001 hypertension in pregnancy

8/10/2019 001 Hypertension in Pregnancy

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Hypertension in PregnancyHypertension in Pregnancy

N.L. Meyer, M.D.N.L. Meyer, M.D.




• Most common medical disorder during pregnancy

•Gestational hypertension – preeclampsia

•70% of HTN in pregnancy

•Wide spectrum

•Mild elevation in BP vs severe hypertensionwith organ dysfunctions

•Acute gestational hypertension

•Preeclampsia

•Eclampsia

•HELLP

•Most common medical disorder during pregnancy•Gestational hypertension – preeclampsia

•70% of HTN in pregnancy•Wide spectrum

•Mild elevation in BP vs severe hypertensionwith organ dysfunctions

• Acute gestational hypertension

•Preeclampsia

•Eclampsia

•HELLP




Clinical Findings

Chronic

Hypertension

Gestational

Hypertension Preeclampsia

Onset < 20 weeks Thirdtrimester ≥20 weeks

Degree Mild or severe Mild Mild or severe

Proteinuria Absent Absent Usually present

Uric acid >5.5 mg/dl Rare Absent Usually present

Hemoconcentration Absent Absent Severe disease

Thrombocytopenia Absent Absent Severe disease

Hepatic dysfunction Absent Absent Severe disease



Gestational HypertensionGestational Hypertension

•Systolic BP ≥140 and/or diastolic ≥90 on atleast 2 occasions at least 6 hours apart after 20

weeks in women known to be normotensivebefore pregnancy and before 20 weeks

gestation

•BP recordings should be no more than 7 days

apart

•Severe gestational hypertension

•Sustained elevations in systolic BP ≥160

and/or diastolic BP ≥110 for 6 hours

•Systolic BP ≥140 and/or diastolic ≥90 on atleast 2 occasions at least 6 hours apart after 20

weeks in women known to be normotensivebefore pregnancy and before 20 weeks

gestation

•BP recordings should be no more than 7 days

apart

•Severe gestational hypertension

•Sustained elevations in systolic BP ≥160

and/or diastolic BP ≥110 for 6 hours




•Most frequent cause of HTN during

pregnancy

•6-17% in healthy nulliparous patients

•2-4% in multiparous patients

•Rates increase

•Previous preeclampsia

•Multifetal gestations

•Most frequent cause of HTN duringpregnancy

•6-17% in healthy nulliparous patients

•2 -4% in multiparous patients

•Rates increase

•Previous preeclampsia

•Multifetal gestations




•Progression

•Gestational age at diagnosis

•50% progression with diagnosis prior to 30

weeks

•Severe hypertension

•Preeclampsia•Eclampsia

•Undiagnosed hypertension

• Progression

•Gestational age at diagnosis

•50% progression with diagnosis prior to 30

weeks

•Severe hypertension

•Preeclampsia

•Eclampsia

• Undiagnosed hypertension




• Most cases develop ≥37 weeks

• Overall outcome similar to or better thannormotensive pregnancies

•Higher gestational age at delivery

•Higher birth weight

• Higher rates of induction

•Higher cesarean section rates

•Most cases develop ≥37 weeks

•Overall outcome similar to or better thannormotensive pregnancies

•Higher gestational age at delivery

•Higher birth weight

•Higher rates of induction

•Higher cesarean section rates



Mild Gestational HypertensionMild Gestational Hypertension

Kuinst(n=396)

Hauth(n=715)

Barton(n=405)

Sibai(n=186)

Gestational age NR 39.7 37.4 39.1

< 37 (%) 5.3 7.0 17.3 5.9

< 34 (%) 1.3 1.0 4.9 1.6

Birth weight (gm) NR 3303 3038 3217

SGA (%) 1.5 6.9 13.8 7.0

< 2500 g (%) 7.1 7.7 23.5 NR

Abruption (%) 0.5 0.3 0.5 0.5

Perinatal death (%) 0.8 0.5 0 0




Maternal Evaluation

•Weekly prenatal visits

•Reporting preeclamptic symptoms

•Laboratory evaluation

•CBC

•Platelets

•LFT's

Maternal Evaluation

•Weekly prenatal visits

•Reporting preeclamptic symptoms

•Laboratory evaluation

•CBC•Platelets

•LFT's




•Amniotic fluid

•Estimated weight

•Weekly nonstress testing

• Amniotic fluid

•Estimated weight

•Weekly nonstress testing

Fetal EvaluationFetal Evaluation




•Salt restriction – not indicated

•Restricted activity – not indicated

•Antihypertensive medication – not indicated

•Continue to term

•Absence of progression

•Seizure prophylaxis – not indicated

•Salt restriction – not indicated

•Restricted activity – not indicated

• Antihypertensive medication – not indicated

•Continue to term

• Absence of progression

•Seizure prophylaxis – not indicated

ManagementManagement



Severe Gestational HypertensionSevere Gestational Hypertension

•Increased maternal and perinatal morbidity

•Outcomes similar to severe preeclampsia

•Abruptio placentae

•Preterm delivery

•< 37 weeks

•< 35 weeks•SGA infants

•Manage as if they had severe preeclampsia

•Increased maternal and perinatal morbidity

•Outcomes similar to severe preeclampsia

• Abruptio placentae

•Preterm delivery

•< 37 weeks

•< 35 weeks•SGA infants

•Manage as if they had severe preeclampsia



Severe Gestational HTN vs Severe PreeclampsiaSevere Gestational HTN vs Severe Preeclampsia

Outcome Relative risk 95% CI

Delivery <37 wk 0.81 0.53-1.24

Delivery <35 wk 0.7 0.32-1.56

SGA infant 1.83 0.56-5.71

Abruption 0.63 0.07-5.69

LGA infant 1.87 0.28-12.49

NICU admissions 0.55 0.23-1.31

RDS 0.75 0.21-2.63

Buchbinder et al AJOG 2002;186:66-71Buchbinder et al AJOG 2002;186:66-71



PreeclampsiaPreeclampsia

•Hypertension unique to human pregnancy

•Rarely reported in primates

•Incidence

•3-7% in nulliparas

•0.8-5% in multiparas

•Significantly increased in multigestations

•Hypertension unique to human pregnancy

•Rarely reported in primates

•Incidence

•3-7% in nulliparas

•0.8-5% in multiparas

•Significantly increased in multigestations

Ri k F



Risk FactorsRisk Factors

• Nulliparity

• Family history

• Obesity• Multifetal gestation

• Previous preeclampsia

• Previous poor outcome

• IUFD

• IUGR

• Abruption

• Nulliparity

• Family history

• Obesity• Multifetal gestation

• Previous preeclampsia

• Previous poor outcome

• IUFD

• IUGR

• Abruption

• Preexisting medical conditions

• CHTN

• Renal disease• Diabetes

• Thrombophilias

• APAS

• Protein S deficiency

• Protein C deficiency

• Factor V Leiden

• Abnormal dopplers

• Preexisting medical conditions

• CHTN

• Renal disease• Diabetes

• Thrombophilias

• APAS

• Protein S deficiency

• Protein C deficiency

• Factor V Leiden

• Abnormal dopplers



PreeclampsiaPreeclampsia

•Gestational hypertension plus proteinuria

•≥300 mg/24 hours

•Classic triad•Hypertension

•Proteinuria

•Edema

•Gestational hypertension plus proteinuria

•≥300 mg/24 hours

•Classic triad•Hypertension

•Proteinuria

•Edema



HypertensionHypertension

•Systolic blood pressure of ≥140 mm or diastolicblood pressure of ≥90 mm after 20 weeks in a

previously normotensive women

• "30 x 15" rule

•↑ 30 mm SBP or 15 mm DBP over baseline

•No longer used

•Gradual rise in BP is seen in most normal

pregnancies•73% of primigravidas demonstrate >15 mm

increase in DBP during pregnancy

•67% with SBP > 30 mm over baseline

•Systolic blood pressure of ≥140 mm or diastolicblood pressure of ≥90 mm after 20 weeks in a

previously normotensive women

• "30 x 15" rule

•↑ 30 mm SBP or 15 mm DBP over baseline

•No longer used

•Gradual rise in BP is seen in most normal

pregnancies•73% of primigravidas demonstrate >15 mm

increase in DBP during pregnancy

•67% with SBP > 30 mm over baseline




Sensitivity PPV

DPB ≥15 mm 39% 32%

SBP ≥30 mm 22% 33%

Villar and Sibai AJOG 1989;60:419Villar and Sibai AJOG 1989;60:419




•Korotkoff phase V

•Appropriate size cuff

•Length 1.5 x upper arm circumference

•Bladder encircles > 80% of the arm

•Upright position after ≥ 10 minutes rest•Hospitalized

•Either sitting up or LLR position•Arm level with heart

•No tobacco or caffeine x 30 minutes

•Mercury sphygmomanometer preferred

•Korotkoff phase V

• Appropriate size cuff

•Length 1.5 x upper arm circumference

•Bladder encircles > 80% of the arm

•Upright position after ≥ 10 minutes rest•Hospitalized

•Either sitting up or LLR position• Arm level with heart

•No tobacco or caffeine x 30 minutes

•Mercury sphygmomanometer preferred



EdemaEdema

•No longer considered part of the diagnosis

•Neither sufficient nor necessary to confirm

•Common finding in normal pregnancies

•1/3 of eclamptic women do not developedema

•No longer considered part of the diagnosis

•Neither sufficient nor necessary to confirm

•Common finding in normal pregnancies

•1/3 of eclamptic women do not developedema

ProteinuriaProteinuria




•≥300 mg/ 24 hours

•30 mg/dL or ≥1+ on dipstick on at least 2 random

samples at least 6 hours apart but <7 days apart

•Dipstick correlates poorly with protein in a 24-hrcollection*

•1+ has PPV of 92% for ≥300 mg /24-hr

•Negative to trace has a NPV of only 34%

•66% have > 300 mg /24-hrs

•Cannot exclude significant proteinuria

•3+ to 4+ have PPV of 36%

•Cannot confirm significant proteinuria

•≥300 mg / 24 hours

•30 mg/dL or ≥1+ on dipstick on at least 2 random

samples at least 6 hours apart but <7 days apart

•Dipstick correlates poorly with protein in a 24-hrcollection*

•1+ has PPV of 92% for ≥300 mg / 24-hr

•Negative to trace has a NPV of only 34%

•66% have > 300 mg / 24-hrs

•Cannot exclude significant proteinuria

•3+ to 4+ have PPV of 36%

•Cannot confirm significant proteinuria* Meyer et al AJOG 1994;170:137-41* Meyer et al AJOG 1994;170:137-41

P t i iProteinuria




Urine protein /24hrs Neg Tr 1+ 2+ 3+ 4+<300 21 21 9 3 3 0

300-4999 37 44 42 38 22 24

≥5000 0 0 2 7 10 17

Meyer et al AJOG 1994;170:137-41Meyer et al AJOG 1994;170:137-41




Dipstick mg / 24-hrs Sensitivity Specificity PPV NPV

> 1+ ≥300 67 74 92 34

> 3+ ≥5000 75 81 36 96

Meyer et al AJOG 1994;170:137-41Meyer et al AJOG 1994;170:137Meyer et al AJOG 1994;170:137--4141





•Can preeclampsia occur withoutproteinuria?

•Consider preeclampsia when gestational

hypertension is associated with other

symptoms

•Persistent cerebral symptoms•Epigastric or right upper quadrant pain

with nausea and vomiting•Thrombocytopenia

•Abnormal liver enzymes•IUGR

•Can preeclampsia occur withoutproteinuria?

•Consider preeclampsia when gestational

hypertension is associated with other

symptoms

•Persistent cerebral symptoms•Epigastric or right upper quadrant pain

with nausea and vomiting•Thrombocytopenia

• Abnormal liver enzymes•IUGR

Severe PreeclampsiaSevere Preeclampsia




• Severe gestational hypertension

associated with abnormal proteinuria

• SBP ≥160 mm or DBP ≥110 mm on 2

occasions >6 hours apart at bed rest

• Hypertension in association with severe

proteinuria

• ≥ 5 g /24 hours

• Severe gestational hypertension

associated with abnormal proteinuria

• SBP ≥160 mm or DBP ≥110 mm on 2

occasions >6 hours apart at bed rest

• Hypertension in association with severe

proteinuria

• ≥ 5 g /24 hours





•Multiorgan involvement•Pulmonary edema

•Seizures•Oliguria

•< 500 mL / 24 hours

•Thrombocytopenia

•<100,000/mm3

•Abnormal LFT with persistent RUQ or

epigastric pain

•Persistent severe CNS symptoms

• Multiorgan involvement•Pulmonary edema

•Seizures

•Oliguria

•< 500 mL / 24 hours

•Thrombocytopenia

•<100,000/mm3

• Abnormal LFT with persistent RUQ or

epigastric pain

•Persistent severe CNS symptoms



Superimposed PreeclampsiaSuperimposed Preeclampsia

•New onset proteinuria complicating

hypertension prior to 20 weeks gestation

•Sudden increase in proteinuria

•Sudden increase in hypertension•HELLP syndrome

•CHTN with HA, scotomata or epigastric

pain

•New onset proteinuria complicating

hypertension prior to 20 weeks gestation

•Sudden increase in proteinuria

•Sudden increase in hypertension•HELLP syndrome

•CHTN with HA, scotomata or epigastric

pain





•Delivery is the only cure

•Primary considerations

•Safety of mother

•Delivery of a live, mature newborn

• Immediate delivery vs expectant management

•Severity of disease process•Maternal / fetal status at initial evaluation

•Gestational age•Labor

•Bishop score

•Maternal desire

•Delivery is the only cure

•Primary considerations

•Safety of mother

•Delivery of a live, mature newborn

• Immediate delivery vs expectant management

•Severity of disease process•Maternal / fetal status at initial evaluation

•Gestational age•Labor

•Bishop score

•Maternal desire

Mild P l i M tMild Preeclampsia Management



Mild Preeclampsia - ManagementMild Preeclampsia - Management

•Mild preeclampsia at term with favorable cervix•Delivery

•Unfavorable cervix ≥37 weeks - ? Cervical ripening•Delivery ≥34 weeks

•Progressive labor •ROM

•Abnormal testing•IUGR

•Deliver by 40 weeks even with unfavorable

conditions

•Mild preeclampsia at term with favorable cervix•Delivery

•Unfavorable cervix ≥37 weeks - ? Cervical ripening•Delivery ≥34 weeks

•Progressive labor •ROM

• Abnormal testing

•IUGR

•Deliver by 40 weeks even with unfavorable

conditions

Mild P l i M tMild Preeclampsia Management



Mild Preeclampsia - ManagementMild Preeclampsia - Management

•Management <37 weeks remains controversial

•Maternal and fetal evaluation?

•Hospitalization vs ambulatory management?

•Antihypertensive medications?

•Bed rest?

•Management <37 weeks remains controversial

•Maternal and fetal evaluation?

•Hospitalization vs ambulatory management?

• Antihypertensive medications?

•Bed rest?

Maternal EvaluationMaternal Evaluation



Maternal EvaluationMaternal Evaluation

•Frequent evaluation for progression of disease

•Lab evaluation•Platelet count

•LFT's

•Renal function

•Urine protein

•Repeat weekly – mild disease, no progression

•Frequent evaluation for progression of disease

•Lab evaluation•Platelet count

•LFT's

•Renal function

•Urine protein

•Repeat weekly – mild disease, no progression





• Weekly antepartum fetal evaluation

•Twice weekly testing with IUGR or oligohydramnios

• Daily fetal movement assessment

•Fetal growth evaluation

•Weekly antepartum fetal evaluation

•Twice weekly testing with IUGR or oligohydramnios

•Daily fetal movement assessment

•Fetal growth evaluation

Outpatient ManagementOutpatient Management



Outpatient ManagementOutpatient Management

•SBP ≤ 150mm / DBP ≤ 100mm

•Urine protein ≤ 1000 mg/24 hours

•Asymptomatic

•Normal LFT's

•Platelets ≥ 1000/mm3

•Daily BP and urinalysis

•Twice weekly evaluation

•Growth and fluid assessment q 3 weeks

•Hospitalize with disease progression

•SBP ≤ 150mm / DBP ≤ 100mm

•Urine protein ≤ 1000 mg/24 hours

• Asymptomatic

•Normal LFT's

•Platelets ≥ 1000/mm3

•Daily BP and urinalysis

•Twice weekly evaluation

•Growth and fluid assessment q 3 weeks

•Hospitalize with disease progression



Magnesium Sulfate ProphylaxisMagnesium Sulfate Prophylaxis



Magnesium Sulfate ProphylaxisMagnesium Sulfate Prophylaxis

•>70 years of use

• Intramuscular (Pritchard) and intravenous (Sibai)

regimes

• "Standard of care" in the US

•10% progression to severe disease withprophylaxis or placebo in 135 women at term*

•12.8% vs 16.8% progression in a recentcontrolled trial of MgSO4 vs placebo**

• >70 years of use

• Intramuscular (Pritchard) and intravenous (Sibai)

regimes

• "Standard of care" in the US

• 10% progression to severe disease withprophylaxis or placebo in 135 women at term*

• 12.8% vs 16.8% progression in a recentcontrolled trial of MgSO4 vs placebo**

*Witlin, Friedman, Sibai AJOG 1997;176:623-7

**Livingston et al Ob Gyn 2003;101:217-220

*Witlin, Friedman, Sibai AJOG 1997;176:623-7

**Livingston et al Ob Gyn 2003;101:217-220





•SBP ≥160mm or DBP ≥110mm on 2 occasions 6hours apart at bed rest

•Significant proteinuria (≥5 g/24–hr)

•Oliguria <500 mL/ 24-h

•Cerebral /visual disturbances

•Epigastric pain, nausea, vomiting

•Pulmonary edema, cyanosis

•Abnormal LFT's

•Thrombocytopenia

•IUGR

•SBP ≥160mm or DBP ≥110mm on 2 occasions 6hours apart at bed rest

•Significant proteinuria (≥5 g/24–hr)

•Oliguria <500 mL/ 24-h

•Cerebral/visual disturbances

•Epigastric pain, nausea, vomiting

•Pulmonary edema, cyanosis

• Abnormal LFT's

•Thrombocytopenia

• IUGR





•Hospitalization

•MgSO4 prophylaxis

•Antihypertensive medication

•Maintain SBP 140-155mm and DBP 90-105mm

•24-34 weeks

•Steroids for lung maturity

•Maternal assessment

•Fetal assessment

•Hospitalization

•MgSO4 prophylaxis

• Antihypertensive medication

•Maintain SBP 140-155mm and DBP 90-105mm

•24-34 weeks

•Steroids for lung maturity

•Maternal assessment

•Fetal assessment

Antihypertensive Medication Antihypertensive Medication



ypyp

Hydralazine5 mg IV or 10 mg IM. Repeat at 20 minintervals pending response. Repeat prn

when controlled (usually 3 hrs). Max dose

20 mg IV or 30 mg IM.

Labetalol

20 mg IV bolus initially, then 40, 80, 80 mg

every 10 minutes for max 220 mg. Caution

with asthma, CHF.

Nifedipine 10 mg po. Repeat in 30 min if necessary.

Sodium Nitroprusside

HTN unresponsive to other drugs or

hypertensive encephalopathy. 0.25µg/kg/min to max 5 µg/kg/min. Fetal

cyanide toxicity if used >4 hrs.

National High Blood Pressure Education Program Working Group on High Blood

Pressure in Pregnancy. AJOG 2000;183:S1-S22.

National High Blood Pressure Education Program Working Group on High Blood

Pressure in Pregnancy. AJOG 2000;183:S1-S22.

Antihypertensive Therapy Antihypertensive Therapy



• Prevent potential cerebrovascular and cardiovascular

complications

• Encephalopathy, hemorrhage, CHF

• No randomized trials to determine what level to treatto prevent complications

• Recommendations vary

• SBP ≥180mm and DBP ≥110mm

• SBP ≥160 mm or DBP ≥105mm

• MABP ≥130mm

• Sibai Ob Gyn 2003;102:181• Intrapartum – SBP ≥170mm or DBP ≥110mm

• Postpartum or thrombocytopenia – SBP ≥160mm

or DBP ≥105mm

• Prevent potential cerebrovascular and cardiovascular

complications• Encephalopathy, hemorrhage, CHF

• No randomized trials to determine what level to treat

to prevent complications

• Recommendations vary

• SBP ≥180mm and DBP ≥110mm

• SBP ≥160 mm or DBP ≥105mm

• MABP ≥130mm

• Sibai Ob Gyn 2003;102:181• Intrapartum – SBP ≥170mm or DBP ≥110mm

• Postpartum or thrombocytopenia – SBP ≥160mm

or DBP ≥105mm




•Progressive deterioration in both maternal and

fetal conditions

•Deliver with onset after 34 weeks

• Increased rate of maternal morbidity/mortality•Significant fetal risk

•Delivery prior to 34 weeks

• Imminent eclampsia

•Multiorgan dysfunction

•Severe IUGR

•Suspected abruption

•Non-reassuring fetal testing

•Progressive deterioration in both maternal and

fetal conditions

•Deliver with onset after 34 weeks

• Increased rate of maternal morbidity/mortality•Significant fetal risk

•Delivery prior to 34 weeks

• Imminent eclampsia

•Multiorgan dysfunction

•Severe IUGR

•Suspected abruption

•Non-reassuring fetal testing

Severe Preeclampsia < 34 WeeksSevere Preeclampsia < 34 Weeks



p

•Considerable disagreement•Delivery is definitive therapy

•Delivery may not be optimal for the prematurefetus

•≥34 weeks – deliver

•< 23 weeks – offer termination

•33 - 34 weeks – steroids with delivery after 48-hrs

•23 - 32 weeks gestation• Individualized treatment based on clinicalresponse during the initial 24 hours

observation

•Considerable disagreement

•Delivery is definitive therapy

•Delivery may not be optimal for the premature

fetus

•≥34 weeks – deliver

•< 23 weeks – offer termination

•33 - 34 weeks – steroids with delivery after 48-hrs

•23 - 32 weeks gestation• Individualized treatment based on clinicalresponse during the initial 24 hours

observation

Chronic HypertensionChronic Hypertension



Chronic HypertensionC o c ype te s o

•5% of pregnant women

•Hypertension before the 20th week or before

pregnancy

•Antihypertensive medication prior to pregnancy

•Persistence beyond the usual postpartum period

•Mild chronic hypertension

•≥140 / 90 mm Hg

•Severe chronic hypertension

•≥180 / 110 mm Hg

•5 % of pregnant women•Hypertension before the 20th week or before

pregnancy

• Antihypertensive medication prior to pregnancy

• Persistence beyond the usual postpartum period• Mild chronic hypertension

•≥140 / 90 mm Hg

•Severe chronic hypertension

•≥180 / 110 mm Hg



Chronic HypertensionChronic Hypertension



ypyp

•Risks

•Superimposed preeclampsia

•4.7 – 52% incidence

•Abruption

•Poor perinatal outcome

•IUGR•IUFD

•PTD

•Risks


•4.7 – 52% incidence

• Abruption

•Poor perinatal outcome

•IUGR•IUFD

•PTD

Low Risk Chronic HTNLow Risk Chronic HTN



•Mild essential hypertension without organ

involvement

•Blood pressure at initial visit regardless of

medication

•BP <180/110 mmHg

•No previous perinatal losses

•Mild essential hypertension without organ

involvement

•Blood pressure at initial visit regardless of

medication

•BP <180/110 mmHg

•No previous perinatal losses

Low Risk Chronic HTNLow Risk Chronic HTN



• Usually good perinatal outcome irrespective ofantihypertensive drugs

• 49% ↓ MAP

• 34% with no change in MAP• Most poor outcomes were related to superimposedpreeclampsia

• Discontinue antihypertensive meds

• Treat BP >160/110 mmHg to keep DBP ≤105 mmHg

• In absence of superimposed preeclampsia, pregnancymay continue

• Favorable cervix

• Labor • Completion of 40 weeks

• Usually good perinatal outcome irrespective ofantihypertensive drugs

• 49% ↓ MAP

• 34% with no change in MAP• Most poor outcomes were related to superimposedpreeclampsia

• Discontinue antihypertensive meds• Treat BP > 160/110 mmHg to keep DBP ≤105 mmHg

• In absence of superimposed preeclampsia, pregnancymay continue

• Favorable cervix

• Labor • Completion of 40 weeks

High Risk Chronic HTNHigh Risk Chronic HTN



gg

•Secondary hypertension

•Maternal age >40

•Duration HTN >15 years

•Target organ damage

•Previous perinatal loss•BP ≥180/110 mmHg

•Secondary hypertension

•Maternal age >40

•Duration HTN >15 years

•Target organ damage

•Previous perinatal loss

•BP ≥180/110 mmHg

High Risk Chronic HTNHigh Risk Chronic HTN



•Antihypertensive medication•Absent target organ damage

•Maintain BP 140-150/90-100 (140-160/90-105)•Target organ damage

•BP <140/90•Close monitoring

•Fetal evaluation at 28 (as early as 26) weeks


•Hospitalization

•Delivery with GA ≥34 weeks

• Antihypertensive medication• Absent target organ damage

•Maintain BP 140-150/90-100 (140-160/90-105)•Target organ damage

•BP <140/90

• Close monitoring

•Fetal evaluation at 28 (as early as 26) weeks

• Superimposed preeclampsia

•Hospitalization

•Delivery with GA ≥34 weeks

Medication for BP ≥180/110Medication for BP ≥180/110



Drug Starting dose Max dose Acute treatment

Hydrazaline 5-10 mg IV q 20 min 30 mg

Labetalol 20-40 mg IV q 5-10 min 220 mg

Nifedipine 10-20 mg po q 30 min 50 mg

Long-term treatment

Methyldopa 250 mg bid 4 g/d

Labetalol 100 mg bid 2400 mg/d

Nifedipine 10 mg bid 120 mg/d

Thiazide diuretic 12.5 mg bid 50 mg/d

Superimposed PreeclampsiaSuperimposed Preeclampsia



• Incidence 4.7-52% depending on initial BP•Exacerbation of HTN

•At least ≥30 mm systolic or ≥15 mm diastolic

•Development of proteinuria

•≥500mg/24 h

•Exacerbation of preexisting proteinuria

•≥5 g /24 h

•↑ LFT's•↓ platelets

•↑ uric acid >6 mg/dL

• Development of symptoms

• Incidence 4.7-52% depending on initial BP•Exacerbation of HTN

• At least ≥30 mm systolic or ≥15 mm diastolic

•Development of proteinuria

•≥500mg/24 h

•Exacerbation of preexisting proteinuria•≥5 g /24 h

•↑ LFT's•↓ platelets

•↑ uric acid >6 mg/dL

•Development of symptoms

001 hypertension in pregnancy

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