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Welcome back, everyone. Today we're diving into one of the most hotly debated topics in obstetrics. But don't worry. Even though it can be a little controversial at first, we, as always, will give you practical clinical insights and application. And to an otherwise kind of gray area, we're going to make it relatively black and white here. We're going to be talking about should we be treating preeclampsia without severe features with antihypertensive meds during expectant management? Now, if you've been following the literature and you follow our show, you know that we've talked about these things in the past. We've talked about the CHAP trial that is chap, and then the CHIP trial. Chip, the landmark CHAP trial, changed the game for chronic hypertension in pregnancy. That showed us that targeting the blood pressure below 14090 reduced serious maternal complications without harming the child. That was a big deal. But here's the thing. Chap, of course, studied chronic hypertension. Then there was the CHIP trial that also found that tight control of gestational hypertension and non proteinuric chronic hypertension was also beneficial. These did not address preeclampsia without severe features. And yet the ripple effect of those trials have sparked a global conversation since their release several years ago. We're doing this podcast topic because somebody asked. I've heard your episode on CHIP and chap, and I know ACOG has a statement on the CHAP trial. Are we supposed to be treating preeclampsia without severe features to those same blood pressure targets at or under 140 over 90? That was the question that came into the show. And I'm telling you guys, it's a very deep question. And here's where it gets Interesting. Guidelines across the globe do not agree. I'll say it again, guidelines on this across the globe do not agree in the US and we're going to talk about this after the intro, ACOG and SMFM still say hold off on antihypertensive therapy unless a blood pressure hits a severe range of 160 over 110. Now of course, that faced a lot of criticism and because we're allowing a patient to get into dangerous territory when we have safe medications to get her off that danger ledge. So even though right now ACOG favors and endorses the CHAP trial for chronic hypertension, it's a little less gray, It's a little bit, I'm sorry, a little bit more gray for gestational hypertension, it's less clear for gestational hypertension and preeclampsia without severe features. However, hold on because if you're thinking, well, there it is, ACOG says no, we're not going to do it. But hold on, outside of the US you're going to find the World Health Organization, the International Society for the Study of Hypertension in pregnancy, Figo Nice and Hypertension Canada all recommend treatment at 140 over 90, just like the CHAP trial. And we're talking about preeclampsia without severe features. So everybody else except, except the US currently, and we're doing this at the end of May of 20, 20, 26 when we're recording this, everybody else currently except the US says yes, we need to keep a lid on blood pressure to prevent severe blood pressure related morbidity from occurring. Blood waiting for a blood pressure of 160 or 110 is simply too high. So in this episode we're going to review the controversy, we're going to walk through the divergent guidelines and most importantly, as I've already stated, we're going to give you real world clinical application here so that when you're watching somebody with preeclampsia without severe features doing expectant management, which we're supposed to do until 37 weeks, I'm going to give you a practical approach and explain why treating these patients with antihypertensive medications using one of the standard medications that we have in our armamentarium, makes the most clinical sense. Now, if you're saying, well, is ACOG ever going to get there? It is, it is. But we can't wait for that as blood pressure of 160, 110 are just simply too high to wait to take action. Again. We've got several organizations like the World Health Organization, the International Society for the Study of Hypertension in Pregnancy. Phi go nice. And Hypertension Canada all say treat at 140 over 90, regardless of the flavor of hypertension in gestation. It's a great topic. Thank you for bringing this up to us. And we're going to talk about should we be treating non severe preeclampsia with blood pressure meds just like ACOG endorses for chronic hypertension via the CHAP trial? The quick answer I'm gonna tell you right now is yes. I'm gonna walk through the data coming up next. We're just trying to fulfill our life calling and our mission. This is Dr. Chapa's OB GYN no Spin podcast. That's right. These guidelines are divergent. They call it divergent, like from the movie Divergent. Not a sponsor. Sorry, guys, that was cheesy. That was not my fault. I'm blaming that completely on Michael, our producer, because I said, oh, these guidelines are divergent. And he said, oh, like the movie with that pretty girl. Yeah, Michael, that was creepy when you said it. Just. Just play the clip. Come on.
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They call it divergent.
- [06:38]
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It's extremely rare. They call it divergent. Actually, having divergent guidelines is not rare at all. It happens frequently. And that's exactly the case here with preeclampsia without severe features and its medical management. Now, to be clear, we know what to do with chronic hypertension. That's CHAP trial. Chronic hypertension and preeclampsia. We know what to do with gestational and chronic hypertension. That is the CHIP trial that stood for control of hypertension in pregnancy. But neither of those really focused on preeclampsia without severe features. However. However, by extrapolation, if keeping a lid on blood pressure in gestational and chronic hypertension prevented severe maternal morbidity related to blood pressure spikes, why would it not for preeclampsia with severe. Now, to be very clear, you gotta know why you would treat this and what you're trying, what your goal is and what it is not. Your goal is simply to prevent severe urgent hypertension so that she doesn't get at risk of having a stroke. Okay? That's the reason. What it's not gonna do is prevent further down the road, end organ issues. So if you're. If the body is going to have a bump in liver enzymes, it's going to do that. If it's going to have a bump in creatinine, it's going to do that. Taking procardia nifedipine or labetalol for preeclampsia without severe features is not going to prevent that. Okay? It doesn't prevent deterioration in that aspect down the road. It only is to keep a lid on severe maternal morbidity and or mortality simply related to blood pressure spikes. Okay, so the thought that, well, it's not going to prevent overall morbidity mortality, no, not overall, but that related to blood pressure is absolutely true. That's what Chip and Chap showed. Okay, Chip and Chap.
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- [08:57]
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Now. The other issue is the fear is, well, I don't want to mask disease progression. You're not going to do that. You're not going to mask anything because remember, according to guidance, which we've already talked about in recent episodes, you if you're doing expectant management with gestational hypertension or preeclampsia without severe features or even with severe features, which you know, you can try to get them to 34 weeks as long as they're hemodynamically stable. You're going to do laboratory surveillance. So you're not going to mask anything. You're supposed to keep your eyes on them for surveillance, which includes weekly lab assessments and if they have gestational hypertension or weekly assessment of quantitative urine proteins and see if they become preeclamptic. So you're going to be watching them anyway. We're supposed to get, according to clinical guidance, which is Practice Bulletin 222, weekly surveillance based on labs hematological surveillance to look for end organ effects. Okay, so you're not going to mask anything. Masking would be if you don't look for anything at all, which you shouldn't do. So will this mask disease progression? No, because you should be looking for it anyway. And does this prevent, you know, other end organ effects? No, what it does do is prevent severe maternal morbidity from blood pressures of 160 over 110. Okay, now here's what's interesting. There was a Cochrane review. So this is not acog, rest, NFM or Candida. This is just a Cochrane review. There was 49 trials and it did in fact confirm that anti pretensive therapy for mild to moderate pregnancy hypertension of any flavor reduced the risk of developing severe hypertension by a 50% reduction. But it did not demonstrate clear reduction in eclampsia, fetal death or other hard maternal outcomes. So you got to know again what you're trying to do and when you're not trying to do this is not going to prevent eclampsia. It's not going to prevent other maternal complications like help, it only prevents by 50% severe hypertension, which is something we should be trying to do anyway. Okay, so this was a Cochrane review, 49 trials. Yes. Anti potential therapy for moderate to mild pregnancy induced hypertension of any flavor reduce the risk of developing severe hypertension by 50%. So very quickly guys, I want to do this very fast. Let me just give you the striking contrast, the divergence, if you will. In published guidance from different organizations, we already talked about ACOG and SMFM that does recommend treatment of chronic hypertension to less than 140 over 90. However, for gestational hypertension and pre clamps without severe features, they say don't do anything until 160 over 110. Now to be very clear, guys, you can do whatever you want to do. I'm not, you know, trying to dictate anybody's management. I'm just saying it is reasonable. Based on international and global consensus. We kind of seem to be the outlier here. Let me explain. International societies so International Society for the Study of Hypertension in Pregnancy who Nice Figo. Hypertension Canada all recommend treating all hypertensive disorders. Let me say that again. All hypertensive disorders at 140 over 90 as they extrapolate the data from CHIP and CHAP, just as I have done here to reduce severe maternal morbidity simply related to stroke risk from high blood pressure spikes. Also watch this. Bring this back now to the U.S. the American Heart association in 2022. Its scientific statement says Quote, there is compelling reason to lower treatment thresholds across all hypertensive disorders of pregnancy, noting that treatment of non severe hypertension may permit prolongation of pregnancy and prevent unnecessary, otherwise rushed deliveries, end quote. But even though that was helpful, it stopped at a formal recommendation stating preeclampsia specifically. So it says, hey, again, 2022American Heart Association. There is, quote, compelling reason to lower treatment thresholds across all hypertensive disorders of pregnancy, end quote. But it stopped short of saying, I want you to treat preeclampsia without severe features. And the reason that they stop short of that is because they're not an obstetrical body. Right? So this is coming from the cardiology house, from the AHA House. And they said, you know, we're going to stay in our lane. We're just seeing what we see here, that there is, quote, compelling reasons, end quote, to treat these patients, again, quote, across all hypertensive disorders, end quote. So here's a very, very quick practical consideration here. Should we treat chronic hypertension at 140 90? Yes, absolutely. Should we treat gestational and preeclampsia without severe. My opinion, based on international data be very clear here. This is my opinion, guys, is yes, absolutely. That's in line with the Cochrane review, that's in line with the American heart association from 2022 and international guidance. However, you know, there's no formal recommendation yet from the US So it is a little controversial here, if you want to know. What I do is yes, we absolutely give these patients extended spectrum, extended release nifedipine. We start at 30 or we give them labetalol. And it really depends again what their delta called. The rule of 55 is if you don't know what that is, then you haven't listened to a lot of shows because we've got several episodes on the rule of 55, whether it's hyperdynamic or non hyperdynamic hypertension. Because if it's hyperdynamic, we can give them labetalol. And if it's non hyperdynamic, in other words, more vasospastic, we give them nifedipine. You gotta go back and listen to the episode. Just look in the search bar under our show and look for rule of 55. Plenty of data on that. Okay, so the bottom line is, although I'm going to be very clear, there is no randomized trial specifically designed using anti hypertensive treatment and preeclampsia without severe features. The CHAP data can apply and the Chip, data can be can apply, they can be extrapolated to preeclampsia without severe features. Since we're still going to be monitoring anyway, we're not going to mask any kind of illness because we're going to do weekly lab checks. We're still gonna do fetal surveillance. If they have gestational hypertension, which we should be treating, according to chip, we're still gonna be checking for weekly quantitative urine proteins, not dipsticks. These are all super important things. So based on that question that was asked to the show, do I treat preeclampsia without severe features with medication? Absolutely. Because I'm trying to keep a lid on her having a severe risk of stroke by letting her get to 160 over 110. Now think about that, guys. 160 over 110. Blood pressure is high for a 70 year old man. Okay, I've got young reproductive age patients, so imagine a 20 year old with that. We're letting the patient get to that danger spot unnecessarily. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. We've covered the divergent guidelines on treatment of severe preeclampsia without severe features. What? We've covered the guidance on treatment of non severe preeclampsia or preeclampsia without severe features. Wow. Crazy show with blood pressure meds. Podcast family. We'll see you on the next episode of the no Spin podcast. This is Dr. Chapma's obgyn no spin podcast. It.