Hypertensive Disorders of Pregnancy Guideline

Transcription

1 Hypertensive Disorders of Pregnancy Guideline Approved by: Senior Director of Operations, Women s & Child Health, GNCH/MCH Facility Chief, Obstetrics/Gynecology, GNCH Facility Chief, Obstetrics/Gynecology, MCH Womens and Child Health Number: EDM-OB-0318 Date Approved February, 2018 Date Effective March 1, 2018 Next Review March 2021 Purpose The purpose of this guideline is to standardize the approach to diagnosis, assessment and management for women presenting with hypertensive disorders of pregnancy, in order to improve care for the mother and fetus and decrease the incidence of morbidity and mortality. The goal for treatment is to obtain a blood pressure (BP) of less than 155/105. These guidelines are based on current recommendations from the Society of Obstetricians and Gynaecologist of Canada, and evidenced based practice standards. Applicability This policy and procedure applies to staff, medical staff, students and any other persons acting on behalf of Covenant Health working in the Women s Health Program. Responsibility Roles of Nurses, Midwives and Physicians All health care professionals working within Obstetrics need to have knowledge regarding pathophysiology, signs and symptoms, diagnostic criteria, treatment options, complications and current practice guidelines in relation to hypertensive disease in pregnancy. Principles Obstetrical consultation or transfer of care is required for patients under the care of a general practitioner or midwife. Family practice physicians will follow the consultation requirements as outlined in the "Family Physicians Guideline for Physician consultation and Transfer Responsibility of Care Edmonton Zone". Midwives will follow the consultation requirements as outlined in the "Midwifery Guidelines for Physician Consultation and Transfer of Responsibility for Care Edmonton Zone". Elements: 1. Classification of Hypertensive Disorders of Pregnancy 1.1 Pre-existing hypertension (divided into two subgroups): Pre-existing hypertension with co-morbid conditions i.e. pre-gestational Type I or Type II Diabetes, renal disease, and indication for antihypertensive therapy outside of pregnancy Pre-existing hypertension with evidence of pre-eclampsia includes development of one or more of the following: resistant hypertension; or new or worsening proteinuria; or the presence of one or more adverse conditions or severe

2 complications (Table 1) EDM-OB-0318 Page 2 of Gestational hypertension (divided into two subgroups): Gestational hypertension with co-morbid conditions i.e. pre-gestational Type I or Type II diabetes, renal disease Gestational hypertension with pre-eclampsia includes one or more of the following: new proteinuria, or the presence of one or more adverse conditions or severe complications (Table 1) TABLE 1: ADVERSE CONDITIONS AND SEVERE COMPLICATIONS ASSOCIATED WITH PREECLAMPSIA Adverse Conditions (that Organ System Severe Complications (that warrant increase the risk of severe Affected delivery) complications) CNS Headache Visual symptoms Eclampsia PRES (posterior reversible leukoencephalopathy syndrome) Cortical blindness or retinal detachment Glasgow coma scale less than 13 Stroke, transient ischemic attack, or reversible neurological deficit less than 48 hours Cardiorespiratory Haematological Renal Hepatic Chest pain Dyspnea Oxygen Saturation less than 97% Elevated WBC count Elevated INR or PTT Low platelet count Elevated serum creatinine Elevated serum uric acid Nausea or vomiting Right upper quadrant or epigastric pain Elevated serum AST, ALT, LDH, or bilirubin Low plasma albumin Uncontrolled severe hypertension (over a period of 12 hours despite use of three antihypertensive agents) Oxygen saturation less than 90, need for greater than or equal to 50% oxygen for greater than 1 hour, intubation (other than for Cesarean section), pulmonary edema Positive inotropic support Myocardial ischemia or infarction Platelet count less than 50X109/L Transfusion of any blood product Acute kidney injury (creatinine greater than 150µM with no prior renal disease) New indication for dialysis Hepatic dysfunction (INR greater than 2 in absence of disseminated intravascular coagulation or warfarin) Hepatic hematoma or rupture

3 EDM-OB-0318 Page 3 of 16 Feto-placental Abnormal fetal heart rate Intrauterine growth restriction Oligohydramnios Absent or reverse enddiastolic flow by Doppler velocimetry 2. Diagnostic Criteria Abruption with evidence of maternal or fetal compromise Reverse ductus venosus A wave Stillbirth 2.1 Hypertension: The diagnosis of hypertension is based on two consecutive BP measurements taken 15 minutes apart on the same arm meeting the following criteria: dbp of greater than or equal to 90 and/or sbp of greater than or equal to Severe Hypertension sbp greater than or equal to 160, or dbp greater than or equal to Proteinuria Proteinuria in pregnancy is defined as excretion of proteins in urine in excess of 300 mg in 24 hours (0.3 g/d) Protein/creatinine ratio (UPCR) equal to or greater than 30 mg/mmol is definitive for proteinuria and correlates with a 24 hour urine collection Dipsticks permit simple and rapid testing, but results are unreliable. Positive dipstick results (greater than or equal to plus one (+1)) warrant further evaluation with a 24-hour urine collection for protein creatinine ratio Proteinuria testing does not need to be repeated once significant proteinuria of preeclampsia has been confirmed. 2.4 Blood Pressure Assessment Accurate blood pressure readings are essential Use the proper-sized cuff and accurate sphygmomanometer Aneroid and automatic sphygmomanometers need to be recalibrated every two years BP can be measured using a calibrated aneroid device, or an automated BP machine that has been validated for use in

4 preeclampsia. EDM-OB-0318 Page 4 of In pre-eclampsia, automated BP machines may underestimate or overestimate both dbp and sbp by 5 mm Hg on average while others suggest that the automated BP device significantly underestimates the BP in pre-eclampsia If an automated BP machine is used, a comparison of readings using an aneroid device is recommended The BP assessment should not occur while the woman is talking. Wait for at least 30 minutes after smoking, consumption of coffee, or exercise. If pain is present, treat pain The woman should be in a sitting position with the arm at heart level and legs should be uncrossed and the back supported. Arm to arm differences should be documented and the arm with the higher blood pressure should be used if there is a consistent difference. Measure BP in the same arm with the woman in the same position each time Maintain a slow, steady deflation rate Use the Korotkoff phase V (disappearance of sound) for recording the diastolic value vs. IV (softening of sound) If dbp greater than or equal to 90 following a five minute rest period, repeat blood pressure in five minutes For severe hypertension, the blood pressure reading should be confirmed after 15 minutes of rest. 3. Assessment/Investigation for Adverse Conditions and Severe Complications 3.1 Maternal Although the severity of the disease can usually be based on the level of hypertension, some women may present only with adverse conditions and/or abnormal lab findings. Women may present with convulsions, headache, abdominal pain or general malaise. Headache, right upper quadrant pain and visual disturbances are potentially ominous symptoms and require immediate attention. A complete and systematic assessment is indicated. 3.2 Urine Testing Urinalysis (Routine and Microscopy with/without additional tests for proteinuria. 3.3 Laboratory Test may include (List continues on 2 nd page) CBC and platelet count WBC and differential

5 EDM-OB-0318 Page 5 of 16 peripheral blood smear for red blood cell fragmentation type and screen serum creatinine, uric acid, glucose, AST or ALT, LDH, bilirubin, albumin PT, PTT, Fibrinogen, D-Dimer 3.4 Other Considerations Maternal Fetal Medicine consultation When local resources are limited and maternal and fetal conditions permit, the outcome may be improved by transporting the mother to an appropriate referral center 3.5 Fetal Testing Fetal movement count Fetal heart rate monitoring Ultrasound assessment, which may include: fetal growth biophysical profile amniotic fluid volume (AFV) umbilical doppler flow studies Other considerations Neonatal Intensive Care (NICU) consult, 4. Medical Management 4.1 Delivery is the definitive treatment for preeclampsia. 4.2 Preeclampsia is associated with adverse conditions, regardless of gestational age. 4.3 Expectant management is potentially harmful in the presence of severe preeclampsia, fetal maturity, or suspected fetal compromise. 4.4 A sbp greater than or equal to 160 or a dbp greater than or equal to 110 in a pregnant woman should be considered an emergency. Severe hypertension should be confirmed with a repeat blood pressure measurement after 15 minutes. Pharmacologic treatment with Labetalol, NIFEdipine or HydrALAzine should be started. 4.5 Treatment for hypertension may start at lower BP levels in specific circumstances such as: teenage pregnancy with pre-pregnant dbp Less than 70; patients demonstrating cardiac decompensation;

6 EDM-OB-0318 Page 6 of 16 patients demonstrating cerebral symptoms. 4.6 A component of maternal hypertension is adrenergic and may be modified by stress reduction (quiet environment; clear explanation of management plan to patient/family; minimization of negative stimuli). 4.7 Consider delivery if the patient is at or near term regardless of the presence of adverse conditions. 4.8 Corticosteroids for Acceleration of Fetal Lung Maturity Antenatal corticosteroids should be considered for all women with preeclampsia at less than or equal to 34+6 weeks gestation. 5. Pharmacological Management 5.1 Pharmacological treatment consists of antihypertensive therapy and/or eclampsia prevention or treatment depending on the severity of the disease. Treatment with antihypertensive medication in women with non-severe hypertension (see below for definition) prevents transient severe hypertension but does not mitigate the occurrence of major complications such as stroke, preterm labor and perinatal death. The following drugs are recommended for severe hypertension, non-severe hypertension and eclampsia. A sudden drop in BP or maternal hypotension should be avoided. This may occurs more easily with polypharmacy. 5.2 Recommended antihypertensive medications for non-sever Hypertension are: (Table 2) Labetalol Long acting NIFEdipine Methyldopa TABLE 2: PHARMACOLOGICAL MANAGEMENT FOR NON-SEVERE HYPERTENSION (ORAL ANTIHYPERTENSIVES COMMONLY USED ARE LISTED) Agent Dose Caution Labetalol NIFEdipine XL Methyldopa Initial Dose 100 mg twice per day; Maximum 400 mg three times per day(1200 mg per day) Initial Dose 20 mg daily; Maximum 60 mg twice per day Initial Dose 250 mg twice per day; Maximum 500 mg four times per day (2 grams per day) Asthma Aortic Stenosis (ENSURE XL PREPARATION) Depression

7 EDM-OB-0318 Page 7 of Recommended antihypertensive medications for sever hypertension are: (Table 3) Intravenous Labetalol Short acting NIFEdipine Intravenous HydrALAzine TABLE 3: PHARMACOLOGICAL MANAGEMENT FOR SEVERE HYPERTENSION Agent Dose Route Onset Peak Caution Labetalol Initial Dose 20 mg; Repeat mg every 30 minutes; Maximum 300 mg IV 5 minutes 30 minutes Women with asthma or heart failure; May cause neonatal bradycardia NIFEdipine Initial Dose 10 mg; Repeat mg every 45 minutes; Maximum 50 mg Swallowed (not chewed) 30 minutes 45 minutes Immediate release preparation is used here (PA no longer available in Canada and XL not for acute therapy) HydrALAzine Initial Dose 5 mg; Repeat 5 10 mg every 30 minutes; Maximum 20 mg IV 5 minutes 30 minutes Maternal hypotension 5.4 Nursing Protocols Intravenous Labetalol (i) (ii) (iii) (iv) (v) all patients receiving intravenous Labetalol are to be cared for in Labor and Delivery; registered nurse with specialized clinical competency in direct IV administration; establish intravenous access (IV) prior to drug administration; resuscitation equipment readily available; non-invasive or invasive blood pressure monitoring is required take blood pressure prior to administration keep patient resting in bed during administration and for at least three hours following administration or until the patient has no symptoms of hypotension with postural change

8 EDM-OB-0318 Page 8 of 16 TABLE 4: INTRAVENOUS LABETALOL MONITORING PARAMETERS Parameter* Frequency Warning Signs Action BP, Heart Rate, Respirations Fetal Heart Rate (FHR) Electrocardiogram (ECG) Just prior to administration After administration: every 5 min for 30 minutes every 30 min for 2 hours hourly for up to 6 hours as needed then as ordered by Physician Continuous FHR monitoring sbp greater than 160 dbp less than 90 Avoid rapid fall in BP Atypical or Abnormal FHR patterns Watch for bradycardia Notify Physician or Intrauterine resuscitation measures Notify Physician or Continuous cardiac monitoring is not necessary routinely, but should be used in patients with relevant co-morbidities (e.g., coronary artery disease) NIFEdipine (i) ensure patient swallows tablet(s) whole (dependent on physician orders and formulation; TABLE 5: NIFEDIPINE MONITORING PARAMETERS Parameter* Frequency Warning Signs Action BP Heart rate Fetal Heart Rate (FHR) Just prior to administration After administration: every 5 min for 30 minutes every 30 min for 2 hours hourly for up to 6 hours as needed then as ordered by Physician Just prior to administration After administration Continuous FHR monitoring sbp greater than 160 dbp less than 90 Less than 50 bpm Greater than 120 bpm Atypicl or Abnormal FHR patterns Avoid rapid fall in BP Notify Physician or Notify Physician or Intrauterine resuscitation measures Notify Physician or

9 5.4.3 HydrALAzine EDM-OB-0318 Page 9 of 16 (i) When using continuous intravenous infusion one to one nurse patient ratio medical staff readily available resuscitation equipment readily available prepare intravenous control solution of 1000 ml as ordered by physician prepare HydrALAzine infusion i. supplied: 20 mg/ml vial ii. reconstitute with 1 ml sterile water iii. add 50 mg HydrALAzine to 500 ml of Normal Saline iv. concentration = 0.1 mg/ml program Alaris pump for HydrALAzine infusion ii. start infusion at 0.05 mg/minute and increase rate every minutes as ordered by physician until desired BP parameters are achieved iii. usual dose = mg/minute an independent double check is required attach HydrALAzine solution to the lowest port on the control solution IV solution is stable for 24 hours at room temperature (does not apply to parenteral products mixed by pharmacy) when HydrALAzine is diluted with IV fluids, a color change occurs over an 8 12 hour period. Color changes do not indicate loss of potency Infusion Rates Pump Setting (ml/hr) Dosage (mg/minute) Dosage (mg/hour mg/minute 3 mg/hour mg/minute 4.5 mg/hour mg/minute 6 mg/hour mg/minute 7.5 mg/hour mg/minute 9 mg/hour mg/minute 10.5 mg/hour mg/minute 12 mg/hour See TABLE 6 for HYDRALAZINE MONITORING PARAMETERS

10 EDM-OB-0318 Page 10 of 16 TABLE 6: HYDRALAZINE MONITORING PARAMETERS Parameter* Frequency Warning Signs Action BP (IV) Monitor BP every 5 minutes while treatment is initiated and then every 15 minutes until BP has stabilized, then every 30 minutes for 2 hours, then every hour or as ordered by Physician Heart Rate (HR) (IV, IM) BP (continuous infusion) Heart rate (HR) (continuous infusion) Fetal Heart Rate (FHR) Intake and Output Just prior to administration and After administration Monitor BP every 5 minutes during infusion Just prior to administration and every 5 minutes during infusion Continuous FHR monitoring Monitor hourly sbp greater than 160 dbp less than 90 HR less than 50 bpm HR greater than 120 bpm s BP greater than 160 d BP less than 90 HR less than 50 bpm HR greater than 120 bpm Atypical or Abnormal FHR patterns Urine output less than 30 ml per hour Avoid rapid fall in BP Notify house staff or physician Notify house staff or physician Avoid rapid fall in BP Notify house staff or physician Notify house staff or physician Intrauterine resuscitation measures. Notify house staff or physician Insert Foley Catheter Notify house staff or physician TABLE 7: METHYLDOPA MONITORING PARAMETERS Parameter Frequency Warning Signs Action BP, Heart Rate Prior to administration sbp greater than 160 dbp less than 90 Avoid rapid fall in BP Notify Physician or Temperature Prior to administration fever Notify Physician or Fetal Heart Rate (FHR) Prior to administration Lab work Liver function tests before initiating medication and CBC As ordered by Physician abnormalities in liver function tests jaundice Notify Physician or

11 EDM-OB-0318 Page 11 of Eclampsia 6.1 Prevention of seizures is crucial with hypertensive disorders in pregnancy. Eclampsia is often preceded by premonitory signs such as headache, visual disturbances, epigastric pain, sensation of constriction of the chest, apprehension, excitability, and hyperreflexia 6.2 Prophylaxis or Treatment There is clear evidence to support the use of Magnesium sulphate in the prevention of seizures in women with severe hypertension and in the treatment of eclamptic seizures. Magnesium sulfate should be used in standard dosing, 4 gram intravenous loading dose followed by 1 gram per hour. A recurrent seizure may require a second 2-4 grams Magnesium sulfate intravenous bolus. The use of Magnesium sulphate in prevention of seizures in women with non-severe hypertension accompanied by proteinuria may be considered. 6.3 Medical Management of the Patient with Eclampsia call for additional help; ensure environment is safe and protect from harm; resuscitation equipment readily available; prepare the medications that are likely to be needed. 6.4 After Seizure Position woman in left lateral Ensure airway is clear Administer oxygen by mask at 8 10 litres Initiate or re-initiate continuous fetal heart rate monitoring Monitor maternal BP, Heart Rate, Respirations Monitor maternal oxygen saturation Ensure intravenous access and Magnesium sulphate is infusing Communicate with the family Document 6.5 Magnesium Sulphate Infusion for Eclampsia Prevention in the Obstetrical Patient a) Equipment (i) Intravenous Solution 1000 ml Ringers Lactate or Normal Saline for control (ii) Premixed Magnesium Sulfate (MgSO4) Solution 50g/500mLs in Normal Saline solution (iii) Alaris Pump with minimum of two channels (iv) Intravenous tray or intravenous equipment

12 EDM-OB-0318 Page 12 of 16 (v) (vii (vii) Fetal heart rate monitor Blood pressure cuff (automated or aneroid) Reflex hammer b) Procedure (i) Explain the procedure to the patient (ii) Ensure resuscitation equipment at bedside (oxygen and suction) is functional (iii) Plan to use an Alaris pump is the patient is fluid restricted for control IV (viii) Run intravenous control infusion at 50 ml/hour until MgSO4 infusion is started or as ordered by Physician (ix) Perform baseline assessment of mother and fetus Blood pressure, heart rate, respirations Deep tendon reflexes Uterine contractions Fetal heart rate Document in patient chart (xi) Program Alaris pump for MgSO4 infusion (see section 8.1.e) An independent double check is required (xii) Attach MgSO4 solution to lowest port on control solution tubing (xiii) Administer 4 gram loading dose of MgSO4 solution over 20 minutes (xiv) At completion of 4 gram loading dose, check that the Alaris pump automatically switched to the set maintenance dose as ordered. c) Nursing Responsibilities (i) Constant attendance is required during the loading dose (ii) One to one nurse to patient ratio is recommended while Magnesium sulfate is infusing (iii) Continuous fetal heart rate monitoring or as ordered by Physician (iv) Maternal vital signs as per Monitoring Parameters d) To Program the Alaris Pump for a Magnesium Sulfate Infusion: i) Choose Magnesium sulfate continuous on Alaris pump program (ii) Select eclampsia (iii) Concentration-choose 50 gm/500mls (iv) Verify (v) Program continuous rate first, by entering dose, rate, and volume to be infused as ordered (vi) Program bolus dose second, by entering dose and duration as ordered (vii) Start Alaris pump (viii) Bolus dose will start infusing (ix) Once bolus dose complete, ensure continuous infusion rate infusing e) Mixing Magnesium Sulfate Solution (i) In the event that a premixed bag of Magnesium sulfate solution is not available: a. Draw up 2 25 gram vials of MgSO4 (50mL per vial = 500 mg/ml)

13 EDM-OB-0318 Page 13 of 16 b. Withdraw 100 ml from a 500 ml I.V. bag of Normal Saline c. Add the 50 grams of MgSO4 (100 ml) to the remaining 400 ml intravenous solution bag d. Concentration = 1 gram /10 ml f) Management of Toxicity (i) When infusing Magnesium sulfate have immediately available a. MgSO4 antidote CALCIUM GLUCONATE 1g (10 ml) of a 10% solution to be administered intravenously over 3 minutes TABLE 8: MAGNESIUM SULFATE INFUSION MONITORING PARAMETERS Parameter Frequency Loading Dose Maintenance dose Signs of Toxicity Action BP every 5 minutes every 15 minutes for first hour then every 1 hour X 4 then every 4 hours or as ordered by Physician Heart Rate every 5 minutes every15 minutes for first hour then every 1 hour X 4 then every 4 hours or as ordered by Physician Respirations every 5 minutes every15 minutes for first hour then every 1 hour X 4 then every 4 hours or as ordered by Physician Breath sounds Prior to start of loading dose every Shift Respirations less than 14 or greater than 26 Stop MgSO4 Notify Physician or Deep Tendon Reflexes (DTRs) Prior to start of loading dose every Shift Should be co-checked at shift change Absent patellar reflexes Loss of deep tendon reflexes Stop MgSO4 Notify Physician or Intake and Output Level of Consciousness every 1 hour or as ordered by Physician Less than 30 ml per hour every 5 minutes every Shift Altered level of consciousness Notify Physician or Stop MgSO4 Notify Physician or 7. HELLP Syndrome 7.1 HELLP stands for hemolysis, elevated liver enzymes, and low platelet count. 7.2 This syndrome is a variant of severe pre-eclampsia. 7.3 Management of this syndrome should be according to careful clinical assessment.

14 EDM-OB-0318 Page 14 of Medical management of HELLP If platelet count greater than 50 X 109/L and no bleeding and no platelet dysfunction, no prophylactic platelet transfusion is necessary pre-op cesarean section If platelet count less than 50 X 109/L and if platelets are falling rapidly and/or there is coagulopathy, consider ordering blood products including platelets prior to cesarean section If platelet count less than 20 X 109/L consider transfusion with platelets prior to vaginal delivery or cesarean section. 8. Postpartum Management 8.1 All women with hypertensive disorders of pregnancy must be monitored carefully in the postpartum period with ongoing attention to blood pressure, renal function, seizure risk, and any end-organ dysfunction (Table 1). 8.2 Hypertension may develop for the first time Postpartum The timing of seizure occurrence is distributed as follows: 50% first appear before labor 25% first occur during labor 25% begin in the early postpartum period. 8.3 Routine blood pressure checks are part of the postpartum care map, more frequent blood pressure measurements may be ordered At least four times a day while the woman is an inpatient. 8.4 Women requiring seizure prophylaxis (pre-eclampsia) should be treated with Magnesium sulphate for a minimum of 24 hours postpartum. 8.5 Laboratory investigations should be directed toward the particular end-organ that has been affected. 8.6 High risk women should not be placed in low risk discharge pathways. 8.7 These women should only be transferred to a postpartum unit when there is a clear trend towards improvement in clinical and laboratory assessments, and when there is an ability to provide surveillance. 8.8 When there has been end-organ dysfunction, there should be evidence that it has resolved prior to the discharging the woman and when follow-up can be arranged within a week for clinical and blood pressure assessment. 8.9 Post-discharge blood pressure measurement should be measured at peak postpartum blood pressure Postpartum day three to six in women diagnosed with hypertensive disorders of pregnancy.

15 EDM-OB-0318 Page 15 of Because early hospital discharge is the current practice, instruction of women at discharge from the hospital should include awareness of symptoms that should be reported to a healthcare provider: severe headache visual disturbances epigastric pain. Definitions Chronic Hypertension: Predates pregnancy or appears before 20 weeks gestation Eclampsia: The occurrence of seizures in a preeclamptic patient that cannot be attributed to other causes. Gestational Hypertension: New onset hypertension after 20 weeks gestation, with no other maternal organ dysfunction Hypertension: Systolic Blood Pressure (sbp) 140 or Diastolic BP (dbp) 90 Non-severe hypertension is defined as: sbp greater than or equal to and/or dbp greater than or equal to Other hypertensive effects a) Transient hypertensive effect is an office sbp greater than 140 and/or a dbp 90 that is not confirmed after rest, on repeat measurement, on the same or on subsequent visits b) White-coat hypertensive effect is a BP that is elevated in the office (sbp greater than or equal to140 or dbp greater than or equal to 90 ), but consistently normal outside of the office (less than135/85 ) by ambulatory monitoring or home monitoring c) Masked hypertensive effect is a BP that is consistently normal in the office (sbp less than 140 or dbp less than 90 ), but elevated outside of the office (greater than or equal to 135/85 ) by ambulatory monitoring or home monitoring. Pre-existing hypertension: Develops either pre-pregnancy or at less than or equal to 20 weeks gestation Preeclampsia: Gestational or Chronic Hypertension along with one or more of the following new onset conditions: a) Proteinuria b) Other maternal organ dysfunction (renal, liver, neurologic, hematologic) c) Uteroplacental dysfunction (fetal growth restriction) Resistant hypertension: Hypertension after 20 weeks gestation requiring 3 antihypertensive medications to control blood pressure Severe Hypertension is defined as:

16 EDM-OB-0318 Page 16 of 16 sbp greater than or equal to 160 and/or dbp greater than or equal to 110 White Coat Hypertension: sbp 140 or dbp 90 in office/clinic, but lower with home or ambulatory BP monitoring. Revision Date(s) Sent for Sign off March 2018