Most pregnancies are complicated by hypertension. This document will describe the pharmacotherapy of hypertension in pregnancy.

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2. OUTLINE
1. Objective
2. Introduction
3. Classification
4. Definition
5. Etiology
6. Risk factors
7. Pathophysiology
8. Clinical presentation
9. Diagnosis
10.Treatment (goal of therapy, pharmacologic and non-pharmacologic therapy)
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3. OBJECTIVE
 Define Hypertensive disorders in pregnancy
 Understand the:
pathophysiology,
sign & symptoms,
diagnosis and
management of Preeclampsia and eclampsia
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4. INTRODUCTION
Hypertension is the most common medical complication encountered
during pregnancy.
Complicating up to 10% of pregnancies.
Increased maternal and perinatal morbidity and mortality.
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5. CLASSIFICATION
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Hypertension in
Pregnancy
Pregnancy Induced
Hypertension
Gestational
Hypertension
Preeclampsia Eclampsia
Chronic
Hypertension

6. DEFINITION
During pregnancy, hypertension is defined as:
SBp ≥140 mmHg and/or DBp ≥90 mmHg on at least 2 occasions 4hrs apart.
Severe hypertension – SBp ≥160 mmHg and/or DBp ≥110 mmHg.
Chronic Hypertension:
Hypertension detected pre-pregnancy or before 20 weeks of gestation.
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7. CONT.
Gestational hypertension:
Hypertension without proteinuria or other signs/symptoms of preeclampsia.
Develops after 20 weeks of gestation.
 Up to 50 percent of these patients may ultimately develop signs and symptoms of
preeclampsia.
True gestational hypertension should resolve by 12 weeks postpartum.
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8. CONT.
Preeclampsia:
 Refers to the new onset of hypertension and proteinuria or significant end-
organ dysfunction with or without proteinuria.
After 20 weeks of gestation or postpartum.
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9. CONT.
Eclampsia:
Occurrence of a tonic-clonic seizure in a patient with preeclampsia in the
absence of other neurologic conditions that could account for the seizure.
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10. PREECLAMPSIA
Preeclampsia is a multisystem progressive disorder characterized by:
 The new onset of hypertension and proteinuria
or the new onset of hypertension plus significant end-organ dysfunction with
or without proteinuria,
 typically presenting after 20 weeks of gestation or Postpartum.
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11. CONT.
Superimposed Preeclampsia:
Preeclampsia occurs in patients with chronic hypertension.
Characterized by:
Acutely worsening hypertension
Resistance hypertension
New onset or sudden increase proteinuria
And/or new systemic/organ features in patients with CHTN
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12. ETIOLOGY
The etiology or exact cause of preeclampsia is not fully understood.
But it is thought to be caused by abnormalities in the development of
placenta.
The placenta not developing properly due to a problem with the blood vessels
supplying it.
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13. RISK FACTORS
Nulliparity
Multifetal gestation
Preeclampsia in previous pregnancy
Family history of preeclampsia
Age > 40 or < 18
Obesity
Chronic hypertension
Chronic kidney disease
Diabetes mellitus
Vascular disease
Autoimmune diseases
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14. PATHOPHYSIOLOGY
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The pathophysiology of
preeclampsia likely involves both
maternal and fetal/placental
factors.

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16. CLINICAL PRESENTATION
Sign/symptoms
Hypertension - All patients with
preeclampsia have hypertension
Persistent and/or severe headache
Visual abnormalities (photophobia,
blurred vision, or temporary blindness
Seizure
Altered mental status (confusion,
altered behavior [agitation])
RUQ, retrosternal, or epigastric
pain
New dyspnea, orthopnea
Oliguria
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17. CONT.
Potential laboratory findings
Proteinuria
Elevated creatinine
Thrombocytopenia
Elevated liver enzymes
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18. DIAGNOSIS
Preeclampsia is diagnosed with measured BP and presence of one or more
end organ dysfunction features.
Measured BP:
SBp ≥140 mmHg and/or DBp ≥90 mmHg (at least 2 occasions 4 hours apart).
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19. End organ dysfunction features:
Proteinuria ≥0.3 g in a 24-hour
urine
Platelet count <100,000/microL
Serum creatinine >1.1 mg/dL
Liver transaminases at least 2x the
UNL
Pulmonary edema
New-onset and persistent headache
Visual symptoms - blurred vision
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20. Severe Preeclampsia/ Preeclampsia with severe features
Diagnosis is with the presence of one or more of the following:
SBp ≥160 mmHg and/or DBp ≥110 mmHg
Symptoms of CNS
 New onset visual disturbance
 Severe headache
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21. Hepatic abnormality
 Liver transaminases at least 2x the UNL
 Severe persistent RUQ or epigastric pain
Kidney function impairment
 Serum creatinine >1.1 mg/dL
Platelet count <100,000/microL
Pulmonary edema
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22. TREATMENT
Goal of therapy
 To Control elevated BP.
To prevent severe HTN.
To prevent complications.
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23. The definitive treatment of preeclampsia is delivery to prevent development
of maternal or fetal complications from the disease.
Timing of delivery is based upon gestational age, the severity of
preeclampsia, and maternal and fetal condition.
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24. TIMING OF DELIVERY IN WOMEN WITH
PREECLAMPSIA
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27. Antihypertensive therapy is required for the treatment of severe hypertension
to prevent stroke, heart failure and other complications.
Antihypertensive therapy to control non severe hypertension does not alter
the course of preeclampsia and avoided in most patients.
Antihypertensive therapy may be suggested in non severe hypertension that
the elevated BP is persists after multiple measurements if delivery is likely to
be delayed for several days or weeks.
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28. MANAGEMENT 0F SEVERE HTN IN PREECLAMPSIA
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30. SEIZURE PROPHYLAXIS
Intrapartum and postpartum seizure prophylaxis is recommended for all
patients with preeclampsia with severe features.
MgSo4 is drug of choice
 Usually initiated at the onset of labor or induction, or prior to.
Loading dose 4 - 6 g of a 10% solution iv over 15 to 20 minutes followed by 1 –
2 g/hour as a continuous infusion
If Cr is 1.1 – 2.5 maintenance dose of 1g/hr. If >2.5 or magnesium toxicity no
maintenance dose.
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31. MgSo4 toxicity:
Loss of deep tendon reflexes
Respiratory paralysis
Altered cardiac conduction
Cardiac arrest
Antidote – calcium gluconate 15 to 30ml of 10% solution Iv over 2 to 5
minutes for severe cardiac toxicity. 10 ml of 10% solution for less severe.
Alternative calcium chloride 5 to 10 ml of 10% solution
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32. PREVENTION OF PREECLAMPSIA
Low dose aspirin prophylaxis:
For high risk patients.
Aspirin 81 mg daily is recommended. 100 – 150 mg can be suggested.
Initiate aspirin in the 12th or 13th wks. of gestation.
Continue until delivery
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33. ECLAMPSIA
Eclampsia refers to the occurrence of new onset generalized tonic-clonic
seizure in patients with preeclampsia.
It is the convulsive manifestation of preeclampsia and one of clinical
manifestation at the severe end of the preeclampsia spectrum.
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34. PATHOGENESIS OF SEIZURE
Risk factors for eclampsia are similar to those for preeclampsia.
The precise cause of eclamptic seizure is not clearly understood. Two models
have been proposed.
1. Hypertension causes a breakdown of the autoregulatory system of cerebral
circulation, leading to hypoperfusion, endothelial dysfunction, and vasogenic
and/or cytotoxic edema.
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35. 2. Hypertension causes activation of the autoregulatory system, leading to
constriction of cerebral vessels, hypoperfusion, localized ischemia,
endothelial dysfunction, and vasogenic and/or cytotoxic edema.
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36. CHARACTERISTICS OF ECLAMPTIC SEIZURE
Generally manifested by self limiting tonic-clonic seizure.
At onset an abrupt loss of consciousness.
The muscles of arms, legs, chest and back become stiff. After approximately
one minute the muscles begin to jerk for additional 1 to 2 minutes
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37. DIAGNOSIS
Clinical diagnosis based on new onset tonic-clonic seizure in the absence of
other causative conditions typically in patients with hypertensive disorders of
pregnancy.
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38. MANAGEMENT
If seizure is witnessed, maintaining air way patency and preventing aspiration
are the initial priorities.
The tonic-clonic phase usually resolves within 2 minutes. However, if the
patient is actively seizing for > 5 minutes:
Lorazepam 4mg IV At maximum rate of 2 mg/min., may repeat at 2 to 5 min if
seizure continues
If IV access has not been established Midazolam 10mg IM is alternative
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39. MgSo4 Prophylaxis:
MgSo4 can initiated after first episode of seizure for prevention of recurrent
seizures.
In patients with recurrent seizures on maintenance magnesium therapy, can
be treated with an additional bolus of 2 to 4 g Mgso4 administered IV over 5
minutes with frequent monitoring of magnesium toxicity.
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40. REFERENCES
1. UpToDate 21.6
2. MSD Manual Professional Version
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