S9 MARCH JOGC MARS 2008

CHAPTER 1
Diagnosis and Classification
The classification of the hypertensive disorders of preg-
nancy is based on the two ost coon anifestations
of preeclapsia! hypertension and protein"ria#
Accordingly$ the eas"reent of blood press"re and
protein"ria and the diagnosis of hypertension and
clinically significant protein"ria are described in detail#
MEASUREMENT OF BP
Recoendations
%# &' sho"ld be eas"red with the woan in the sitting
position with the ar at the level of the heart# ())-2A*
2# An appropriately si+ed c"ff (i#e#$ length of %#, ties
the circ"ference of the ar* sho"ld be "sed# ())-2A*
-# .orot/off phase 0 sho"ld be "sed to designate
diastolic
&'# ()-A*
1# )f &' is consistently higher in one ar$ the ar with
the higher val"es sho"ld be "sed for all &'
eas"reents# ()))-&*
,# &' can be eas"red "sing a erc"ry
sphygoanoe- ter$ calibrated aneroid device$ or
an a"toated &' device that has been validated for
"se in preeclapsia# ())-2A*
2# A"toated &' achines ay "nderestiate &' in
woen with preeclapsia$ and coparison of
readings "sing erc"ry sphygoanoetry or an
aneroid device is recoended# ())-2A*
3# Ab"latory &' onitoring (by 21-ho"r or hoe
ea- s"reent* ay be "sef"l to detect isolated
office (white coat* hypertension# ())-2&*
8# 'atients sho"ld be instr"cted on proper &'
eas"reent techni4"e if they are to perfor hoe
&' onitoring# ()))-&*
Coents
5e have foc"sed on eas"reent iss"es that are
specific to pregnancy# The reader sho"ld refer to the
ost recent CH6' doc"ent for general g"idelines#
%0
&' eas"reent sho"ld follow standardi+ed techni4"e$
as o"tside pregnancy#
%0
)t is preferable to have woen rest for five in"tes# )n
par- tic"lar$ .orot/off phase 0 sho"ld be "sed for
designation of diastolic &'$ as it is ore reliable$
%%
and
with its "se (co- pared with "se of phase )0*$
pregnancy o"tcoe is siilar#
%2
S10 MARCH JOGC MARS
2008
This recoendation replaces the previo"s
recoenda- tion to "se both phase )0 and phase 0#
'hase )0 ("ffling* sho"ld be "sed for diastolic &'
only if .orot/off so"nds are a"dible as the level
approaches 0 Hg# A c"ff that is too sall (i#e#$ s"ch
that the white lines do not cross* will overestiate s&'
by 37%- Hg and d&' by ,7%0 Hg# A c"ff sho"ld
never be placed over clothing# 5oen sho"ld be in the
sitting position that gives the highest &'8 s"pine
positioning has the potential to ca"se hypotension$ and
left lateral positioning has the potential to give the low-
est &' val"e$ beca"se the right ar is fre4"ently
elevated above the level of the heart d"ring &'
eas"reent#
%-
Any ar-to-ar differences sho"ld be
doc"ented$ and if the &' is consistently higher in one
ar$ that ar sho"ld be "sed for all &' eas"reents#
%1
&' can be eas"red "sing a erc"ry
sphygoanoeter$ aneroid device$ or a"toated
("s"ally oscilloetric* &' device$ as erc"ry
sphygoanoeters have been elii- nated fro any
instit"tions# 5hen choosing a &' ea- s"reent device$
considerations incl"de observer error$ val- idation$
disease specificity$ and the need for reg"lar
recalibration#
Recalibration involves coparing readings ta/en with a
given device with readings ta/en with a erc"ry
anoe- ter# Aneroid devices "st be recalibrated
every two years against erc"ry devices# This is
perfored by the bioedi- cal departent of hospitals
b"t "st be arranged separately by those practitioners
with private offices#
0alidation is "nderta/en to deterine the acc"racy of a
device$ at all levels of &' readings$ on several occasions
and for woen with different H9's#
%,
0alidation "st
be done partic"larly in woen with preeclapsia for
two reasons# :irst$ the detection of preeclapsia is the
a;or p"rpose of &' eas"reent in pregnancy#
Second$ woen with pre-e<isting hypertension have
appro<iately a 20= ris/ of preeclapsia$
%2720
and
woen with gestational hyperten- sion ay develop
typical preeclapsia#
2%722
A"toated &' eas"reent
devices will eliinate observer error# How- ever$ only
soe devices have been validated in pregnancy
%,
and in
preeclapsia$ specifically#
23
A"toated devices ay
"nderestiate &' in preeclapsia by an average of ,
Hg in systolic and diastolic$ b"t there is wide
variation#
28
Most errors in office &' eas"reents are operator
dependent and correctable#
%1
However$ ab"latory
Diagnosis, Evaluation, and Management of the Hypertensive Disorders of Pregnancy
eas"reents have gained pop"larity# Twenty-fo"r-
ho"r ab"latory &' onitoring or serial &'
eas"reents in an obstetrical day "nit ay identify
woen who have isolated office hypertension#
Copared with persistently hyperten- sive woen$
woen with isolated office hypertension are at lower
ris/ of aternal and perinatal coplications#
2>7--
However$ 21-ho"r ab"latory &' onitoring is of only
odest "se for an individ"al woan beca"se of negative
predictive val"es that only odestly decrease the ris/ of
adverse o"tcoes s"ch as severe hypertension$ preter
delivery$ and adission to the neonatal intensive care
"nit#
2>$-2$--
Hoe &' onitoring is widely available$
eco- noical$ cofortable$ and easy to repeat when
disease evo- l"tion is s"spected$ and pregnant
woen prefer it to
21-ho"r ab"latory &' onitoring#
-1
However$ val"es
have not been validated against adverse pregnancy
o"tcoes#
Therefore$ at present$ there is ins"fficient inforation to
define the role of either ethod of ab"latory &'
onitor- ing in hypertensive (or norotensive*
pregnancy# To date$ no RCT has been perfored to
assess the ipact of any type of ab"latory &'
eas"reent on aternal or perinatal o"tcoes#
-,
D!AGNOS!S OF H"PERTENS!ON
Recoendations
%# The diagnosis of hypertension sho"ld be based on
office or in-hospital &' eas"reents# ())-2&*
2# Hypertension in pregnancy sho"ld be defined as a
dia- stolic &' of >0 Hg$ based on the average of
at least two eas"reents$ ta/en "sing the sae ar#
())-2&*
-# 5oen with a systolic &' of %10 Hg
sho"ld be followed closely for developent of
diastolic hypertension# ())-2&*
1# Severe hypertension sho"ld be defined as a systolic
&' of
%20 Hg or a diastolic &' of %%0 Hg# ())-
2&*
,# :or non-severe hypertension$ serial &' eas"reents
sho"ld be recorded before a diagnosis of hypertension
is ade# ())-2&*
2# :or severe hypertension$ a repeat eas"reent sho"ld
be ta/en for confiration in %, in"tes# ()))-&*
3# )solated office (white coat* hypertension sho"ld be
defined as office d&' of >0 Hg$ b"t hoe &'
of
? %-,@8, Hg# ()))-&*
Coents
The definition of hypertension in pregnancy is d&' >0
Hg by office eas"reent# A d&' of >0 Hg
identifies a level above which perinatal orbidity is
increased in
Diagnosis, Evaluation, and Management of the Hypertensive Disorders of Pregnancy
non-protein"ric hypertension$ and d&' is a better
predictor of adverse pregnancy o"tcoes than
is s&'#
-2$-2
Aon-severely elevated &' sho"ld be confired by
repeat eas"reent$ preferably on ore than one visit$
as -0= to
30= of woen with an office &' of %10@>0 Hg
have noral &' on s"bse4"ent eas"reents on the
sae visit$ after serial eas"reent in an obstetrical
day "nit$ or after hoe &' onitoring#
-0$-2$--$-3
5hether
the &' is repeated over ho"rs$ days$ or wee/s will
depend on the "nderlying H9'#
Systolic &' was previo"sly e<cl"ded fro the definition
of hypertension in pregnancy for several reasons# :irst$
it is s"b;ect to ore variation than is d&'# Second$ it is
"s"ally increased along with d&'#
-8
Third$ there is the
potential for overlabelling and seeing woen ore
fre4"ently than nec- essary# However$ even an
interittently elevated s&' is a ris/ ar/er for later
developent of gestational hyperten- sion$
->
so elevated
s&' sho"ld trigger closer follow-"p and investigation as
appropriate#
9efining severe hypertension as a systolic &' %20
Hg
(instead of %30 Hg* is based on the fact that
s&'
%20 Hg is associated with an increased ris/ of
stro/e in pregnancy#
10$1%
A relative rise in &' is not part of the definition of
hyperten- sion$ given that it is within the variation in &'
seen in all tri- esters of pregnancy$ and there is a high
false positive rate for s"spected preeclapsia#
12
Mean
arterial press"re is not part of the definition of
hypertension in pregnancy as it is c"bersoe to
calc"late#
)f hoe &' onitoring is "sed to identify woen with
isolated office hypertension$ then ideally$ noral hoe
&' val"es sho"ld be confired by 21-ho"r ab"latory
&' onitoring# As criteria for norality have varied$
"se of the widely accepted threshold (o"tside
pregnancy* of
? %-,@ 8, Hg for noral hoe &' eas"reents is
recoended
%0
(see disc"ssion in BP measurement*#
MEASUREMENT OF PROTE!NUR!A
Recoendations
%# All pregnant woen sho"ld be assessed for
protein"ria# ())-2&*
2# Brinary dipstic/ testing ay be "sed for screening for
protein"ria when the s"spicion of preeclapsia is
low# ())-2&*
-# More definitive testing for protein"ria (by "rinary
pro- tein! creatinine ratio or 21-ho"r "rine collection*
is enco"raged when there is a s"spicion of
preeclapsia$ incl"ding in hypertensive pregnant
woen with rising
CHAPTER 1: Diagnosis and Classification
&' or in norotensive pregnant woen with
syptos or signs s"ggestive of preeclapsia# ())-
2A*
Coents
Most testing for "rinary protein is perfored to screen
for preeclapsia in hypertensive woen or those at
increased ris/ of preeclapsia$ altho"gh "rinary protein
screening is "sed in early pregnancy to detect pre-
e<isting renal disease# The c"rrent recoendations
have been revised to reflect the critical fact that
protein"ria is b"t one diagnostic crite- rion for
preeclapsia# The end-organ coplications of
preeclapsia ay occ"r in the absence of protein"ria8
for e<aple$ 20= of woen who develop eclapsia
will have had only hypertension in the wee/ preceding
their sei+"re$
%0= will have had only protein"ria$ and %0= will have
had neither#
1-
There is also the need for both efficiency
and econoy in clinical care#
There are any options for diagnosis of protein"ria$
incl"d- ing "rinary dipstic/ testing$ "rinary protein!
creatinine ratio$ and vario"s tied "rine collections
(ost coonly$
21-ho"r*# 5e do not /now the ethod that best
identifies woen at increased ris/ of aternal and@or
perinatal co- plications# However$ in a retrospective
st"dy$ increasing n"ber of pl"ses of "rinary dipstic/
protein"ria was associ- ated with increasing ris/ of
adverse aternal o"tcoes#
11
Most research has foc"ssed on ethods that best atch
the 4"antification of "rinary protein by 21-ho"r "rine
collec- tion$ considered to be the gold standard#
However$ 21-ho"r "rine collection is tie-cons"ing$
inconvenient$ and often not coplete (as assessed by
collection of %-7%8= of the ideal body weight as
"rinary creatinine Col@dD*#
1,
:or diagnosis of
protein"ria$ these logistical considerations have
propted the Aational .idney :o"ndation to aban- don
tied collections in favo"r of the spot "rine saples#
D!AGNOS!S OF C#!N!CA##" S!GN!F!CANT PROTE!NUR!A
Recoendations
%# 'rotein"ria sho"ld be strongly s"spected when "rinary
dipstic/ protein"ria is 2E# ())-2A*
2# 'rotein"ria sho"ld be defined as 0#-g@d in a 21-
ho"r "rine collection or -0 g@ol "rinary
creatinine in a spot (rando* "rine saple# ())-2&*
-# There is ins"fficient inforation to a/e a
recoenda- tion abo"t the acc"racy of the "rinary
alb"in! creatinine ratio# ())-2 )*
Coents
The "pper liit of noral 21-ho"r "rine protein
e<cretion is 0#- g@d and is based on a >,= C) for "rinary
protein in pregnancy# )t is "sed by convention8
however$ a "rinary
protein eas"reent of 0#,g@d ay be a better
predictor of adverse clinical o"tcoe#
12
The "rinary protein! creatinine ratio has been accepted
for diagnosis by the )nternational and A"stralasian
pregnancy hypertension societies# )deally$ this test
sho"ld be per- fored in the orning b"t not on the
first voided "rine8 however$ tiing ay not be critical
in pregnancy#
13
The reported c"t-off varies fro %3 to
,3 g@ol (edian
22 g@ol* in %0 st"dies (%03> hypertensive
woen*#
187,3
:or a c"t-off of - 0 g@ol "rinary creatinine (as
reco- ended by the ASSH'*$ and aong woen
with a H9' specifically$ the sensitivities and
specificities were 0#8, (>,= C) 0#387 0#>%* and 0#32
(0#3-70#38*$ respectively#
,8
6fforts are "nderway to
iprove the standardi+ation of "rinary pro- tein and
ser" creatinine eas"reent across laboratories#
,>
Brinary dipstic/ testing is ine<pensive$ easy$ and widely
"sed# )ts "sef"lness is "ncertain for screening either
woen with hypertension or those who are at increased
ris/ of preeclapsia# A negative or trace val"e
sho"ld not be ignored in a woan with new
hypertension or syptos or signs s"ggestive of
preeclapsia8 %2= of negative@trace res"lts will be false
negatives as assessed against 21-ho"r protein"ria of 0#-
g@d$
20
and$ regardless$ these woen ay have
preeclapsia witho"t protein"ria#
:or the detection of significant protein"ria$ "rinary alb"-
in! creatinine ratio (BACR* generally perfored well
(in coparison with 21-ho"r "rinary protein e<cretion*
in three prospective st"dies
2%72-
b"t not in a fo"rth
21
(-2% hypertensive woen*# More inforation is needed
before clinical "se of the "rinary ACR can be
recoended#
)t is not clear that there is a role for the 4"antification of
protein"ria in pregnancy for p"rposes of
prognostication$ which is disc"ssed "nder Prediction,
Prevention, and Prognosis of Preeclampsia. )f
4"antification is so"ght$ then 21-ho"r "rine collection
sho"ld be "sed as the B 'CR is less reliable at high
levels of protein"ria#
C#ASS!F!CAT!ON OF HDP
Recoendations
%# Hypertensive disorders of pregnancy sho"ld be
classified as pre-e<isting or gestational hypertension
on the basis of different diagnostic and therape"tic
factors# ())-2&*
2# The presence or absence of preeclapsia "st be
ascer- tained$ given its clear association with ore
adverse aternal and perinatal o"tcoes# ())-2&*
-# )n woen with pre-e<isting hypertension$
preeclapsia sho"ld be defined as resistant
hypertension$ new or worsening protein"ria$ or one
or ore of the other adverse conditions# ())-2&*
Diagnosis, Evaluation, and Management of the Hypertensive Disorders of Pregnancy
S12 MARCH JOGC MARS
2008
1# )n woen with gestational hypertension$
preeclapsia sho"ld be defined as new-onset
protein"ria or one or ore of the other adverse
conditions# ())-2&*
,# Severe preeclapsia sho"ld be defined as
preeclapsia with onset before -1 wee/sF gestation$
with heavy protein"ria or with one or ore
adverse conditions#
a!le 2" #lassification of the hypertensive disorders of
pregnancy$
Primary diagnosis Definition of preeclampsia
Pre-existing hypertension
ith comor!id conditions"
())-2&*
2# The ter ')H (pregnancy-ind"ced hypertension*
sho"ld be abandoned$ as its eaning in clinical
practice is "nclear# ()))-9*
Coents
The p"rpose of classification is to facilitate
co"nication
ith preeclampsia
#after $% &ee's( gestation)
*estational hypertension
ith comor!id conditions"
ith preeclampsia
#after $% &ee's( gestation)
Resistant hypertension+ or
,e& or &orsening protein-ria+ or
.ne/more ad0erse condition#s)1
,e& protein-ria+ or
.ne/more ad0erse condition#s)1
aong caregivers$ and to create eaningf"l gro"ps with
dif- ferent prognoses$ considerations for s"rveillance$
and@or o"tcoes# To this end$ the classification syste
for the hypertensive disorders of pregnancy has been
siplified#
According to pop"lation-based data$ appro<iately %=
of pregnancies are coplicated by pre-e<isting
hypertension$
,= to 2= by gestational hypertension witho"t
protein"ria$ and %= to 2= by preeclapsia#
2,
)t can be
e<pected that these n"bers will increase given the
trend towards an older and ore obese obstetric
pop"lation#
Hypertension is classified as pre-e<isting or gestational
(Table 2*# 're-e<isting hypertension pre-dates pregnancy
or appears before 20 wee/s$ and gestational
hypertension appears at or after 20 wee/s# :or both
pre-e<isting and gestational hypertension$ there are two
s"bgro"ps! (%* with coorbid conditions and (2* with
preeclapsia$ defined by three criteria! hypertension$
protein"ria$ and adverse condi- tions# 6dea and weight
gain reain e<cl"ded fro the definition of
preeclapsia# 6dea$ even facial$ is neither sensitive
nor specific for preeclapsia#
22$23
Aeither edea nor
weight gain is significantly associated with perinatal
ortality and orbidity#
-2$22
This liberal definition of
preeclapsia is eant to signal a need for
heightened aternal and fetal s"rveillance$ recogni+ing
that not all of the adverse conditions have e4"al weight
(e#g#$ eclapsia has different significance fro
persistent$ new@"n"s"al headache*#
Severe preeclapsia is defined as preeclapsia with
onset before -1 wee/sF gestation$ with heavy protein"ria
(-7, g@d according to other international g"idelines*$ or
with one or ore adverse conditions# This definition is
consistent with Aerican g"idelines
3
and those fro the
)SSH'$
22
with the e<ception of the gestational age
criterion (see Prediction, Pre- vention, and Prognosis of
Preeclampsia and Place of Care, and spe- cific therapy*#
Altho"gh the agnit"de of protein"ria has not been
consistently associated with worse aternal or perinatal
prognosis$ protein"ria is retained in the definition of
severe preeclapsia for face validity$ "ntil there are
Diagnosis, Evaluation, and Management of the Hypertensive Disorders of Pregnancy
S1% MARCH JOGC MARS
2008
2 omen may !e classified into more than one s-!gro-p3
4e0ere preeclampsia corresponds to preeclampsia: &ith onset !efore
56 &ee's( gestation+ &ith hea0y protein-ria #578 g/d according to other
international g-idelines)+ or &ith one or more ad0erse conditions3
"Comor!id conditions+ s-ch as type 9 or 99 dia!etes mellit-s+ renal disease+ or
an indication for antihypertensi0e therapy o-tside pregnancy3
1.ther ad0erse conditions consist of maternal symptoms #persistent or
ne&/-n-s-al headache+ 0is-al dist-r!ances+ persistent a!dominal or right
-pper :-adrant pain+ se0ere na-sea or 0omiting+ chest pain or dyspnea)+
maternal signs of end-organ dysf-nction #eclampsia+ se0ere hypertension+
p-lmonary edema+ or s-spected placental a!r-ption)+ a!normal maternal
la!oratory testing #ele0ated ser-m creatinine ;according to local la!oratory
criteria<= ele0ated A4T+ A>T or >DH ;according to local la!oratory criteria<
&ith symptoms= platelet co-nt ?1%%x1%@/>= or ser-m al!-min ? $% g/>)+ or fetal
mor!idity #oligohydramnios+ intra-terine gro&th restriction+ a!sent or re0ersed
end-diastolic flo& in the -m!ilical artery !y Doppler 0elocimetry+
or intra-terine fetal death)3
A>T: alanine aminotransferase8 A4T: aspartate
aminotransferase= >DH: lactate dehydrogenase
definitive data to indicate that heavy protein"ria sho"ld
be reoved#
5oen with pre-e<isting hypertension have a %0= to
20= ris/ of developing preeclapsia$ defined by
resistant hyper- tension$ new@worsening protein"ria$ or
one or ore adverse condition (Table 2*#
%2720
5oen
with certain coorbidities (e#g#$ renal disease or pre-
e<isting diabetes ellit"s* at also at increased ris/#
28
5oen with gestational hypertension with onset before
-1 wee/s (as opposed to
onset at -1 wee/s* are ore li/ely to develop
preeclapsia$ with rates of abo"t -,=#
2%722
&ith #omor!id #onditions
G5ith coorbid conditionsH refers to conditions that are
strong indications for ore aggressive antihypertensive
therapy o"tside pregnancy$
2>
and as s"ch$ they warrant
spe- cial &' treatent thresholds and goals in
pregnancy# Coorbid conditions are highlighted
beca"se they consti- t"te indications for
antihypertensive therapy over the short-ter$ o"tside
pregnancy# These are "s"ally a;or car- diovasc"lar ris/
factors$ s"ch as type ) or )) (b"t not gesta- tional*
diabetes$ renal parenchyal or vasc"lar disease$ or
cerebrovasc"lar disease#