Hypertension in Pregnancy
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Hypertension in
Pregnancy
Incidence
Complicates 10-20% of
pregnancies
Directly responsible for
17.6% of maternal deaths
in the U.S.
Risk Factors
Nulliparity
Preeclampsia in a previous pregnancy
Age >40 years or <18 years
Family history of pregnancy-induced hypertension
Chronic hypertension
Chronic renal disease
Antiphospholipid antibody syndrome or inherited thrombophilia
Vascular or connective tissue disease
Diabetes mellitus (pregestational and gestational)
Multifetal gestation
High body mass index
Male partner whose previous partner had preeclampsia
Hydrops fetalis
Unexplained fetal growth restriction
Molar pregnancy
Complications of Hypertension
in Pregnancy
MATERNAL
Abruptio placenta
Eclampsia
Subcapsular liver
hematoma
CVA
DIC
Pulmonary edema
FETAL
Prematurity
IUGR
Ureteroplacental
insufficiency
IUFD (2 fold increase
in risk)
Definition
SBP ≥140 mmHg and/or DBP ≥90 mmHg
After 20 WGA with previously normal BP
two occasions at least 6 hours apart
BP returns to normal 12 weeks after delivery
Categories
Gestational Hypertension
Chronic Hypertension – 0.5-3%
Preeclampsia – 5-8%
Preeclampsia superimposed on Chronic Hypertension – 2.8-5.2%
Gestational Hypertension
Mild hypertension without proteinuria or other signs
of preeclampsia.
Develops in late pregnancy, after 20 weeks gestation.
Resolves by 12 weeks postpartum.
25% progress to preeclampsia
Often when hypertension develops <30 weeks gestation.
Preeclampsia Spectrum
New onset of hypertension and proteinuria after 20 weeks gestation Mild Preeclampsia
Severe Preeclampsia
HELLP Syndrome
Eclampsia Occurrence of generalized convulsion and/or coma in the
setting of preeclampsia, with no other neurological condition.
25% of woman with evidence of only mild preeclampsia
Mild Preeclampsia
SBP ≥140 mmHg and/or DBP ≥90 mmHg
After 20 WGA with previously normal BP
two occasions at least 6 hours apart
BP returns to normal 12 weeks after delivery
Proteinuria 300mg/day
Severe Preeclampsia Severe Preeclampsia must have one of the following:
Systolic blood pressure ≥160 mm Hg or diastolic ≥110 mm Hg on two occasions at least six hours apart at rest
Proteinuria ≥ 5g in 24 hours
Cerebral or visual disturbances
Symptoms of liver capsule distention (RUQ/Epigastric pain)
Hepatocellular injury Elevated LFT’s
Thrombocytopenia ≤100,000 platelets per cubic milimeter
Oliguria ≤500 mL in 24 hours
Severe fetal growth restriction
Pulmonary edema or cyanosis
Cerebrovascular accident
Pre-eclampsia
Pathogenesis
Abnormal placental
implantation
Poor trophoblast
remodeling of spiral
arteries
Myometrial segments
retain intima and
smooth muscle with
reduced diameter
mild pre-eclampsia Severe pre-eclampsia
BP SBP≥140; DBP≥90 SBP ≥ 160; DBP ≥ 110
Proteinuria ≥ 300mg/24hr ≥ 5g/24hr; 3+ x2 4hr apart
Symptoms
* HA
* vision changes
* RUQ pain
None Presence of any
Labs Normal •Low platelets < 100
•Elevated LFTs
•Renal failure Cr > 1.5
Signs Absent •Oliguria < 500cc/24hr
•IUGR
HELLP Syndrome
Hemolysis, Elevated Liver Enzymes, Low
Platelets
+/- HTN and proteinuria
Management similar to preeclampsia
20% of woman with severe preeclampsia
Chronic Hypertension
“Preexisting Hypertension”
Definition
Systolic pressure ≥ 140 mmHg, diastolic pressure ≥90 mmHg, or both.
Presents before 20th week of pregnancy or persists longer then 12 weeks postpartum.
Causes
Essential or Secondary
Prenatal Care for Chronic
Hypertensives
In long-standing disease, evaluate end-organ function
Echocardiogram
Baseline 24-hour total urine protein
Labs
Dilated Eye Exam
Any increase in BP or ≥ 1+ protein should be re-
evaluated
Treatment for Chronic
Hypertension When to treat:
- If no end-organ damage, goal <150/95
- If end-organ damage present, goal <140/90
Medication choices: Oral methyldopa and labetalol.
Preeclampsia superimposed on
Chronic Hypertension
Affects 10-25% of patients with chronic HTN
Preexisting Hypertension with the following:
New onset proteinuria
A sudden increase in blood pressure.
Thrombocytopenia.
Elevated aminotransferases.
Evaluation of Hypertension in
Pregnancy
History ID and Complaint
HPI (S/S of Preeclampsia)
Past Medical Hx, Past
Family Hx
Past Obstetrical Hx, Past
Gyne Hx
Social Hx
Medications, Allergies
Prenatal serology, blood
work
Assess for Hypertension in
Pregnancy risk factors
Physical Vitals
HEENT = Vision
Cardiovascular
Respiratory
Abdominal = Epigastric
pain, RUQ pain
Neuromuscular and
Extremities = Reflex,
Clonus, Edema
Fetus = Leopold’s, FM,
NST
Evaluation of Hypertension in
Pregnancy
Laboratory Tests
CBC (Hgb, Plts)
CMP (Cr, AST, ALT, AP)
LDH (↑ with hemolysis)
Uric Acid (↑oxidative stress/ ↓clearance)
Coagulation (PT, PTT, INR, Fibrinogen)
Urine Protein (Dipstick, 24 hour)
Seizure
Prophylaxis
Timing of
Delivery
Treatment
Chronic HTN No 39 wga PO meds if
indicated
Gestational HTN No 39 wga None
Mild Pre-eclampsia Yes/No 37 wga None
Severe Pre-eclampsia Yes At Diagnosis IV
labetolol/hydralazine
prn
HELLP Yes At Diagnosis
Eclampsia Yes At Diagnosis
Management of Hypertension in
Pregnancy
Depends on severity of hypertension and gestational age
Observational Management Restricted activity
Close Maternal and Fetal Monitoring BP Monitoring
S/S of preeclampsia
Fetal growth and well being (NST, and U/S)
Routine weekly or biweekly blood work and urine
Management of Hypertension in
Pregnancy
Medical Management Acute Therapy = IV Labetalol, IV Hydralazine, SR
Nifedipine
Expectant Therapy = Oral Labetalol, Methyldopa, Nifedipine
Eclampsia prevention = MgSO4
Contraindicated antihypertensive drugs ACE inhibitors
Angiotensin receptor antagonists
Treatment of Preeclampsia
Definitive Treatment = Delivery
Major indication for antihypertensive therapy is
prevention of intracranial bleeding/stroke.
Diastolic pressure ≥105-110 mmHg or systolic
pressure ≥160 mmHg
Choice of drug therapy:
Acute – IV labetalol, IV hydralazine, PO Nifedipine
Long-term – Oral methyldopa or labetalol
Management of Hypertension in
Pregnancy
Proceed with Delivery
Vaginal Delivery VS Cesarean Section
Depends on severity of hypertension
May need to administer antenatal corticosteroids
depending on gestation
Only cure is DELIVERY!!!
Questions?
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