This document summarizes the classification, risk factors, pathophysiology, evaluation, and management of hypertensive disorders during pregnancy including gestational hypertension, preeclampsia, eclampsia, and HELLP syndrome. Delivery is the only cure for preeclampsia. Magnesium sulfate is the first-line treatment for eclampsia prevention and control of severe hypertension involves antihypertensive drugs.

1. Ri 簡睦旼
2012/5/3

2. Classification
 Pregnancy-induced hypertension (Gestational
hypertension)5-10%
 Preeclampsia3.9%
 Eclampsia
 Preeclampsia superimposed on chronic hypertension
 Chronic hypertension
William’s Obstertrics, 23ed

3. Gestationa Pre- Eclampsia
l HTN Eclampsia
Superimposed
Preeclampsia
SBP≥140
Proteinuria Generalized
or
seizures
DBP ≥ 90
Severe
Preeclampsia
≥ 0.3 g/ 24hr
> GA 20th wk before , during
>30 mg/dL
< PP 12th wk or after labor
(1+ on dipstick)
HELLP
syndrome

4. Preeclampsia
 2~7% of healthy nulliparous; 0.8~5% of
multiparous women
 The third leading cause of maternal mortality
(17%)
 A major cause of neonatal morbidity and
mortality (intrauterine growth restriction,
abruptio placentae and the need for preterm
delivery) Preeclampsia
Deadly
Triad
Hemorrhage Infection

5. Severe preeclampsia
 BP 160/110 mm Hg
 Proteinuria 2.0 g/24 hours or 2+ dipstick
 Increase severity /certainty
 Serum creatinine >1.2 mg/dL unless known to be previously elevated
 Platelets < 100,000/L
 Microangiopathic hemolysis—increased LDH
 Elevated serum transaminase levels—ALT or AST
 Persistent headache or other cerebral or visual disturbance
 Persistent epigastric pain

6. Superimposed
Chronic
Preeclampsia
HTN
SBP≥140
or Proteinuria
DBP ≥ 90
< GA 20th wk > 20th GA wk
> PP 12th wk
HTN + PTuria b4 20wk
↑proteinuria or
↑BP or
PLT < 100,000/L

7. Risk factors
 Nulliparity
 Age >35 years (superimposed) or teenager
 Obesity
 Multifetal gestation
 Medical illness: Chronic hypertension, lupus
erythematosus, IDDM, APS, PT C/S deficiency, renal
disease
 Genetic: Hx / FH of previous preeclampsia or eclampsia
 Hydatidiform moles
 Smoking, placenta previa

8. ↓NO, PGE2, PGI2,
PlGF, VEGF
↑TXA2, Endothelin
Stage 1
Poor
Placentation Vasoconstriction
Endothelial
Stage 2 Cytokines
integrity ↓
Placental
oxidative Antiangiogenic
stress Endothelial
peptides
damage
sFlt-1,sEng

9. Endothelial
integrity ↓
Vasoconstriction Endothelial
damage
MAHA
HELLP

10. Principle of management
 Difinitive treatment is delivery
 BP control
 Seizure prophylaxis

11. Evaluation of a new-onset HTN
 Clinical findings:
 headache, visual disturbance, epigastric pain, rapid
weight gain…
 Measure BW QD
 Analysis for proteinuria on admission and QOD
 BP measurement Q4H
 CRE, AST/ALT, CBC (for PLT). UA? LDH?
Coagulation profile?
 Sonography: fetal size, amnionic fluid
William’s Obstertrics, 23ed

12. Management of HTN disorder
 Dietary
 Lifestyle
 Place of care
 Antihypertensive therapy
 Corticosteroids
 Mode of delivery

13. Management of HTN disorder
 Dietary
 Salt restriction is not recommended
 Insufficient evidence to make recommendation
 Lifestyle
 Avoid vigorous exercise
 Bed rest?
 Place of care
 Severe hypertension or preeclampsia
(BP>160/110)should be hospitalized
Laura Magee et al, 2008, JOGC

14. Management of HTN disorder
 Antihypertensive therapy
 For severe hypertension (BP>160/110)
 BP goal: <160/110
 Initial antihypertensive: labetalol, nifedipine
hydralazine.
 MgSO 4 is not recommended as antihypertensive
(only transient decrease in 30 mins)
 Continuous FHR monitoring is advised until BP is
stable.
Laura Magee et al, 2008, JOGC

15. Management of HTN disorder
 Antihypertensive therapy
 Non-severe hypertension (BP:140-159/90-109
mmHg)
 BP goal: w/o cormorbid - 130-155/80-105
w/ cormorbid – 130-139/80-89
 Drug of choice: methyldopa, labetalol, other beta-
blockers, CCB (nifedipine). (I-A)
 ACEi and ARBs should not beused. (II-2E)
 Atenolol and prazosin are not recommended.
Laura Magee et al, 2008, JOGC

16. Management of HTN disorder
 Mode of delivery
 Induction of labour
 Vaginal delivery, unless C/S is indicated
 Oxytocin at 3rd stage of labor, esp.
thrombocytopenia or coagulopathy
 Ergometrine should not be given
Laura Magee et al, 2008, JOGC

17. Management of HTN disorder
 Corticosteroids
 To accelerate fetal pulmonary maturity
 Pre-eclampsia & GA < 34 wks
 Gestational HTN & GA < 34 wks, about to deliver
within next 7 days
Laura Magee et al, 2008, JOGC

18. Management of Pre-eclampsia
 Delivery is the only cure
 Timing of delivery
 MgSO4
 Plasma volume expansion
Laura Magee et al, 2008, JOGC

19. Management of Pre-eclampsia
 Timing of delivery
 GA < 34 wks: expectant management
 GA: 34-36 wks, non-severe pre-eclampsia:
debated
 GA > 37 wks: immediate delivery
Laura Magee et al, 2008, JOGC

20. William’s Obstertrics, 23ed

21. Management of Pre-eclampsia
 MgSO4
 First-line Tx for eclampsia
 Prophylaxis against eclampsia in severe-
preeclampsia
 Phenytoin and BZD should not be used for
eclampsia prophylaxis, unless MgSO4 is
contraindicated or ineffective
 Plasma volume expansion
 Not recommended
Laura Magee et al, 2008, JOGC

22. Management for HELLP
syndrome
 PLT count > 50x109 /L
 Prophylactic transfusion of platelets is not
recommended
 Consider ordering blood when PLT drop rapidly
 PLT count < 20 x 109 /L.
 Platelet transfusion prior to vaginal delivery or C/S)
 Corticosteriods may be considered for PLT count
< 50x109 /L
 Plasma exchange or plasmapheresis?
Laura Magee et al, 2008, JOGC

23. Postpartum treatment
 BP follow-up
 Peak postpartum, D3, D6
 Antihypertensive therapy may be restart, BP
goal <160/110 mmHg
 Acceptable in breastfeeding: Nifedipine, labetalol,
methyldopa, captopril, enalapril
 NSAID should be avoid if hypertension is
difficult to control, or oliguria, CRE ↑, PLT↓
 Thromboporphylaxis may be considered
Laura Magee et al, 2008, JOGC