Antihipertensivos en el embarazo

1. Dra. Blanca N. Rodríguez Grijalva R1 Ginecología y
obstetricía
Hospital del Niño y la Mujer - HGO
ANTHIPERTENSIVOS EN EL EMBARAZO

2. METILDOPA
 Ha demostrado beneficio a largo plazo en el
feto
 Es solo un antihipertensivo medio y tiene un
inicio de accion lento (3 a 6 horas)
 Muchas mujeres no logran el efecto deseado
con esto medicamento solo.
Final report of study on hypertension during pregnancy: the effects of specific treatment on the growth and
development of the children.
Cockburn J, Moar VA, Ounsted M, Redman CW
Lancet. 1982;1(8273):647.

3. BETABLOQUEADORES
 Labetalol (accion beta y alfa) (1-2 hrs)
 Pindolol y Metoprolol aceptados
 Propanolol (reporta APP, apnea neonatal,
RCIU bradicardia e hipoglucemia).
 Chronic hypertension in pregnancy.
Sibai BM, Obstet Gynecol. 2002;100(2):369.
Atenolol and fetal growth in pregnancies complicated by hypertension. Lydakis C, Lip GY, Beevers M,
Beevers DG Am J Hypertens. 1999;12(6):541.

4. BLOQUEADORES DE LOS CANALES DE CALCIO
 Nifedipino (30-60mg c/24hrs), no se utiliza
por que causa un descenso rápido en la TA
 Amlodipino, verapamilo y diltiazem aun no
hay reportes significativos
Oral beta-blockers for mild to moderate hypertension during pregnancy. Magee LA, Duley L Cochrane
Database Syst Rev. 2003;
Nifedipine in pregnancy. Smith P, Anthony J, Johanson R BJOG. 2000;107(3):299. McMaster University,
Hamilton, Ontario, Canada.
Exposure to amlodipine in the first trimester of pregnancy and during breastfeeding.
Ahn HK, Nava-Ocampo AA, Han JY, Choi JS, Chung JH, Yang JH, Koong MK, Park CT Hypertens
Pregnancy. 2007;26(2):179.

5. HIDRALAZINA
 Tiene un efecto hipotensor poco predecible
 Causa taquicardia refleja, retención de
líquidos.
American College of Obstetricians and Gynecologists. Diagnosis and management of preeclampsia
and eclampsia. ACOG practice bulletin #33. American College of Obstetricians and
Gynecologists, Washington, DC 2002. Obstet Gynecol 2002.
Committee Opinion no. 514: emergent therapy for acute-onset, severe hypertension with
preeclampsia or eclampsia.
Committee on Obstetric Practice
Obstet Gynecol. 2011;118(6):1465.

6. DIURETICOS TIAZIDICOS
 Controversiales
 Sin embargo no son utilizados hasta que hay
EAP
Overview of randomised trials of diuretics in pregnancy. Collins R, Yusuf S, Peto R Br Med J (Clin Res Ed).
1985;290(6461):17.
ACOG Practice Bulletin No. 125: Chronic hypertension in pregnancy. American College of Obstetricians and
Gynecologists Obstet Gynecol. 2012;119(2 Pt 1):396.

7. INDICACIONES DE TERAPIA ANTIHIPERTENSIVA
 No tratamiento para TA < 150/100
 Bajar la TA no afecta el curso de la
preeclampsia, debido a que la causaprincipal es
una anormalidad en la vascularidad placentaria
que resulta en una hipoperfusión placentaria ,
que lleva a una disfunción multiorganica.
 No iniciar terapia hasta TA >160/100mmHg
Antihypertensive drug therapy for mild to moderate hypertension during pregnancy.
Abalos E, Duley L, Steyn DW, Henderson-Smart DJ Cochrane Database Syst
Rev. 2007

8. ELECCIÓN DEL MEDICAMENTO

9. Fase aguda
LABETALOL HIDRALAZINA
 Begin with 20 mg intravenously
over 2 minutes followed at 10-
minute intervals by doses of 20 to
80 mg up to a maximum total
cumulative dose of 300 mg. As an
example, give 20 mg, then 40 mg,
then 80 mg, then 80 mg, then 80
mg. A constant infusion of 1 to
2 mg/min can be used instead of
intermittent therapy. The fall in
blood pressure begins within 5 to
10 minutes and lasts from 3 to 6
hours. Continuous cardiac
monitoring is not necessary
routinely, but should be used in
patients with relevant co-morbidities
(eg, coronary artery
COMMITTEE OPINION NO. 514: EMERGENT THERAPY FOR ACUTE-ONSET, SEVERE HYPERTENSION WITH PREECLAMPSIA OR
ECLAMPSIA. COMMITTEE ON OBSTETRIC PRACTICESO OBSTET GYNECOL. 2011;118(6):1465.
disease).
 Begin with 5 mg intravenously
over 1 to 2 minutes; if the
blood pressure goal is not
achieved within 20 minutes,
give a 5 to 10 mg bolus
depending upon the initial
response. The maximum
bolus dose is 20 mg. If a total
dose of 30 mg does not
achieve optimal blood
pressure control, another
agent should be used. The fall
in blood pressure begins
within 10 to 30 minutes and
lasts from 2 to 4 hours.

10. BLOQUEADORES DE LOS CANALES DE CALCIO
 Con experiencia limitada
 No se utiliza como primera linea por el resigo
de una hipotensión precipitada, asociada a
seriasmorbilidades cardiovasculares.
Nicardipine for the treatment of severe hypertension in pregnancy: a review of the literature. Nij Bijvank
SW, Duvekot JJ Obstet Gynecol Surv. 2010;65(5):341.

11. NITROGLICERINA
 Tratamiento para hipertensiona sociada a
edema pulmonar en infusion IV de 5mcg/min
e incrementar cada 3 a 5 minutos hasta un
máximo de 100 mcg/min
ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the
Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology
(ESC).
European Society of Gynecology (ESG), Association for European Paediatric Cardiology (AEPC), German
Society for Gender Medicine (DGesGM), Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, Cifkova
R, Ferreira R, Foidart JM, Gibbs JS, Gohlke-Baerwolf C, Gorenek B, Iung B, Kirby M, Maas AH, Morais
J, Nihoyannopoulos P, Pieper PG, Presbitero P, Roos-Hesselink JW, Schaufelberger M, Seeland U,
Torracca L, ESC Committee for Practice Guidelines Eur Heart J. 2011;32(24):3147

12. TERAPIA A LARGO PLAZO
MANAGEMENT OF HYPERTENSIVE DISORDERS DURING PREGNANCY: SUMMARY OF NICE GUIDANCE.
VISINTIN C, MUGGLESTONE MA, ALMERIE MQ, NHERERA LM, JAMES D, WALKINSHAW S, GUIDELINE
DEVELOPMENT GROUP BMJ. 2010;341:C2207
OBJETIVOS
COMPLICACIONES DE
ANTIHIPERTENSIVOS
 Sistólica <130-150
 Diastólica <80-100
 No reducir ala TA mas del
25% dentor de dos horas,
alcanzando los objetivos
 Isquemia al miocardio
 inferto

13. GESTATIONAL HYPERTENSION
 Total blood and plasma volumes are
significantly lower in women with preeclampsia
(mean 2660 mL/m2 and
1790 mL/m2, respectively) than in women with
gestational hypertension (3139 mL/m2 and
2132 mL/m2, respectively)
 La preeclampsia se desarrolla en un 15-25%
Comparison of total blood volume in normal, preeclamptic, and nonproteinuric gestational hypertensive
pregnancy by simultaneous measurement of red blood cell and plasma volumes. Silver HM, Seebeck
M, Carlson R Am J Obstet Gynecol. 1998;179(1):87

14. MILD GESTATIONAL HYPERTENSION
 ASA
 Reposo
 Patient education and counseling
 Fetal assessment
 No antihypertensive therapy
 No antenatal glucocorticoids
 No se administra sulfato de magnesio a menos que
se demuestre proteinuria
Does admission to hospital for bed rest prevent disease progression or improve fetal outcome in pregnancy complicated by
non-proteinuric hypertension? Crowther CA, Bouwmeester AM, Ashurst HM Br J Obstet Gynaecol. 1992;99(1):13
Placental morphometrical and histopathology changes in the different clinical presentations of hypertensive syndromes in
pregnancy. Corrêa RR, Gilio DB, Cavellani CL, Paschoini MC, Oliveira FA, Peres LC, Reis MA, Teixeira VP, Castro EC
Arch Gynecol Obstet. 2008;277(3):201.

15. SEVERE GESTATIONAL HYPERTENSION

16. CHRONIC (PREEXISTENT) HYPERTENSION
 MILD
 Superimposed preeclampsia — 10 to 25
percent (versus 3 to 5 percent in the general
obstetrical population)
 Abruptio placentae — 0.7 to 1.5 percent (versus
≤1 percent in the general obstetrical population)
 Fetal growth restriction — 8 to 16 percent
(versus 10 percent in the general obstetrical
population)
Chronic hypertension in pregnancy Sibai BM Obstet Gynecol. 2002;100(2):369.

17.  SEVERE
 Superimposed preeclampsia — 50 percent
 Abruptio placenta — 5 to 10 percent
 Preterm birth — 62 to 70 percent
 Fetal growth restriction — 31 to 40 percent

18. LABORATORIOS
 Urinalysis
 Urine culture
 Creatinine
 Glucose
 Electrolytes
 Quantitative analysis of urine protein

19. COMPLICATED AND SECONDARY
HYPERTENSION
 Secondary, rather than essential,
hypertension
 Target-organ damage (eg, left ventricular
hypertrophy, microalbuminuria, retinopathy)
 Dyslipidemia
 Maternal age over 40 years old
 History of stroke
 Previous perinatal loss
 Diabetes

20. SEVERE HYPERTENSION
 The United States National High Blood Pressure
Education Program (NHBPEP) Working Group on High
Blood Pressure in Pregnancy states that anti-hypertensive
therapy is indicated for women with chronic
hypertension and blood pressures exceeding 150 to 160
mmHg systolic or 100 to 110 mmHg diastolic or the
presence of target organ damage (eg, renal insufficiency,
left ventricular hypertrophy) [1]. They also recommend
treatment of “dangerously high” blood pressure in women
with preeclampsia; they do not define a specific level, but
suggest a diastolic pressure greater than 100 to 110
mmHg be considered depending on patient-specific risk
factors, such as baseline blood pressure.

21.  The Society of Obstetricians and Gynaecologists of
Canada (SOGC) guideline recommends anti-hypertensive
treatment for new onset systolic blood pressure >160
mmHg or diastolic blood pressure >110 mmHg, with goal
blood pressure <160/110 mmHg [33]. For women with
chronic hypertension without comorbid conditions and
blood pressure of 140 to 159/90 to 109 mmHg,
antihypertensive drug therapy should be used to keep
systolic blood pressure at 130 to 155 mmHg and diastolic
blood pressure at 80 to 105 mmHg. For women with
chronic hypertension with comorbid conditions,
antihypertensive drug therapy should be used to keep
systolic blood pressure at 130 to 139 mmHg and diastolic
blood pressure at 80 to 89 mmHg.

22.  The National Institute for Health and Clinical
Excellence (NICE) recommends that for pregnant
women with uncomplicated chronic hypertension the
goal is to keep blood pressure lower
than 150/100 mmHg [34]. In women with gestational
hypertension or preeclampsia, treatment is initiated at
blood pressures ≥150/100 mmHg with the goal of
systolic blood pressures <150 mmHg and diastolic
blood pressures of 80 to 100 mmHg. They also
recommend use of low dose aspirin (75 mg/day) from
12 weeks of gestation to reduce the risk of
preeclampsia. (See "Prevention of preeclampsia",
section on 'Approach to therapy'.)

23.  The American College of Obstetricians and
Gynecologists (ACOG) recommends
treatment of severe hypertension and
suggests labetalol as first-line therapy [16].
They also suggest avoiding atenolol,
angiotensin-converting enzyme inhibitors,
and angiotensin receptor blockers.

24. THE TASK FORCE ON THE MANAGEMENT OF
CARDIOVASCULAR DISEASES DURING
PREGNANCY OF (ESC) RECOMMENDS THE
FOLLOWING [23]:  Nonpharmacological management for pregnant women
with systolic blood pressure of 140 to 150 mmHg or
diastolic blood pressure of 90 to 99 mmHg
 In women with gestational hypertension or preexisting
hypertension superimposed by gestational hypertension
or with hypertension and subclinical organ damage or
symptoms at any time during pregnancy, initiation of drug
treatment is recommended at blood pressure
of 140/90mmHg. In any other circumstances, initiation of
drug treatment is recommended if systolic blood pressure
is ≥150 mmHg or diastolic blood pressure is ≥95 mmHg.
 Systolic blood pressure ≥170 mmHg or diastolic blood
pressure ≥110 mmHg in a pregnant woman is an
emergency, and hospitalization is indicated

25. POSTPARTUM HYPERTENSION
 One guideline suggests
avoiding methyldopa postpartum because of
the risk of postnatal depression
ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task
Force on the Management of Cardiovascular Diseases during Pregnancy of the European
Society of Cardiology (ESC). European Society of Gynecology (ESG), Association for
European Paediatric Cardiology (AEPC), German Society for Gender Medicine
(DGesGM), Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, Cifkova R, Ferreira R,
Foidart JM, Gibbs JS, Gohlke-Baerwolf C, Gorenek B, Iung B, Kirby M, Maas AH, Morais
J, Nihoyannopoulos P, Pieper PG, Presbitero P, Roos-Hesselink JW, Schaufelberger M,
Seeland U, Torracca L, ESC Committee for Practice GuidelinesEur Heart J.
2011;32(24):3147