Hypertension in Pregnancy

Dr. Sahala Panggabean SpPD-KGH

Classification of Hypertensive Disorders in Pregnancy

Preeclampsia,eclampsia Chronic hypertension Chronic hypertension with superimposed preeclampsia Transient hypertension/gestational hypertension

Incidence

12 22% pregnancies affected by hypertensive diseases during pregnancy 5% - chronic hypertension in pregnancy. 5-8% - preeclampsia, 10% of whom develop eclampsia Hypertensive diseases - responsible for 17.6% of maternal deaths in the US. In 2003, there were 495 pregnancy-associated deaths, 68 (14%) due to hypertension.

Preeclampsia

Preeclmapsia is a syndrome with both maternal and fetal manifestation. Hypertension develops after 20 weeks, with normal blood presure in the first half of pregnancy Sudden appearance of edema, especially in hands and face. Rapid weight gain

Pathophysiology

Maternal manifestations of preeclampsia

Renal:

LABORATORY ABNORMALITIES IN PREECLAMPSIA

Creatinine Uric acid Urinary protein Urinary calcium Increased Increased (>5.5 mg/dL) >300 mg/d <150 mg/d Increased (>38%) Decreased Increased Increased Decreased

Heme:
Hematocrit Platelets

Liver function tests:

Aspartate aminotransferase Alanine aminotransferase Albumin

HELLP Syndrome

Occurs in up to 20% of women with severe preeclampsia, more commonly in white women and multigravid women H-Hemolysis EL-Elevated liver function tests

AST> 72 IU; LDH > 600 IU

LP-Low platelets

TREATMENT OF PREECLAMPSIA

Close monitoring of maternal and fetal conditions Hospitalization in most cases Lower blood pressure for maternal safety Seizure prophylaxis with magnesium sulfate Timely delivery

ANTIHYPERTENSIVE THERAPY IN PREECLAMPSIA

Imminent delivery
Hydralazine (IV,IM)
Labetalol (IV) Calcium channel blockers Diazoxide (IV)

Delivery postpone
Methyldopa
Labetalol, other B blocker Calcium channel blockers Hydralazine blockers Clonidine

ANTIHYPERTENSIVE THERAPY IN PREECLAMPSIA

Decreased uteroplacental blood flow and placental ischemia are central to the pathogenesis of preeclampsia. Lowering blood pressure does not prevent or cure preeclampsia and does not benefit the fetus unless delivery can be safely postponed. Lowering blood pressure is appropriate for maternal safety: maintain blood pressure at 130150/85100 mm Hg

Eclampsia

Seizure activity unrelated to other central nervous system disorders (epilepsy, meningitis, mass lesion, intracranial hemorrhage), with or without resultant coma Associated with ~50,000 maternal deaths (10% of total) worldwide each year

Eclampsia

Typical seizure lasts 75-90 seconds with 2 phases: 15-30 seconds of facial twitching progressing to generalized rigidity, then about 60 seconds of tonic-clonic activity Segmental constriction and dilatation of cortical arterioles leads to decreased perfusion and cerebral edema Reduced breathing, fetal bradycardia occur

Eclampsia - Treatment

1. Protect airway 2. Position in left lateral decubitus (prevent aspiration, aid uterine perfusion) 3. Prevent injury 4. Oxygen 5. Magnesium sulfate (after seizure has terminated)

Magnesium Sulfate

Magnesium as the primary agent in the treatment of eclampsia and suggested its use for the prevention of eclampsia Raises the seizure threshold Has a direct vascular relaxant effect, but is NOT an antihypertensive agent

Magnesium Sulfate

Given IV (most commonly) or IM 6 gram load followed by 2 grams per hour Therapeutic range 6-8 mg/dL Supratherapeutic levels lead to CNS depression, cardiac arrythmias, possible cardiac arrest (Mg level 15-20 mg/dL) Antidote - Calcium gluconate

Magnesium Sulfate

Continued until about 24 hours post-partum, depending on the patients condition While some argue the use of magnesium in mild preeclampsia, most authorities advocate its use in all women with preeclampsia

Chronic Hypertension

Women are older, more likely to be multiparous Hypertension: present before 20 wk, or documented previous pregnancy Present before 20th week of pregnancy or persists longer then 12 weeks postpartum. Risk of superimposed preeclampsia of 1530%

Renal:

LABORATORY ABNORMALITIES IN CHRONIC HYPERTENSION

Creatinine Uric acid Urinary protein Urinary calcium Normal Normal <300 mg/d >200 mg/d Normal Normal Normal Normal Normal

Heme:
Hematocrit Platelets

Liver function tests:

Aspartate aminotransferase Alanine aminotransferase Albumin

Treatment Chronic Hypertension(1)

The overall treatment goals of chronic hypertension in pregnancy are to ensure a successful full-term delivery of a healthy infant without jeopardizing maternal wellbeing The level of blood pressure control that is tolerated in pregnancy may be higher, because the risk of exposure of the fetus to additional antihypertensive agents might outweigh the benefits to the mother (for the duration of pregnancy) of having a normal blood pressure

Treatment Chronic Hypertension(2)

Methyldopa is considered to be one of the safest drugs during pregnancy B blockers and calcium channel blockers are acceptable second- and third-line agents. Diuretics can be used at low doses, particularly in salt-sensitive hypertensive patients on chronic diuretic therapy

Preeclampsia superimposed upon Chronic Hypertension

Preexisting Hypertension with the following additional signs/symptoms;

New onset proteinuria Hypertension and proteinuria beginning prior to 20 weeks of gestation. A sudden increase in blood pressure. Thrombocytopenia. Elevated aminotransferases.

Gestational Hypertension/Transient Hypertension

Mild hypertension without proteinuria or other signs of preeclampsia. Develops in late pregnancy. Resolves by 12 weeks postpartum. Can progress into preeclampsia. Usually when gestational hypertension develops before 30 weeks gestation. The hypertension resolves with delivery, often recurs in subsequent pregnancies, and predicts essential hypertension later in life.