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?