A Proposed Plan for Prenatal Care to Minimize Risks of COVID-19 to Patients and Providers: Focus on Hypertensive Disorders of Pregnancy

Abstract

Hypertensive disorders are the most common medical complications of pregnancy and a major cause of maternal and perinatal morbidity and death. The detection of elevated blood pressure during pregnancy is one of the cardinal aspects of optimal antenatal care. With the outbreak of novel coronavirus disease 2019 (COVID-19) and the risk for person-to-person spread of the virus, there is a desire to minimize unnecessary visits to health care facilities. Women should be classified as low risk or high risk for hypertensive disorders of pregnancy and adjustments can be accordingly made in the frequency of maternal and fetal surveillance. During this pandemic, all pregnant women should be encouraged to obtain a sphygmomanometer. Patients monitored for hypertension as an outpatient should receive written instructions on the important signs and symptoms of disease progression and provided contact information to report the development of any concern for change in status. As the clinical management of gestational hypertension and preeclampsia is the same, assessment of urinary protein is unnecessary in the management once a diagnosis of a hypertensive disorder of pregnancy is made. Pregnant women with suspected hypertensive disorders of pregnancy and signs and symptoms associated with the severe end of the disease spectrum (e.g., headaches, visual symptoms, epigastric pain, and pulmonary edema) should have an evaluation including complete blood count, serum creatinine level, and liver transaminases (aspartate aminotransferase and alanine aminotransferase). Further, if there is any evidence of disease progression or if acute severe hypertension develops, prompt hospitalization is suggested. Current guidelines from the American College of Obstetricians and Gynecologists (ACOG) and The Society for Maternal-Fetal Medicine (SMFM) for management of preeclampsia with severe features suggest delivery after 34 ^0/7 weeks of gestation. With the outbreak of COVID-19, however, adjustments to this algorithm should be considered including delivery by 30 ^0/7 weeks of gestation in the setting of preeclampsia with severe features.

Key Points

• Outbreak of novel coronavirus disease 2019 (COVID-19) warrants fewer office visits.

• Women should be classified for hypertension risk in pregnancy.

• Earlier delivery suggested with COVID-19 and hypertensive disorder.

Keywords

preeclampsia - hypertension in pregnancy - coronavirus - COVID-19

• References

• 1 Roberts JM, August PA, Bakris G. , et al; American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' task force on hypertension in pregnancy. Obstet Gynecol 2013; 122 (05) 1122-1131
• 2 Levine RJ, Hauth JC, Curet LB. , et al. Trial of calcium to prevent preeclampsia. N Engl J Med 1997; 337 (02) 69-76
• 3 Hauth JC, Ewell MG, Levine RJ. , et al; Calcium for Preeclampsia Prevention Study Group. Pregnancy outcomes in healthy nulliparas who developed hypertension. Obstet Gynecol 2000; 95 (01) 24-28
• 4 Sibai BM, Koch MA, Freire S. , et al. The impact of prior preeclampsia on the risk of superimposed preeclampsia and other adverse pregnancy outcomes in patients with chronic hypertension. Am J Obstet Gynecol 2011; 204 (04) 345.e1-345.e6
• 5 Barton JR, Sibai BM. Prediction and prevention of recurrent preeclampsia. Obstet Gynecol 2008; 112 (2, Pt 1): 359-372
• 6 Pickering TG, Hall JE, Appel LJ. , et al; Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Recommendations for blood pressure measurement in humans and experimental animals: Part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Hypertension 2005; 45 (01) 142-161
• 7 Barton JR, Stanziano GJ, Sibai BM. Monitored outpatient management of mild gestational hypertension remote from term. Am J Obstet Gynecol 1994; 170 (03) 765-769
• 8 Barton JR, Istwan NB, Rhea D, Collins A, Stanziano GJ. Cost-savings analysis of an outpatient management program for women with pregnancy-related hypertensive conditions. Dis Manag 2006; 9 (04) 236-241
• 9 Sibai BM, Barton JR. Expectant management of severe preeclampsia remote from term: patient selection, treatment, and delivery indications. Am J Obstet Gynecol 2007; 196 (06) 514.e1-514.e9
• 10 ACOG Practice Bulletin No. ACOG practice bulletin no. 202: gestational hypertension and preeclampsia. Obstet Gynecol 2019; 133 (01) e1-e25
• 11 Sperling JD, Dahlke JD, Huber WJ, Sibai BM. The role of headache in the classification and management of hypertensive disorders in pregnancy. Obstet Gynecol 2015; 126 (02) 297-302
• 12 Barton JR, Witlin AG, Sibai BM. Management of mild preeclampsia. Clin Obstet Gynecol 1999; 42 (03) 455-469
• 13 Chahine KM, Sibai BM. Chronic hypertension in pregnancy: new concepts for classification and management. Am J Perinatol 2019; 36 (02) 161-168
• 14 Odegård RA, Vatten LJ, Nilsen ST, Salvesen KA, Austgulen R. Preeclampsia and fetal growth. Obstet Gynecol 2000; 96 (06) 950-955
• 15 Altman D, Carroli G, Duley I, et al; The Magpie Trial Collaborative Group. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet 2002;359(9321):1877–1890