosure. Um So today I want to start by talking about um sort of this umbrella term of hypertensive disorders of pregnancy. Um going through some specific definitions, standard delivery timing. Um Some of the maternal and fetal sequelae of hypertensive disorders of pregnancy, including pre eclampsia, the indications for outpatient management for in patient management. Um And then I want to end with sort of a proposed clinical algorithm because it's my understanding that the desire today is to talk about sort of when do patients with pre eclampsia need to be admitted to the hospital. So in terms of the definitions, hypertensive disorders of pregnancy is basically an umbrella term that is inclusive of three main entities chronic hypertension. Gestational hypertension and preeclampsia. And all of these entities have pretty significant overlap in their definitions. So chronic hypertension um is something where the definition of it has evolved significantly over the last few years. Traditionally, ACOG and S. M. F. M. Um So the major obstetrics societies have defined chronic hypertension as being systolic blood pressure greater than 1 40 or a diastolic blood pressure greater than 90 Prior to 20 weeks gestation. Um But then in 2017, the american College of Cardiology and the american Heart Association actually changed the diagnostic thresholds for chronic hypertension, such that a systolic blood pressure greater than 1 30 or a diastolic blood pressure greater than 80 outside of pregnancy was considered um to be consistent with a diagnosis of chronic hypertension. And I bring this up because um in the spectrum of hypertensive disorders of pregnancy, some of this nuance is becomes important in terms of how the patients are managed, so as opposed to chronic hypertension. Gestational hypertension is defined by a cog in that some of them as a systolic blood pressure greater than 1 40 or diastolic blood pressure greater than 90 on two separate occasions, at least four hours apart after 20 weeks of gestation and then pre eclampsia um is a specific definition that's defined as the same elevated blood pressure greater than 1 40 or a diastolic blood pressure greater than 90 plus. An additional finding either protein urea as measured either on a 24 hour urine collection or a spot protein to creatinine ratio, or if neither of those is available, then having two plus protein on like a your analysis. Um Or if you don't have protein area, then you need to have lab abnormalities To meet the diagnostic definition of preeclampsia and these lab abnormalities include low platelets, liver function tests. Uh Two times the upper limit of normal Creating of 1.1 or twice the patient's own baseline. If you have that available or symptoms such as pulmonary oedema or headache, that's not attributable to another cause or relieved by medications. So putting it all together in terms of these different entities along the spectrum of hypertensive disorders of pregnancy. It really depends on this um semi arbitrary convention of 20 weeks gestation. So women with the normal blood pressure prior to 20 weeks gestation are defined as normal intensive. Women with elevated blood pressures depending on your definition. Prior to 20 weeks gestation are chronic hypertensive, Normal intensive women that then develop elevated blood pressures after 20 weeks become diagnosed with gestational hypertension. Women with chronic hypertension that develop new protein urea new lab abnormalities um become diagnosed with preeclampsia. But then women with normal blood pressures can develop preeclampsia. And women with gestational hypertension can develop frequency to by having lab abnormalities or um The addition of protein in their urine hypertensive disorders of pregnancy can then further be delineated into what's considered with severe features or without severe features. Without severe features was previously called mild preeclampsia whereas with severe features is called severe preeclampsia. But the nomenclature now is moving kind of a way towards that and moving more towards just saying with or without severe features. The reason this becomes important is because this distinction between proclaims deal with severe features and proclaims it without severe features has been sort of at the crux of much of the literature surrounding the decision making as to whether to admit someone inpatient or manage them out patient. So it's important to kind of outline what are these severe features. A severe um feature is defined as an abnormality, a severe abnormality in blood pressure's lab value. Systolic blood pressure greater than 1 60 millimeters of mercury or a diastolic blood pressure greater than 1 10 millimeters of mercury is considered a super feature. I'll bring up here that some institutions argue that if someone has a diastolic blood pressure greater than 105, that you really should consider them sort of in the realm of severe features, just because 1 10 is so very abnormal. So I'll kind of qualify by saying a diastolic blood pressure of one oh 5 to 1 10 is I would just count that as severe futures um the lab abnormalities are the ones we discussed before. Low platelets, elevated liver function tests elevated kidney function, and then clinical features include things like a headache evidence of pulmonary oedema or visual disturbances, which are usually described as um sort of classic blurry vision or flashing lights or spots in the vision with sort of a bluish halo. All of these would be considered worrisome severe features. And then on the most kind of serious end of the spectrum is something called help syndrome, which is characterized as Hamal Asus, elevated liver enzymes and low platelets. Help syndrome is an acronym for the findings that are typical in health. Um I think it's important also to note that about 15-20 of women that have helped syndrome lack elevated blood pressure or protein. And so in these women, it's really um, mhm. Timely diagnosis is very dependent on both the reported symptoms from the patient and a clinical index of suspicion. And the reason I bring this up is because Help syndrome is the most severe form of um or the most significant side of the spectrum of hypertensive disorders of pregnancy. And it's the one that is um let the least easily screened for on the basis of things like, you know, objective data in terms of like checking blood pressures at home or in the office. Because a lot of times you do just have to rely on a patient telling you they don't feel well in order to oh, order the appropriate tests. So in terms of standard delivering delivery timing for all of these entities, gestational hypertension or pre eclampsia without severe features, deliveries typically recommended at 37 weeks. Whereas for severe gestational hypertension or presented with severe features, delivery is generally recommended at 34 weeks. That said, if there's evidence of maternal or fetal deterioration, um delivery maybe earlier. Um and really as early as anytime after viability depending on how sick the mom or the baby um is, and then help syndrome typically recommended a basically at the time of diagnosis, um That said, oftentimes because of the implications of the diagnosis, especially earlier gestational age. Often it takes sort of the 1st 12 to 24 hours to confirm the diagnosis, stabilized mom start the induction and so a lot of times people will, if they have a suspicion of help syndrome, preterm, start the process with like steroids for fetal lung maturity and so the delivery ends up being a day or so after that initial presentation. So in terms of prevalence, this chart actually demonstrates um sort of the rates of hypertensive disorder between 1999 and 2005. And you'll see there's a kind of slow steady increase granted this data is 15 years old at this point in time. But as you can imagine, this trend has completely continued to be on the uptick. Especially as things like obesity and other maternal cavorted. Co morbid conditions like diabetes have also been on the rise. Um, and in fact, I I previously had mentioned that, you know, the definition of chronic hypertension has changed. And so this chart is actually from the consensus statement that said, hey, these are the new definitions of chronic hypertension On the right hand side. Um, you'll see that the old definitions, which are the ones that a cock still uses for um chronic hypertension where the systolic is greater than 140 or the diastolic is greater than 90. And you'll see that among reproductive age women, which is largely captured in their age group of 20-44. But at Um, per the old definitions, about 10 of the general population of reproductive age women would meet diagnosis for chronic hypertension With the lower threshold of 1, 30/80. That the percentage of women with elevated blood pressure is thought to be double that at almost 20%. So I bring this up because these are the women that are going to be um entering pregnancy with this diagnosis. And we know that chronic hypertension, regardless of the definition, is a very strong predictor um for the development of preeclampsia. So this really just goes to show how prevalent this um clinical conundrum is, in fact, So looking specifically at pre eclampsia, it's estimated that between three and eight of pregnant women um experience preeclampsia at some point um in the reproductive lives. And that pregnancy actually accounts for about 10-15 of all maternal deaths worldwide. As well as 4-5 of stillbirths are due to preeclampsia. Now, looking specifically back at California, um I think we would all agree that the most severe maternal outcome would be a maternal death. So this was actually the California pregnancy. Associate pregnancy associated mortality review committee looked at five years of maternal death data And they actually found that out of the 333 deaths in that time period That about 16 were due to preeclampsia is like the most direct contributor. But I also want to bring up the other sequelae associated with preeclampsia Are also contributors. So cardiovascular disease accounted for 26%. Um stroke, which is one of the main maternal sequelae of pregnancy accounted for eight And then hemorrhage which could be associated with things like abruption improvements to um accounted for 10%. So um I highlight this just to show sort of the breadth and the scope of the problem. Since all of the decisions about inpatient and outpatient um monitoring are really trying to avoid significant maternal and fetal morbidity and mortality. So in terms of who develops preeclampsia, there are several well defined risk factors. Um and I've listed a few of them here, so this list is not exhaustive, but it highlights some of the more significant ones. So demographic factors, obesity, advanced maternal age, greater than 35, uh excessive antenatal weight gain. All of those things can increase your risk for preeclampsia. Um There's also in terms of demographics, a pretty significant one that does impact um sort of anti part of management are like socio economics, education level, health, literacy, race. All of those can predispose to pre eclampsia. Um In terms of pregnancy related Nolan parodies of women having their first baby are at higher risk of pregnancy. A history of pregnancy and a prior pregnancy increases your recurrence risk. Um The use of um assistive reproductive technologies like IVF increase your risk and and then also to investigation or higher order multiples increase your risk as well. And then finally there's medical conditions such as diabetes, high blood pressure, renal disease, lupus, autoimmune disorders, all of those also increase your risk. So in terms of the maternal sequelae of preeclampsia, there's um there's several that are pretty consistently thought of. One is placental abruption or the separation of the um placenta from the wall of the uterus and organ damage. Specifically renal damage is liver damage, renal damage. But even, you know heart uh like heart attack stroke, all of those things um eyes D. I. C. Picture can be seen with pre eclampsia, major hemorrhage, which kind of goes along with the abruption. Um The biggest risk or the the largest contributor to maternal morbidity is actually stroke related to the elevated blood pressures um seizures certainly diagnosed as eclampsia. Um And then excuse me. And then there's a higher risk of death or cardiovascular disease in later life. And associated with pretty fancy in terms of the fetal sequelae of for example to the predominant one is that the risk of having a growth restricted or low birth weight infants. Preterm birth need uh intra intra uterine fetal demise or neonatal death. And then actually there's more recent body of literature suggesting that actually the baby is born to proclaim dick mothers are at higher risk of themselves having cardiovascular disease later in life. Um The other thing I want to point out that it's not on this infographic is that um because preterm birth is a risk of preeclampsia. Um Also associated with that risk of preterm birth are all this equality of preterm birth depending on the gestational age. So things like make you stay rds um uh neck I. B. H. Like all of the negative sequelae for them units can also be attributable in part to pick names yet. Mhm. Okay. So um in terms of the enterprise management, so now that we've talked about sort of the definitions of prick, Lancia and the sequoia live, the question becomes how to manage women that present to you um with elevated blood pressures. Do they necessarily have to stay in the hospital? Can they go home? And what determines where those women um where they go? And this has become particularly relevant in the time of covid, because there's um I think more of a discussion as to do we need to bring people into the hospital in the middle of a pandemic, or can they safely be managed in a way that allows them to isolate um and and not drained down on resources. Um And so that's sort of the crux of the discussion. So in terms of outpatient management, it's actually something that's been a standard part of care for many years. If you look back in the in the literature, there's descriptions about patient management of pre eclampsia um Going back decades to at least, you know, the 90s or even earlier. Um but I will say that in in the height of sort of the pandemic and COVID, it's kind of gotten the discussion about patient management of hypertensive disorders of pregnancy has gotten kind of a renaissance of sorts. Um just because now there's additional pressure to really consider who's being admitted to the hospital and why the benefits about patient management of course are increased patient self efficacy and participation in their own care and their own advocacy for their well being. Um Certainly come there's a component of cost savings compared to in patient management um and improved resource utilization um as well as um decreased hospital associated morbidity. Um You know although these things are rare and can be somewhat purple axed against things like V. T. E. Mood disorders. Especially in you know times of covid some of these women if they get diagnosed with preeclampsia at 32 weeks that would be looking at a five week potentially a five week hospitalization prior to delivery. And that's a lot of time away from family and loved ones and their support network. And so certainly there's some benefits to them not being in the hospital. The generally accepted components about patient management. They differ a little bit but generally speaking, the recommendation is that if a woman is diagnosed with preeclampsia and is managed as an outpatient but she undergoes non stress testing to monitor the plutonium function in the fetal well being once or twice per week. Um she undergo fetal growth evaluation every 3-4 weeks as well as home blood pressure monitoring. And generally I recommend um and I think it's Pretty standard practice that you have the patient monitor their own blood blood pressure at home 1-2 times per day. And then it's also recommended that there be weekly contact with the health care provider and consideration of weekly lab evaluation to make sure that they are not. There's no um development of end organ damage and things of that nature because of the significant risk for maternal and fetal morbidity and complications. As well as the relatively intense nature of what is required to be managed as an outpatient with great francia. Um The appropriate candidates for women to be manages an outpatient are generally those that don't have any evidence of severe disease. So that means they have mile range blood pressures, They don't have any lab abnormalities. They don't have any clinical signs or symptoms that would be concerning for severe disease. And again, that's headache, that's unremitting or not improved with uh medication, pulmonary oedema, persistent vision changes. Things like that should prompt you to consider in patient management. Um And then the other component is, you know, because it's so complicated the women managers that are patient, they really need to be able to comply with the recommended management and advocate for themselves and have some self awareness in a way that allows them to seek help if their status changes. So, for instance, reliable transportation, health literacy, insight into their symptoms, um you know, the ability to work with their providers, communicate with the clinic gets seen when they need. Um So this is where some have advocated the use of like a patient navigator or a care coordinator or making sure that everyone has access to sort of a my chart equivalent just to make sure that they're not like sent out into the world and unable to follow up as as is required. So the question comes, you know, what what is the safety about patient management? Is it equivalent to in patient management or are women incurring additional risk by not being in the hospital? And generally speaking, the focus on the safety of outpatient management has used um the progression to severe disease as the primary safety measure. So it hasn't used things like how many women had a stroke. How many women have a seizure because those are just relatively rare events. But really people have looked for, how long could they be outpatient before they had to be impatient? And did they have any sort of um severe disease develop that wasn't identified as timely as it would have been if they had been in patients? So the older studies, the ones that I refer to from like the 90's Demonstructionate essentially that they felt that outpatient management had adequate safety and similar outcomes to women who are managed as impatient. More recently, there was a 2017 study that had a um had a composite maternal morbidity of 36% and their primary outcome, the maternal morbidity, just so that you know what that means exactly looked at rates of abruption, eclampsia, postpartum hemorrhage, icu admission, um severe features, help syndrome and or maternal death. And so they found that of the women that We're manages an outpatient, 36 of those women ultimately developed one of those things, but it's important to note that they compared them and That outcome occurred in 41%. So there was no significant difference between the two groups, but it does go to show that about a third of their patients ultimately went on to develop severe disease. Um a later 2019 study actually looked at a few 100 women and found that the progression to severe disease was in a higher was in about 56 of the cohort. And interestingly, from the time of diagnosis and and initiation about patient management to the time that they developed those severe features was about seven days. So not that long, but they also included some of their higher risk individuals in their group, ones that has higher blood pressures and maybe um as I'll get to in a minute, maybe weren't the best outpatient management candidates. So the question that I was tasked with was um who are the people that should be managed as an inpatient? And so, generally speaking, as you can imagine, it's the opposite of the people that should be manages an outpatient. So, um specifically, um, severe disease as defined by a systolic blood pressure greater than 1 60 or a diastolic pressure, blood pressure greater than one 105-1 10. Again, I would I would propose to you that admitting someone to the hospital with a diastolic blood pressure of one oh seven seems very reasonable. Lab abnormalities in terms of elevated kidney function or elevated um, liver function or maternal symptoms like the headache, the pulmonary oedema. Certainly if someone has a seizure or stroke, they get admitted to the hospital, um, and then also, um, things that may be more of a sick, well a of pregnancy to such as any evidence of vaginal bleeding or abruption, um, fetal heart rate changes and concerning for a problem with the baby. Um, those would all be reasons to admit someone to the hospital. The benefits of in patient management, of course, are the close monitoring of blood pressures that can be done once the patient is in the hospital, probably more feasibly than can be done at home. And then the close response to those blood pressures. If someone has a severe range blood pressure that requires ivy into hypotensive medication, you don't have to wait for them to get to the hospital to then administer the medications. Um, And then also with in patient management, there's, I won't say I shouldn't say no reliance on the patient's health literacy and compliance but there's less reliance because there um in constant contact, you know daily with their with their health care providers. Um So the the the generally accepted components of in patient management include frequent vital sign monitoring. Um And it depends on sort of how the vital signs look. Could be anywhere from once per shift which is kind of the minimum to as frequently as every 15 minutes depending on if someone's requiring I. D. Anti hypertensive medications. Um There should be daily assessment of maternal symptoms and fetal well being with non stress testing. There should be regular laboratory evaluation. Again, this could go anywhere from you know Daily or every 3-4 days to as frequently as every six hours if you're really trending labs and really worried about someone's renal function or liver function and then regular evaluation, a fetal growth and fluid volume. So that's generally kind of weekly evaluation of the fluid volume and growth evaluation every kind of three to 3 to 4 weeks. And we will say to that. So this is from the C N Q C C, which is the California, maternal care quality care collaborative. Um and they have this really excellent preeclampsia toolkit where it basically goes through some of kind of some of this information that I've presented in terms of the risk of relapse CIA and the concerns for pregnancy A and then proposed management. And then it also goes into some really nice um algorithms and specifics on in patient management. And I don't go into the full detail there, but I did want to present this slide from their slide deck, which is readily available online because it brings up sort of that what that initial 24 to 48 hour period looks like. So when someone comes in and this is specifically with severe proclaims yet at a pre term gestation, Um, prior to 34 weeks because if they present after 34 weeks you're going to deliver them. So these are for the people that you're wondering, they seem sick, they seem to need to be in the hospital. How long can I watch them in the hospital? And I bring up this Um, initial to my 4-48 hours of observation because I think that it highlights um, almost like a third group of individuals where it's not a completely clear picture. Yeah. And so that for me kind of highlights the option for observation, preeclampsia. I hope I've convinced you by now that it's sort of a spectrum and a disease process that can evolve over time. Not everybody that comes in is going to have all of the plastic features and not everybody is going to have um completely objective data, especially if they're severe feature is something clinical like a headache. Um And so for that reason observation may be a good option for women with borderline blood pressures. Maybe her first blood pressure was a systolic to 1 50 then she had a bunch of one thirties or maybe there's a non specific symptoms. Oh I have a headache. I guess it kind of gets better with Tylenol. I kind of get headaches outside of pregnancy, I'm not really sure. Or perhaps mildly abnormal labs like a mildly elevated lft but also has a history of cool stasis of pregnancy or um fatty liver like um and maybe the lab abnormalities are actually reflective of something else. The in these cases I feel observation provides an opportunity to gather more data and during that kind of observation, time period that may be an opportunity to administer steroids, fetal lung maturity, collect a 24 hour urine, try medications to get rid of the headache or see if the right upper quadrant pain or something improves. Um And so that also kind of brings up the question of, well, how long do people that undergo expectant management tend to, how long does it take for one to quote unquote declare themselves. So when someone comes in with pre eclampsia, if you're not sure where, whether they're appropriate for outpatient or inpatient, how long do you have to watch them? And this is something that's actually been previously looked at to some extent. Um Prior trials that have looked at this question have demonstrated roughly an average latency of seven days from diagnosis to delivery with expectant management. This is most often evaluated In severe pre eclampsia prior to 30 34 weeks. Um And so this that kind of seven day rule, maybe a little bit less relevant for the people with clearly mild disease at the outset. Yeah, I think it's worth considering this kind of typical agency period for women borderline disease just to have set expectation. The other thing to consider is that is that the administration of antenatal steroids can actually temporarily improve a lot of the objective markers including um some of the lab, excuse me, some of the lab abnormalities. And so when someone with a borderline clinical picture percent even if outpatient management is desired, I think it's worth initially observing women um and they may warrant that observation for several days. So I know this is kind of a busy slide, but this is actually a recent clinical algorithm that was proposed by um survives group. And it basically is proposing a way to standardize the decision making around whether people should be managed as an inpatient or outpatient with proclaims, Yeah. So their recommendation is essentially that if you have new onset of hypertension After 20 weeks gestation. So this is not referring to your chronic hypertensive is that then have a change in the clinical picture that women have a maternal evaluation with labs fetal evaluation with a non stress test and they get evaluated for clinical symptoms. If there are any signs of severe preeclampsia or pregnancy with severe features that they get admitted to the hospital. It's not then they get to carry on without patient management. And their recommended outpatient management is at least one visit per week in clinic serial ultrasounds for field growth weekly in a part of testing. Um Some people do twice weekly have something to do with it, close monitoring blood pressure and then weekly labs they are um just to kind of the asterix in the bottom left corner is that they feel that the distinction between pre eclampsia and gestational hypertension on the basis of the year and protein doesn't change management. And so they actually are not big proponents of even evaluating that. Um But I think that's a little bit more institutions specific. Um so then for the women that are managed outpatients there either they make it to 37 weeks where they are delivered or if any of those things change such that now they've met criteria for severe features then they get admitted to the hospital at that point and managed accordingly. And I like this. Um I like this algorithm because it's simple, it's objective, it's easily reproducible. It's easily adaptable to most clinical settings. But I will say that my personal clinical practice and I feel like um of many practitioners differs in a few ways. So I would add that the ability to comply with outpatient management is something that needs to be considered in the algorithm. Um One could argue that um that you can always try outpatient management and if outpatient management fails that then I think it's reasonable to then convert to in patient management. And then I also Bring up again these kind of borderline clinical pictures and generally speaking, the people that I initially bring in patient to gather more data are individuals with blood pressures in the 150s over hundreds um sort of intermittent non specific symptoms or mildly abnormal labs. And that's at that time where I'm admitting them sometimes for 24 hour observation. Sometimes it's in a shorter inpatient admission where I don't necessarily commit them to being there until delivery. But I at least want to gather more blood pressure data. I might want to do Some um some labs, 24 hour urine collection steroids if applicable for preterm negotiation. Um And so that would be sort of the only thing that I would maybe add to this algorithm is a consideration of this kind of in between group. So I'm hoping that the take home points that you have from today are that outpatient management is a viable option for women with mild disease. That maternal morbidity may be similar in this group to the women that are managed as an inpatient as well as your selecting wealthy as long as you are managing well selected women as outpatients. Women with severe disease should be managed as in patients and that an observation period is sometimes necessary. Final, prior to final disposition. In the cases where the clinical picture, maybe a little bit more ambiguous again, thank you so much for letting me talk today and I'd be happy to take any questions. Mm.
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