HighriskObstetricalClinicalPracticeGuidelines

Definitions

Effectsof Hypertension onPregnancy Initial Evaluationin Chronic Hypertension Medication Management

PregnancyInducedHypertension Preeclampsiaishypertensionwithproteinuriaandedemaoccurringafter20weeksbut goingawayby12weekspostpartum. Mildpreeclampsia:140159/90109mmHg,proteinuria300mg4999mg/24hours Severepreeclampsia:160/110mmHg,5000mg24hours,oliguria,endorgan symptoms(headache,visualchanges,epigastriapain)ACOGPracticeBulletinnumber33,June2002. (reaffirmed2010) EclampsiaispreeclampsiawithseizureACOGPracticeBulletinnumber33,June2002.(reaffirmed2010) HELLPSyndromeispreeclampsiawithH=hemolysis(thebreakdownofredbloodcells) EL=elevatedliverenzymesandLP=lowplateletcount.ACOGPracticeBulletinnumber33,June2002. (reaffirmed2010) Gestationalhypertensionisdefinedasnewonsethypertensionwithoutproteinuria occurringafter20weeksofgestation.ACOGPracticeBulletinnumber33,June2002.(reaffirmed2010) Chronichypertensionishypertensionpresentbeforepregnancyorabloodpressureof 140/90mmHgormorepresentbeforethe20thweekofpregnancyorthatpersists longerthanthepostpartumperiod.ACOGPracticeBulletinnumber29,July2001,(Reaffirmed2010). Prematurebirth,IntrauterineGrowthRestriction(IUGR),fetaldemise,placental abruption,Perinatal,andneonatalmorbidityandmortality. Besidesathoroughhistorydocumentingageofonset,durationandseverityofher hypertension,womenwithyearsofinvolvementtendtoneedanophthalmologicexam (ruleoutretinopathy),echocardiogram,electrocardiogram,(ruleoutischemicheart diseaseandcardiomegaly),renalultrasound,24hoururineforproteinandcreatinine clearanceaswellasacomprehensivemetabolicpanel(ruleoutrenalinvolvement). 1. MedicationandChronicHypertension Mildchronic Hypertension: As a rule, mildchronic hypertensives do not require medication although the majority will be on one if diagnosed prior to the pregnancy and should probably continue it if they are one of the two types used inpregnancy.Methyldopaisthegoldstandardinpregnancybecauseofitslimited effects on uteroplacental blood flow. Labetalol, a combined alphaand beta blocker can be used as an alternative. AngiotensinConverting Enzyme (ACE) inhibitors are contraindicated in pregnancy Second line medications for hypertensive control can be oral hydralazine, calcium channel blockers and possiblycataprespatch. Severechronichypertensionrequiresantihypertensive. Both types of chronic hypertensives, must be watched for super imposed preeclampsia. 2. MedicationsandAcuteHypertension

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For acute forms of hypertension especially in labor, hydralazine (510mg IV push q 20 minutes to a max dose of 40 mg) is the most widely used antihypertensive, while Labetalol (1020mg IV push every 15 minutes to a max single dose of 80 mgandtotaldoseof220mg)isequallyaseffective.Thesemedicationsshouldbe usedwhenSBPis180mmHgorDBP110mmHg.Avoidmaternalhypotension.

Although used more often, it is still controversial to use antihypertensive in gestationalhypertension. Consider Maternal Fetal Medicine (MFM) Specialist or Intensivist consult if patient continuestobeunresponsivetoothermedications. 3. SeizureProphylaxis Magnesiumsulfateisthedrugofchoiceforpreventionofseizures.Fourgram bolusover20minutesfollowedby2gramsperhour.Therapeuticserumlevels4 8mg/dl.Continuepostpartumforatleast24hours. 4. HELLP,severepreeclampsia,severechronichypertensionandchronichypertension withimposedpreeclampsianeedMgSO4protocolforprophylaxis.
5. Mild chronic hypertension, gestational hypertension and mild preeclampsia are decidedonacasebycasebasisregardingMGSO4protocol.

Antepartum Testingand Treatment

Timingfor Delivery

Althoughcontroversial,mostwouldarguethatpatientsdiagnosedwithchronic hypertensionshouldreceivetwiceweeklyNonstressTests(NST)withAmnioticFluid Index(AFI)weeklyorBiophyisicalProphile(BPP)weeklyalongwith: Ultrasoundevery46weeksafter2832weekstoassessfetalgrowth Ifintrauterinegrowthrestrictionissuspected,testingshouldincludeumbilicalartery Dopplerflowstudies WeeklyNSTforgestationalhypertensiveingoodcontrolarenotindicated Antenatalcorticosteroids Ifdeliveryseemsimminent(between2434weeks),steroidsshouldbeinitiated; deliveryshouldnotbedelayedforsteroidsifimmediatedeliveryisnecessary Treatmentshouldconsistofeithertwodosesofbetamethasoneorfourdosesof dexamethasoneasasinglecourse GestationalhypertensionDeliveryafter39weeksbasedonstabilityandbishopscore ofthecervix. Deliveryshouldbeprolongeduntilafter39weeksifpatientismaintaininga reassuringfetalheartrate. ChronichypertensionPregnantwithuncomplicatedchronichypertensionofamild degreegenerallycanbedeliveredvaginallyatterm.ACOGPracticeBulletinnumber29,July2001,

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(Reaffirmed2010)

FluidControl

Mildpreeclampsia <39weeksExpectantmanagementwithclinicaljudgmentregardingmaternaland fetalstabilityconsiderMGSO4protocol 39weeksDeliveryandconsiderMgSO4protocol Severepreeclampsia <28weeksGivesteroids,counselregardingpooroutcomeandifmaternalfetalunit deteriorating,deliverwithMgSO4protocol;transfertoatertiarycarefacility 2832weeksHospitalizeforobservation,steroids,expectantmanagementif maternal/fetalunitstable,ifunstabledeliverwithMgSO4protocol;considertransfer toatertiarycarefacility 3234weeksConsideramniocentesisandiffetallungsaremature,deliverwith MgSO4protocol;iffetallungsareimmature,givesteroidsanddeliverwithMgSO4 protocol >34weeksDeliverwithMgSO4protocol ConsiderMFMconsult Monitorinputandoutputclosely,considerFoley.Considerfluidrestriction. Ifunstableorifinpulmonaryedema,considerMFMconsultorintensivecare specialistifneeded

ChronicHypertensionwithsuperimposedpreeclampsiaconsideredbasedon gestationanddeliverywithMgS04protocol HELLPsyndromedeliverywithMgS04protocol

DiagnosisandTreatmentStrategies

LevelofIllness Preeclampsia Mild

ClinicalCriteria BloodPressure(BP) 140/90mmHg Proteinuria300mg/24 hours

Preeclampsia Severe

BPof160/110mmHg Proteinuria>5Gms/24 hours Oliguria<500ml/24 hours Platelets<150K Increasedbloodurea

Treatment >37Weeks:DeliverwithMgSO4protocol 3437Weeks:Useexpectantmanagementwithclinical judgmentregardingmaternalandfetalunitstability <34Weeks:Useexpectantmanagementwithclinical judgmentregardingsteroidtherapy >34Weeks:DeliverwithMgSO4protocol 3234Weeks:Iffetallungsaremature,deliverwith MgSO4protocol.Iffetallungsareimmature,usesteroid treatmentanddeliverwithMgSO4protocol. 2832Weeks:Hospitalizeforobservation.Evaluatethe useofsteroids.Expectantmanagementifmaternal/fetal unitstable.Ifthematernal/fetalunitisunstable,deliver

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Gestational Hypertension HELLP

nitrogen,creatinine, liverenzymes URGR/oligohydramnios Endorgansymptoms: headache,visual changes,epigastricor rightupperquadrant pain BPwithoutproteinuria

withMgSO4protocol. <28Weeks:Counselregardingpooroutcome.Ifthe maternal/fetalunitisdeteriorating,deliverwithMgSO4 protocol.

Hemolysis,elevatedliver enzyme,lowplatelets MgSO4Protocol Guidelines

DeliverwithMgSO4protocol AdministerIVduringlabor Giveduringinitialevaluationforseverepreeclampsia whentheplanistomanageconservatively Loadingdose:4Gm(range26Gm)over20minutes Maintenancedose:24Gm/hour Therapeuticserumlevels:48mg/dl Postpartum:continue24hoursormoreuntilclinical indicatorsimprove Hydralazine510mgintravenouslyq2030minutesto amaximumof40mg Labetalol1020mgintravenouslyevery15minutesto amaximumsingledoseof80mg(totalmaximum dose220mg) MonitorInputandOutput(I&O) Foley Pulmonaryarterycatheterifhemodynamically unstableorifpulmonaryedema(withMFMconsult) MFMconsultisappropriateforsevereanddifficult cases O2saturation

BPControl

Guidelines

FluidControl

Guidelines

PregnancyPretermDelivery Definitions Pretermdeliveryisadeliverypriorto37weeksgestation. Pretermlaborisregularcontractionsthatoccurbefore37weeksandareassociatedwithchangesinthe cervix. Teststhatcanhelpidentify Althoughmanytestshavebeenproposed,onlycervicallengthby patientsatriskforpreterm ultrasoundandfetalfibronectin(fFN)havebeenshowntohave

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delivery

benefit.However,theirclinicalusefulnessmayrestprimarilywith theirabilitytoidentifywomenwhoareleastlikelytodeliver (negativepredictivevalue),asopposedtopredictingthosewhowill deliverbefore37weeks. Acervicallengthat24weeksof3.0orgreaterhasaveryhigh negativepredictivevalue.AnegativefFNbetween2434weekshas anevengreaternegativepredictivevalue. Althoughmanytestshavebeenproposed,onlycervicallengthby ultrasoundandfetalfibronectin(fFN)havebeenshowntohave benefit.However,theirclinicalusefulnessmayrestprimarilywith theirabilitytoidentifywomenwhoareleastlikelytodeliver (negativepredictivevalue),asopposedtopredictingthosewhowill deliverbefore37weeks. Acervicallengthat24weeksof3.0orgreaterhasaveryhigh negativepredictivevalue.AnegativefFNbetween2434weekshas anevengreaternegativepredictivevalue. Althoughnotassensitive,combiningthetwotestscanbepartofa preventingpretermdeliveryalgorithm.

Antenataltestingfor predictabilityofpatientsatrisk forpretermdelivery Teststhatcanhelpidentify patientsatriskforpreterm delivery

Algorithmforpreventing pretermdelivery

Ifcervicallengthisgreaterthan30mmand/orthefFNisnegative,the patientcanbereassuredthatdeliveryisnotimminentandcanbe managedexpectantlyasanoutpatient.Ifthecervicallengthis1530mm, thefFNresultcanbeusedtofurthertriagethesepatients.Patientswith anegativefFNresultcanalsobemanagedexpectantlyanddonot requirehospitalization.ConsiderrepeatingthefFNevery2weeksand theultrasoundsmonthlyfor34weeks.IfthefFNispositiveand/orthe cervicallengthisshorterthan15mm,thesepatientswarrantclose observationandconsiderationforadditionalintervention 1. Tocolytics:Dotheywork? Tocolyticshaveonlybeenproventoprolonggestationfor27 days,whichcanprovidetimeforadministrationofsteroidsand maternaltransporttoafacilitywithNICU. TheAmerigroupMFMadvisorypanelhighlyrecommendsacute tocolysisforpretermlabor. ConsidershorttermuseofIVMgSO4forneonatalneurological protectionforpatientsatrisk. 2. AntenatalCorticosteroids:Usethem. Themostbeneficialinterventionforpatientsintruepreterm laboristheadministrationofcorticosteroidsbetween24and34 weeksgestation.Treatmentshouldconsistofeithertwodosesof

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betamethasoneorfourdosesofdexamethasoneasasingle course. Theuseofcorticosteroidswilldecreasetheincidenceof intraventricularhemorrhageandnecrotizingenterocolitis, respiratorydistresssyndrome,aswellasdecreasedneonatal mortality. 3. Shouldweuseantibiotics? Antibioticsdonotappeartoprolonggestationandshouldbe reservedforGroupBStreptococcus(GBS)prophylaxisinpatients inwhomdeliveryisimminent. 4. ShouldwescreenforBacterialVaginosis(BV)inwomenatriskforPTD? PregnantwomenatriskforPTDmaybescreenedforBVduring thefirstorearlysecondtrimesteraccordingtheCDCguidelines, butstudieshaveshownmixedresults. 5. Progesteronetoreducepretermbirth Anywomenwithapriorpretermdeliveryshouldstronglybe consideredforweeklyIMinjectionsof17alpha hydroxyprogesteronecaproate(17P)startingat1620weeksand endingin36weeks.IMprogesteroneshowsasignificant reductioninallracesforpretermbirth,lowbirthweight, intraventricularhemorrhage,necrotizingenterocolitis,NICU admissionsandtheneedforsupplementaloxygentherapy,while a4yearfollowupfoundnoadversehealthoutcomesofthe children. Althoughotherformsorroutinesofprogesteronehavebeen studied(especiallyvaginaldosing,whichwouldbeeasierto accomplish),theresultshavebeenmixed,withsomestudies showingimprovementswhileothersdidnot. Twingestationdidnotshowthesamebenefitsasdidsingleton pregnanciesonIMprogesterone. IMprogesteronemaybeconsideredinthefutureforthose womenwhosecervixis15mmandwitha+fFN,butmore studiesneedtobedone.

GestationalDiabetesMellitus(GDM) Screening 1. Screenforundiagnosedtype2diabetesatthefirstprenatalvisitin thosewithriskfactors,usingstandarddiagnosticcriteria. a. Overweight(BMI25kg/m2*)andhaveadditionalriskfactors: i. Physicalinactivity ii. Firstdegreerelativewithdiabetes iii. Highriskrace/ethnicity(e.g.,AfricanAmerican,Latino,
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NativeAmerican,AsianAmerican,PacificIslander iv. Womenwhodeliveredababyweighing>9lborwere diagnosedwithGDM v. Hypertension(140/90mmHgorontherapyfor hypertension) vi. HDLcholesterollevel<35mg/dl(0.90mmol/l)and/or atriglyceridelevel>250mg/dl(2.82mmol/l) vii. Womenwithpolycysticovariansyndrome(PCOS) viii. A1C5.7%,IGT,orIFGonprevioustesting ix. Otherclinicalconditionsassociatedwithinsulin resistance(e.g.,severeobesity,acanthosisnigricans x. HistoryofCVD 2. Inpregnantwomennotknowntohavediabetes,screenforGDMat 2428weeksofgestationusingeithera50gramonehourglucose challengetestora75gramglucosetolerancetest.Whenusingthe 50gramglucosechallengetest,avalueof130140mg/dlis consideredabnormalandrequiresa3hourglucosetolerancetest (GTT)fordiagnosis.Avalueof130mg/dlhasasensitivityof90% while140mg/dlrevealsasensitivityof80%.The75gramglucose tolerancetestisadiagnostictest. 3. ScreenwomenwithGDMforpersistentdiabetes612weeks postpartum. 4. WomenwithahistoryofGDMshouldhavelifelongscreeningforthe developmentofdiabetesorprediabetesatleastevery3years. *AtriskBMImaybelowerinsomeethnicgroups DiagnosisofGestationalDiabetes Table1DiagnosisofGDMwith75goralglucoseload(testispositivewhenanysinglevalueismetor exceeded Status Fasting 92mg/dl 5.1mmol/l 1h 180mg/dl 10.0mmol/l 2h 153mg/dl 8.5mmol/l
Source:AdaptedAmericanDiabetesAssociationDiabetesCareJanuary2011;34s15.

Table2DiagnosisofGDMwitha100goralglucoseload(twoormoreofthevaluesmustbemetor exceededforapositivediagnosis) Status Fasting 95mg/dl 5.3mmol/l

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1h 2h 3h

180mg/dl 155mg/dl 140mg/dl

10.0mmol/l 8.6mmol/l 7.8mmol/l

Source:ACOGPracticeBulletinNumber30,September2001,(Reaffirmed2010).BasedonMFMCommitteeMembers&basedonMFMpracticepatterns andcommunitystandardsofcare,bothADAandACOGstrategieswouldapply.Thediagnostictestspecificforpregnancyandaboutwhichthegreatest bodyofdataexistsisthe100g,3houroralGTT.Mostpractitionersprovidingobstetricalcarearefamiliarwiththistest.Othersmaychoosetoadoptthe newerrecommendationsbytheADA

ManagementofGDM

OnceGDMisdiagnosed,whatisthenextstep? TheAmericanDiabetesAssociation(ADA)dietisgiven,nutritional counselingandanexerciseprogramisstarted.Fingersticks(fasting and2hourpostprandial)shouldbedonedaily,recordedandthen sentinweeklytophysician. Iffastingbloodsugarsareconsistentlyabove95105orpostprandial are>120thenmedicaltherapyshouldbestarted.Bloodglucose

monitoringtoincludeeither1or2hourpostprandialBSmonitoringwith1 hrvalues<or=120and2hrvalue<or=120

GDMA1isgestationaldiabetescontrolledwithdiet. GDMA2isgestationaldiabetesthatisinsulinororalhypoglycemic controlled. DietTherapy TheADArecommendsanaverageof30kcal/kg/d/basedonpre pregnantbodyweightfornonobeseindividuals. Ifobese(BMI>30prepregnancy)thencalorierestrictionsof3033 percent,butnogreater,willimprovepregnancyoutcomes.However, avoidketonuriabyfollowingweeklyurinedipsticks. AntepartumTesting GDMA1goodcontrolistreatedlikeanyotherpregnancyexceptkick countsstartat28weeksandNSTsareinitiatedafter40weeks. Ultrasoundshouldbedoneonlyifmeasuringlarger. GDMA2shouldhavemonthlyultrasoundsandtwiceweeklyNSTsor weeklyBiophysicalProfile(BPPs)andAmnioticFluidIndex(AFIs) Whenandhowshoulddeliveryoccur? DeliverGDMA1patientsingoodcontrolasanyotherpatientwithout complications. DeliverGDMA2patientsat39Weeks.Ifdeliveringbefore39weeks, stronglyconsideranamniocentesisunlessclinicallycontraindicated. Diet controlled (A1): Fetal evaluation per clinical indications. Deliver by40weeks(orsoonerifclinicallyindicated). Insulincontrolled(A2):WeeklyBPP:oneortwotimesweeklystarting at32weeks(orsoonerifclinicallyindicated).Sonogrameverythree tofourweeksforfetalgrowth.Deliverat38to39weeks,ifthefetus
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ismature(orsoonerifclinicallyindicated).

ReferencesandResearchMaterial 1. AmericanDiabetesAssociation.GestationalDiabetesMellitus.DiabetesCare2003;26s103s105. 2. DiabetesCareJanuary2011;34s15. 3. ACOGPracticeBulletinNumber30,September2001,(Reaffirmed2010). 4. ACOGCommitteeOpinionnumber435,June2009. 5. ACOGCommitteeOpinionnumber475,February2011. 6. ACOGPracticeBulletinnumber33,June2002.(Reaffirmed2010) 7. ACOGCommitteeOpinionnumber455,March2010. 8. ACOGPracticeBulletinnumber60,March2005,(Reaffirmed2010). 9. ACOGPracticeBulletinnumber43,May2003(Reaffirmed2011). 10. ACOGPracticeBulletinnumber29,July2001,(Reaffirmed2008.)

Allmembercareandrelateddecisionsarethesoleresponsibilityoftheprovider.Thisinformationdoesnotdictatenor controltheprovidersclinicaldecisionsregardingtheappropriatecareofmembers.Guidelinesaresubjecttostate regulationsandbenefits.

MACAPPROVAL51012 OBACReview HRPMPC TNPEC040412HighRiskObstetrical SMEUpdated9/2011 MPC 9