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Hypertension in Pregnancy

Third year Clerkship


Ralph J. Kehl M.D.
Hypertension in Pregnancy
Introduction

Complicates 7-10% of pregnancies


70% Preeclampsia-eclampsia
30% Chronic hypertension
Eclampsia 0.05% incidence
20% of Maternal Deaths
Cause of 10% of Preterm birth
Etiology unknown
Hypertension in Pregnancy
Introduction

Young female 3 fold increased risk


African American 2 fold increased risk
Multifetal pregnancies
Twins
Triplets
Hypertension
Renal Disease
Collagen Vascular Disease
Hypertension in Pregnancy
Classification
Chronic hypertension

Preeclampsia-eclampsia

Preeclampsia Superimposed upon chronic


hypertension or Renal Disease

Gestational hypertension (only during pregnancy)

Transient hypertension (only after pregnancy)


Chronic Hypertension
Defined as hypertension
diagnosed
Before pregnancy
Before the 20th week of gestation
During pregnancy and not resolved
postpartum
Gestational Hypertension

Gestational Hypertension:
Systolic >140
Diastolic>90
No Proteinurea
25% Develop Pre-eclampsia
Gestational Hypertension
Diagnosis of gestational hypertension:
Detected for first time after midpregnancy
No proteinuria
Only until a more specific diagnosis can be assigned
postpartum

If preeclampsia does not develop and


BP returns to normal by 12 weeks postpartum, diagnosis is
transient hypertension.
BP remains high postpartum, diagnosis is chronic
hypertension.
Proteinurea develops Preeclampsia is diagnosed (25%
incidence)
Preeclampsia-Eclampsia

Occurs after 20th week (earlier with


trophoblastic disease)
Increased BP (gestational BP
elevation) with proteinuria
Edema is NOT part of this definition
Diagnosis of Preeclampsia-
Eclampsia
Gestational Hypertension:
Systolic >140
Diastolic>90
Proteinuria is defined as urinary
excretion
0.3 g protein or greater in a 24-hour
+2 or greater on urine dip specimen
Preeclampsia-Eclampsia
Blood pressure
Measure blood pressure in the sitting position, with the
cuff at the level of the heart. Inferior vena caval
compression by the gravid uterus while the patient is
supine can alter readings substantially, leading to an
underestimation of the blood pressure. Blood pressures
measured in the left lateral position similarly may yield
falsely low values if the blood pressure is measured in
the higher arm and the cuff is not maintained at heart
level.
Allow women to sit quietly for 5-10 minutes before
measuring the blood pressure.
Preeclampsia-Eclampsia
Blood pressure
Record Korotkoff sounds I (the first sound)
and V (the disappearance of sound) to denote
the systolic blood pressure (SPB) and DPB,
respectively. In about 5% of women, an
exaggerated gap exists between the fourth
(muffling) and fifth (disappearance) Korotkoff
sounds, with the fifth sound approaching zero.
In this setting, record both the fourth and fifth
sounds (eg, 120/80/40 with sound I = 120, sound
IV = 80, sound V = 40).
Classification of Preeclampsia-
Eclampsia
Mild Pre-eclampsia
Severe Pre-eclampsia
Classification of Preeclampsia-
Eclampsia
Criteria for Severe Preeclampsia (one or more)
Blood Pressure: >160 systolic, >110 diastolic
Proteinurea: >5gm in 24 hours, over 3+ urine dip
Oligurea: less than 400ml in 24 hours
CNS: Visual changes, headache, scotomata, mental
status change
Pulmonary Edema
Epigastric or RUQ Pain: Usually indicates liver
involvement
Classification of Preeclampsia-
Eclampsia
Criteria for Severe Preeclampsia (one or more)
Impaired Liver Function tests
Thrombocytopenia: >100,000
Intrauterine Growth Restriction: With or without
abnormal doppler assessment
Oligohydramnios
Classification of Preeclampsia
Superimposed Upon Chronic
Hypertension
Hypertension and no proteinuria < 20 weeks:
New-onset proteinuria after 20 weeks
Hypertension and proteinuria < 20 weeks:
Sudden increase in proteinuria
Sudden increase in BP in women whose
hypertension was well controlled
Thrombocytopenia (platelet count <100,000
cells/mm3)
Increase in ALT or AST to abnormal levels
Clinical Implications of
Preeclampsia
Preeclampsia ranges from mild to severe.
Progression may be slow or rapid hours
to days to weeks.

For clinical management, preeclampsia


should be over diagnosed to prevent
maternal and perinatal morbidity and
mortality primarily through timing of
delivery.
Pathophysiology
Of importance, and distinguishing
preeclampsia from chronic or
gestational hypertension, is that
preeclampsia is more than
hypertension; it is a systemic
syndrome, and several of its
nonhypertensive complications
can be life-threatening when blood
pressure elevations are quite mild.
Pathophysiology
The maternal disease is characterized by
Vasospasm
Activation of the coagulation system
Perturbations in humoral and autacoid systems
related to volume and blood pressure control
Oxidative stress and inflammatory-like responses
Pathologic changes that are ischemic in nature
Pathophysiology
Heart: Generally unaffected; cardiac
decompensation in the presence of preexisting
heart disease.
Kidney: Renal lesions (glomerular
endotheliosis); GFR and renal blood flow
decrease; hyperuricemia; proteinuria may appear
late in clinical course; hypocalciuria; alterations
in calcium regulatory hormones; impaired sodium
excretion; suppression of renin angiotensin
system.
Pathophysiology
Coagulation System: Thrombocytopenia;
low antithrombin III; higher fibronectin.
Liver: HELLP syndrome (hemolysis, elevated ALT
and AST, and low platelet count).
CNS: Eclampsia is the convulsive phase of
preeclampsia. Symptoms may include headache
and visual disturbances, including blurred vision,
scotomata, and, rarely, cortical blindness.
Symptoms of Preeclampsia
Visual disturbances typical of preeclampsia are
scintillations and scotomata. These disturbances
are presumed to be due to cerebral vasospasm.
Headache is of new onset and may be described as
frontal, throbbing, or similar to a migraine
headache. However, no classic headache of
preeclampsia exists.
Epigastric pain is due to hepatic swelling and
inflammation, with stretch of the liver capsule.
Pain may be of sudden onset, it may be constant,
and it may be moderate-to-severe in intensity.
Symptoms of preeclampsia
While mild lower extremity edema is common in
normal pregnancy, rapidly increasing or
nondependent edema may be a signal of
developing preeclampsia. However, this signal
theory remains controversial and recently has been
removed from most criteria for the diagnosis of
preeclampsia.
Rapid weight gain is a result of edema due to
capillary leak as well as renal sodium and fluid
retention.
Physical Findings in Preeclampsia

Blood Pressure
Proteinurea
Retinal vasospasm or Retinal edema
Right upper quadrant (RUQ) abdominal
tenderness stems from liver swelling and
capsular stretch
Physical findings in Preeclampsia
Brisk, or hyperactive, reflexes are common
during pregnancy, but clonus is a sign of
neuromuscular irritability that raises concern.
Among pregnant women, 30% have some
lower extremity edema as part of their normal
pregnancy. However, a sudden change in
dependent edema, edema in nondependent areas
such as the face and hands, or rapid weight gain
suggests a pathologic process and warrants
further evaluation
Differential Diagnosis
Documentation of HBP before conception
or before gestational week 20 favors a
diagnosis of chronic hypertension
(essential or secondary).

HBP presenting at midpregnancy (weeks


20 to 28) may be due to early
preeclampsia, transient hypertension, or
unrecognized chronic hypertension.
Differential Diagnosis
Thrombotic Thrombocytopenic
Purpura (TTP)
Hemolytic Uremic Syndrome (HUS)
Acute Fatty Liver of Pregnancy
(AFLP)
Laboratory Tests
High-risk patients presenting with normal
BP:
Hematocrit
Hemoglobin
Serum uric acid
If 1+ protein by routine urinalysis (clean catch)
present obtain a timed collection for protein and
creatinine
Accurate dating and assessment of fetal growth
Baseline sonogram at 25 to 28 weeks
Laboratory Tests
Patients presenting with hypertension
before gestation week 20:

Same tests as described for high-risk


patients presenting with normal BP

Early baseline sonography for dating


and fetal size
Laboratory Tests
Patients presenting with hypertension
after midpregnancy:
Quantification of protein excretion
Hemoglobin and hematocrit and platelet
count
Serum creatinine, uric acid, and
transaminase level
Serum albumin, LDH, blood smear, and
coagulation profile
Preeclampsia: Treatment
Goal is to prevent eclampsia and other
severe complications.
Attempts to treat preeclampsia by
natriuresis or by lowering BP may
exacerbate pathologic changes.
Palliate maternal condition to allow fetal
maturation and cervical ripening.
Preeclampsia: Treatment
Maternal Evaluation
Goals:
Early recognition of preeclampsia
Observe progression, both to prevent maternal
complications and protect well-being of fetus.
Early signs:
BP rises in late second and early third
trimesters.
Initial appearance of proteinuria is important.
Preeclampsia: Treatment
Maternal Evaluation (cont.)
Often, hospitalization recommended with new-
onset preeclampsia to assess maternal and fetal
conditions.
Hospitalization for duration of pregnancy
indicated for preterm onset of severe
gestational hypertension or preeclampsia.
Ambulatory management at home or at day-
care unit may be considered with mild
gestational hypertension or preeclampsia
remote from term
Preeclampsia
Preeclampsia
Antepartum Management of Preeclampsia
Little to suggest therapy alters the underlying
pathophysiology of preeclampsia.

Restricted activity may be reasonable.


Sodium restriction and diuretic therapy appear
to have no positive effect.
Preeclampsia
Indications for Delivery in Preeclampsia*
Maternal
Gestational age 38 weeks
Platelet count < 100,000 cells/mm3
Progressive deterioration in liver and renal function
Suspected abruptio placentae
Persistent severe headaches, visual changes, nausea,
epigastric pain, or vomiting
*Delivery should be based on maternal and fetal
conditions as well as gestational age.
Preeclampsia
Indications for Delivery in Preeclampsia* -
Fetal
Severe fetal growth restriction
Nonreassuring fetal testing results
Oligohydramnios

*Delivery should be based on maternal and


fetal conditions as well as gestational age.
Preeclampsia
The cure for preeclampsia is delivery
The cure is always beneficial for the
mother, although c-section might be needed
The cure may be deleterious for the fetus
Preeclampsia
Route of Delivery
Vaginal delivery is preferable.
Aggressive labor induction (within 24 hours).
Neuraxial (epidural, spinal, and combined
spinal-epidural) techniques offer advantages.
Hydralazine, nitroglycerin, or labetalol may be
used as pretreatment to reduce significant
hypertension during delivery.
Preeclampsia
Anticonvulsive Therapy
Indicated to prevent recurrent
convulsions in women with eclampsia or
to prevent convulsions in women with
preeclampsia.
Parenteral magnesium sulfate reduces
the frequency of eclampsia and maternal
death. (Caution in renal failure.)
Treatment of Acute Severe
Hypertension in Pregnancy
SBP > 160 mm Hg and/or DBP > 105 mm Hg
Parenteral hydralazine is most commonly
used.
Parenteral labetalol is second-line drug (avoid
in women with asthma and CHF.)
Oral nifedipine used with caution. (Short-
acting nifedipine is not approved by FDA for
managing hypertension.)
Sodium nitroprusside may be used in rare
cases.
Postpartum Counseling and
Followup
Counseling for Future Pregnancies

Risk of recurrent preeclampsia increases with


Preeclampsia before 30 weeks (40%)
Multiparas as compared with nulliparas or new
father
Risk of recurrent preeclampsia may be
substantially greater in African Americans.
Remote Prognosis
Preeclampsia-Eclampsia
The more certain the diagnosis of preeclampsia,
the lower the prevalence of remote
cardiovascular disorders.
Preeclampsia-eclampsia in subsequent
pregnancies helps define future risk.
Gestational hypertension in any pregnancy
increases remote cardiovascular risk.