Diagnóstico, Evaluación y Manejo de Los Desordenes Hipertensivos Del Embarazo PDF

416 l MAY JOGC MAI 2014
No. 307, May 2014 (Replaces No. 206, March 2008)

SOGC CLINICAL PRACTICE GUIDELINE
Diagnosis, Evaluation, and Management
of the Hypertensive Disorders of Pregnancy:
Executive Summary

This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information
should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate
amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be
reproduced in any form without prior written permission of the SOGC.
The guideline summarized here has been prepared by the
Canadian Hypertensive Disorders of Pregnancy Working
Group, reviewed and approved by the Hypertension
Guideline Committee, reviewed by the Maternal Fetal
Medicine and Family Physician Advisory committees, and
approved by the Executive and Council of the Society of
Obstetricians and Gynaecologists of Canada.
PRINCIPAL AUTHORS
Laura A. Magee, MD, Vancouver BC
Anouk Pels, MSc, Amsterdam, the Netherlands
Michael Helewa, MD, Winnipeg MB
Evelyne Rey, MD, Montreal QC
Peter von Dadelszen, MBChB, Vancouver BC
HYPERTENSION GUIDELINE COMMITTEE
Laura A. Magee, MD (Chair), Vancouver BC
Francois Audibert, MD, Montreal QC
Emmanuel Bujold, MD, Quebec QC
Anne-Marie Ct, MD, Sherbrooke QC
Myrtle Joanne Douglas, MD, Vancouver BC
Genevieve Eastabrook, MD, FRCSC, London ON
Tabassum Firoz, MD, Vancouver BC
Paul Gibson, MD, Calgary AB
Andre Gruslin, MD, Ottawa ON
Jennifer Hutcheon, PhD, Vancouver BC
Gideon Koren, MD, Toronto ON
Ian Lange, MD, Calgary AB
Line Leduc, MD, Montreal QC
Alexander G. Logan, MD, Toronto ON
Key Words: Hypertension, blood pressure, pregnancy,
preeclampsia, maternal outcome, perinatal outcome, long-term
prognosis
J Obstet Gynaecol Can 2014;36(5):416438
Abstract
Objective: This executive summary presents in brief the current
evidence assessed in the clinical practice guideline prepared by
the Canadian Hypertensive Disorders of Pregnancy Working
Group and published by Pregnancy Hypertension
(http://www.pregnancyhypertension.org/article/S2210-
7789(14)00004-X/fulltext) to provide a reasonable approach to the
diagnosis, evaluation, and treatment of the hypertensive disorders
of pregnancy.
Evidence: Published literature was retrieved through searches of
Medline, CINAHL, and The Cochrane Library in March 2012
using appropriate controlled vocabulary (e.g., pregnancy,
hypertension, pre-eclampsia, pregnancy toxemias) and key
words (e.g., diagnosis, evaluation, classifcation, prediction,
prevention, prognosis, treatment, postpartum follow-up). Results
were restricted to systematic reviews, randomized control trials,
controlled clinical trials, and observational studies published in
French or English between January 2006 and February 2012.
Searches were updated on a regular basis and incorporated in the
guideline to September 2013. Grey (unpublished) literature was
identifed through searching the websites of health technology
assessment and health technology-related agencies, clinical
practice guideline collections, clinical trial registries, and national
and international medical specialty societies.
Values: The quality of evidence in the guideline summarized here
was rated using the criteria described in the Report of the
Canadian Task Force on Preventative Health Care (Table 1).
Karen L. MacDonell, PhD, Vancouver BC
Jean-Marie Moutquin, MD, Sherbrooke QC
Ilana Sebbag, MD, Vancouver BC
Disclosure statements have been received from all members of
the committee.
The literature searches and bibliographic support for this
guideline were undertaken by Becky Skidmore, Medical
Research Analyst, Society of Obstetricians and Gynaecologists
of Canada.
MAY JOGC MAI 2014 l 417
Diagnosis, Evaluation, and Management of the Hypertensive Disorders of Pregnancy: Executive Summary
RECOMMENDATIONS
CHAPTER 1:
DIAGNOSIS AND CLASSIFICATION OF THE
MEASUREMENT OF BP FOR HDPs
BP Measurement: 110
Diagnosis of Hypertension: 1117
Measurement of Proteinuria: 1824
Classifcation of HDPs: 2531
Investigations to Classify HDPs: 3237
CHAPTER 2:
PREDICTION AND PREVENTION
Predicting Preeclampsia: 3840
Preventing Preeclampsia and its Complications in Women
at Low Risk: 4146
Preventing Preeclampsia and its Complications in Women
at Increased Risk: 4754
CHAPTER 3:
TREATMENT OF THE HDPs
Dietary and Lifestyle Changes: 5559
Place of Care: 60, 61
Antihypertensive Therapy for Severe Hypertension: 6268
Antihypertensive Therapy for Non-Severe Hypertension
Without Comorbid Conditions: 6973
For Non-Severe Hypertension (BP of 140159/
90109 mmHg) With Comorbid Conditions: 7476
Corticosteroids for Acceleration of Fetal Pulmonary Maturity:
7780
Timing of Delivery for Women With Preeclampsia: 8188
Timing of Delivery for Women With Gestational Hypertension:
89, 90
Timing of Delivery for Women with Pre-existing
Hypertension: 91
Mode of Delivery: 9297
Anaesthesia: General Principles: 98101
Anaesthesia: Fluid Administration: 102105
Monitoring: 106108
Coagulation: 109, 110
Aspects of Care Specifc to Women Wth Pre-Existing
Hypertension: 111115
Aspects of Care for Women With Preeclampsia: Magnesium
Sulphate for Preventing or Treating Eclampsia: 116123
Aspects of Care for Women With Preeclampsia: Plasma
Volume Expansion: 124
Therapies for HELLP Syndrome: 125131
Care in the 6 Weeks Postpartum: 132142
Care Beyond 6 Weeks Postpartum: 143148
Effects of Maternal Hypertension and its Therapies on Child
Neurobehavioural Development: 149, 150
CHAPTER 4:
PATIENT PERSPECTIVE: 151153
Table 1. Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force
on Preventive Health Care
Quality of evidence assessment* Classifcation of recommendations
I: Evidence obtained from at least one properly randomized
controlled trial
A. There is good evidence to recommend the clinical preventive action
II-1: Evidence from well-designed controlled trials without
randomization
B. There is fair evidence to recommend the clinical preventive action
II-2: Evidence from well-designed cohort (prospective or
retrospective) or casecontrol studies, preferably from
more than one centre or research group
C. The existing evidence is conficting and does not allow to make a
recommendation for or against use of the clinical preventive action;
however, other factors may infuence decision-making
II-3: Evidence obtained from comparisons between times or
places with or without the intervention. Dramatic results in
uncontrolled experiments (such as the results of treatment with
penicillin in the 1940s) could also be included in this category
D. There is fair evidence to recommend against the clinical preventive action
E. There is good evidence to recommend against the clinical preventive
action
III: Opinions of respected authorities, based on clinical experience,
descriptive studies, or reports of expert committees
L. There is insuffcient evidence (in quantity or quality) to make
a recommendation; however, other factors may infuence
decision-making
*The quality of evidence reported in these guidelines has been adapted from The Evaluation of Evidence criteria described in the Canadian Task Force on
Preventive Health Care.
39
Recommendations included in these guidelines have been adapted from the Classifcation of Recommendations criteria described in the Canadian Task Force
on Preventive Health Care.
39
ABBREVIATIONS
BP blood pressure
HDP hypertensive disorder of pregnancy
HELLP hemolysis, elevated liver enzymes, low platelets
IUGR intrauterine growth restriction
NICU neonatal intensive care unit
RCT randomized control trial
RDS respiratory distress syndrome
INTRODUCTION
H
ypertensive disorders of pregnancy remain leading
causes of maternal and perinatal morbidity and
mortality.
1,2
The guideline summarized here assesses the
quality of the relevant existing evidence and provides
a reasonable approach to the diagnosis, evaluation, and
treatment of the HDP, focusing on Canadian context.
Our purpose is to support evidence-based maternity care
of women who are planning pregnancy and are at risk of
an HDP, have an HDP in the current pregnancy, or are
postpartum and had an HDP. When necessary, we have
provided expert opinion about reasonable clinical care.
Our health intent and aim is to improve short- and long-
term maternal, perinatal, and paediatric outcomes and the
cost-effectiveness of related interventions in pregnancies
complicated by an HDP. The expected beneft of this
guideline is improved outcomes for mother, baby, and child
through evidence-advised practice. Our target users are
multidisciplinary maternity care providers from primary to
tertiary levels of health care.
The questions that this guideline seeks to address are:
How, and in what setting, should BP be measured in
pregnancy, and what is an abnormal BP?
How should proteinuria be measured in pregnancy?
What constitutes signifcant proteinuria? Is heavy
proteinuria an indication for delivery?
How should the HDPs be diagnosed and classifed?
What constitutes severe preeclampsia?
What are the prognoses of pregnancies complicated by
pre-existing hypertension, gestational hypertension, or
preeclampsia?
How can preeclampsia and its complications be
predicted and/or prevented by lifestyle changes,
medication, and/or care of a specifc type or in a
specifc location?
How should women with an HDP be managed
regarding initial investigations, dietary and lifestyle
changes, place of care, antihypertensive therapy,
aspects of care specifc to women with preeclampsia
(such as magnesium sulphate), mode and timing of
delivery, intrapartum care (including BP monitoring and
analgesia/anaesthesia), and postpartum monitoring,
treatment, and counselling regarding the impact of an
HDP on both future pregnancy outcomes and long-
term maternal and paediatric outcomes?
What is the patients perspective on her diagnosis and
evaluation?
How can this guideline be implemented into clinical
practice?
This document presents a summary of the
recommendations, along with supporting text for the new
classifcation of the HDPs, and all of the tables provided
in the full guideline. Because of the breadth of the
topic and the volume of material covered, the methods,
supporting text for all recommendations, and the full list
of references, including those for the tables, have been
published separately as an open-access article in Pregnancy
Hypertension.
3
Important changes affect all aspects of care covered in the
2008 guidelines. Notable examples include the addition of
systolic BP in the defnition of pregnancy hypertension,
revised HDP classifcation, new information on
prevention, more direction with respect to timing of
delivery in women with any HDP, information about
magnesium sulphate for fetal neuroprotection at < 32
weeks, a new gestational age cut-off ( 34+6 instead of
33+6 weeks) for administration of steroids, and a
section on knowledge translation with links to useful
tools for women and practitioners.
CHAPTER 1:
DIAGNOSIS OF HDP AND CLASSIFICATION
OF BP MEASUREMENTS
BP Measurement
Recommendations
1. Blood pressure should be measured with the
woman in the sitting position with the arm at the
level of the heart. (II-2A)
2. An appropriately sized cuff (i.e., length
1.5 times the circumference of the arm) should
be used. (II-2A)
3. Korotkoff phase V should be used to designate
diastolic blood pressure. (I-A)
4. If blood pressure is consistently higher in one arm,
the arm with the higher values should be used for
all blood pressure measurements. (III-B)
5. Blood pressure can be measured using a mercury
sphygmomanometer, a calibrated aneroid device, or
an automated blood pressure machine that has been
validated for use in preeclampsia. (II-2A)
6. Automated blood pressure machines that have
not been validated for use in women with
preeclampsia may underestimate or overestimate
blood pressure in those women; a comparison of
readings using mercury sphygmomanometry or a
calibrated aneroid device is recommended. (II-2A)
7. In the offce setting, when blood pressure elevation
is non-severe and preeclampsia is not suspected,
ambulatory blood pressure monitoring or home
blood pressure monitoring is useful to confrm
persistently elevated blood pressure. (II-2C)
8. When home blood pressure monitoring is used,
maternity care providers should ensure that patients
have adequate training in measuring their blood
pressure and interpreting the readings. (III-C)
9. The accuracy of all blood pressure measurement
devices used in hospitals or offces should be
checked regularly against a calibrated device. (II-3C)
10. The accuracy of all automated devices used
for home blood pressure monitoring should be
checked regularly against a calibrated device. (III-C)
Diagnosis of Hypertension
Recommendations
11. The diagnosis of hypertension should be based
on offce or in-hospital blood pressure
measurements. (II-B)
12. Hypertension in pregnancy should be defned as an
offce (or in-hospital) systolic blood pressure
140 mmHg and/or diastolic blood pressure
90 mmHg, based on the average of at least 2
measurements, taken at least 15 minutes apart, using
the same arm. (II-2B)
13. Resistant hypertension should be defned as the
need for 3 antihypertensive medications for blood
pressure control at 20 weeks gestation. (III-C)
14. A transient hypertensive effect should be defned as
an offce systolic blood pressure 140 mmHg or
a diastolic blood pressure 90 mmHg that is not
confrmed after rest, on repeat measurement, on the
same or on subsequent visits. (II-2B)
15. A white-coat hypertensive effect refers to blood
pressure that is elevated in the offce (i.e., systolic
140 mmHg or diastolic 90 mmHg), but
< 135 mmHg (systolic) and < 85 mmHg
(diastolic) on ambulatory or home blood pressure
monitoring. (II-2B)
16. A masked hypertensive effect refers to blood
pressure that is normal in the offce (i.e., systolic
< 140 mmHg and diastolic < 90 mmHg) but
elevated on ambulatory or home blood pressure
monitoring (i.e., systolic 135 mmHg or diastolic
85 mmHg). (II-2B)
17. Severe hypertension should be defned, in any
setting, as a systolic blood pressure of 160 mmHg
or a diastolic blood pressure of 110 mmHg based
on the average of at least 2 measurements, taken at
least 15 minutes apart, using the same arm. (II-2B)
Measurement of Proteinuria
Recommendations
18. All pregnant women should be assessed for
proteinuria. (II-2B)
19. Urinary dipstick testing (by visual or automated
testing) may be used for screening for proteinuria
when the suspicion of preeclampsia is low. (II-2B)
20. Signifcant proteinuria should be defned as
0.3 g/d in a complete 24-hour urine collection
or 30 mg/mmol urinary creatinine in a spot
(random) urine sample. (II-2B)
21. Signifcant proteinuria should be suspected when
urinary dipstick proteinuria is 1+. (II-2A)
22. More defnitive testing for proteinuria (by urinary
protein:creatinine ratio or 24-hour urine collection)
is encouraged when there is a suspicion of
preeclampsia, including: 1+ dipstick proteinuria
in women with hypertension and risingblood
pressure and in women withnormal blood
pressure, but symptoms or signs suggestive of
preeclampsia. (II-2A)
23. Proteinuria testing does not need to be repeated
once signifcant proteinuria of preeclampsia has
been confrmed. (II-2A)
24. There is insuffcient information to make a
recommendation about the accuracy of the urinary
albumin:creatinine ratio. (II-2L)
Classifcation of HDPs
Recommendations
25. Hypertensive disorders of pregnancy should be
classifed as pre-existing hypertension, gestational
hypertension, preeclampsia, or other hypertensive
effects on the basis of different diagnostic and
therapeutic considerations. (II-2B) (Table 2)
26. The presence or absence of preeclampsia must be
ascertained, given its clear association with more
adverse maternal and perinatal outcomes. (II-2B)
27. In women with pre-existing hypertension,
preeclampsia should be defned as resistant
hypertension, new or worsening proteinuria, one
or more adverse conditions, or one or more severe
complications. (II-2B)
28. In women with gestational hypertension,
preeclampsia should be defned as new-onset
proteinuria, one or more adverse conditions, or one
or more severe complications. (II-2B)
29. Severe preeclampsia should be defned as
preeclampsia complicated by one or more severe
complications. (II-2B)
30. Severe preeclampsia, as defned in this guideline,
warrants delivery. (II-2B)
31. The term PIH (pregnancy-induced hypertension)
should be abandoned, as its meaning in clinical
practice is unclear. (III-D)
Defnition of Preeclampsia
Preeclampsia is most commonly defned by new-onset
proteinuria and, potentially, other end-organ dysfunction.
Hypertension and proteinuria are discussed above under
Diagnosis of Hypertension and Management of
Proteinuria. Women with preeclampsia may have a
diminished, or no, nocturnal BP decrease.
4
Maternal
end-organ dysfunction and fetal manifestations of
preeclampsia illustrated in the Figure are all non-specifc.
In this model of its origins we describe preeclampsia that
arises primarily through imperfect placentation (early-
onset or placental preeclampsia [pink]) or through either
a lowered maternal threshold or excessive physiological
placentation (late-onset or maternal preeclampsia
[blue]). Some aspects of the preeclampsia process are
specifc to it, while others are shared with normotensive
IUGR. A lowered maternal threshold may also infuence
the development of early-onset preeclampsia through
Table 2. Classifcation of the hypertensive disorders of pregnancy
Disorder Comments
Pre-existing (chronic) hypertension This is defned as hypertension that develops either pre-pregnancy or at < 20+0 weeks' gestation
With comorbid condition(s) Comorbid conditions (e.g., pre-gestational type I or II diabetes mellitus or kidney disease)
warrant tighter BP control outside of pregnancy because of their association with heightened
cardiovascular risk.
With evidence of preeclampsia This is also known as superimposed preeclampsia, and is defned by the development of one or
more of the following at 20 weeks:
resistant hypertension, or
new or worsening proteinuria, or
one or more adverse conditions,* or
one or more severe complications.*
Severe preeclampsia is defned as preeclampsia with one or more severe complications.
Gestational hypertension This is defned as hypertension that develops for the frst time at 20+0 weeks' gestation.
With comorbid condition(s) Comorbid conditions (e.g., pre-gestational type I or II diabetes mellitus or kidney disease)
warrant tighter BP control outside of pregnancy because of their association with heightened
cardiovascular risk.
With evidence of preeclampsia Evidence of preeclampsia may appear only many weeks after the onset of gestational
hypertension.
Preeclampsia is defned as gestational hypertension with one or more of the following:
new proteinuria, or
Preeclampsia Preeclampsia may arise de novo. It is defned as gestational hypertension with one or more of the
following:
new proteinuria, or
Other hypertensive effects
Transient hypertensive effect Elevated BP may be due to environmental stimuli, e.g., the pain of labour.
White-coat hypertensive effect This is defned as BP that is elevated in the offce (sBP 140 mmHg or dBP 90 mmHg), but
consistently normal outside of the offce (< 135/85 mmHg) by ABPM or HBPM
Masked hypertensive effect This is defned as BP that is consistently normal in the offce (sBP < 140 mmHg or dBP
< 90 mmHg), but elevated outside of the offce ( 135/85 mmHg) by ABPM or repeated HBPM.
sBP: systolic BP; dBP diastolic BP; ABPM: ambulatory BP monitoring; HBPM: home BP monitoring
*Adverse conditions and severe complications of preeclampsia are defned in Table 3.
These may occur in women whose BP is elevated at < 20+0 or 20+0 weeks who are suspected of having pre-existing or gestational hypertension/
preeclampsia, respectively.
direct endothelial cell activation. The consequences of
endothelial cell activation that appear consistent between
all women with preeclampsia include a variable impact
on multiple vulnerable organ systems. Disease severity
generally correlates with the degree and number of organ
dysfunctions. Fetal manifestations may occur before, with,
or in the absence of maternal manifestations.
5
Table 3 outlines the end-organ dysfunctions
of preeclampsia: adverse conditions and severe
complications. Adverse conditions consist of maternal
symptoms, signs, and abnormal laboratory results, and
abnormal fetal monitoring results that may herald the
development of severe maternal or fetal complications
(including stillbirth). The adverse conditions are those that
we wait for and respond to (e.g., low oxygen saturation)
in an effort to avoid entirely the severe complications
(e.g., pulmonary edema). That response could be
more intensive maternal or fetal monitoring, specifc
treatment, or delivery. Severe maternal complications of
preeclampsia warrant delivery.
The adverse conditions are manifestations of preeclampsia that
increase the risk of adverse maternal or perinatal outcomes.
6

Table 3 lists the adverse conditions by maternal organ
system. Of particular importance are preterm preeclampsia,
chest pain or dyspnea, and abnormality of one or more of
oxygen saturation by pulse oximetry, platelet count, serum
creatinine, or aspartate transaminase.
6
Proteinuria predicts
neither short-term adverse outcomes nor long-term maternal
renal prognosis.
7,8
HELLP syndrome is represented by its
component parts (hemolysis, elevated liver enzymes, and low
platelets), to which we react to by initiating delivery.
How maternal adverse conditions may predict fetal or
neonatal outcomes in preeclampsia is unclear. The perinatal
literature suggests that abnormal fetal monitoring of various
types may identify increased fetal risk. The biophysical
profle has unproven utility in high risk women,
9,10
and may
falsely reassure with early-onset IUGR
11
or preeclampsia.
12
Currently, there is no single fetal monitoring test to
accurately predict fetal compromise in women with

cardiorespiratory
hypertension
ARDS
pulmonary oedema
cardiomyopathy / LV dysfunction
intravascular volume constriction
generalised oedema
CNS
eclampsia
TIA / RIND / CVA
PRES
GCS<13
renal
glomerular endotheliosis
proteinuria
ATN
AKI
hepatic
periportal inflammation
hepatic dysfunction / failure
hepatic haematoma / rupture
haematological
microangiopathic haemolysis
thrombocytopoenia
DIC
placental IUGR
( maternal syndrome)
endothelial cell activation
intervillous soup
pre-eclampsia-specific shared with IUGR
placental debris angiogenic imbalance
innate immune activation
oxidative stress
eicosanoids
cytokines
uteroplacental mismatch
decidual immune cell -
EVT interactions
(invasion & uteroplacental
artery remodelling)
inadequate placentation
(early-onset pre-eclampsia)
genetic factors
familial risks
SNPs
epigenetics
lowered threshold
metabolic syndrome
chronic infection / inflammation
pre-existing hypertension
chronic kidney disease / DbM
high altitude
maternal syndrome
normal placentation
(late-onset pre-eclampsia)
macrosomia
multiple pregnancy
lowered threshold
immunological factors
antigen exposure
primigravidity ( ) / primipaternity ( )
donor gamete(s) ( )
duration of cohabitation ( )
barrier contraception ( ) / fellatio ( )
prior miscarriage ( )
smoking ( )
EVT: extravillous trophoblast; SNP: single nucleotide polymorphism; ARDS: acute respiratory distress syndrome; CNS: central nervous system;
TIA: transient ischemic attack; RIND: reversible ischemic neurological defcit; CVA: cerebrovascular accident; PRES: posterior reversible
encephalopathy syndrome; GCS: Glasgow Coma Scale; ATN: acute tubular necrosis; AKI: acute kidney injury; DIC: disseminated intravascular
coagulation; DbM: diabetes mellitus; LV: left ventricle
The origins and consequences of preeclampsia
preeclampsia. Most experts suggest a combination of tests,
with emphasis on umbilical artery Doppler when there is
IUGR.
9
Other non-specifc risk factors for severe complications
of preeclampsia are immigrant status, young maternal
age, nulliparity, lower maternal weight, and in the
index pregnancy, multiple pregnancy and early-onset
preeclampsia.
13
Defnitions of severe preeclampsia vary, but most include
multi-organ involvement
1416
We modifed our defnition
of severe preeclampsia to preeclampsia associated with
one or more severe complications. Severe preeclampsia
now warrants delivery regardless of gestational age.
Our defnition excludes heavy proteinuria and HELLP
syndrome, which are not absolute indications for delivery,
and includes stroke
17
and pulmonary edema, which are
leading causes of maternal death in preeclampsia.
2
Other
A transient hypertensive effect is not associated with an
increased risk of adverse outcomes. White-coat effect in
early pregnancy (~30%) is common.
18
Forty percent of
women progress to persistent hypertension at 20 weeks
(i.e., gestational hypertension) and 8% to preeclampsia.
Women with white-coat effect have risks (e.g., severe
hypertension, preterm delivery, and NICU admission)
intermediate between normotension and either pre-
existing or gestational hypertension.
1924

Masked hypertension in early pregnancy (~30%) is also
common,
18
but associated perinatal risks are unknown.
Outcomes with masked hypertension at 20 weeks (~10%)
equate to those of gestational hypertension.
25,26
Masked
hypertension could be considered (and ambulatory or
home BP monitoring performed) if there are unexplained
maternal or perinatal complications typically associated
with the HDPs.
Table 3. Adverse conditions and severe complications of preeclampsia

Organ system affected
Adverse conditions
(that increase the risk of severe complications)
Severe complications
(that warrant delivery)
Central nervous system Headache/visual symptoms Eclampsia
PRES
Cortical blindness or retinal detachment
Glasgow coma scale < 13
Stroke, TIA, or RIND
Cardiorespiratory Chest pain/dyspnea
Oxygen saturation < 97%
Uncontrolled severe hypertension (over a period of 12 h
despite use of three antihypertensive agents)
Oxygen saturation < 90%, need for 50% oxygen for
> 1 h, intubation (other than for Caesarean section),
pulmonary edema
Positive inotropic support
Myocardial ischemia or infarction
Haematological Elevated WBC count
Elevated INR or aPTT
Low platelet count
Platelet count < 50 10
9
/L
Transfusion of any blood product
Renal Elevated serum creatinine
Elevated serum uric acid
Acute kidney injury (creatinine > 150 M with no prior
renal disease)
New indication for dialysis
Hepatic Nausea or vomiting
RUQ or epigastric pain
Elevated serum AST, ALT, LDH, or bilirubin
Low plasma albumin
Hepatic dysfunction (INR > 2 in absence of DIC or
warfarin)
Hepatic haematoma or rupture
Feto-placental Abnormal FHR
IUGR
Oligohydramnios
Absent or reversed end-diastolic fow by Doppler
velocimetry
Abruption with evidence of maternal or fetal compromise
Reverse ductus venosus A wave
Stillbirth
PRES: posterior reversible leukoencephalopathy syndrome; TIA: transient ischemic attack; RIND: reversible ischemic neurological defcit (< 48 hr);
WBC: white blood cell; INR: international normalized ratio; aPTT: activated partial thromboplastin time; RUQ: right upper quadrant; AST: aspartate
aminotransferase; ALT: alanine aminotransferase; LDH: lactate dehydrogenase; DIC: disseminated intravascular coagulation; FHR: fetal heart rate.
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Investigations to Classify HDPs
Recommendations
32. For women with pre-existing hypertension, the
following should be performed in early pregnancy
(if not previously documented): serum creatinine,
fasting blood glucose, serum potassium, and
urinalysis (III-D), and EKG. (II-2C)
33. Among women with pre-existing hypertension
or those with a strong clinical risk marker for
preeclampsia, additional baseline laboratory testing
may be based on other considerations deemed
important by health care providers. (III-C)
34. Women with suspected preeclampsia should
undergo the maternal laboratory (II-2B) and
pertinent fetal (II-1B) testing. (Table 4)
35. Doppler velocimetry-based assessment of the fetal
circulation may be useful to support a placental
origin for hypertension, proteinuria, and/or adverse
conditions including intrauterine growth restriction,
(II-2B) and for the timing of delivery. (I-A)
36. There is insuffcient evidence to recommend use of
the biophysical profle as part of a schedule of fetal
testing in women with a hypertensive disorder of
pregnancy. (II-2L)
37. If initial testing is reassuring, but there is ongoing
concern about preeclampsia (e.g., change in
maternal and/or fetal condition), maternal and fetal
testing should be repeated. (III-C)
Comments
Most abnormalities found in maternal and fetal testing are
non-specifc. When preeclampsia is suspected, interpretation
relies on fndings of multiple (not single) abnormalities.
Preeclampsia imitators share manifestations with pre-
eclampsia, but require different treatment.
2731
(Table 5)
CHAPTER 2:
PREDICTION AND PREVENTION
Predicting Preeclampsia
Recommendations
38. Women should be screened for clinical risk markers
of preeclampsia from early pregnancy. (II-2C)
(Table 6)
39. Consultation with an obstetrician or an obstetric inter-
nist, by telephone if necessary, should be con sidered
for women with a history of previous preeclampsia
or another strong clinical marker of increased
preeclampsia risk, particularly multiple pregnancy,
antiphospholipid antibody syndrome, signifcant
proteinuria at frst antenatal visit (usually early in
pregnancy), or a pre-existing condition of hyper-
tension, diabetes mellitus, or renal disease. (II-2B)
40. Screening using biomarkers or Doppler ultrasound
velocimetry of the uteroplacental circulation cannot
be recommended routinely at present for women
at low or increased risk of preeclampsia until such
screening has been shown to improve pregnancy
outcome. (II-2C)
Preventing Preeclampsia and its
Complications in Women at Low Risk
We based our recommendations on the need to prevent
preeclampsia and/or its associated complications. Pregnant
women are classifed as being at either low or increased risk
of preeclampsia, usually by the presence of one or more of
the risk markers in Table 6 (see Predicting Preeclampsia).
Preventative interventions may be best started before 16 weeks
gestation when most of the physiologic transformation of
uterine spiral arteries occurs. Such early intervention has the
greatest potential to decrease early forms of preeclampsia.
32

Women at low risk of preeclampsia have usually been from
unselected populations of nulliparous and multiparous
women.
Recommendations
41. Calcium supplementation of at least 1 g/d, orally,
is recommended for women with low dietary intake
of calcium (< 600 mg/d). (I-A)
42. The following are recommended for other
established benefcial effects in pregnancy: abstention
from alcohol for prevention of fetal alcohol
effects (II-2E), exercise for maintenance of ftness
(I-A), periconceptual use of a folate-containing
multivitamin for prevention of neural tube defects
(I-A), and smoking cessation for prevention of low
birthweight and preterm birth. (I-E)
43. Periconceptual and ongoing use of a folate-
containing multivitamin (I-B) or exercise (II-2B)
may be useful in preventing preeclampsia.
44. Prostaglandin precursors and supplementation
with magnesium or zinc are not recommended for
preeclampsia prevention, but may be useful for
prevention of other pregnancy complications. (I-C)
45. Dietary salt restriction during pregnancy (I-D),
calorie restriction during pregnancy for overweight
women (I-D), low-dose acetylsalicylic acid (I-E),
vitamins C and E (based on current evidence)
(I-E), and thiazide diuretics (I-E) are not
recommended.
46. There is insuffcient evidence to make a
recommendation about a heart-healthy diet (II-2L);
workload or stress reduction (including bedrest)
(II-2L); supplementation with iron with or without
folate (I-L); vitamin D (I-L); pyridoxine (I-L); or
food rich in favonoids. (I-L)
Preventing Preeclampsia and its
Complications in Women at Increased Risk
Women at increased risk of preeclampsia are most
commonly identifed by a personal or family history of an
HDP, chronic medical disease, and/or abnormal uterine
artery Doppler before 24 weeks gestation. Combining
clinical, biochemical, and/or ultrasonographic risk markers
may better identify women at increased preeclampsia risk
(see Prediction); however, no intervention trial has used
such an approach to evaluate preventative therapy.
33,34

Recommendations
47. Low-dose acetylsalicylic acid and calcium
supplementation (of at least 1 g/d) for women with
low calcium intake are recommended for preventions
of preeclampsia in women at high risk. (I-A)
48. Acetylsalicylic acid should be: taken in a low dose
(75162 mg/d), (III-B) administered at bedtime,
(I-B) initiated after diagnosis of pregnancy but
before 16 weeks gestation, (I-B) and considered for
continuation until delivery. (I-C)
49. Prophylactic doses of low-molecular-weight
heparin may be discussed in women with previous
placental complications (including preeclampsia)
to prevent the recurrence of severe or early-onset
preeclampsia, preterm delivery, and/or infants that
are small for gestational age. (I-B)
50. The following may be useful: L-arginine (I-B),
increased rest at home in the third trimester (I-C),
and reduction of workload or stress. (III-C)
51. The following may be useful for prevention of other
pregnancy complications: prostaglandin precursors
(I-B), magnesium supplementation (I-C), and heparin
to prevent venous thromboembolic disease. (I-B)
52. The following are recommended for other
established benefcial effects in pregnancy (as
discussed for women at low risk of preeclampsia):
abstention from alcohol (II-2E), periconceptual
use of a folate-containing multivitamin (I-A), and
smoking cessation. (I-E)
53. The following are not recommended: calorie
restriction in overweight women during pregnancy
(I-D), weight maintenance in obese women during
pregnancy (III-D), antihypertensive therapy
specifcally to prevent preeclampsia (I-D), and
vitamins C and E. (I-E)
recommendation about the usefulness of the
following: the heart-healthy diet (III-L); exercise
(I-L); selenium (I-L); garlic (I-L); zinc, pyridoxine,
iron (with or without folate), vitamin D, or
multivitamins with/without micronutrients. (III-L)
CHAPTER 3:
TREATMENT OF THE HDPs
Dietary and Lifestyle Changes
Recommendations
recommendation about the usefulness of the
following: new severe dietary salt restriction for
Table 5. Preeclampsia imitators
Pregnancy related Not pregnancy related
Preeclampsia/HELLP syndrome Malignant hypertension regardless of the cause
Acute fatty liver of pregnancy Secondary causes of hypertension when associated with end-organ involvement
(e.g., renal disease, pheochromocytoma)
Disseminated intravascular coagulation (from any cause)
Thrombotic thrombocytopenic purpura
Hemolytic uremic syndrome
Vasculitis or other systemic rheumatic condition (systemic lupus erythematous,
scleroderma, cryoglobulinemia, catastrophic antiphospholipids syndrome)
Sepsis
Medications
Cavernous hemangiomas
Malignancy
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r
a
n
d

f
a
c
t
o
r
,

a
n
d

l
e
p
t
i
n
.
women with any HDP, ongoing salt restriction
among women with pre-existing hypertension,
heart-healthy diet, and calorie restriction for obese
women. (III-L)
recommendation about the usefulness of exercise,
workload reduction, or stress reduction. (III-L)
57. For women with gestational hypertension
(without preeclampsia), some bed rest in hospital
(vs. unrestricted activity at home) may be useful
to decrease severe hypertension and preterm
birth. (I-B)
58. For women with preeclampsia who are hospitalized,
strict bed rest is not recommended. (I-D)
59. For all other women with an HDP, the evidence
is insuffcient to make a recommendation
about the usefulness of some bed rest, which
may nevertheless be advised based on practical
considerations. (III-C)
The following recommendations apply to women with
either pre-existing or gestational hypertension.
Place of Care
Recommendations
60. In-patient care should be provided for women with
severe hypertension or severe preeclampsia. (II-2B).
61. A component of care through hospital day units or
home care can be considered for women with non-
severe preeclampsia or non-severe pre-existing or
gestational hypertension. (I-B, II-2B)
Antihypertensive Therapy for Severe Hypertension
Recommendations
62. Blood pressure should be lowered to
< 160 mmHg systolic and < 110 mmHg
diastolic. (I-A)
63. Initial antihypertensive therapy in the hospital
setting should be with nifedipine short-acting
capsules, parenteral hydralazine, or parenteral
labetalol. (I-A) (Table 7)
64. Alternative antihypertensive medications include
a nitroglycerin infusion (I-B), oral methyldopa
(I-B), oral labetalol (I-B), oral clonidine (III-B), or
postpartum, oral captopril. (III-B)
65. Refractory hypertension may be treated with
sodium nitroprusside. (III-B)
66. Nifedipine and magnesium sulphate can be used
contemporaneously. (II-2B)
67. Magnesium sulphate is not recommended solely as
an antihypertensive agent. (I-E)
68. Continuous fetal heart rate monitoring is advised
until blood pressure is stable. (III-L)
Antihypertensive Therapy for Non-Severe
Hypertension Without Comorbid Conditions
Recommendations
69. Antihypertensive drug therapy may be used to
keep systolic blood pressure at 130 to
155 mmHg and diastolic blood pressure at
80105 mmHg. (I-B)
Table 7. The most commonly used agents for treatment of blood pressure 160/110 mmHg
Agent Dosage Onset Peak Duration Comments
Labetalol Start with 20 mg IV; repeat 20 to
80 mg IV q 30 min, or 1 to 2 mg/min,
max 300 mg (then switch to oral)
5 min 30 min 4 hr Best avoided in women with asthma
or heart failure. Neonatology should
be informed if the woman is in labour,
as parenteral labetalol may cause
neonatal bradycardia.
Nifedipine 5 to 10 mg capsule to be swallowed,
or bitten then swallowed, every 30
min
5 to 10 min 30 min ~6 hr Staff should be aware of the
distinction between short-acting
nifedipine capsules used to treat
severe hypertension and both the
intermediate-acting PA tablet (which
can be used for treatment of non-
severe or severe hypertension), and
the slow-release tablets (XL) that are
used for non-severe hypertension.
Hydralazine Start with 5 mg IV; repeat 5 to
10 mg IV every 30 min, or 0.5 to
10 mg/hr IV, to a maximum of
20 mg IV (or 30 mg IM)
5 min 30 min May increase the risk of maternal
hypotension.
IV: intravenous; IM: intramuscular; PA: prolonged action; XL: slow release
70. The choice of antihypertensive agent for initial
treatment should be based on characteristics of the
patient, contraindications to a particular drug, and
physician and patient preference. (III-C)
71. Initial therapy in pregnancy can be with one of
a variety of antihypertensive agents available in
Canada: methyldopa (I-A), labetalol (I-A), other
beta-blockers (acebutolol, metoprolol, pindolol, and
propranolol), (I-B) and calcium channel blockers
(nifedipine). (I-A) (Table 8)
72. Angiotensin-converting enzyme inhibitors and
angiotensin receptor blockers should not be used
during pregnancy. (II-2E)
73. Atenolol and prazosin are not recommended prior
to delivery. (I-D)
For Non-Severe Hypertension (BP of 140159/
90109 mmHg) With Comorbid Conditions
Recommendations
74. For women with comorbid conditions,
antihypertensive drug therapy should be used to
keep systolic blood pressure at < 140 mmHg and
diastolic blood pressure at < 90 mmHg. (III-C)
75. Initial therapy in pregnancy can be with one of
a variety of antihypertensive agents as listed for
women without co-morbidities. (III-C)
76. Captopril, enalapril, or quinapril may be used
postpartum, even during breastfeeding. (III-B)
Corticosteroids for Acceleration of
Fetal Pulmonary Maturity
Recommendations
77. Antenatal corticosteroid therapy should be
considered for all women who present with
preeclampsia at 34+6 weeks gestation. (I-A)
78. Antenatal corticosteroid therapy should be considered
for women who present at 34+6 weeks gestation
with gestational hypertension (despite the absence of
proteinuria or adverse conditions) only if delivery is
contemplated within the next 7 days. (III-L)
79. A rescue dose of corticosteroids may be considered
for women at 34+6 weeks gestation who remain
at high risk of preterm delivery 7 days or more after
an initial course of antenatal corticosteroids. (I-C)
80. Antenatal corticosteroids may be considered for
women delivered by elective Caesarean delivery
at 38+6 weeks gestation to reduce respiratory
morbidity. (I-B)
Comments
When administered at 34+6 weeks gestation, antenatal
corticosteroids accelerate fetal pulmonary maturity and
decrease neonatal mortality and morbidity, including among
women with HDPs.
35
RCTs that administered steroids at
33+0 to 34+6 weeks resulted in reduced neonatal RDS.
35

Prior to elective Caesarean section at 38+6 weeks
gestation, antenatal corticosteroids decrease the excess
neonatal respiratory morbidity and NICU admissions.
36,37

All subgroup analyses have not necessarily revealed such
benefts following Caesarean or vaginal delivery.
35
Timing of Delivery for Women With Preeclampsia
Delivery is the only intervention that initiates resolution of
preeclampsia, and women with gestational hypertension or
pre-existing hypertension may develop preeclampsia.
Recommendations
81. Consultation with an obstetrician (by telephone
if necessary) is mandatory in women with severe
preeclampsia. (III-B)
82. All women with severe preeclampsia should be
delivered immediately (either vaginally or by
Caesarean), regardless of gestational age. (III-C)
83. For women with non-severe preeclampsia at < 24+0
weeks gestation, counselling should include, as an
option, information about delivery within days. (II-2B)
84. For women with non-severe preeclampsia at 24+0
to 33+6 weeks gestation, expectant management
Table 8. Doses of the most commonly used agents for treatment of blood pressures 149 to 159/90 to 105 mmHg
Agent Dosage Comments
Methyldopa 250 to 500 mg po bid-qid (max 2 g/d) There is no evidence to support a loading dose of methyldopa.
Labetalol 100 to 400 mg po bid-tid (max 1200 mg/d) Some experts recommend a starting dose of 200 mg po bid.
Nifedipine* XL preparation (20 to 60 mg po OD, max 120 mg/d) Ensure that the correct form of nifedipine has been prescribed
so that the XL preparation is not confused with the capsules.
XL: slow release
*The prolonged action nifedipine tablet is no longer available in Canada.
should be considered, but only in perinatal centres
capable of caring for very preterm infants. (I-B)
85. For women with non-severe preeclampsia at 34+0
to 36+6 weeks gestation, there is insuffcient
evidence to make a recommendation about the
benefts or risks of expectant management. (III-L)
86. For women with preeclampsia at 37+0 weeks
gestation, immediate delivery is recommended. (I-A)
87. For women with non-severe preeclampsia
complicated by hemolysis, elevated liver enzymes,
low platelets syndrome at 24+0 to 34+6 weeks
gestation, consider delaying delivery long enough
to administer antenatal corticosteroids for
acceleration of fetal pulmonary maturity if there
is temporary improvement in maternal laboratory
testing. (II-2B)
88. All women with hemolysis, elevated liver enzymes,
low platelets syndrome at 35+0 weeks
gestation should be considered for immediate
delivery. (II-2B)
Timing of Delivery for Women With
Gestational Hypertension
Recommendations
89. For women with gestational hypertension (without
preeclampsia) at 37+0 weeks gestation, delivery
within days should be discussed. (I-B)
90. For women with gestational hypertension (without
preeclampsia) at < 37+0 weeks gestation, there is
insuffcient evidence to make a recommendation
about the benefts or risks of expectant
management. (III-L)
Timing of Delivery for Women With
Pre-Existing Hypertension
Recommendation
91. For women with uncomplicated pre-existing
hypertension who are otherwise well at 37+0
weeks gestation, delivery should be considered at
38+0 to 39+6 weeks gestation. (II-1B)
Mode of Delivery
Recommendations
92. For women with any hypertensive disorder of
pregnancy, vaginal delivery should be considered
unless a Caesarean delivery is required for the usual
obstetric indications. (II-2B)
93. If vaginal delivery is planned and the cervix is
unfavourable, then cervical ripening should be
used to increase the chance of a successful vaginal
delivery. (1-A)
94. At a gestational age remote from term, women with
a hypertensive disorder of pregnancy with evidence
of fetal compromise may beneft from delivery by
emergency Caesarean section. (II-2B)
95. Antihypertensive treatment should be continued
throughout labour and delivery to maintain systolic
blood pressure at < 160 mmHg and diastolic blood
pressure at < 110 mmHg. (II-2B)
96. The third stage of labour should be actively
managed with oxytocin, 5 units intravenous or 10
units intramuscular, particularly in the presence of
thrombocytopenia or coagulopathy. (I-A)
97. Ergometrine maleate should not be administered
to women with any hypertensive disorder of
pregnancy, particularly preeclampsia or gestational
hypertension; alternative oxytocics should be
considered. (II-3D)
Anaesthesia: General Principles
Recommendations
98. The anaesthesiologist should be informed when
a woman with preeclampsia is admitted to the
delivery suite. (II-3B)
99. Early insertion of an epidural catheter (in the
absence of contraindications) is recommended for
control of labour pain. (I-A)
100. In the absence of contraindications, all of the
following are acceptable methods of anaesthesia
for women undergoing Caesarean delivery:
epidural, spinal, combined spinal-epidural, and
general anaesthesia. (I-A)
101. A routine fxed intravenous fuid bolus should not
be administered prior to neuraxialanaesthesia. (I-E)
Anaesthesia: Fluid Administration
Recommendations
102. Intravenous and oral fuid intake should be
minimized in women with preeclampsia, to avoid
pulmonary edema. (II-2B)
103. Fluid should not be routinely administered to
treat oliguria (< 15 mL/hr for 6 consecutive
hours). (III-D)
104. For treatment of persistent oliguria, neither
dopamine nor furosemide is recommended. (I-E)
105. Phenylephrine or ephedrine may be used to
prevent or treat hypotension during neuraxial
anaesthesia. (I-A)
Monitoring
Recommendations
106. Arterial line insertion may be used for continuous
arterial blood pressure monitoring when blood
pressure control is diffcult or there is severe
bleeding. (II-3B)
107. Central venous pressure monitoring is not
routinely recommended, and if a central venous
catheter is inserted, it should be used to monitor
trends and not absolute values. (II-2D)
108. Pulmonary artery catheterization is not
recommended unless there is a specifc associated
indication (III-D), and then only in an intensive
care unit setting. (III-B)
Coagulation
Recommendations
109. Upon admission to delivery suite, women with
preeclampsia should have a platelet count
done. (II-1A)
110. Neuraxial analgesia and/or anaesthesia are
appropriate in women:
a. with preeclampsia, provided there are no
associated coagulation concerns (II-2E)
(Table 9);
b. with a platelet count 75 10
9
/L, (II-2B);
c. taking low-dose acetylsaliclylic acid in
the presence of an adequate platelet
count (I-A);
d. receiving unfractionated heparin in a dose
of 10 000 IU/d subcutaneously, 4 hours
after the last dose and possibly
immediately after the last dose without
any delay (III-B);
e. receiving unfractionated heparin in a dose
> 10 000 IU/d subcutaneously if they have
a normal activated partial thromboplastin time
4hours after the last dose (III-B);
f. receiving intravenous heparin in a therapeutic
dose if they have a normal activated partial
thromboplastin time 4 hours after the last
dose (III-B); or
g. receiving low-molecular-weight heparin 10 to
12 hours after a prophylactic dose, or 24 hours
after a therapeutic dose. (III-B)
Aspects of Care Specifc to Women
With Pre-Existing Hypertension
Recommendations
111. Pre-conceptual counselling for women
with pre-existing hypertension is
recommended. (III-C)
112. The following antihypertensive drugs are all
acceptable for use in the frst trimester of
pregnancy: methyldopa, labetalol, and
nifedipine. (II-2B)
113. Angiotensin-converting enzyme inhibitors
and angiotensin receptor blockers should be
discontinued when planning pregnancy or as soon
as pregnancy is diagnosed. (II-2D)
114. Atenolol should be discontinued when pregnancy
is diagnosed. (I-D)
115. Planned changes in antihypertensive agent(s)
for care in pregnancy should be made while
the woman is planning pregnancy if the woman
has uncomplicated pre-existing hypertension,
or, if in the presence of comorbid conditions,
she is likely to conceive easily (within 12
months). (III-L)
Aspects of Care for Women With Preeclampsia:
Magnesium Sulphate for Preventing or
Treating Eclampsia
Recommendations
116. Magnesium sulphate is recommended for frst-line
treatment of eclampsia. (I-A)
117. Magnesium sulphate is recommended as
prophylaxis against eclampsia in women with
severe preeclampsia. (I-A)
118. Magnesium sulphate may be considered as
prophylaxis against eclampsia in women with
non-severe preeclampsia but with severe
hypertension, headaches/visual symptoms, right
upper quadrant/epigastric pain, platelet count
< 100 000 10
9
/L, progressive renal insuffciency,
and/or elevated liver enzymes, based on cost
considerations. (I-C)
119. Magnesium sulphate should be used in standard
dosing, usually 4 g intravenous loading dose
followed by 1 g/hour. (I-A)
120. Routine monitoring of serum magnesium levels is
not recommended. (I-E)
121. Phenytoin and benzodiazepines should not be
used for eclampsia prophylaxis or treatment,
unless there is a contraindication to magnesium
sulphate or it is ineffective. (I-E)
122. In women with pre-existing or gestational
hypertension, magnesium sulphate should be
considered for fetal neuroprotection in the setting
of imminent preterm birth (within the next 24
hours) at 31+6 weeks. (1-A)
123. Delivery should not be delayed in order to
administer antenatal magnesium sulphate for
fetal neuroprotection if there are maternal
and/or fetal indications of emergency
delivery. (III-E)
There is no international consensus on what defnes severe
preeclampsia. This document defnes it as preeclampsia
requiring delivery due to serious maternal end-organ
involvement and/or fetal compromise (see Classifcation
of HDPs). For eclampsia prevention in the setting of
non-severe preeclampsia, we have added to the indication
for magnesium sulphate (in Recommendation 120) the
following symptoms/signs as these are included in the
defnition of severe preeclampsia by other organizations:
severe hypertension, headaches/visual symptoms, right
upper quadrant/epigastric pain, platelet count < 100 000
10
9
/L, progressive renal insuffciency, and/or elevated
liver enzymes.
Aspects of Care for Women With Preeclampsia:
Plasma Volume Expansion
Recommendation
124. Plasma volume expansion is not recommended for
women with preeclampsia. (I-E)
Therapies for HELLP Syndrome
Recommendations
125. Every obstetrical centre should be aware of
the local delay between ordering and receiving
platelets units. (III-B)
126. For a platelet count of < 20 10
9
/L with
hemolysis, elevated liver enzymes, low platelets
Table 9. Eligibility for neuraxial anaesthesia

Treatment with ASA
or heparin

Normal platelet count

Low platelet count
(normal INR and aPTT)
Abnormal INR or
aPTT (regardless of
platelet count)*
None or low-dose ASA
if platelet count > 75 10
9
/L
Unclear if platelet count 50 to 75 10
9
/L
X if platelet count < 50 10
9
/L
UFH
10 000 IU/d (SC)

0 to 4 hr after last dose
Unclear
> 10 000 IU/d (SC)

4 hr after last dose and a
normal aPTT
Unclear
Therapeutic dose (IV)

4 hr after last dose and a
normal aPTT
Unclear
LMWH
Prophylactic dose

10 to 12 hr after last dose
Unclear
Therapeutic dose

24 hr after last dose
Unclear
Low dose ASA + prophylactic UFH
or LMWH
Unclear Unclear
INR: international normalized ratio; aPTT: activated partial thromboplastin time; UFH: unfractionated heparin; SC: subcutaneous; IV: intravenous;
LMWH: low-molecular-weight heparin
Note: These recommendations are based on the absence of a rapidly falling platelet count or a known platelet dysfunction (e.g., von Willebrands disease).
*Other than a lupus anticoagulant
Prophylactic dosing is defned as 10 000 IU/d
Therapeutic dosing (SC) is defned as > 10 000 IU/d
Prophylactic doses of UFH are defned as 10 000 IU/d
Unless ASA is stopped 7 days or more before delivery
X
C
o
n
t
r
a
i
n
d
i
c
a
t
e
d
syndrome, platelet transfusion is recommended
regardless of mode of delivery. (III-B) (Table 9)
127. For a platelet count of 20 10
9
to 49 10
9
/L
with hemolysis, elevated liver enzymes, low
platelets syndrome, platelet transfusion is
recommended prior to Caesarean delivery. (III-B)
(Table 9)
9
to 49 10
9
/L
with hemolysis, elevated liver enzymes, low
platelets syndrome, platelet transfusion should
be considered prior to vaginal delivery if there
is excessive active bleeding, known platelet
dysfunction, a rapidly falling platelet count, or
coagulopathy. (II-2D) (Table 10)
9
/L with
hemolysis, elevated liver enzymes, low platelets
syndrome, platelet transfusion and/or packed
red blood cells should be considered prior to
either Caesarean or vaginal delivery only if
there is excessive active bleeding, known platelet
dysfunction, a rapidly falling platelet count, or
coagulopathy. (III-B)
130. We do not recommend corticosteroids for
treatment of hemolysis, elevated liver
enzymes, low platelets syndrome until they
have been proven to decrease maternal
morbidity. (II-3L)
131. We recommend against plasma exchange or
plasmapheresis for hemolysis, elevated liver
enzymes, low platelets syndrome, particularly
within the frst 4 days postpartum. (II-3E)
Care in the 6 Weeks Postpartum
Recommendations
132. Blood pressure should be measured during the
time of peak postpartum blood pressure, at days
3 to 6 after delivery. (III-B)
133. Women with postpartum hypertension should
be evaluated for preeclampsia (either arising
de novo or worsening from the antenatal
period). (II-2B)
134. Consideration should be given to continuing
antihypertensive therapy postpartum, particularly
in women with antenatal preeclampsia and those
who delivered preterm. (II-2L)
135. Severe postpartum hypertension must be treated
with antihypertensive therapy to keep systolic
blood pressure < 160 mmHg and diastolic blood
pressure < 110 mmHg. (I-A)
136. In women without co-morbidities,
antihypertensive therapy should be considered to
treat non-severe postpartum hypertension to keep
blood pressure < 140/90 mmHg. (III-L)
137. Women with co-morbidities other than
pre-gestational diabetes mellitus should be treated
to keep blood pressure < 140/90 mmHg (III-C)
138. Women with pre-gestational diabetes mellitus
should be treated to keep blood pressure
< 130/80 mmHg. (III-C)
139. Antihypertensive agents generally acceptable
for use in breastfeeding include the following:
nifedipine XL, labetalol, methyldopa, captopril,
and enalapril. (III-B)
Table 10. Recommendations for the transfusion of platelets related to mode of delivery
in HELLP
Mode of delivery
Platelet count Caesarean delivery Vaginal delivery
< 20 10
9
/L

20 to 49 10
9
/L

Consider in presence of:
excessive active bleeding
known platelet dysfunction
platelet count falling rapidly
coagulopathy
50 10
9
/L Consider in presence of:
coagulopathy
Consider in presence of:
coagulopathy
Regardless of the platelet count No platelets should be transfused if there is a strong suspicion of HIT
or TTP-HUS
HIT: heparin-induced thrombocytopenia; TTP-HUS: thrombotic thrombocytopenic purpurahemolytic uremic syndrome
140. There should be confrmation that end-organ
dysfunction of preeclampsia has
resolved. (III-C)
141. Non-steroidal anti-infammatory drugs should
not be given postpartum if hypertension is
diffcult to control, there is evidence of kidney
injury (oliguria and/or creatinine 90 M), or
platelets are < 50 to 10
9
/L. (III-C)
142. Postpartum thromboprophylaxis should be
considered in women with preeclampsia,
particularly in the presence of other risk
factors. (II-2B)
Care Beyond 6 Weeks Postpartum
Recommendations
143. Women with a history of severe preeclampsia
(particularly those who presented or delivered
before 34 weeks gestation) should be screened
for pre-existing hypertension and underlying renal
disease. (II-2B)
144. Referral for internal medicine or nephrology
consultation (by telephone if necessary)
should be considered for women with:
(i) postpartum hypertension that is diffcult
to control, or
(ii) women who had preeclampsia and have
at 3-6 months postpartum either ongoing
proteinuria, decreased estimated glomerular
fltration rate (eGFR) (< 60 mL/min), or
another indication of renal disease, such as
abnormal urinary sediment. (III-A)
145. Women who are overweight should be encouraged
to attain a healthy body mass index to decrease
risk in future pregnancy (II-2A) and for long-term
health. (I-A)
146. Women with pre-existing hypertension or
persistent postpartum hypertension should
undergo the following investigations (if not
done previously) at least six weeks postpartum:
urinalysis; serum sodium, potassium and
creatinine; fasting glucose; fasting lipid
profle; and standard 12-lead electrocardio-
graphy. (III-L)
147. Women who are normotensive but who have had
a hypertensive disorder of pregnancy, may beneft
from assessment of traditional cardiovascular risk
markers. (II-2B)
148. All women who have had a hypertensive disorder
of pregnancy should pursue a healthy diet and
lifestyle. (I-B)
Effects of Maternal Hypertension and Its Therapies
on Child Neurobehavioural Development
Recommendations
149. Clinicians should be aware that gestational
hypertension and preeclampsia may each be
associated with an increase in adverse paediatric
neurodevelopmental effects, such as inattention
and externalizing behaviours (e.g.,
aggressiveness). (II-2B).
150. Clinicians should be reassured that there is
no compelling evidence that antihypertensive
medications (specifcally labetalol, nifedipine, or
methyldopa) are themselves associated with clear
adverse neurodevelopmental effects. (I-B)
CHAPTER 4:
PATIENT PERSPECTIVE
Recommendations
151. Health care providers should be alert to symptoms
of posttraumatic stress following a hypertensive
disorder of pregnancy and refer women for
appropriate evaluation and treatment. (II-2B)
152. Health care providers should inform their patients,
antepartum and postpartum, about preeclampsia,
its signs and symptoms, and the importance of
timely reporting of symptoms to health care
providers. (II-2B)
153. Information should be re-emphasized at
subsequent visits. (III-C)
CHAPTER 5:
KNOWLEDGE TRANSLATION TOOLS AND
IMPLEMENTATION OF THE GUIDELINE
The Appendix (Table 10 in the full document
3
) lists tools
to support the application of this guideline. Some websites
provide general information about BP measurement for
non-pregnant patients, but the recommendations are
similar enough to those for pregnant women to be useful.
Patients, their partners, and their care providers should be
well educated about the HDP, and relevant sites are listed.
Implementation of any evidence depends on individual
knowledge and beliefs, as well as institutional culture. Strong
recommendations should be incorporated into clinical
practice. In well-resourced settings, almost all preeclampsia-
related maternal deaths involve substandard care.
38
Some updates to the 2008 SOGC guidelines on the HDP
may require additional effort to implement.
Recommendation 9 states that all measurement devices
used in hospitals or offces should be checked regularly
against a calibrated device may not be possible for all
Canadian hospitals and offces to do on a regular basis.
Physicians should consider the category other HDP
(white-coat and masked hypertension) as part of the
classifcation of hypertensive women and consider using
some form of out-of-offce BP measurement to evaluate
women with non-severe pre-existing or gestational
hypertension.
Health care providers should inform pregnant women
about the symptoms and signs of the HDPs and refer
them to appropriate knowledge translation tools.
We recommend the use of corticosteroids for women
34+6 weeks gestation who are at high risk of delivery
within the next seven days. This gestational age cut-off
represents a fundamental change in practice that will require
discussion.
Physicians should be familiar with the blood bank policies
of their own hospital.
Physicians should be aware of postpartum signs of
maternal posttraumatic stress disorder and the maternal
and perinatal long-term effects of HDPs, especially at this
vulnerable time in maternal care when the maternity care
provider is often handing back care to the primary care
physician.
The reader is reminded to refer to the full open-access
guideline published in Pregnancy Hypertension,
3
which contains
not only the recommendations and tables presented here,
but also all explanatory text and additional references.
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416 l MAY JOGC MAI 2014

No. 307, May 2014 (Replaces No. 206, March 2008)

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