Hypertension in Hypertension in PregnancyPregnancy

Dr. Sahala Panggabean Dr. Sahala Panggabean SpPDSpPD--KGHKGH

Classification of Hypertensive Classification of Hypertensive Disorders in PregnancyDisorders in Pregnancy

Preeclampsia,eclampsiaPreeclampsia,eclampsia Chronic hypertensionChronic hypertension Chronic hypertension with Chronic hypertension with

superimposed preeclampsiasuperimposed preeclampsia Transient hypertension/gestational Transient hypertension/gestational

hypertensionhypertension

Incidence 12 – 22% pregnancies – affected by 12 – 22% pregnancies – affected by

hypertensive diseases during pregnancyhypertensive diseases during pregnancy 5% - chronic hypertension in pregnancy.5% - chronic hypertension in pregnancy. 5-8% - preeclampsia, 10% of whom 5-8% - preeclampsia, 10% of whom

develop eclampsiadevelop eclampsia Hypertensive diseases - responsible for Hypertensive diseases - responsible for

17.6% of maternal deaths in the US. In 17.6% of maternal deaths in the US. In 2003, there were 495 pregnancy-2003, there were 495 pregnancy-associated deaths, 68 (14%) due to associated deaths, 68 (14%) due to hypertension.hypertension.

PreeclampsiaPreeclampsia Preeclmapsia is a syndrome with both Preeclmapsia is a syndrome with both

maternal and fetal manifestation.maternal and fetal manifestation. Hypertension develops after 20 weeks, Hypertension develops after 20 weeks,

with normal blood presure in the first half with normal blood presure in the first half of pregnancyof pregnancy

Sudden appearance of edema, especially in hands and face.

Rapid weight gain

Pathophysiology

Maternal manifestations of preeclampsia

LABORATORY ABNORMALITIES IN

PREECLAMPSIARenal:Creatinine IncreasedUric acid Increased (>5.5 mg/dL)Urinary protein >300 mg/dUrinary calcium <150 mg/d

Heme:Hematocrit Increased (>38%)Platelets Decreased

Liver function tests:Aspartate aminotransferase IncreasedAlanine aminotransferase IncreasedAlbumin Decreased

HELLP Syndrome Occurs in up to 20% of women with Occurs in up to 20% of women with

severe preeclampsia, more severe preeclampsia, more commonly in white women and commonly in white women and multigravid womenmultigravid women

HH-Hemolysis-Hemolysis ELEL-Elevated liver function tests-Elevated liver function tests

AST> 72 IU; LDH > 600 IUAST> 72 IU; LDH > 600 IU LPLP-Low platelets-Low platelets

TREATMENT OF PREECLAMPSIA

Close monitoring of maternal and fetal conditions

Hospitalization in most cases Lower blood pressure for maternal

safety Seizure prophylaxis with magnesium

sulfate Timely delivery

ANTIHYPERTENSIVE THERAPY IN

PREECLAMPSIA Imminent delivery Delivery

postpone Hydralazine (IV,IM) Methyldopa Labetalol (IV) Labetalol, other B blocker Calcium channel blockers Calcium channel blockers Diazoxide (IV) Hydralazine

α blockers Clonidine

ANTIHYPERTENSIVE THERAPY

IN PREECLAMPSIA Decreased uteroplacental blood flow and

placentalischemia are central to the pathogenesis ofpreeclampsia.

Lowering blood pressure does not prevent or curepreeclampsia and does not benefit the fetus unlessdelivery can be safely postponed.

Lowering blood pressure is appropriate for maternal safety: maintain blood pressure at 130–150/85–100 mm Hg

Eclampsia Seizure activity unrelated to other Seizure activity unrelated to other

central nervous system disorders central nervous system disorders (epilepsy, meningitis, mass lesion, (epilepsy, meningitis, mass lesion, intracranial hemorrhage), with or intracranial hemorrhage), with or without resultant comawithout resultant coma

Associated with ~50,000 maternal Associated with ~50,000 maternal deaths (10% of total) worldwide deaths (10% of total) worldwide each yeareach year

Eclampsia Typical seizure lasts 75-90 seconds with 2 Typical seizure lasts 75-90 seconds with 2

phases: 15-30 seconds of facial twitching phases: 15-30 seconds of facial twitching progressing to generalized rigidity, then progressing to generalized rigidity, then about 60 seconds of tonic-clonic activityabout 60 seconds of tonic-clonic activity

Segmental constriction and dilatation of Segmental constriction and dilatation of cortical arterioles leads to decreased cortical arterioles leads to decreased perfusion and cerebral edemaperfusion and cerebral edema

Reduced breathing, fetal bradycardia Reduced breathing, fetal bradycardia occur occur

Eclampsia - Treatment 1. Protect airway1. Protect airway 2. Position in left lateral decubitus 2. Position in left lateral decubitus

(prevent aspiration, aid uterine (prevent aspiration, aid uterine perfusion)perfusion)

3. Prevent injury3. Prevent injury 4. Oxygen4. Oxygen 5. Magnesium sulfate (after seizure 5. Magnesium sulfate (after seizure

has terminated)has terminated)

Magnesium Sulfate Magnesium as the primary agent in Magnesium as the primary agent in

the treatment of eclampsia and the treatment of eclampsia and suggested its use for the prevention suggested its use for the prevention of eclampsiaof eclampsia

Raises the seizure thresholdRaises the seizure threshold Has a direct vascular relaxant effect, Has a direct vascular relaxant effect,

but is NOT an antihypertensive but is NOT an antihypertensive agentagent

Magnesium Sulfate Given IV (most commonly) or IMGiven IV (most commonly) or IM 6 gram load followed by 2 grams per 6 gram load followed by 2 grams per

hourhour Therapeutic range 6-8 mg/dLTherapeutic range 6-8 mg/dL Supratherapeutic levels lead to CNS Supratherapeutic levels lead to CNS

depression, cardiac arrythmias, possible depression, cardiac arrythmias, possible cardiac arrest (Mg level 15-20 mg/dL)cardiac arrest (Mg level 15-20 mg/dL)

Antidote - Calcium gluconateAntidote - Calcium gluconate

Magnesium Sulfate Continued until about 24 hours post-Continued until about 24 hours post-

partum, depending on the patient’s partum, depending on the patient’s conditioncondition

While some argue the use of While some argue the use of magnesium in mild preeclampsia, magnesium in mild preeclampsia, most authorities advocate its use in most authorities advocate its use in all women with preeclampsiaall women with preeclampsia

Chronic HypertensionChronic Hypertension Women are older, more likely to be

multiparous Hypertension: present before 20 wk, or

documented previous pregnancy Present before 20Present before 20thth week of pregnancy week of pregnancy

or persists longer then 12 weeks or persists longer then 12 weeks postpartum.postpartum.

Risk of superimposed preeclampsia of 15–30%

LABORATORY ABNORMALITIES IN

CHRONIC HYPERTENSIONRenal:Creatinine NormalUric acid NormalUrinary protein <300 mg/dUrinary calcium >200 mg/d

Heme:Hematocrit NormalPlatelets Normal

Liver function tests:Aspartate aminotransferase NormalAlanine aminotransferase NormalAlbumin Normal

Treatment Chronic Hypertension(1)

The overall treatment goals of chronic hypertension in pregnancy are to ensure a successful full-term delivery of a healthy infant without jeopardizing maternal well-being

The level of blood pressure control that is tolerated in pregnancy may be higher, because the risk of exposure of the fetus to additional antihypertensive agents might outweigh the benefits to the mother (for the duration of pregnancy) of having a normal blood pressure

Treatment Chronic Hypertension(2)

Methyldopa is considered to be one of the safest drugs during pregnancy

B blockers and calcium channel blockers are acceptable second- and third-line agents.

Diuretics can be used at low doses, particularly in salt-sensitive hypertensive patients on chronic diuretic therapy

Preeclampsia superimposed Preeclampsia superimposed upon Chronic Hypertensionupon Chronic Hypertension

Preexisting Hypertension with the Preexisting Hypertension with the following additional signs/symptoms; following additional signs/symptoms; New onset proteinuriaNew onset proteinuria Hypertension and proteinuria beginning Hypertension and proteinuria beginning

prior to 20 weeks of gestation.prior to 20 weeks of gestation. A sudden increase in blood pressure.A sudden increase in blood pressure. Thrombocytopenia.Thrombocytopenia. Elevated aminotransferases.Elevated aminotransferases.

Gestational Gestational Hypertension/Transient Hypertension/Transient

HypertensionHypertension Mild hypertension Mild hypertension without without proteinuria or other proteinuria or other

signs of preeclampsia.signs of preeclampsia. Develops in late pregnancy.Develops in late pregnancy. Resolves by 12 weeks postpartum.Resolves by 12 weeks postpartum. Can progress into preeclampsia.Can progress into preeclampsia.

Usually when gestational hypertension Usually when gestational hypertension develops before 30 weeks gestation.develops before 30 weeks gestation.

The hypertension resolves with delivery, often recurs in subsequent pregnancies, and predicts essential hypertension later in life.