Pregnant Woman

ACOG Issues Updated Hypertension Guidance, Discusses New ACC/AHA Criteria to Reduce Risks During Pregnancy

The American College of Obstetricians and Gynecologists (ACOG) released today two new pieces of guidance on one of the leading causes of maternal deaths—hypertension or high blood pressure in pregnancy.

December 20, 2018

Pregnant WomanWashington D.C.—The American College of Obstetricians and Gynecologists (ACOG) released today two new pieces of guidance on one of the leading causes of maternal deaths—hypertension or high blood pressure in pregnancy.

Gestational Hypertension and Preeclampsia” and “Chronic Hypertension in Pregnancy” will update and replace the association’s Hypertension in Pregnancy task force report developed in 2013. A woman is considered to have gestational hypertension, or high blood pressure developed in pregnancy, after the first 20 weeks. Prior to that, hypertension is generally deemed to have predated the pregnancy and is considered chronic hypertension.

“The task force was a tour de force in creating a comprehensive view of hypertensive diseases of pregnancy, including research,” said Christian Pettker, M.D., a lead author of the guidance. “The updated guidance provides clearer recommendations for the management of gestational hypertension with severe-range blood pressure, an emphasis on and instructions for timely treatment of acutely elevated blood pressures, and more defined recommendations for the management of pain in postoperative patients with hypertension.”

The latest Practice Bulletins also include discussion of recent ACOG’s guidance that conflicts with the American College of Cardiology (ACC) and the American Heart Association (AHA) new criteria for diagnosing hypertension in adults. The criteria classify blood pressure in four categories—normal, elevated, stage 1 hypertension and stage 2 hypertension.

“The new blood pressure ranges for nonpregnant women have a lower threshold for hypertension diagnosis compared to ACOG’s criteria,” said Pettker. “This will likely cause a general increase in patients classified as chronic hypertensive and will require shared decision-making by the ob-gyn and the patient regarding appropriate management in pregnancy.”

The ACC and AHA have recommended that nonpregnant patients who fall within the stage 1 hypertension category begin treatment if they have risk factors for cardiovascular disease. According to ACOG’s latest guidance, it is reasonable for obstetric care providers to continue to manage the patient in pregnancy as a chronic hypertensive based on the ACC/AHA recommendations.

However, according to ACOG’s guidance, this new approach should continue to be an “active area of investigation” because it could potentially mislabel some women as abnormal who have only borderline or possibly inconsequential cases of blood pressure elevation.

“The new criteria further challenge the idea that the 20-week mark can determine for every patient whether hypertension predates the pregnancy or is pregnancy-related,” said Pettker. “Ob-gyns will need to focus more on individualized care and may find it’s best to err on the side of caution because the appropriate treatment of hypertensive diseases in pregnancy may be the most important focus of our attempts to improve maternal mortality and morbidity in the United States.”

Practice Bulletin #202, “Gestational Hypertension and Preeclampsia” and Practice Bulletin #203, “Chronic Hypertension in Pregnancy” are published in the January issue of Obstetrics & Gynecology.

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Other recommendations issued in the January Obstetrics & Gynecology: 

Committee Opinion #761, ” Cesarean Delivery on Maternal Request”

The incidence of cesarean delivery on maternal request and its contribution to the overall increase in the cesarean delivery rate are not well known, but it is estimated that 2.5% of all births in the United States are cesarean delivery on maternal request. Cesarean delivery on maternal request is not a well-recognized clinical entity. The available information that compared the risks and benefits of cesarean delivery on maternal request and planned vaginal delivery does not provide the basis for a recommendation for either mode of delivery. When a woman desires a cesarean delivery on maternal request, her health care provider should consider her specific risk factors, such as age, body mass index, accuracy of estimated gestational age, reproductive plans, personal values, and cultural context. In the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended. After exploring the reasons behind the patient’s request and discussing the risks and benefits, if a patient decides to pursue cesarean delivery on maternal request, the following is recommended: in the absence of other indications for early delivery, cesarean delivery on maternal request should not be performed before a gestational age of 39 weeks; and patients should be informed that the risks of placenta previa, placenta accreta spectrum, and gravid hysterectomy increase with each cesarean delivery. Given the high repeat cesarean delivery rate, the patient should be made aware that these risks increase with each subsequent delivery. This Committee Opinion has been revised to incorporate additional data regarding outcomes and information on counseling, and to link to existing ACOG resources.

Committee Opinion #762, “Prepregnancy Counseling”

The goal of prepregnancy care is to reduce the risk of adverse health effects for the woman, fetus, and neonate by working with the woman to optimize health, address modifiable risk factors, and provide education about healthy pregnancy. All those planning to initiate a pregnancy should be counseled, including heterosexual, lesbian, gay, bisexual, transgender, queer, intersex, asexual, and gender nonconforming individuals. Counseling can begin with the following question: “Would you like to become pregnant in the next year?” Prepregnancy counseling is appropriate whether the reproductive-aged patient is currently using contraception or planning pregnancy. Because health status and risk factors can change over time, prepregnancy counseling should occur several times during a woman’s reproductive lifespan, increasing her opportunity for education and potentially maximizing her reproductive and pregnancy outcomes. Many chronic medical conditions such as diabetes, hypertension, psychiatric illness, and thyroid disease have implications for pregnancy outcomes and should be optimally managed before pregnancy. Counseling patients about optimal intervals between pregnancies may be helpful to reduce future complications. Assessment of the need for sexually transmitted infection screening should be performed at the time of prepregnancy counseling. Women who present for prepregnancy counseling should be offered screening for the same genetic conditions as recommended for pregnant women. All patients should be routinely asked about their use of alcohol, nicotine products, and drugs, including prescription opioids and other medications used for nonmedical reasons. Screening for intimate partner violence should occur during prepregnancy counseling. Female prepregnancy folic acid supplementation should be encouraged to reduce the risk of neural tube defects.

Committee Opinion #763, ” Ethical Considerations for the Care of Patients With Obesity”

Obesity is a medical condition that may be associated with bias among health care professionals, and this bias may result in disrespectful or inadequate care of patients with obesity. Obstetrician–gynecologists regularly care for patients with obesity and play an integral role in advocating for best practices in health care and optimizing health outcomes for patients with obesity.  Obstetrician–gynecologists should be prepared to care for their patients with obesity in a nonjudgmental manner, being cognizant of the medical and societal implications of obesity. This Committee Opinion has been updated from its previous version to focus on obesity bias within the medical community and to provide practical guidance using people-first language instead of labels (ie, “patients with obesity” versus “obese patients”) to help obstetrician–gynecologists deliver effective, compassionate medical care that meets the needs of patients with obesity.

Committee Opinion #766, “Approaches to Limit Intervention During Labor and Birth” 

Obstetrician–gynecologists, in collaboration with midwives, nurses, patients, and those who support them in labor, can help women meet their goals for labor and birth by using techniques that require minimal interventions and have high rates of patient satisfaction. Many common obstetric practices are of limited or uncertain benefit for low-risk women in spontaneous labor. For women who are in latent labor and are not admitted to the labor unit, a process of shared decision making is recommended to create a plan for self-care activities and coping techniques. Admission during the latent phase of labor may be necessary for a variety of reasons, including pain management or maternal fatigue. Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor. Data suggest that for women with normally progressing labor and no evidence of fetal compromise, routine amniotomy need not be undertaken unless required to facilitate monitoring. The widespread use of continuous electronic fetal monitoring has not been shown to significantly affect such outcomes as perinatal death and cerebral palsy when used for women with low-risk pregnancies. Multiple nonpharmacologic and pharmacologic techniques can be used to help women cope with labor pain. Women in spontaneously progressing labor may not require routine continuous infusion of intravenous fluids. For most women, no one position needs to be mandated or proscribed. Obstetrician–gynecologists and other obstetric care providers should be familiar with and consider using low-interventional approaches, when appropriate, for the intrapartummanagement of lowrisk women in spontaneous labor. Birthing units should carefully consider adding family-centric interventions that are otherwise not already considered routine care and that can be safely offered, given available environmental resources and staffing models. These family-centric interventions should be provided in recognition of the value of inclusion in the birthing process for many women and their families, irrespective of delivery mode. This Committee Opinion has been revised to incorporate new evidence for risks and benefits of several of these techniques and, given the growing interest on the topic, to incorporate information on a family-centered approach to cesarean birth.

Committee #767, “Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period” 

Obstetrician–gynecologists, in collaboration with midwives, nurses, patients, and those who support them in labor, can help women meet their goals for labor and birth by using techniques that require minimal interventions and have high rates of patient satisfaction. Many common obstetric practices are of limited or uncertain benefit for low-risk women in spontaneous labor. For women who are in latent labor and are not admitted to the labor unit, a process of shared decision making is recommended to create a plan for self-care activities and coping techniques. Admission during the latent phase of labor may be necessary for a variety of reasons, including pain management or maternal fatigue. Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor. Data suggest that for women with normally progressing labor and no evidence of fetal compromise, routine amniotomy need not be undertaken unless required to facilitate monitoring. The widespread use of continuous electronic fetal monitoring has not been shown to significantly affect such outcomes as perinatal death and cerebral palsy when used for women with low-risk pregnancies. Multiple nonpharmacologic and pharmacologic techniques can be used to help women cope with labor pain. Women in spontaneously progressing labor may not require routine continuous infusion of intravenous fluids. For most women, no one position needs to bemandated or proscribed. Obstetrician–gynecologists and other obstetric care providers should be familiar with and consider using low-interventional approaches, when appropriate, for the intrapartummanagement of lowrisk women in spontaneous labor. Birthing units should carefully consider adding family-centric interventions that are otherwise not already considered routine care and that can be safely offered, given available environmental resources and staffing models. These family-centric interventions should be provided in recognition of the value of inclusion in the birthing process for many women and their families, irrespective of delivery mode. This Committee Opinion has been revised to incorporate new evidence for risks and benefits of several of these techniques and, given the growing interest on the topic, to incorporate information on a family-centered approach to cesarean birth.

Obstetric Care Consensus #8, “Interpregnancy care”

Interpregnancy care aims to maximize a woman’s level of wellness not just in between pregnancies and during subsequent pregnancies, but also along her life course. Because the interpregnancy period is a continuum for overall health and wellness, all women of reproductive age who have been pregnant regardless of the outcome of their pregnancies (ie, miscarriage, abortion, preterm, full-term delivery), should receive interpregnancy care as a continuum from postpartum care. The initial components of interpregnancy care should include the components of postpartum care, such as reproductive life planning, screening for depression, vaccination, managing diabetes or hypertension if needed, education about future health, assisting the patient to develop a postpartum care team, and making plans for long-term medical care. In women with chronic medical conditions, interpregnancy care provides an opportunity to optimize health before a subsequent pregnancy. For women who will not have any future pregnancies, the period after pregnancy also affords an opportunity for secondary prevention and improvement of future health.

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The American College of Obstetricians and Gynecologists (ACOG) is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, ACOG strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. www.acog.org

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