Tuesday, March 28, 2017

ACOG releases recommendations for management of acute onset, severe hypertension in pregnancy and postpartum period.

It is estimated that ten million women develop preeclampsia each year around the world, with 76,000 deaths due preeclampsia and related hypertensive disorders.  It is also responsible for 50,000 stillbirths and early neonatal deaths in developing nations.

A woman in developing country is seven times more likely to develop preeclampsia than a woman in a developed country, contributing to 10-25% of all Maternal mortality.

In the United States, preeclampsia complicates approximately 3-5% of pregnancies, accounting for 10-15% of maternal deaths and 3% of perinatal deaths.

ACOG says “Introducing standardized, evidence-based clinical guidelines for the management of patients with preeclampsia and eclampsia has been demonstrated to reduce the incidence of adverse maternal outcomes.”

ACOG committee opinion was published online ahead of print in Journal of Obstetrics and Gynecology.

Women who are pregnant or postpartum presenting with acute onset severe systolic (greater than or equal to 160 mm Hg) as well as severe diastolic hypertension (greater than or equal to 110 mm Hg) require urgent antihypertensive therapy.

Hospitals, doctor’s office and other institutions handling emergencies should initiate treatment with first line drugs within 30-60 minutes of confirming the diagnosis to prevent maternal stroke.

Intravenous labetalol and hydralazine have long been used as the first line drugs in managing hypertensive emergencies in antenatal and postnatal women.

Recent available evidence suggests that immediate release oral nifedipine may also be considered an alternative first line therapy, especially in circumstances when an IV line is not secured. Some studies in recent time have shown that it brings down BP faster than labetalol and hydralazine. Concurrent use of Nifedipine and Magnesium Sulfate requires tertiary care setup and close monitoring of mother’s vital signs.

Use of all these three drugs does not requires cardiac monitoring.

In rare cases all the three drugs, labetalol, hydralazine and nifedipine may fail to relieve acute hypertensive emergency. In such circumstances, expert opinion of maternal-fetal medicine specialist, anesthesiologist and critical care subspecialist is sought. The second line alternative to be considered are nicardipine or esmolol by infusion pump.

Once the blood pressure is stabilized, detail evaluation of maternal and fetal well-being is carried out to make plans for long term drug therapy and timing of delivery.

The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. It may be viewed at www.acog.org/More-Info/Hypertension In Pregnancy.

The full text of the ACOG recommendations and suggestions can be accessed here.