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CMECNE

Chronic Hypertension in Pregnancy: Diagnosis and BP Measurement

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. List the definitions of chronic hypertension in pregnancy
2. Discuss the difficulty in making a diagnosis of superimposed preeclampsia

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Jan 9 2019 through 07/15/2022, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the test and evaluation. Upon registering and successfully completing the test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

SUMMARY:

The ACOG guidance on chronic hypertension in pregnancy addresses diagnosis, particularly in light of the 2017 ACC/AHA recommendations that lowered the BP thresholds (see ‘Related ObG Topics’, below). ACOG states that for patients with stage 1 hypertension (systolic blood pressure of 130–139 mm Hg or diastolic blood pressure of 80–89 mm Hg) 

…it is reasonable to continue to manage the patient in pregnancy as chronically hypertensive as specified in this guideline.

The uncertainty of the new approach to hypertension recommended by the ACA and AHA as applied to the care of pregnant women should be an active area of investigation.

Chronic Hypertension: Definitions and Criteria   

  • Definition: Hypertension that is  
    • Diagnosed or present before pregnancy or before 20 weeks of gestation 
    • Diagnosed for the first time during pregnancy without resolution postpartum 
    • Note: ACOG states that “the 20-week convention should not be used dogmatically, but rather for orientation while maintaining clinical judgment.” 
  • Traditional criteria  
    • Systolic BP: ≥140 mm Hg  and/or
    • Diastolic BP: ≥90 mm Hg  
    • ≥2 determinations at least 4 hours apart 
    • Note: In the context of severe hypertension, “the diagnosis can be confirmed within a shorter interval (even minutes) to facilitate timely therapy” 
  • ACC/AHA criteria and definition  
    • Lower threshold (see above) may result in false positive assignment of chronic hypertension  

Superimposed Preeclampsia 

  • Preeclampsia that “complicates preexisting chronic hypertension”  
    • May occur in up to 50% of women with chronic hypertension or higher with end-organ failure  
  • Risk increased in the following 
    • African American | Obesity | Smoker | Hypertension ≥4 years | DBP >100 mm Hg at baseline | Previous history of preeclampsia  
  • Consider diagnosis in the following clinical scenarios 
    • Sudden increase in BP or 
    • Proteinuria (above threshold or patient baseline)  
    • Thrombocytopenia | Abnormal LFTs | Elevated Uric Acid  
  • Consider referral to MFM

BP Measurements 

  • Avoid caffeine and smoking prior to taking measurements (minimum 30 minutes)  
  • Cuff size should  
    • Be 1.5 times upper arm circumference or 
    • Encircle arm by at least 80% of the arm width | at last 40% arm circumference  
    • Arm should be at level of the heart  
  • Repeat measurements at a minimum 10 minutes apart  
  • Patient should be seated, legs uncrossed and back supported

Key Points:

  • Distinction between chronic hypertension and gestational hypertension/preeclampsia can be difficult in the following clinical scenarios 
    • Patient enters care after 20 weeks 
    • Patients with chronic hypertension may have proteinuria due to nephropathy 
    • BP in pregnant women can drop for physiologic reasons, rebounding to pregestational levels later in pregnancy  
    • Acceptable time for resolution of hypertension postpartum not well established  
  • ACOG addresses out-of-office and self-monitoring of BP  
    • Advantages include patient convenience and adherence  
    • Procedures should include 
      • Patient education | Ensure device validation   
    • Home devices can be compared to office devices to ensure accuracy

Learn More – Primary Sources:  

ACOG Practice Bulletin 203: Chronic Hypertension in Pregnancy

Locate a Maternal Fetal Medicine Specialist

Maternal Fetal Medicine Specialist Locator-SMFM

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Related ObG Topics:

ACOG Guidance: Emergency Treatment for Severe Hypertension in Pregnancy
Diagnosing Preeclampsia – Key Definitions and ACOG Guidelines
Chronic Hypertension in Pregnancy: Evaluation and Management
Labetalol or Nifedipine for Chronic Hypertension in Pregnancy?
ACC/AHA Blood Pressure Guideline: Current Classification System and Treatment Targets
ACOG Preeclampsia Guidelines: Antenatal Management and Timing of Delivery
CHAP RCT Results: Should We Treat Mild Chronic Hypertension During Pregnancy?

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OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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