UPDATE: WHAT’S NEW IN A FEW HOT TOPICS IN OBSTETRICS

JAMES W. VAN HOOK, MD MATERNAL FETAL MEDICINE- PROMEDICA HEALTH SYSTEM SHEELY PROFESSOR AND CHAIR DEPARTMENT OF OBSTETRICS AND GYNECOLOGY UNIVERSITY OF TOLEDO COLLEGE OF MEDICINE

Objectives:! Describe issues with use of late preterm Antenatal Corticosteriods

! Define Late Preterm To give or not to give ANCS

! Explain the appropriate medical treatment for Gestational Diabetes (GDMA2) when diet is not enough ! How to diagnose Gestational diabetes ! Oral medications or Insulin- New guideline

!   ! Describe the difference of Gestational Hypertension (GHTN) vs Pre eclampsia (20min)

! Definitions ! Treatment differences ! When to induce the labor ! Prevention next pregnancy

Conflicts of Interest:

! Safety Monitor for Phase III Preeclampsia Treatment Study- Velo Pharmaceutical- No direct conflict

! No other potential conflicts ! Most medications including corticosteroid lung maturation treatment

and antihypertensive agents, Diabetes treatment agents, etc are not specifically FDA approved for use in pregnancy

Update Topics:

! Late Preterm Corticosteroids ! Diagnosis and changes regarding Gestational Diabetes ! Preeclampsia versus Gestational Hypertension

Late Preterm (34 0/7- 36 6/7 Weeks Gestation) Corticosteroids- Background

! Standard traditional indications for beclomethasone corticosteroid lung maturation treatment:

! Prematurity: ! 24 0/7 (23 0/7?)- 33 6/7 weeks’ ! Single course of ‘rescue treatment’ if delivery deemed likely within 2

(1?) weeks ! Preterm Prolonged Ruptured Membranes

! Consensus recommendation similar ! NICHD Borderline viability recommendations ! 32-34 weeks?

! Twins ! Recommendation similar to as with singleton pregnancy

ACOG Committee Opinion No. 713, August 2017- Antenatal Corticosteroid Administration for Fetal Maturation Crowther, et al. Cochrane Database of Systematic Reviews, 2015, No. 7. Periviable birth. Obstetric Care consensus No. 4. ACOG. Obstet Gynecol 2016;127:e157-69.

Late Preterm Steroids

! An appreciable number (Denominator of total) deliveries occur in the late preterm period ! Late Preterm = 34 0/7- 36 6/7 weeks’ best estimated GA

! Some practitioners and authorities have long questioned upper gestational age threshold of 34 0/7 weeks for corticosteroid administration- Outcome data mixed

! Issue of fetal lung maturity testing clouds the picture… ! Immature fetal lung maturity testing = corticosteroids? ! Recent data investigating this practice did not demonstrate

benefit, yet some benefit suggested by same authors and others…

Kamath-Rayne BD, DeFranco EA, Marcotte MP. Obstet Gynecol 2012. Kamath-Rayne BD, DeFranco EA. Evid Based Nurs 2013. Yinon Y, et al. Am J Obstet Gynecol 2012

Late Preterm SteroidsRandomized Controlled Trial

Inclusion Criteria:

34 0/7-36 6/7 weeks

High risk for delivery

Exclusions:

Twins

Diabetics (Except GDM)

Anomalies

Immediate need for delivery

Did not already receive steroids

Delivery not indicated to occur immediately

Outcome:

Neonatal Composite:

O2 > 4 hrs

CPAP, High flow,etc > 2 hrs

ECMO, Mech Vent, etc win 72 hrs

Stillbirth (?), Neonatal death

https://s3.amazonaws.com/lowres.cartoonstock.com/business-commerce-devils-demons-details-planners-plans-bven358_low.jpg- EDUCATIONAL USE ONLY- Not otherwise for COPY

NEJM Article- “Devil is in the Details”

! Ineligible if antenatal steroids for lung maturation previously received ! Ineligible if expected to deliver within 12 hours ! Ineligible if ROM with more than 6 contractions per hour ! Ineligible if > 3 cm dilated unless oxytocin withheld as “on purpose”. ! Ineligible if diagnosis of chorioamnionitis, nonreassuring fetal status,

or cervical dilation > 8 cm ! Ineligible if multiple gestation, anomalies (broad definition!),

maternal instability, or Diabetes in pregnancy ! Inclusion for those not in labor/ROM was for patients planned for

delivery between 24 hours and 7 days after randomization

Important Points- NEJM Late Preterm Steroids:

! Diabetics (Except Gestational)- EXCLUDED ! Multiple Gestations- EXCLUDED ! Outcomes:

! Reduction in Respiratory Complications (Primary Outcome 11.6% vs 14.4% control; P= 0.02)

! Reduction in Severe Complications, ICU admissions, and other outcomes ! Neonatal hyperglycemia more frequent in steroid intervention arm ! Neonatal sepsis NS although greater in treatment group

! Important points: ! For patients with anticipated or planned deliveries prior to 37 0/7 weeks

NEJM, 2016

Copyright Elsevier 2016 http://dx.doi/10.1016/j.ajog.2016.03.013 August 2016

Antenatal Corticosteroids- Term and Near Term Meta Analysis (Saccone & Berghella, BMJ 2016)

! Pregnant patients (n = 3200) at 34 0/7- 36 6/7 weeks who were at risk of imminent preterm delivery at the time of admission

! Also included 2498 patients with planned early term CS delivery > 37 0/7 weeks

! Infants of patients that received corticosteroids at or above 34 0/7 weeks with lower risk of RDS (RR= 0.74; 95% CI = 0.61-0.91)

! Infants of patients that received corticosteroids prior to early term delivery, had lower risk of RDS (RR = 0.40; CI = 0.27-0.59)

BMJ 2016;355;i5044

Antenatal Corticosteroids Beyond 34 Weeks Gestation: What Do We Do Now? (AJOG, Oct 2016)

! Authors include one of the original researchers (Jobe) that investigated and developed the recommendations for administration of corticosteroids for fetal lung maturation in preterm pregnancy

! Concerns and Issues: ! Predominant impact of therapy = Transient tachypnea of newborn- Self

limited ! Defacto endorsement of late preterm delivery (Recognition of risk of non-

respiratory morbidity and mortality) ! Alteration in follow up management (“Look good, No RDS. So OK to go

home as if term”) ! Slippery slope

! Recommend ongoing research and careful use of available evidence to choose patients for late preterm corticosteroid therapy

Kamath-Rayne BD, Rozance PJ, Goldenberg RL, Jobe AH; Am J Obestet Gynecol, 2016.

https://qph.ec.quoracdn.net/main-qimg-d2f8f3df48b13252631743114f84c6f4-c Educational use only- not otherwise for duplication or use

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Slippery Slope and Unintended Consequences….

Conclusions- Late Preterm Corticosteroids

! Reduces RDS (Predominantly TTN) ! Should NOT delay indicated delivery ! NOT studied in Diabetes (Principal complication is hypoglycemia which

is in itself a problem!!) ! What about steroids in late preterm period prior to delivery in early

term?!!?? ! No real consensus yet regarding special scenarios. Consensus and guideline

basically along the lines of the NEJM investigation- indicated for likely or planned delivery prior to 37 0/7 weeks.

! ACOG and SMFM guideline indicate that steroids for delivery planned prior to 36 6/7 weeks.

! At least one comprehensive review suggests value in C-section (I personally support this view now but did not until I recently reviewed the literature).

! Watch for the “Slippery slope effect” and unintendied consequences!

Gestational Diabetes

https://resources.stuff.co.nz/content/dam/images/1/4/m/x/g/9/image.related.StuffLandscapeSixteenByNine.620x349.1k1mwm.png/1498682179926.jpg. Educational use only

Gestational Diabetes (GDM)- Diagnosis and Oral Hypoglycemic Agent Update 2018

! 6-9% of pregnancies complicated by Diabetes ! 90% of patients with Diabetes in pregnancy represented by diagnosis

of GDM ! Populations with higher prevalence of Type II Diabetes and women

with risk factors for Type II Diabetes are more likely to have GDM ! Management and diagnosis of GDM have the potential for high

impact on pregnancy

1. Wier LM, Witt E, Burgess J, Elixhauser A. Hospitalizations related to diabetes in pregnancy, 2008. Statistical Brief #102. Rockville MD: Agency for Healthcare Research and Quality; 2010 2. DeSisto CL, Kim SY, Sharma AJ. Prevalence estimates of of gestational diabetes mellitus in the United States, Pregnancy Risk Assessment Monitoring System (PRAMS), 2007-2010. Prev Chronic Dis 2014;11:E104. 3. American College of Obstetricians and Gynecologists. Gestational Diabetes, Practice Bulletin No. 180, July 2017

Things That Make a Screening Test Suitable:

! Acceptable (Safe; Able to perform) ! Practical (Results available, Easy to perform by screeners,etc) ! Low enough cost ! Validity: (Good sensitivity and specificity) ! Yield: Performance (Predictive value of test good enough)* ! Reliability: (Precision and repeatability adequate)

* Predictive value of a screening test depends on how common the screened for condition is present in the population one is screening

Historical Risk to Determine Need to Screen…

! 95% of US OB providers use at least one laboratory screening test ! If history and prior outcome are used to determine if pregnant

patients need to be screened, approximately ½ of patients with GDM will be missed

! Very low risk women can be identified. ! Only 10% of current US pregnant population meet low risk criteria!!

! US Preventive Services Task Force recommends to screen all pregnant women for GDM between 24-28 weeks.

Moyer VA, Screening for gestational diabetes mellitus: US Preventive Services Task Force recommendation statement. US Preventive Services Task Force. Ann Intern Med 2014;160:414-420.

How and When to Screen (1) ….

! GDM prevalence is greater later in pregnancy. So, if single event screening used, it must be early enough to allow meaningful clinically useful diagnosis and treatment while capturing the majority of patients who will diagnose positive for GDM

! Additional issue with screening for GDM is the (increasing) prevalence of pregnant patients with undiagnosed Type II Diabetes (DM) ! Type II Diabetes and impaired glucose tolerance (IGT) may not be

recognizable in the younger population that does not seek preventative care and does not have advanced end organ damage

! GDM diagnosis at 24-28 weeks includes patients with unrecognized Type II DM or IGT

Risk Factors for Pregestational Diabetes- Screen Earlier

! Physical inactivity ! First-degree relative with DM ! Previous 4000 gm delivery ! Hypertension (HTN) or on RX for HTN ! A1C > 5.7% or history of IGT ! History of acquired cardiovascular

disease

! High risk race or ethnicity (African American, Native American, Asian American, Pacific Islander, Latino)

! HDL < 35mg/dL or TG > 250 mg/dL ! History of PCOS ! BMI > 40kg/m2 ! Acanthosis nigrans

American Diabetes Association. Classification and diagnosis of diabetes. Diabetes Care 2017:40 (Suppl. 1); S-11-S24

How and When to Screen (2)…! One Step Screening- 2010 International Association of Diabetes and Pregnancy

Study Group (IADPSG) ! 2- hour OGTT- any one value abnormal = DGM

! Fasting > 92 mg/dL ! 1 hour > 180 mg/dL ! 2 hour > 153 mg/dL

! Early pregnancy HgA1C for IGT or Type II DM ! Two Step Screening (“ACOG Screening”)- American College of Obstetricians and

Gynecologists (ACOG) + National Institute of Child Health and Human Development- (National Institute of Health)

! I-hour non-fasting 50 gm test (130?, 135?, 140? Mg/dL) screen ! Abnormal = 3 hour OGTT

1. Metzgar BE, et al. International Association of Diabetes and Pregnancy Study Groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. International Association of Diabetes and Pregnancy Study Groups Consensus Panel. Diabetes Care 2010:33;676-682.

2. Vandorsten JP, Dodson WC, Espeland MA, Gorbman WA, Guise JM, Mercer BM, et al. NIH consensus development conference: diagnosing gestational diabetes mellitus. NIH Consens State Sci Statements 2013;29:1-31.

IADPSG versus ACOG Screening for GDM

! IADPSG: ! Only one screening and diagnostic test at 24-28 weeks (but combined with early A1C

and FBS)- Lower complexity ! 18% of women would be identified with GDM (Is this a good thing or a bad thing…??)

! Higher diagnostic rate ! Higher cost ! Identifies cohort of patients without increased risk of adverse consequences (?)

! ACOG: ! Two step approach ! More screening cost- less diagnostic cost ! Reference for diagnosis (this method used for the standard- how does one interpret

increased diagnostic rate for IADPSG

! Hemoglobin A1C: ! Decreased sensitivity as stand alone- (Use early in pregnancy with 2- hour late test and

FBS or random glucose early..)

IADPSG versus ACOG Screening- Conclusion! Currently- No one screening/diagnostic strategy is felt to be superior (Cochrane

Review- 2015) ! ACOG supports two step approach with additional high risk screening earlier in

pregnancy ! ACOG also does not exclude the validity of IADPSG method in an individual

practice or health system ! Opinion-Uniformity has value- since more practices in US use two step approach

and two step approach is NICHD and ACOG recommended, two-step approach probably recommended at present

Farrar D, Duley L, Medley N, Lawlor DA. Different strategies for diagnosis gestational diabetes to improve maternal and infant health. Cochrane Database of Systematic Reviews 2015, Issue 1 Art. No. CD007122.

Things That Make a Screening Test Suitable:

! Acceptable (Safe; Able to perform) ! Practical (Results available, Easy to perform by screeners,etc) ! Low enough cost ! Validity: (Good sensitivity and specificity) ! Yield: Performance (Predictive value of test good enough)* ! Reliability: (Precision and repeatability adequate)

* Predictive value of a screening test depends on how common the screened for condition is present in the population one is screening

https://drjengunter.files.wordpress.com/2014/10/imgres-1.jpg?w=240 For educational use only

The GREAT QUESTION: 130 mg%, 135 mg%, or 140 mg% cutoff??

! Lower cutoff = MORE “test positive” + MORE “diagnostic tests performed” + MORE “negative diagnosis”

! Higher cutoff = More “test negative” + More missed opportunity for diagnosis

! There is no consensus for which threshold to use ! One study showed that 140 mg% screen cutoff had lower false

positive and improved positive predictive value across wide population ! Test sensitivity only marginally improved with lower threshold

Esakoff TF, Cheng YW, Caughey AB. Screening for gestational diabetes: different cut-offs for different ethnicities? Am J Obstet Gynecol2005;193:1040-1044.

3- hour 100 gm OGTT Diagnostic Criteria! Carpenter and Coustan Criteria:

! Fasting -95 mg% ! 1 hour -180 mg% ! 2 hour -155 mg% ! 3 hour -140 mg%

! National Diabetes Data Group (NDDG) Criteria: ! Fasting -105 mg% ! 1 hour -190 mg% ! 2 hour -165 mg% ! 3 hour 145 mg%

! 3- hour OGTT considered diagnostic for GDM with two abnormal values.

American Diabetes Association. Classification and Diagnosis of Diabetes. Diabetes Care 2017;40 (Suppl.1):S11-S24

The Second GREAT QUESTION: What values to use for 3- hour diagnostic test?

! No clear standard adopted ! Value in uniformity ! Carpenter and Coustan positive patients who would have not been

diagnosed with GDM via National Diabetes Data Group criteria were found to have higher rate of adverse outcome ! Another study showed Carpenter and Coustan with 50% more DGM

diagnosis (Albeit less than with one step diagnostic approach discussed earlier)

! Adverse outcomes also somewhat more likely in those with “one value” positive 3 hour OGTT- No agreement on what to do ! (BTW-If early screen positive but 3H-GTT negative, 24-28 week test should

be 3H-GTT)

Ferrara A, et al. Diabetes Care 2002;25:1625-30. Cheng YW et al. Obstet Gynecol 2009;114:326-332.

Roeckner JT, et al. Am J Obstet Gynecol 2016;215:287-297.

Conclusion-Recommendation:

! Either one step or two step assessment can be used- For uniformity, recommend two step assessment in USA. Screening of some type is recommended.

! If two step assessment is used, would screen higher risk groups early as well as at 24-28 weeks’

! Uniformity matters ! One might make a good argument to use 50 gm screening threshold

of 140 mg%, screen higher risk groups twice, and use Carpenter and Coustan diagnostic criteria…

GDM Screening- Special Circumstances

! Gastric Bypass Surgery (Roux-en-Y): ! Wide and rapid changes in postprandial period ! Often still at risk (BMI) ! Often unable to tolerate 50 gm glycemic load ! If not tolerated (LEVEL III evidence) many recommend Fasting and

Postprandial glucose monitoring for 1-2 weeks early in pregnancy with repeat at 24-28 weeks. CGMS is another option

! “I WILL NOT DRINK THAT GLUCOSE DRINK STUFF” ! Offer glucose monitoring ! One (older) study with Jellybeans…

Medical Treatment of GDM- New Recommendations for A2 DM

! Dietary treatment mainstay for management of GDM: ! No more than 40% CHO- complex

! Three meals, two snacks ! NO truly convincing outcome study!!! (Probably because compliance

and activity level variation confound investigation

! Moderate activity recommended: ! Moderate intensity aerobic exercise at least 5 days per week or minimum

of 150 minutes per week ! One trial showed that walking 10-15 minutes after each meal improved

glycemic control

American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No.108- Gestational Diabetes. American College of Obstetricians and Gynecologists, Washington DC, 2017 (and other sources referenced within)

Treatment Failure Necessitating Medical Treatment:

! Optimal control: ! Fasting blood glucose below 95 mg% ! 1 hour postprandial glucose below 140 mg% (Or 2 hour postprandial

glucose below 120 mg%

! Definition of suboptimal control (How many abnormal values?) not uniformly agreed upon- “Consistently abnormal” ! For uniformity, many use 30% or 50% abnormal without another

explanation (Diet, Compliance, etc)

! Threshold largely extrapolated from outside of pregnancy Diabetes

Agency for Healthcare Research and Quality. Therapeutic management, delivery, and postpartum risk assessment and screening in gestational diabetes. Evidence Report/Technology Assessment No. 162. Rockville MD: AHQR;2008.

https://www.bing.com/images/search?view=detailV2&ccid=cybDv%2b1N&id=C5AEAD6B250DFD50825C0454C976F2CA0242FCF1&thid=OIP.cybDv-1NlAtnnnBsmN-8RgDZEf&mediaurl=http%3a%2f%2fcdn.shopify.com%2fs%2ffiles%2f1%2f0770%2f1197%2fproducts%2fALLABOUTTHEFOOD_grande.jpg%3fv%3d1427220352&exph=599&expw=454&q=its+all+about+the+food&simid=607999051400348203&selectedIndex=3&ajaxhist=0 (Access 1/17/2018)

Oral Medication or Insulin?

! In years past (Many years!) insulin was primary treatment for dietary failure

! Insulin does not cross the placenta ! Insulin replacement is pseudo-physiologic ! Non-gestational Diabetes treatment in pregnancy was

predominantly via insulin ! Dosing beyond scope of talk:

! Long acting plus very short acting insulin with less hypoglycemia than NPH and Regular regimens for most patients

Oral Medications:

! Glyburide: ! Sulfonylurea ! Binds to pancreatic B-cell ATP calcium channel receptors ! Increases insulin secretion and some increase in insulin sensitivity

! Metformin: ! Biguanide that inhibitis gluconeogenesis and glucose absorption ! Augments glucose uptake in peripheral tissues

! Acarbose: ! Inhibits alpha-glucosidase enzymes in the brush border of the small

intestines, and pancreatic alpha-amylase.

Data supporting oral hypoglycemic agents (1)

! Agents used: ! Glyburide ! Metformin ! Acarbose

! Cochrane Review: ! Insufficient high quality data to make conclusions

! Laing, et al (Meta analysis): ! Glyburide- Best rate of control ! Metformin- Fastest control and best pregnancy outcome ! Limited data on Acarbose

Hui-ling Liang MM, et al. Comparative efficacy and safety of oral antidiabetic drugs and insulin in treating gestational diabetes mellitus. Medicine 2017;96:38.

Brown J, Martis R, Hughes B, Rowan J, Crowther CA. Oral anti-diabetic pharmacological therapies for the treatment of women with gestational diabetes. Cochrane Database of Systematic Reviews 2017, Issue 1. Article No:CD011967

ACOG (2017) and ADA Position: Oral Therapy

! “Insulin is considered first line therapy for patients who fail dietary and lifestyle therapy” (!!?)

! Metformin is considered second line therapy in patients unable to tak insulin

! Glyburide is not recommended as first line or second line therapy ! (Limited comments – Acarbose)

Management of diabetes in pregnancy. American Diabetes Association. Diabetes Care 2017;40:S114-9

American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No.108- Gestational Diabetes. American College of Obstetricians and Gynecologists, Washington DC, 2017

https://www.bing.com/images/search?view=detailV2&ccid=qob%2fN2Hq&id=D5FE666346543DF10892F60D743A1203AC6463F2&thid=OIP.qob_N2HqL7ZZTxYt5Ni7ngHaFu&mediaurl=http%3a%2f%2fwww.mobieg.co.za%2fwp-content%2fuploads%2f2014%2f04%2fsad_quotes_about_depression_tumblr.jpg&exph=387&expw=500&q=Sad+Where+Did+This+Come+From&simid=607997715666701039&selectedIndex=57&ajaxhist=0 (Access 1/17/2018)

Preeclampsia Classification

Princess Charlotte Sir Richard Croft

ACOG (2013) Hypertension in Pregnancy

! Consensus document ! Defines diagnostic taxonomy and treatment guidelines for

hypertension in pregnancy ! Several diagnostic criteria were changed

American College of Obstetricians and Gynecologists. Hypertension in Pregnancy ACOG 2013, Washington DC

Diagnostic Criteria- Preeclampsia

! Blood Pressure: ! SBP > 140 mmHg or DBP > 90 mmHg on two occasions at least 4 hours

apart (greater than 20 weeks’ gestation) ! SBP > 160 mmHg or DBP > 110 mmHg confirmed over short interval

! Proteinuria: ! Greater than 300 mg in 24 hours (or extrapolated) ! Protein/Creatinine > 0.3 ! Dipstick reading of 1+ or greater (If other method NA)

Preeclampsia Diagnosis (2)

! Preeclampsia = HTN + Proteinuria ! In absence of proteinuria, preeclampsia diagnosis made by HTN plus

any of following: ! Platelet Count < 100,000/microliter ! Serum creatinine concentration > 1.1 mg/dL or a doubling of serum

creatinine concentration in absence of other renal disease ! Twice x normal elevation of liver transaminases ! Pulmonary edema ! Cerebral or visual disturbance (Thought to be associated with

preeclampsia)

Preeclampsia- Severe Features

! Systolic BP > 160 mmHg or diastolic BP > 110 mmHg on at least two occaisons 4 hours apart while the patient is at bedrest: ! If first elevation treated with BP meds, does not need to stay up 4 hours ! In text, it is presumed that consistent elevation of BP over 4 hours is the intent

! Thrombocytopenia < 100,000/microliter ! Hepatic Preeclampsia:

! Doubling of hepatic transaminases ! RUQ or Epigastric pain not relieved and not because of other reasons

! Progressive renal insufficiency (Se Cr > 1.1 mg/dL or doubling of Se Cr in absence of other renal disease

! Pulmonary edema ! New onset cerebral or visual disturbances

Changes from old criteria…

! No Proteinuria requirement for severe features ! Degree of protein not tied to outcome

! Do not have to have proteinuria to have preeclampsia diagnosis ! Severe features trump proteinuria in the classification

! IUGR not a part of classification ! 6 hour rule changed to 4 hour rule- text within monograph implies

persistent hypertension ! Clarification (Severe features) regarding treatment of blood pressure

Chronic Hypertension (HTN):

! Chronic Hypertension- Hypertension known to pre-date pregnancy or HTN in pregnancy diagnosis first made prior to 20 weeks’ gestation

! Superimposed Preeclampsia- Likely in any of the following: ! Patient with chronic HTN only < 20 weeks who develop proteinuria > 20 weeks ! Previously well controlled chronic HTN patient with sudden exacerbation and

need to escalate therapy ! Sudden development of thrombocytopenia or abnormal liver function testing ! Renal insufficiency (As with severe features) ! Pulmonary edema ! Sudden substantial sustained protein excretion (How much?)

Difficulty With Diagnosis of Superimposed Preeclampsia!! Blood pressure normally declines by mid pregnancy and then increases –

(Need to increase medication to control BP confounded) ! Preexisting proteinuria early in pregnancy increases (GFR and FF increase in

pregnancy as pregnancy progresses – confounds proteinuria criteria) ! Underlying disease co-morbidities associated with chronic HTN

! Diabetes ! Renal disease ! Autoimmune disease

Gestational Hypertension:

! Blood pressure elevation alone to meet HTN criteria beginning after 20 weeks gestation ! “Severe criteria” change diagnosis to Preeclampsia with severe features

! If blood pressure elevation persists postpartum, retrospective change in diagnosis to chronic HTN

! “Late postpartum HTN” which occurs 2 weeks to 6 months postpartum and then resolves ! Not part of classification system but mentioned in guideline

! Gestational HTN and “Late Postpartum HTN” associated with subsequent development of chronic HTN

Important points- HTN in Pregnancy Classification:

! Preeclampsia is a clinical syndrome: ! Not all patients meet the renal biopsy criteria for preeclampsia

! Differential diagnosis of preeclampsia includes several other diseases that have modified presentation in pregnancy: ! Chronic hypertension ! Diabetes with renal disease ! Lupus

! On one hand we do not want to miss diagnosis of preeclampsia. On the other hand, over diagnosis of disease is one of the drivers of preterm, late preterm and early term delivery

! Measure BP correctly and……LOOK AT AND TALK TO THE PATIENT

Delivery Timing Preeclampsia:

! Preeclampsia With Severe Features: ! >34 weeks upon diagnosis ! Unstable disease ! Consider delivery in pre-viable gestation

! Preeclampsia Without Severe Features (& Gestational Hypertension): ! Steroids?

! Use for delivery < 34 weeks if stable to allow delay ! Late preterm steroids for severe disease- Be CAREFUL! (Need to be

delivered ideally within about 24 hours of diagnosis)

American College of Obstetricians and Gynecologists. Hypertension in Pregnancy ACOG 2013, Washington DC *** (More specific in Hypertension guideline than in Medically Indicated Delivery Publication)

Original Reference: LeFevre ML. Low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia: US Preventative Services task Force recommendation statement. US Preventative Services Task Force. Ann Intern Med 2014;161:819-26.

https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/low-dose-aspirin-use-for-the-prevention-of-morbidity-and-mortality-from-preeclampsia-preventive-medication- Access January 2018