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.