Hypertension in Pregnancy
Topic List : may 14th , 2012
Introduction
Most common medical complication of pregnancy
6 to 8 % of gestations in the US.
In 2000, the National High Blood Pressure
Education Program Working Group on High Blood
Pressure in Pregnancy defined four categories of
hypertension in pregnancy:
Chronic hypertension
Gestational hypertension
Preeclampsia
Preeclampsia superimposed on chronic hypertension
Chronic Hypertension Defined
1.
BP measurement of 140/90 mm Hg or
more on two occasions
2.
Before 20 weeks of gestation OR
Persisting beyond 12 weeks postpartum
Chronic Hypertension
Treatment of mild to moderate chronic
hypertension neither benefits the fetus nor
prevents preeclampsia.
Excessively lowering blood pressure may
result in decreased placental perfusion and
adverse perinatal outcomes.
When BP is 150 to 180/100 to 110 mm Hg,
pharmacologic treatment is needed to prevent
maternal end-organ damage.
Treatment of Chronic Hypertension
Methyldopa , labetalol, and nifedipine most
common oral agents.
AVOID: ACEI and ARBs, atenolol, thiazide
diuretics
Women in active labor with uncontrolled
severe chronic hypertension require
treatment with intravenous labetalol or
hydralazine.
Gestational Hypertension
Formerly called PIH (Pregnancy Induced HTN)
HTN without proteinuria occurring after 20
weeks gestation and returning to normal within
12 weeks after delivery.
50% of women diagnosed with gestational
hypertension between 24 and 35 weeks
develop preeclampsia.
Preeclampsia
New onset hypertension with proteinuria after 20
weeks gestation.
Resolves by 6 weeks postpartum.
Characterized as mild or severe based on the
degree of hypertension and proteinuria, and the
presence of symptoms resulting from involvement
of the kidneys, brain, liver, and cardiovascular
system
Risk Factors
FACTOR
Renal disease
RISK RATIO
20:1
Chronic hypertension
Antiphospholipid
syndrome
10:1
10:1
Family history of PIH
Twin gestation
5:1
4:1
Nulliparity
Age > 40
3:1
3:1
Diabetes mellitus
2:1
African American
1.5:1
Diagnostic Criteria for Preeclampsia
1.
2.
SBP of 140 mm Hg or more or a DBP of 90
mm Hg or more on two occasions at least six
hours apart after 20 weeks of gestation AND
Proteinuria 300 mg in a 24-hour urine
specimen or 1+ or greater on urine dipstick
testing of two random urine samples collected
at least four hours apart.
A random urine protein/creatinine ratio < 0.21 indicates that
significant proteinuria is unlikely with a NPV of 83%.
Generalized edema (affecting the face and hands) is often present
in patients with preeclampsia but is not a diagnostic criterion.
HELLP Syndrome
Is a variant of severe preeclampsia
Occurs in up to 20% of pregnancies
complicated by severe preeclampsia.
Variable clinical presentation; 12 to 18% are
normotensive and 13% do not have
proteinuria.
At diagnosis, 30% of women are postpartum,
18% are term, and 52% are preterm.
HELLP Syndrome
Common presenting complaints are RUQ or
epigastric pain, N/V, malaise or nonspecific
symptoms suggesting an acute viral syndrome.
Any patient with these symptoms or signs of
preeclampsia should be evaluated with CBC,
platelet count, and liver enzymes.
When platelet count < 50,000/mm3 or active
bleeding occurs, coagulation studies needed to
R/O DIC.
Prevention of Preeclampsia
Routine supplementation with calcium, magnesium,
omega-3 fatty acids, or antioxidant vitamins is ineffective.
Calcium reduces the risk of developing preeclampsia in
high-risk women and those with low dietary calcium intake.
Low-dose aspirin (75 to 81 mg per day) is effective for
women at increased risk of preeclampsia, NNT = 69 ; NNT
= 227 to prevent one fetal death.
Low-dose aspirin is effective for women at highest risk
from previous severe preeclampsia, diabetes, chronic
hypertension, or renal or autoimmune disease, NNT = 18.
Multiorgan Effects of Preeclamsia
Cardiovascular HTN, increased cardiac
output, increased systemic vascular
resistance, hypovolemia
Neurological Seizures-eclampsia,
headache, cerebral edema, hyperreflexia
Pulmonary Capillary leak, reduced colloid
osmotic pressure, pulmonary edema
Multiorgan Effects cont.
Hematologic Volume contraction, elevated
hematocrit, low platelets, anemia due to
hemolysis
Renal Decreased GFR, increased
BUN/creatinine, proteinuria, oliguria, ATN
Fetal Increased perinatal morbidity,
placental abruption, fetal growth restriction,
oligohydramnios, fetal distress
Management of Preeclampsia
The ultimate cure is DELIVERY.
Assess gestational age
Assess cervix
Fetal well-being
Laboratory assessment
Rule out severe disease
Gestational HTN at Term
Delivery is always a reasonable option if term
If cervix is unfavorable and maternal disease
is mild, expectant management with close
observation is possible
Mild Gestational HTN Not at Term
Rule out severe disease
Conservative management
Serial labs
Twice weekly visits
Antenatal fetal surveillance
Outpatient versus inpatient
Indications for Delivery in Preeclampsia
Fetal indications
Severe intrauterine growth restriction
Nonreassuring fetal surveillance
Oligohydramnios
Indications for Delivery in Preeclampsia
Maternal indications
Gestational age of 38 weeks or greater
Platelet count below 100,000
Progressive deterioration of hepatic or renal
function
Suspected placental abruption
Persistent severe headache or visual changes
Persistent severe epigastric pain, nausea, or
vomiting
Eclampsia
Criteria for Treatment
Diastolic BP > 105-110
Systolic BP > 200
Avoid rapid reduction in BP
Do not attempt to normalize BP
Goal is DBP < 105 not < 90
May precipitate fetal distress
Hypertensive Emergencies
Fetal monitoring
IV access
IV hydration to maintain urine output > 30 mL
per hour, limit to 100 mL per hour.
The reason to treat is maternal, not fetal
May require ICU
Characteristics of Severe HTN
Crises are associated with hypovolemia
Clinical assessment of hydration is inaccurate
Unprotected vascular beds are at risk, ie.,
uterine
Key Steps Using Vasodilators
250-500 cc of fluid, IV
Avoid multiple doses in rapid succession
Allow time for drug to work
Maintain LLD position
Avoid over treatment
Acute Medical Therapy
Hydralazine
Labetalol
Nifedipine
Nitroprusside
Clonidine
Hydralazine
Dose: 5-10 mg every 20 minutes
Onset: 10-20 minutes
Duration: 3-8 hours
Side effects: headache, flushing, tachycardia,
lupus like symptoms
Mechanism: peripheral vasodilator
Labetalol
Dose: 20 mg, then 40, then 80 every 20
minutes, for a total of 220mg
Onset: 1-2 minutes
Duration: 6-16 hours
Side effects: hypotension
Mechanism: Alpha and Beta blockade
Nifedipine
Dose: 10 mg po, not sublingual
Onset: 5-10 minutes
Duration: 4-8 hours
Side effects: chest pain, headache,
tachycardia
Mechanism: CA channel blockade
Clonidine
Dose: 1 mg po
Onset: 10-20 minutes
Duration: 4-6 hours
Side effects: unpredictable, avoid rapid
withdrawal
Mechanism: Alpha agonist, works centrally
Nitroprusside
Dose: 0.2 0.8 mg/min IV
Onset: 1-2 minutes
Duration: 3-5 minutes
Side effects: cyanide accumulation,
hypotension
Mechanism: direct vasodilator
Seizure Prophylaxis
Magnesium sulfate
Loading dose of 4 to 6 g diluted in 100 mL of
normal saline, given IV over 15 to 20
minutes, followed by a continuous infusion of
1-2 g per hour
Monitor urine output, RR and DTRs
With renal dysfunction, may require a lower
dose
Magnesium Sulfate
Is NOT a hypotensive agent
Works as a centrally acting anticonvulsant
Also blocks neuromuscular conduction
Serum levels: 4-7 mg/dL
Additional benefit of reducing the incidence of
placental abruption
Toxicity
Respiratory rate < 12
DTRs not detectable
Altered sensorium
Urine output < 25-30 cc/hour
Antidote: 10 ml of 10% solution of calcium
gluconate 1 g IV over 2 minutes.
Eclampsia
New onset of seizures in a woman with preeclampsia.
Preceded by increasingly severe preeclampsia,
or it may appear unexpectedly in a patient with
minimally elevated blood pressure and no
proteinuria.
Blood pressure is only mildly elevated in 30-60%
of women who develop eclampsia.
Occurs: Antepartum - 53%, intrapartum - 19%,
or postpartum - 28%
Treatment of Eclampsia
Protecting the patient and her airway
Place patient on left side and suction to
minimize the risk of aspiration
Give oxygen
Avoid insertion of airways and padded tongue
blades
IV access
Mag Sulfate 4-6 g IV bolus, if not effective,
give another 2 g
Alternate Anticonvulsants
Diazepam 5-10 mg IV
Sodium Amytal 100 mg IV
Pentobarbital 125 mg IV
Dilantin 500-1000 mg IV infusion
After the Seizure
Assess maternal labs
Fetal well-being
Effect delivery
Transport when indicated
No need for immediate cesarean delivery
Other Complications
Pulmonary edema
Oliguria
Persistent hypertension
DIC
Pulmonary Edema
Fluid overload
Reduced colloid osmotic pressure
Occurs more commonly following delivery as
colloid oncotic pressure drops further and
fluid is mobilized
Treatment of Pulmonary Edema
Avoid over-hydration
Restrict fluids
Lasix 10-20 mg IV
Usually no need for albumin or Hetastarch
(Hespan)
Oliguria
25-30 cc per hour is acceptable
If less, small fluid boluses of 250-500 cc as
needed
Lasix is not necessary
Postpartum diuresis is common
Persistent oliguria almost never requires a
PA cath
Persistent Hypertension
BP may remain elevated for several days
Diastolic BP less than 100 do not require
treatment
By definition, preeclampsia resolves by 6
weeks
Disseminated Intravascular Coagulopathy
Rarely occurs without abruption
Low platelets is not DIC
Requires replacement blood products and
delivery
Anesthesia Issues
Continuous lumbar epidural is preferred if
platelets normal
Need adequate pre-hydration of 1000 cc
Level should always be advanced slowly to
avoid low BP
Avoid spinal with severe disease
SORT: KEY RECOMMENDATIONS FOR
PRACTICE
In women without end-organ damage, chronic hypertension
in pregnancy does not require treatment unless the patient's
blood pressure is persistently greater than 150 to 180/100 to
110 mm Hg. C
Calcium supplementation decreases the incidence of
hypertension and preeclampsia, respectively, among all
women (NNT = 11 and NNT = 20), women at high risk of
hypertensive disorders (NNT = 2 and NNT = 6), and women
with low calcium intake (NNT = 6 and NNT = 13). A
Low-dose aspirin (75 to 81 mg daily) has small to moderate
benefits for the prevention of preeclampsia (NNT = 72),
preterm delivery (NNT = 74), and fetal death (NNT = 243).
The benefit of aspirin is greatest (NNT = 19) for prevention
of preeclampsia in women at highest risk (previous severe
preeclampsia, diabetes, chronic hypertension, renal
disease, or autoimmune disease). B
For women with mild preeclampsia, delivery is generally
not indicated until 37 to 38 weeks of gestation and should
occur by 40 weeks. C
Magnesium sulfate is the treatment of choice for
women with preeclampsia to prevent eclamptic
seizures (NNT = 100) and placental abruption
(NNT = 100). A
Intravenous labetalol or hydralazine may be
used to treat severe hypertension in pregnancy
because neither agent has demonstrated
superior effectiveness. B
For managing severe preeclampsia between 24 and 34
weeks of gestation, the data are insufficient to determine
whether an "interventionist" approach (i.e., induction or
cesarean delivery 12 to 24 hours after corticosteroid
administration) is superior to expectant management.
Expectant management, with close monitoring of the
mother and fetus, reduces neonatal complications and
stay in the newborn intensive care nursery. B
Magnesium sulfate is more effective than diazepam
(Valium; NNT = 8) or phenytoin (Dilantin; NNT = 8) in
preventing recurrent eclamptic seizures. A
References
Lawrence L, Fontaine P. Hypertensive Disorders in Pregnancy.
American Family Physician. July 1, 2008.
Wagner L. Diagnosis and Management of Preeclampsia. American
Family Physician. December 15, 2004.
ACOG Committee on Obstetric Practice. ACOG practice bulletin.
Diagnosis and management of preeclampsia and eclampsia. No. 33,
January 2002. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2002;99:159-67.
Report of the National High Blood Pressure Education Program Working
Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol.
2000;183(1):S1-S22.
