Hypertension

in
Pregnancy
Anady V. Eleccion
Clinical Clerk
WVSU-Medical Center
 CHARACTERISTICS OF
WOMEN MOST LIKELY TO
DEVELOP
GESTATIONAL HPN
 Hypertension
• Appropriately take blood pressure
• >140 mm Hg systolic or 90 mm Hg diastolic
 Basic Classification of Hypertension
1. Gestational Hypertension
2. Preeclampsia/Eclampsia Syndrome
3. Chronic Hypertension (of any etiology)
4. Preeclampsia superimposed on chronic
hypertension
 Gestational Hypertension
• New-onset of BP elevation after 20 weeks AOG
without proteinuria.
• BP returns to normal by 12 weeks postpartum
• May have other signs or symptoms of preeclampsia

Transient hypertension
 PREECLAMPSIA
• New onset hypertension + new onset Proteinuria
• 24-hour Urinary excretion >300mg
• Urine Protein:Creatinine Ratio ≥ 0.3
• Persistent 30mg/dL protein: dipstick 1+
• BP elevation occurs after 20 weeks AOG and most
often near term
 PREECLAMPSIA
• In the absence of proteinuria, preeclampsia is diagnosed as
hypertension with the following:
Thrombocytopenia Platelet count: <100,000/uL
Renal Insufficiency S. Creatinine >1.1 mg/dL, or doubling of baseline
Liver Involvement Serum Transaminase levels (AST/ALT) twice normal
Cerebral Symptoms Headache, Visual Disturbances, convulsions
Pulmonary Edema
 PREECLAMPSIA
!Proteinuria is no longer and important criterion or is
not absolutely required for diagnosis of preeclampsia
 Severe Features of Preeclampsia
–BP ≥160/110 mmHg on 2 occasions at least 4 hours apart
while the patient is on bedrest
–Thrombocytopenia- platelet count <100,000/uL
–Impaired liver function- abnormally elevated liver enzymes
to 2x normal), severe right upper quadrant pain
–Progressive renal insufficiency- s. crea>1.1mg/dl or doubling
–Pulmonary edema
–New onset of cerebral/visual disturbances
 Symptoms of Preeclampsia with
Severe Features
–Headaches or visual disturbances (such as scotomas)-
premonitory symptoms of preeclampsia
–Epigastric or right upper quadrant abdominal pain-
frequently accompanies hepatocellular necrosis, ischemia,
and edema that stretches the Glisson capsule
 Mild preeclampsia is no longer used.
Diagnosis is either preeclampsia with severe
features or preeclampsia without severe features
(usually the latter falls under Gestational HPN)
 ECLAMPSIA
–Convulsive phase of the disorder
–New-onset grand mal seizures in a woman with preeclampsia
–It can occur before, during and after labor
–Often preceded by premonitory events, but it can occur in the
absence of warning S/Sx
–Ominous signs: severe headache, epigastric distress,
hyperreflexia
–If seen in a patient, give MgSO4
 CHRONIC HYPERTENSION
–High BP before pregnancy or detected before 20
weeks or both
–Failure of BP to normalize postpartum
–If patient has taken anti-hypertensives before pregnancy,
you can surmise that the patient has chronic HPN
–Usual causes: chronic kidney disease (most common),
primary aldosteronism or phaeochromocytoma
 Categories of Chronic Hypertension Based on
Blood Pressure Levels

Mild to Severe
Moderate
Systolic 140-159 ≥160

Diastolic 90-109 ≥110

CHRONIC HPN WITH SUPERIMPOSED PRE
–Patients with chronic Hypertension who develop
preeclampsia
–Usually earlier and more severe than pure
preeclampsia
–Associated with fetal growth restriction
 CHRONIC HPN WITH SUPERIMPOSED PRE
–Includes patents with Hypertension in early gestation
with the following findings:
–Proteinuria develops after 20 weeks
–Proteinuria present before 20 weeks with:
– Sudden exacerbation of Hypertension
– RUQ pain and severe headache, increase in
liver enzymes
– Pulmonary congestion/edema
– Renal insufficiency
– Sudden, substantial and sustained increase in protein excretion
 ETIOLOGY OF
PREECLAMPSIA
 ETIOLOGY OF PREECLAMPSIA
1. Abnormal trophoblastic invasion
– Placental implantation with abnormal trophoblastic invasion of uterine
vessels
2. Immunologic Factors
– Maladaptive tolerance between maternal, paternal (placental) and fetal
tissues
3. Endothelial Cell Activation
– Maternal maladaptation to cardiovascular or inflammatory changes of
normal pregnancy
4. Genetic Factors
– Inherited predisposing genes as well as epigenetic influences
 ABNORMAL TROPHOBLASTIC INVASION
• Defective remodeling of spiral arteries
Normal Placental implantation In Preeclampsia
Proliferation of extravillous Defective implantation
trophoblasts from the anchoring characterized by incomplete
villous invasion of spiral arteriolar wall by
extravillous trophoblasts
Trophoblasts invade the deciduas This results in a small caliber
and the walls of the spiral arteriole vessel with high resistance to flow
to replace the endothelium and
muscular wall to create a dilated
low resistance vessel
 IMMUNOLOGICAL FACTORS
• Loss of tolerance or dysregulation of paternally derived placental and
fetal antigens
• Immune maladaptation – extravillous trophoblasts early in pregnancy
expressed reduced amounts of immunosuppressive nonclassic HLA G
→ defective placental vascularization
• Women with 1597ΔC allele are predisposed to develop preeclampsia
• Possibly shared susceptibility genes with diabetes and
chronic hypertension
histological changes at the maternal-placental interface are
suggestive of acute graft rejection
 ENDOTHELIAL CELL ACTIVATION
• continuation of defective placentation that leads to inflammatory
and ischemic changes that provokes endothelial cell injury
• Results from extreme activated state of leukocytes in the
maternal circulation
• Oxidative stress generates toxic radicals that injure endothelial
cells
• The toxic radicals from oxidative stress can spread to the
maternal circulation
 GENETIC FACTORS
• Multifactorial, polygenetic
• Predisposition is likely the result of interactions of
literally hundreds of inherited genes – both paternal
and maternal that controls metabolic and enzymatic
functions on every organ systems
PATHOGENESIS AND
PATHOPHYSIOLOGY
SCREENING TESTS
SCREENING TESTS
 SCREENING TESTS
• Mean Arterial Pressure (MAP)
-defined as 1/3 systolic BP plus 2/3 the diastolic BP
-MAP value in the second trimester of >90mmHg and a MAP value in
the 3rd trimester of >105mmHg has resulted in an increase incidence
of preeclampsia
• Supine pressor test/ Roll over Test
-done between 28-32 weeks (increased plasma volume)
-an increase of at least 20mmHg in diastolic pressure constitutes a
Positive Roll over Test
-positive predictive value is only 33%
Combination of MAP and roll over test
-prediction rate increased to 78%
MANAGEMENT
 Basic management objectives:
• Termination of pregnancy with the least trauma to
mother and fetus
• Consider the safety of the mother first then
delivery of the baby
• Birth of an infant who subsequently thrives
• Complete restoration of health to the mother
 MATERNAL EVALUATION
A. Laboratory Exam
a. CBC with Platelet
b. S. Creatinine
c. Lactic dehydrogenase
d. Liver enzymes
e. 24-hour urine protein or protein/creatinine ratio
B. Assess for symptoms of severe preeclampsia
 FETAL EVALUATION
• Sonographic Estimated Fetal Weight
• Non stress test
• Biophysical profile
• Doppler velocimetry
• Fetal weight – to check for presence of IUGR
• Amniotic Fluid – to check for oligohydramnios
MANAGEMENT OF SEVERE PREECLAMPSIA
• Aggressive • Expectant
- High neonatal mortality - Fetal death
and morbidity due to - Asphyxial damage in
prematurity utero
- Prolonged NICU stay - Increased maternal
- Long term disability morbidity
 PHARMACOLOGY
The following drugs are given to immediately lower BP:
• Labetalol – first line because it has decreased S/E of
tachycardia; not available locally; Contraindicated in asthma,
heart disease
• Hydralazine – aka apresoline; available in the Philippines;
maximum dose: 20-25 mg
• Nifedipine – if both drugs are not available
Rule of thumb: There should only be GRADUAL reduction of BP, never
abrupt to preserve adequate fetal circulation.
 PHARMACOLOGY
Antihypertensive medications for urgent BP control during
pregnancy
• Labetalol – 10-20mg IV then 20-80mg q20-30min to
a maximum dose of 300mg
• Hydralazine – 5mg IV or IM then 5-10mg IV q15-20
min or constant infusion of .5-10mg/h
• Nifedipine – 10-20mg orally, repeat in 30 mins if
needed then 10-20mg q 2-6H
 PHARMACOLOGY
Maintenance Medications

Do NOT give methyldopa for the purpose of immediate

reduction of BP. It should only be for maintenance.
 OBJECTIVES FOR TREATMENT

A. Prevent complications such as:

• Congestive heart failure
• Myocardial ischemia
• Renal injury or failure
• Ischemic or hemorrhagic stroke
 OBJECTIVES FOR TREATMENT
B. Prevent and control Eclampsia

Premonitory S/Sx of eclampsia

• Presence of headache, visual disturbances and scotomata
• Epigastric or RUQ pain
• Hyperreflexia
 Magnesium Sulfate (MgSO4) Prophylaxis
Can be given as an continuous IV infusion or intermittent IM
injections
• Should be given up to 24Hours after delivery
• Monitor urine output, reflexes and respiration
• Loading dose: 4g IV diluted in 100 ml IVF given for 15 min
• Continuous infusion: 2g/hr
• 10g IM (5g per buttock)
• Maintenance: 5g every 4h or 1-2g IV
Do NOT stop MgSO4 after delivery because eclampsia may still occur!
 DELIVERY
Termination of the pregnancy is the only cure for
preeclampsia
• AOG – preterm, term
• Presence or absence of severe features
• Presence of eclampsia, HELLP syndrome
• Presence of maternal or fetal compromise –
placental abruption, IUGR
If in the presence of eclampsia, you should DELIVER the baby
after the patient was stabilized.
Maternal Indications for Delivery in Women
With Severe Preeclampsia
• Oliguria (<500ml/24hr)
• HELLP syndrome
• Platelet counts <100,000/mm3
• Deterioration of renal function
(serum creatinine >/=1.5 mg/dl)
• Suspected abruptio placenta, progressive labor,
and/or rupture of membranes

Sibai et al AmJOG 2007

Fetal Indications For Delivery In Women With
Severe Preeclampsia
• Repetitive late or severe variable deceleration
• Biophysical profile </=4 on 2 occasions at 6 hours
apart
• IUGR (Estimated fetal weight <5th percentile)
• Umbilical artery Doppler with reverse end
diastolic flow
• Severe oligohydramnios

Sibai et al AmJOG 2007

 Mode of Delivery

• Vaginal delivery
- Inducible cervix
- No fetal distress
• Cesarean section
 GLUCOCORTICOIDS FOR LUNG MATURATION

• Steroids to improve fetal lung maturity in preterm infants

• Decrease incidents of respiratory distress
• Improve fetal survival
 HOSPITALIZATION

Recommendation for immediate hospitalization

(gestational hypertension and preeclampsia without
severe features)
• New S/Sx of severe preeclampsia
• Evidence of fetal growth restriction
• Elevation of liver enzymes
• Thrombocytopenia
COMPLICATIONS
 ECLAMPSIA
Maternal complications
- Cerebrovascular accident – hemorrhage/infarction
- Abruption placenta and DIC
- Aspiration pneumonia
- Pulmonary edema
- Renal failure
- C-P arrest
 ECLAMPSIA
Fetal Complications
- Fetal death
- Prematurity- in cases of preterm pregnancies
- Fetal complications may be due to placental
insufficiency or abruption placenta
 PREVENTION OF
HYPERTENSION IN
PREGNANCY
 PREVENTION OF HPN IN PREGNANCY
• Low dose aspirin – recommended in reducing the risk
of preeclampsia in patients who are moderate to high
risk
• Dose – 60-80mg/day
• Calcium supplementation – may prevent preeclampsia
in patients with low dietary intake of calcium
• Dose – 1.5-2g elemental calcium/day
• Vit C, Vit E, selenium, Vit A, Fish oil – not effective
 PREVENTION OF HPN IN PREGNANCY
•Early and frequent prenatal check-ups and
good nutrition is still the most effective
means of decreasing the incidence and
severity of HPN in pregnancy