CONTROL OF BLOOD PRESSURE IN PREGNANCY: HOW HIGH IS TOO HIGH? EVELYNE REY, CHU Ste-Justine, Montreal

Transcription

1 CONTROL OF BLOOD PRESSURE IN PREGNANCY: HOW HIGH IS TOO HIGH? EVELYNE REY, CHU Ste-Justine, Montreal

2 CONFLICTS OF INTEREST $: None Others: Canadian guidelines, CHIPS CSIM2015 2

3 LEARNING OBJECTIVES New data on the treatment of hypertensive disorders in pregnancy Apply the new guidelines Evaluate the need of modifications CSIM2015 3

4 JESSICA G1, 26y, 32.4 wks; Hypertension FH+ 90kg/1,65m 14w: 120/78; 28w: 130/84 Outside: /80-96; 30w: 144/88. No symptoms Uric acid: 450, ALT: 60 (N 20-50) CSIM2015 4

5 Preeclampsia? CSIM2015 5

6 CSIM2015 6

7 PREECLAMPSIA Pre-e HT G HT.Resistant hypertension or.new/worsening proteinuria or. 1 adverse condition or. 1 severe complication OTHER: Transient, white coat, masked CSIM2015 7

8 CLASSIFICATION Adverse condition Risk of complication Severe complication Morbidity Mortality CSIM2015 8

9 Severe Headache, visual disturbance AntiHT, MgSo4, betamethasone, Delivery CSIM2015 9

10 Adverse cdts Early onset Symptoms 90-97% SpO2 Laboratory abnormalities Fetal: abnormal NST, SGA, AF, OA abnormal Doppler flow Platelets < 150 WBC aptt-inr Creatinine Uric acid ALT-AST LDH Bilirubin Albumin CSIM

11 Adverse conditions Early onset Symptoms 90-97% SpO2 Laboratory abnormalities Fetal: abnormal NST, SGA, AF, OA abnormal Doppler flow Severe complications Eclampsia, PRES, Stroke, TIA, Coma, Cortical blindness Uncontrolled severe HT Pulmonary edema SpO2 <90%, O2 need Transfusion Ptl<50, Creat>150, dialysis Hepatic haematoma, rupture Cardiac ischemia Stillbirth, severe Abruptio, reverse DV A wave CSIM

12 JESSICA (2) Preeclampsia AntiHT? CSIM

13 SEVERE HT CSIM

14 NON SEVERE HT GOAL: /80-105mmHg Acebutolol, metoprolol, pindolol, propanolol DO NOT USE: Atenolol, prazosin, ACE inhibitors, ARB, renin inhibitors, mineralocorticoid antagonists CSIM

15 International, multicenter, randomised controlled, Chronic HT or Gestational HT w dbp mmHg (85-105mmHg if on antiht) Randomized to less-tight or tight control of BP Intend to treat Secondary maternal outcome: one/more serious maternal complications (including death) CSIM

16 CSIM

17 CSIM

18 CSIM

19 CSIM

20 CONCLUSION CHIPS For cht or GH, DBP ± 85 better for mother without problems for BB CSIM

21 CHIPS group BJOG 2015, August 11 CSIM

22 Table 2: Outcomes according to methyldopa or labetalol therapy, either at randomisation, or post-randomisation before delivery MD N=241 Primary 67/241 outcome (27.8) Secondary 7/241 outcome (2.9) BW <10 th 30/240 centile (12.5) Severe HT 79/241 (32.8) Preeclampsia 113/241 (46.9) Delivery 31/240 <34 weeks (12.9) Delivery 68/240 <37 weeks (28.3) At randomisation LB N=237 93/237 (39.2) 10/237 (4.2) 51/234 (21.8) 80/237 (33.8) 104/23 6 (44.1) 41/235 (17.4) 95/235 (40.4) Post-randomisation, before delivery Adjusted* Unadjusted Adjusted* OR [95% CI] p MD LB OR [95% CI] p OR[95% CI] p N=224 N= [0.42, / / [0.41, [0.40, ] (25.9) (37.4) 0.84] 1.00] 0.82 [0.22, /224 17/ [0.32, [0.28, 2.31] ] (3.1) (3.9) 1.93] 0.48 [0.26, /223 91/ [0.40, [0.32, ] (14.3) (21.2) 0.97] 0.92] 0.80 [0.48, / / [0.37, < [0.31, 0.83] ] (24.1%) (37.4%) 0.76] 1.05 [0.66, / / [0.44, [0.36, ] (39.7) (52.2) 0.84] 0.85] 0.84 [0.45, /223 81/ [0.30, [0.29, ] (10.3) (18.8) 0.82] 0.96] 0.65 [0.40, / / [0.38, < [0.35, ] (27.4) (41.4) 0.76] 0.85] *Adjustment was made for allocation group, centre, type of hypertension, antihypertensive therapy at randomisation, prior BP 160/110 mm Hg in this pregnancy, gestational age at randomisation, region, in hospital status at enrolment, and systolic BP at randomisation, and whether women were on an antihypertensive at randomisation (yes/no). CSIM

23 JESSICA (3) 37.1 W 150/94; Platelets 96; ALT 100 Delivery MgSo4? Betamethasone? CSIM

24 MgSo4 1. Eclampsia 2. Severe Preeclampsia 3. Suggested if preeclampsia +. Severe HT. Cerebral/visual symptoms. Epigastric pain or ALT. Platelets < 100. Creatinine 4g IV +1g/hr Serum level not needed CSIM

25 HELLP CORTICOIDS NOT RECOMMANDED CSIM

26 THANK YOU! JOIN US AT GEMOQ.CA CSIM

27 NSAIDS postpartum No if HT difficult to control Oliguria, creatinine >90 Platelets < 50 CSIM

28 1 2 CSIM

29 ASPIRIN Paris Collaborative Group Lancet 2007 CSIM

30 CALCIUM <1g/d Hofmeyr GJ BJOG 2014 CSIM

31 Composite outcome: PEE, Abruptio, IUGR<10 th, IUD p=0.01 Rodger MA, Blood 2014 CSIM

32 AFTER Normalisation Early-onset/severe preeclampsia: cht? Renal disease? Information: incresed risk of cardiovascular disease, renal disease, type 2 diabetes CSIM

33 PREECLAMPSIA:DEFINITION Resistant HT or New/worsening proteinuria or 1 adverse cdt or 1 severe complication New proteinuria or Platelets < 100 or Creatinine 97 or Creatinine 2x or ALT 2x or Pulmonary edema or Cerebral/visual disturbances CSIM

34 SEVERE PREECLAMPSIA 1 severe complication = delivery Severe HT Platelets < 100 or ALT 2x and/or severe epigastric pain or Creatinine 97 or 2x or Pulmonary edema or Cerebral/visual disturbances CSIM

35 Comments: Dipstick for significant proteinuria A dipstick value of 1+ proteinuria has low sensitivity 55% [95% CI 37 72%] Negative or trace result should not exclude further investigation if preeclampsia is suspected. Urinary dipstick testing has reasonable specificity 84% [95% CI 57 95%] 1+ result should prompt additional investigations 2+ result strongly suggests 0.3 g/day 35 CSIM2015 Waugh JJ, Clark TJ, Divakaran TG, Khan KS, Kilby MD. Accuracy of urinalysis dipstick techniques in predicting significant proteinuria in pregnancy. Obstet Gynecol Apr;103(4):