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Hypertension in
Pregnancy
Dr.Rafi Rozan
Obstetrician & Gynecologist
Specialist in Comprehensive Family Medicine
Medical Technologist
Classification of Hypertensive
disorders
• Preeclampsia-Eclampsia
• Chronic Hypertension
• Chronic Hypertension with Superimposed
Preeclampsia
• Gestational hypertension
Epidemiology and Risk factors
• 1st degree relative (2-4x)
• Previous pregnancy (7x)
• Multiple gestation
• AMA, DM, obesity, preexhisting HTN
• IVF
• History of thrombocytopenia
• SLE
Predicting preeclampsia
• Uterine artery doppler velocimetry
-increased resistance to flow abnormal waveforms(increased
resistance or pulsatility indices with persistence of diastolic
notch)
-low predicitve value alone
• Biomarkers (angiogenesis related and placental protein
13)- none currently recommended. Future studies needed
• Screening to predict preeclampsia beyond obtaining an
appropriate medical history to evaluate for risk factors is
not recommended
Preeclampsia-Eclampsia
• Pregnancy specific hypertensive disease with
multisystem involvement
• >20w of gestation
• Most common: HTN + Proteinuria
• Without Protein: thrombocytopenia, impaired LFTs,
the new development of renal insufficiency,
pulmonary edema, cerebral or visual disturbances
Preeclampsia-Eclampsia
• Hypertension: mild >140/90. at least 2 readings 4h
apart. Severe >160/110 diagnosis can be confirmed
within shorter interval to facilitate timely
antihypertensive therapy
• Proteinuria: 300mg in 24h, Protein:Creatinine ratio >0.3
on random void, 1+ dipstick
• Eclampsia: convulsive phase
• “mild preeclampsia” and “severe preeclampsia” are not
specific classifications and should be replaced by
preeclampsia with or without severe features
Assessing the severity of
Preeclampsia
Establishing the diagnosis
• Taking a BP
-patient seated, legs uncrossed, back and arm supported
-middle of the cuff on the upper arm at the level of the
right atrium (midpoint of sternum)
-pt to relax and not talk for 5 minutes prior to BP reading
-wait several minutes before repeating if elevated
-BP taken in upper arm with woman in left lateral
position will be falsely low
Prediagnostic findings warranting
increased surveillance
• New onset headache, visual disturbance, RUQ pain,
epigastric pain
• New onset proteinuria in second half of pregnancy
• Fetal growth restriction
• Biochemical markers (uric acid) value of management of
specific patients. Associated with poorer outcomes.
Should not be used to support the initiation of specific
interventions by themselves
• Edema or rapid weight gain: nondiagnostic
Eclampsia
• New onset grand mal seizures in woman with
preeclampsia
• Can occur before, during, or after labor
• Differential: bleeding AV malformation, ruptured
aneurysm, idiopathic seizure disorder
• Alternative diagnosis may be more likely if seizures
occur after 48-72h postpartum or when new seizures
occur during use of antiepileptic therapy with
magnesium sulfate
Chronic Hypertension
• High BP known to predate conception
• High BP detected before 20w
Chronic Hypertension with
superimposed preeclampsia
• Incidence preeclampsia 4-5x that in nonhypertensive
pregnant women
• Women with HTN who develop proteinuria after 20w
and women who have proteinuria before 20w who:
-Need to escalate antihypertensive treatment
-increased LFTs
-Plts <100,000
-RUQ pain or HA
-Pulmonary edema
-Cr >1.1 or doubled
-sudden increase in proteinuria
Gestational Hypertension
• New elevations in BP in the absence of proteinuria
• Failure of BP to normalize postpartumchange
diagnosis to chronic hypertension
• Women with BP elevation to severe level have
similar outcomes to women with preeclampsia
• Require enhanced surveillance
Management of preeclampsia
and HELLP syndrome
• Initial Evaluation
• CBC, Cr, LFTs
• 24h urine protein collection or protein:creatinine ratio
• Evaluate for symptoms
• Fetal evaluation: EFW, AFI, NST
• Continued evaluation:
• Daily kick count
• Fetal growth US q3w
• AFI q week
• NST q week (gHTN), NST twice weekly (Preeclampsia without severe features)
• Twice weekly BP
• Assess for proteinuria weekly (gHTN)
• Weekly labs
Management of preeclampsia
and HELLP syndrome
• Antihypertensive Therapy:
• Decrease progression to severe range BP
• Increase fetal growth restriction
• No effect on development of preeclampsia, eclampsia,
pulmonary edema, fetal or neonatal death, preterm birth
Management of preeclampsia
and HELLP syndrome
• Intrapartum management
• Timing of delivery 37w0d IOL
-Lower risk of new onset severe features, HELLP syndrome,
eclampsia
-No difference neonatal morbidities or cesarean
• Magnesium Sulfate
-studies not powered to demonstrate signifcant reduction in eclampsia
-routine magnesium sulfate not indicate in Preeclampsia without severe
features
• Antihypertensive therapy: BP>160/110. decrease CV, renal,
cerebrovascular events
-Labetalol or hydralazine
-Nifedipine controversial: theoredical risk if on mag. Excessive
hypotension and neuromuscular blockade
Management of preeclampsia
and HELLP syndrome
• Severe Preeclampsia
• Progressive deterioration of maternal and fetal conditions if delivery not pursued
• Delivery at 34w0d
• Prompt delivery in pulmonary edema, renal failure, abruptio placenta, severe
thrombocytopenia, DIC, persistent cerebral symptoms, nonreassuring fetal testing or
fetal demise irrespective of GA less than 34w
• Corticosteroids for fetal lung maturity: for women <34w, decrease RDS and IVH
• Severe Proteinuria: resolution of renal dysfunction by 3 months. no difference in
rates of eclampsia, placental abruption, pulmonary edema, HELLP, neonatal
death/morbidity
• Previable Preeclampsia should not be expectantly managed
• Mode of delivery should be determined by fetal GA, fetal presentation, cervical
status, maternal-fetal condition
Management of preeclampsia
and HELLP syndrome
• Eclampsia
• Magnesium sulfate superior to phenytoin and diazepam
• Continue mag for 24h after last convulsion
• Loading 4-6g followed by 1-2g/hr
• HELLP (hemolysis, abnormal LFTs, thrombocytopenia)
• Delivery delayed for fetal steroids
• Cochran review demonstrating inprovement of platelet levels
following steroids, no improvement of morbidity/mortality
Management of preeclampsia
and HELLP syndrome
• Postpartum
• BP decrease within 48h
• BP increases again 3-6d PP
• NSAIDs can raise BP suggest replacing if BP
persistently elevated for 1d PP
• Recommend BP monitoring for 72h PP and again 7-
10d PP
• Antihypertensive therapy if BP> 150/100 on 2
occasions 4-6h apart
• 24h mag for women with HTN and severe features
Preconceptual counseling
Chronic hypertension in pregnancy and
superimposed preeclampsia
• Uncomplicated cHTN higher rates of cesarean and PP
hemorrhage
• Superimposed preeclampsia 13-40% pregnancies with cHTN
• Avoid ACEi, ARBs mineralicorticoids and statins
• Initial eval:
• baseline HELLP labs and urinalysis
• ECHO if cHTN >4y
• Home BP monitoring suggested. Ambulatory monitoring
good to rule out white coat HTN
Chronic hypertension in pregnancy and
superimposed preeclampsia
• Initiate antihypertensive therapy for BP >160/105
• Suggested to maintain BP 120-160/80-105
• 10mmHg decrease in mean arterial pressure has been
shown to decrease fetal weight by 145g
• Medications in pregnancy: labetalol, nifedipine,
methyldopa
• Incidence SGA 8-15.5% (growth US, doppler PRN)
• Deliver at 38w
Chronic hypertension in pregnancy and
superimposed preeclampsia
• Superimposed Preeclampsia
• Without severe features: new proteinuria or increasing
BP
• Does not require antihypertensive therapy if BP
<160/105
• Avoid mag
• Superimposed preeclampsia with severe features
• Expectantly managing <34w steroids
• Magnesium for seizure prophylaxis(2.4%)
Prevention of Preeclampsia
• Alterations in systemic prostacyclin-thromboxane balance
• Inflammation increased
• Meta-analysis 30,000 women from 31 trials: ASA modest benefit
with RR 0.9
• Cochran review 59 trials and 37,000 women: 17% reduction with
significant reduction in high risk patients
• High risk women: cHTN, DM, previous preterm preeclampsia
(number needed to treat=50)
• Initiate in late 1Trimester for women with a medical history of
early onset preeclampsia and preterm delivery less than 34w or
Preeclampsia in more than 1 pregnancy
Prevention of Preeclampsia
• Calcium supplementation (1.5-2g) may be considered in
pregnant women from populations with low baseline
calcium intake (less than 600mg/d)
• Dietary salt should not be restricted. Meta analysis of
7,000 patients suggest diuretics do not reduce
preeclampsia
• Oxidative stress contributes to Preeclampsia: Vitamin C
and Vitamin E with no benefit in prevention
• Bedrest not recommended: further studies need
examining exercise
References
• ACOG task force: Hypertension in pregnancy
• ACOG Committee opinion 623: Emergent therapy
for acute onset, severe hypertension during
pregnancy and the postpartum period

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Hypertension in Pregnancy: Classification, Risk Factors, and Management

  • 1. Hypertension in Pregnancy Dr.Rafi Rozan Obstetrician & Gynecologist Specialist in Comprehensive Family Medicine Medical Technologist
  • 2. Classification of Hypertensive disorders • Preeclampsia-Eclampsia • Chronic Hypertension • Chronic Hypertension with Superimposed Preeclampsia • Gestational hypertension
  • 3. Epidemiology and Risk factors • 1st degree relative (2-4x) • Previous pregnancy (7x) • Multiple gestation • AMA, DM, obesity, preexhisting HTN • IVF • History of thrombocytopenia • SLE
  • 4. Predicting preeclampsia • Uterine artery doppler velocimetry -increased resistance to flow abnormal waveforms(increased resistance or pulsatility indices with persistence of diastolic notch) -low predicitve value alone • Biomarkers (angiogenesis related and placental protein 13)- none currently recommended. Future studies needed • Screening to predict preeclampsia beyond obtaining an appropriate medical history to evaluate for risk factors is not recommended
  • 5. Preeclampsia-Eclampsia • Pregnancy specific hypertensive disease with multisystem involvement • >20w of gestation • Most common: HTN + Proteinuria • Without Protein: thrombocytopenia, impaired LFTs, the new development of renal insufficiency, pulmonary edema, cerebral or visual disturbances
  • 6.
  • 7. Preeclampsia-Eclampsia • Hypertension: mild >140/90. at least 2 readings 4h apart. Severe >160/110 diagnosis can be confirmed within shorter interval to facilitate timely antihypertensive therapy • Proteinuria: 300mg in 24h, Protein:Creatinine ratio >0.3 on random void, 1+ dipstick • Eclampsia: convulsive phase • “mild preeclampsia” and “severe preeclampsia” are not specific classifications and should be replaced by preeclampsia with or without severe features
  • 8. Assessing the severity of Preeclampsia
  • 9. Establishing the diagnosis • Taking a BP -patient seated, legs uncrossed, back and arm supported -middle of the cuff on the upper arm at the level of the right atrium (midpoint of sternum) -pt to relax and not talk for 5 minutes prior to BP reading -wait several minutes before repeating if elevated -BP taken in upper arm with woman in left lateral position will be falsely low
  • 10. Prediagnostic findings warranting increased surveillance • New onset headache, visual disturbance, RUQ pain, epigastric pain • New onset proteinuria in second half of pregnancy • Fetal growth restriction • Biochemical markers (uric acid) value of management of specific patients. Associated with poorer outcomes. Should not be used to support the initiation of specific interventions by themselves • Edema or rapid weight gain: nondiagnostic
  • 11. Eclampsia • New onset grand mal seizures in woman with preeclampsia • Can occur before, during, or after labor • Differential: bleeding AV malformation, ruptured aneurysm, idiopathic seizure disorder • Alternative diagnosis may be more likely if seizures occur after 48-72h postpartum or when new seizures occur during use of antiepileptic therapy with magnesium sulfate
  • 12. Chronic Hypertension • High BP known to predate conception • High BP detected before 20w
  • 13. Chronic Hypertension with superimposed preeclampsia • Incidence preeclampsia 4-5x that in nonhypertensive pregnant women • Women with HTN who develop proteinuria after 20w and women who have proteinuria before 20w who: -Need to escalate antihypertensive treatment -increased LFTs -Plts <100,000 -RUQ pain or HA -Pulmonary edema -Cr >1.1 or doubled -sudden increase in proteinuria
  • 14. Gestational Hypertension • New elevations in BP in the absence of proteinuria • Failure of BP to normalize postpartumchange diagnosis to chronic hypertension • Women with BP elevation to severe level have similar outcomes to women with preeclampsia • Require enhanced surveillance
  • 15. Management of preeclampsia and HELLP syndrome • Initial Evaluation • CBC, Cr, LFTs • 24h urine protein collection or protein:creatinine ratio • Evaluate for symptoms • Fetal evaluation: EFW, AFI, NST • Continued evaluation: • Daily kick count • Fetal growth US q3w • AFI q week • NST q week (gHTN), NST twice weekly (Preeclampsia without severe features) • Twice weekly BP • Assess for proteinuria weekly (gHTN) • Weekly labs
  • 16. Management of preeclampsia and HELLP syndrome • Antihypertensive Therapy: • Decrease progression to severe range BP • Increase fetal growth restriction • No effect on development of preeclampsia, eclampsia, pulmonary edema, fetal or neonatal death, preterm birth
  • 17. Management of preeclampsia and HELLP syndrome • Intrapartum management • Timing of delivery 37w0d IOL -Lower risk of new onset severe features, HELLP syndrome, eclampsia -No difference neonatal morbidities or cesarean • Magnesium Sulfate -studies not powered to demonstrate signifcant reduction in eclampsia -routine magnesium sulfate not indicate in Preeclampsia without severe features • Antihypertensive therapy: BP>160/110. decrease CV, renal, cerebrovascular events -Labetalol or hydralazine -Nifedipine controversial: theoredical risk if on mag. Excessive hypotension and neuromuscular blockade
  • 18.
  • 19. Management of preeclampsia and HELLP syndrome • Severe Preeclampsia • Progressive deterioration of maternal and fetal conditions if delivery not pursued • Delivery at 34w0d • Prompt delivery in pulmonary edema, renal failure, abruptio placenta, severe thrombocytopenia, DIC, persistent cerebral symptoms, nonreassuring fetal testing or fetal demise irrespective of GA less than 34w • Corticosteroids for fetal lung maturity: for women <34w, decrease RDS and IVH • Severe Proteinuria: resolution of renal dysfunction by 3 months. no difference in rates of eclampsia, placental abruption, pulmonary edema, HELLP, neonatal death/morbidity • Previable Preeclampsia should not be expectantly managed • Mode of delivery should be determined by fetal GA, fetal presentation, cervical status, maternal-fetal condition
  • 20. Management of preeclampsia and HELLP syndrome • Eclampsia • Magnesium sulfate superior to phenytoin and diazepam • Continue mag for 24h after last convulsion • Loading 4-6g followed by 1-2g/hr • HELLP (hemolysis, abnormal LFTs, thrombocytopenia) • Delivery delayed for fetal steroids • Cochran review demonstrating inprovement of platelet levels following steroids, no improvement of morbidity/mortality
  • 21. Management of preeclampsia and HELLP syndrome • Postpartum • BP decrease within 48h • BP increases again 3-6d PP • NSAIDs can raise BP suggest replacing if BP persistently elevated for 1d PP • Recommend BP monitoring for 72h PP and again 7- 10d PP • Antihypertensive therapy if BP> 150/100 on 2 occasions 4-6h apart • 24h mag for women with HTN and severe features
  • 23. Chronic hypertension in pregnancy and superimposed preeclampsia • Uncomplicated cHTN higher rates of cesarean and PP hemorrhage • Superimposed preeclampsia 13-40% pregnancies with cHTN • Avoid ACEi, ARBs mineralicorticoids and statins • Initial eval: • baseline HELLP labs and urinalysis • ECHO if cHTN >4y • Home BP monitoring suggested. Ambulatory monitoring good to rule out white coat HTN
  • 24. Chronic hypertension in pregnancy and superimposed preeclampsia • Initiate antihypertensive therapy for BP >160/105 • Suggested to maintain BP 120-160/80-105 • 10mmHg decrease in mean arterial pressure has been shown to decrease fetal weight by 145g • Medications in pregnancy: labetalol, nifedipine, methyldopa • Incidence SGA 8-15.5% (growth US, doppler PRN) • Deliver at 38w
  • 25. Chronic hypertension in pregnancy and superimposed preeclampsia • Superimposed Preeclampsia • Without severe features: new proteinuria or increasing BP • Does not require antihypertensive therapy if BP <160/105 • Avoid mag • Superimposed preeclampsia with severe features • Expectantly managing <34w steroids • Magnesium for seizure prophylaxis(2.4%)
  • 26. Prevention of Preeclampsia • Alterations in systemic prostacyclin-thromboxane balance • Inflammation increased • Meta-analysis 30,000 women from 31 trials: ASA modest benefit with RR 0.9 • Cochran review 59 trials and 37,000 women: 17% reduction with significant reduction in high risk patients • High risk women: cHTN, DM, previous preterm preeclampsia (number needed to treat=50) • Initiate in late 1Trimester for women with a medical history of early onset preeclampsia and preterm delivery less than 34w or Preeclampsia in more than 1 pregnancy
  • 27. Prevention of Preeclampsia • Calcium supplementation (1.5-2g) may be considered in pregnant women from populations with low baseline calcium intake (less than 600mg/d) • Dietary salt should not be restricted. Meta analysis of 7,000 patients suggest diuretics do not reduce preeclampsia • Oxidative stress contributes to Preeclampsia: Vitamin C and Vitamin E with no benefit in prevention • Bedrest not recommended: further studies need examining exercise
  • 28. References • ACOG task force: Hypertension in pregnancy • ACOG Committee opinion 623: Emergent therapy for acute onset, severe hypertension during pregnancy and the postpartum period