Management of Preeclampsia

Educational Objectives

The goal of this program is to improve preeclampsia in pregnancy. After hearing and assimilating this program, the clinician will be better able to:

1. Optimize management of chronic hypertension in pregnancy.
2. Contrast use of medications in early-onset preeclampsia vs late-onset preeclampsia.

Summary

Hypertensive disorders in pregnancy: encompass 6 conditions; chronic hypertension (HTN) refers to HTN diagnosed before 20 wk of gestation; gestational HTN is diagnosed when blood pressure (BP) exceeds 140 mm Hg systolic or 90 mm Hg diastolic without proteinuria; gestational HTN typically resolves within 12 wk after childbirth; preeclampsia involves HTN >140/90 mm Hg with or without severe features and proteinuria >300 mg; superimposed preeclampsia occurs in individuals with chronic HTN who subsequently develop preeclampsia symptoms; eclampsia is characterized by HTN related to preeclampsia accompanied by seizures

Guidelines: the American College of Cardiology and the American Heart Association have redefined stage 1 HTN as 130/80 mm Hg; BPs previously considered pre-hypertension are now diagnosed as HTN; many patients consistently have BPs in the range of 130/80 mm Hg in the first trimester; per guidelines from the American College of Obstetricians and Gynecologists, these women are not diagnosed as chronic HTN, but women who have been given a diagnosis of chronic HTN and have persistent BPs in this range during pregnancy should be treated as having chronic HTN; BP in early pregnancy should be low, with the nadir at ≈18 wk; stage 1 HTN at this stage should raise concerns

Monitoring chronic HTN in pregnancy: baseline workup should include a complete blood count and comprehensive metabolic panel; proteinuria screening can be done using a spot urine protein-to-creatinine ratio, with a ratio of <0.15 mg/mg indicating low risk; higher ratios or abnormal serum creatinine levels should undergo a 24-hr urine protein collection; 20% to 30% of patients with chronic HTN have significant proteinuria; secondary evaluations for secondary HTN should be considered for patients with atypical features or risk factors; most patients should undergo screening electrocardiography, with echocardiography recommended for those with abnormalities or long-standing poorly controlled HTN; patients should monitor their BP ≈3 times/wk at home; white-coat HTN poses an increased risk for hypertensive complications in pregnancy; initiate low-dose aspirin before 16 wk of gestation

The CHAP trial: randomized women with mild chronic HTN before 23 wk to a target BP of <140/90 mm Hg or a standard target of <160/105 mm Hg; the primary outcome was a composite of severe preeclampsia, preterm birth before 35 wk, placental abruption, or perinatal death; the safety outcome was small for gestational age birth weight; the intervention group showed a significantly lower rate of the primary outcome (30% vs 37%), with no difference in the safety outcome; the current recommendation is to treat individuals with chronic HTN to a goal of <140/90 mm Hg; the speaker prefers labetalol or nifedipine over methyldopa (less effective)

Preeclampsia: severe features include thrombocytopenia (platelet count <100), elevated serum creatinine (>1.1 or twice their baseline if elevated), transaminitis (twice the upper limit of normal for liver function tests), pulmonary edema, new-onset headache unresponsive to acetaminophen (Tylenol), and unrelenting epigastric pain not explained by another diagnosis; ≈50% of patients with gestational HTN develop end-organ dysfunction or proteinuria; a study found patients with proteinuria (preeclampsia) were more likely to experience severe HTN, preterm birth, and increased neonatal morbidity; individuals with gestational HTN without proteinuria were more likely to have severe thrombocytopenia and liver dysfunction, including liver rupture; both conditions carry a risk for significant morbidity; preeclampsia affects multiple organs

Cardiac dysfunction and preeclampsia: preeclampsia is believed to be caused by abnormal placentation; an alternative theory proposed by European scientists suggests preeclampsia is independent of the placenta and is caused by cardiac dysfunction; cardiac dysfunction is observed in the early stages of preeclampsia and even prior to conception; 50% of patients with signs of early cardiac dysfunction develop preeclampsia; these patients also face an increased risk for longitudinal global strain changes for 10 yr after delivery; much data to show poor uterine perfusion caused by cardiac dysfunction leads to a high resistance state, triggering spiral artery transformation and preeclampsia; it has been suggested that different cardiac phenotypes require different treatment approaches; individuals with low heart rates (early-onset preeclampsia) may respond better to nifedipine, while those with high heart rates (late-onset preeclampsia) may benefit more from labetalol; contrary to the belief that delivering the placenta cures preeclampsia, studies show that preeclampsia and gestational HTN increase future risk for cardiovascular disease for affected individuals; pregnancy may exacerbate underlying cardiac dysfunction, contributing to increased cardiovascular risk

Postpartum management of hypertensive disorders: postpartum follow-up within a few weeks is recommended, with establishment of care with a primary care physician (according to ACOG) and regular annual examinations (according to European Society of Cardiology); optimizing cardiovascular disease (CVD) risk factors is emphasized in Australian and New Zealand guidelines, especially for patients >40 yr of age, according to speaker; continuation of BP medication and ongoing monitoring of cardiovascular risks are advised; one paper recommended assessment of CVD risk, adoption of a healthy diet (eg, DASH diet), regular exercise, weight management, and consideration of statin therapy for high-risk individuals

Readings

Beardmore-Gray A, Seed PT, Fleminger J, et al. Planned delivery or expectant management in preeclampsia: an individual participant data meta-analysis. Am J Obstet Gynecol. 2022; 227 (2): 218-230. View article; Louis JM, Parchem J, Vaught A, et al. Preeclampsia: a report and recommendations of the workshop of the Society for Maternal-Fetal Medicine and the Preeclampsia Foundation. American Journal of Obstetrics and Gynecology. 2022; 227 (5): B2-B24. View article; Magee L, Wright D, Syngelaki A, et al (2023). Preeclampsia prevention by timed birth at term. Hypertension, 80 (5), 969-978. View article; Rekawek P, Akerman M, Corbo A, et al. Postpartum maternal echocardiography and its effect on hospital management in patients with severe preeclampsia [ID: 1378829]. Obstetrics & Gynecology. 2023; 141 (5S): 68S-68S. View article; Sanjanwala AR, Jauk VC, Cozzi GD, et al. Outcomes before and after adopting guidelines for expectant management of severe preeclampsia. Am J Perinatol. 2022; 39 (2): 172-179. View article.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Benson was recorded at the 46th Annual Pacific Northwest Update in OB-GYN and Women's Health, held on October 20, 2022, in Portland, OR, and presented by the Oregon Health and Science University. For information about upcoming CME activities from this presenter, please visit ohsu.edu/school-of-medicine/cpd. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

FP713302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.