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Hypertension in Pregnancy. Lianne Beck, MD Assistant Professor Emory Family Medicine. OBJECTIVES. Know criteria for the diagnosis of chronic hypertension, gestational hypertension and preeclampsia List criteria for the diagnosis of severe preeclampsia/HELLP syndrome

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hypertension in pregnancy

Hypertension in Pregnancy

Lianne Beck, MD

Assistant Professor

Emory Family Medicine

objectives
OBJECTIVES
  • Know criteria for the diagnosis of chronic hypertension, gestational hypertension and preeclampsia
  • List criteria for the diagnosis of severe preeclampsia/HELLP syndrome
  • Discuss current management considerations
introduction
Introduction
  • Most common medical complication of pregnancy
  • 6 to 8 % of gestations in the US.
  • In 2000, the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy defined four categories of hypertension in pregnancy:
    • Chronic hypertension
    • Gestational hypertension
    • Preeclampsia
    • Preeclampsia superimposed on chronic hypertension
chronic hypertension defined
Chronic Hypertension Defined
  • BP measurement of 140/90 mm Hg or more on two occasions
  • Before 20 weeks of gestation OR Persisting beyond 12 weeks postpartum
chronic hypertension
Chronic Hypertension
  • Treatment of mild to moderate chronic hypertension neither benefits the fetus nor prevents preeclampsia.
  • Excessively lowering blood pressure may result in decreased placental perfusion and adverse perinatal outcomes.
  • When BP is 150 to 180/100 to 110 mm Hg, pharmacologic treatment is needed to prevent maternal end-organ damage.
treatment of chronic hypertension
Treatment of Chronic Hypertension
  • Methyldopa , labetalol, and nifedipine most common oral agents.
  • AVOID: ACEI and ARBs, atenolol, thiazide diuretics
  • Women in active labor with uncontrolled severe chronic hypertension require treatment with intravenous labetalol or hydralazine.
gestational hypertension
Gestational Hypertension
  • Formerly called PIH (Pregnancy Induced HTN)
  • HTN without proteinuria occurring after 20 weeks gestation and returning to normal within 12 weeks after delivery.
  • 50% of women diagnosed with gestational hypertension between 24 and 35 weeks develop preeclampsia.
older criteria for gestational htn
Older Criteria for Gestational HTN
  • 30/15 increase in BP over baseline levels
  • No longer appropriate
  • 73% of patients will exceed 30 mm systolic and 57% will exceed 20 mm diastolic
preeclampsia
Preeclampsia
  • New onset hypertension with proteinuria after 20 weeks gestation.
  • Resolves by 6 weeks postpartum.
  • Characterized as mild or severe based on the degree of hypertension and proteinuria, and the presence of symptoms resulting from involvement of the kidneys, brain, liver, and cardiovascular system
diagnostic criteria for preeclampsia
Diagnostic Criteria for Preeclampsia
  • SBP of 140 mm Hg or more or a DBP of 90 mm Hg or more on two occasions at least six hours apart after 20 weeks of gestation AND
  • Proteinuria – 300 mg in a 24-hour urine specimen or 1+ or greater on urine dipstick testing of two random urine samples collected at least four hours apart.
  • A random urine protein/creatinine ratio < 0.21 indicates that significant proteinuria is unlikely with a NPV of 83%.
  • Generalized edema (affecting the face and hands) is often present in patients with preeclampsia but is not a diagnostic criterion.
hellp syndrome
HELLP Syndrome
  • Is a variant of severe preeclampsia
  • Occurs in up to 20% of pregnancies complicated by severe preeclampsia.
  • Variable clinical presentation; 12 to 18% are normotensive and 13% do not have proteinuria.
  • At diagnosis, 30% of women are postpartum, 18% are term, and 52% are preterm.
hellp syndrome16
HELLP Syndrome
  • Common presenting complaints are RUQ or epigastric pain, N/V, malaise or nonspecific symptoms suggesting an acute viral syndrome.
  • Any patient with these symptoms or signs of preeclampsia should be evaluated with CBC, platelet count, and liver enzymes.
  • When platelet count < 50,000/mm3 or active bleeding occurs, coagulation studies needed to R/O DIC.
prevention of preeclampsia
Prevention of Preeclampsia
  • Routine supplementation with calcium, magnesium, omega-3 fatty acids, or antioxidant vitamins is ineffective.
  • Calcium reduces the risk of developing preeclampsia in high-risk women and those with low dietary calcium intake.
  • Low-dose aspirin (75 to 81 mg per day) is effective for women at increased risk of preeclampsia, NNT = 69 ; NNT = 227 to prevent one fetal death.
  • Low-dose aspirin is effective for women at highest risk from previous severe preeclampsia, diabetes, chronic hypertension, or renal or autoimmune disease, NNT = 18.
multiorgan effects of preeclamsia
Multiorgan Effects of Preeclamsia
  • Cardiovascular – HTN, increased cardiac output, increased systemic vascular resistance, hypovolemia
  • Neurological – Seizures-eclampsia, headache, cerebral edema, hyperreflexia
  • Pulmonary – Capillary leak, reduced colloid osmotic pressure, pulmonary edema
multiorgan effects cont
Multiorgan Effects cont….
  • Hematologic – Volume contraction, elevated hematocrit, low platelets, anemia due to hemolysis
  • Renal – Decreased GFR, increased BUN/creatinine, proteinuria, oliguria, ATN
  • Fetal – Increased perinatal morbidity, placental abruption, fetal growth restriction, oligohydramnios, fetal distress
management of preeclampsia
Management of Preeclampsia
  • The ultimate cure is DELIVERY.
  • Assess gestational age
  • Assess cervix
  • Fetal well-being
  • Laboratory assessment
  • Rule out severe disease
gestational htn at term
Gestational HTN at Term
  • Delivery is always a reasonable option if term
  • If cervix is unfavorable and maternal disease is mild, expectant management with close observation is possible
mild gestational htn not at term
Mild Gestational HTN Not at Term
  • Rule out severe disease
  • Conservative management
  • Serial labs
  • Twice weekly visits
  • Antenatal fetal surveillance
  • Outpatient versus inpatient
indications for delivery in preeclampsia
Indications for Delivery in Preeclampsia
  • Fetal indications
    • Severe intrauterine growth restriction
    • Nonreassuring fetal surveillance
    • Oligohydramnios
indications for delivery in preeclampsia28
Indications for Delivery in Preeclampsia
  • Maternal indications
    • Gestational age of 38 weeks or greater
    • Platelet count below 100,000
    • Progressive deterioration of hepatic or renal function
    • Suspected placental abruption
    • Persistent severe headache or visual changes
    • Persistent severe epigastric pain, nausea, or vomiting
    • Eclampsia
criteria for treatment
Criteria for Treatment
  • Diastolic BP > 105-110
  • Systolic BP > 200
  • Avoid rapid reduction in BP
  • Do not attempt to normalize BP
  • Goal is DBP < 105 not < 90
  • May precipitate fetal distress
hypertensive emergencies
Hypertensive Emergencies
  • Fetal monitoring
  • IV access
  • IV hydration to maintain urine output > 30 mL per hour, limit to 100 mL per hour.
  • The reason to treat is maternal, not fetal
  • May require ICU
characteristics of severe htn
Characteristics of Severe HTN
  • Crises are associated with hypovolemia
  • Clinical assessment of hydration is inaccurate
  • Unprotected vascular beds are at risk, ie., uterine
key steps using vasodilators
Key Steps Using Vasodilators
  • 250-500 cc of fluid, IV
  • Avoid multiple doses in rapid succession
  • Allow time for drug to work
  • Maintain LLD position
  • Avoid over treatment
acute medical therapy
Acute Medical Therapy
  • Hydralazine
  • Labetalol
  • Nifedipine
  • Nitroprusside
  • Clonidine
hydralazine
Hydralazine
  • Dose: 5-10 mg every 20 minutes
  • Onset: 10-20 minutes
  • Duration: 3-8 hours
  • Side effects: headache, flushing, tachycardia, lupus like symptoms
  • Mechanism: peripheral vasodilator
labetalol
Labetalol
  • Dose: 20 mg, then 40, then 80 every 20 minutes, for a total of 220mg
  • Onset: 1-2 minutes
  • Duration: 6-16 hours
  • Side effects: hypotension
  • Mechanism: Alpha and Beta blockade
nifedipine
Nifedipine
  • Dose: 10 mg po, not sublingual
  • Onset: 5-10 minutes
  • Duration: 4-8 hours
  • Side effects: chest pain, headache, tachycardia
  • Mechanism: CA channel blockade
clonidine
Clonidine
  • Dose: 1 mg po
  • Onset: 10-20 minutes
  • Duration: 4-6 hours
  • Side effects: unpredictable, avoid rapid withdrawal
  • Mechanism: Alpha agonist, works centrally
nitroprusside
Nitroprusside
  • Dose: 0.2 – 0.8 mg/min IV
  • Onset: 1-2 minutes
  • Duration: 3-5 minutes
  • Side effects: cyanide accumulation, hypotension
  • Mechanism: direct vasodilator
seizure prophylaxis
Seizure Prophylaxis
  • Magnesium sulfate
  • Loading dose of 4 to 6 g diluted in 100 mL of normal saline, given IV over 15 to 20 minutes, followed by a continuous infusion of 1-2 g per hour
  • Monitor urine output, RR and DTR’s
  • With renal dysfunction, may require a lower dose
magnesium sulfate
Magnesium Sulfate
  • Is NOT a hypotensive agent
  • Works as a centrally acting anticonvulsant
  • Also blocks neuromuscular conduction
  • Serum levels: 4-7 mg/dL
  • Additional benefit of reducing the incidence of placental abruption
toxicity
Toxicity
  • Respiratory rate < 12
  • DTR’s not detectable
  • Altered sensorium
  • Urine output < 25-30 cc/hour
  • Antidote: 10 ml of 10% solution of calcium gluconate 1 g IV over 2 minutes.
eclampsia
Eclampsia
  • New onset of seizures in a woman with pre-eclampsia.
  • Preceded by increasingly severe preeclampsia, or it may appear unexpectedly in a patient with minimally elevated blood pressure and no proteinuria.
  • Blood pressure is only mildly elevated in 30-60% of women who develop eclampsia.
  • Occurs: Antepartum - 53%, intrapartum - 19%, or postpartum - 28%
treatment of eclampsia
Treatment of Eclampsia
  • Protecting the patient and her airway
  • Place patient on left side and suction to minimize the risk of aspiration
  • Give oxygen
  • Avoid insertion of airways and padded tongue blades
  • IV access
  • Mag Sulfate 4-6 g IV bolus, if not effective, give another 2 g
alternate anticonvulsants
Alternate Anticonvulsants
  • Diazepam 5-10 mg IV
  • Sodium Amytal 100 mg IV
  • Pentobarbital 125 mg IV
  • Dilantin 500-1000 mg IV infusion
after the seizure
After the Seizure
  • Assess maternal labs
  • Fetal well-being
  • Effect delivery
  • Transport when indicated
  • No need for immediate cesarean delivery
other complications
Other Complications
  • Pulmonary edema
  • Oliguria
  • Persistent hypertension
  • DIC
pulmonary edema
Pulmonary Edema
  • Fluid overload
  • Reduced colloid osmotic pressure
  • Occurs more commonly following delivery as colloid oncotic pressure drops further and fluid is mobilized
treatment of pulmonary edema
Treatment of Pulmonary Edema
  • Avoid over-hydration
  • Restrict fluids
  • Lasix 10-20 mg IV
  • Usually no need for albumin or Hetastarch (Hespan)
oliguria
Oliguria
  • 25-30 cc per hour is acceptable
  • If less, small fluid boluses of 250-500 cc as needed
  • Lasix is not necessary
  • Postpartum diuresis is common
  • Persistent oliguria almost never requires a PA cath
persistent hypertension
Persistent Hypertension
  • BP may remain elevated for several days
  • Diastolic BP less than 100 do not require treatment
  • By definition, preeclampsia resolves by 6 weeks
disseminated intravascular coagulopathy
Disseminated Intravascular Coagulopathy
  • Rarely occurs without abruption
  • Low platelets is not DIC
  • Requires replacement blood products and delivery
anesthesia issues
Anesthesia Issues
  • Continuous lumbar epidural is preferred if platelets normal
  • Need adequate pre-hydration of 1000 cc
  • Level should always be advanced slowly to avoid low BP
  • Avoid spinal with severe disease
sort key recommendations for practice
SORT: KEY RECOMMENDATIONS FOR PRACTICE
  • In women without end-organ damage, chronic hypertension in pregnancy does not require treatment unless the patient's blood pressure is persistently greater than 150 to 180/100 to 110 mm Hg. – C
  • Calcium supplementation decreases the incidence of hypertension and preeclampsia, respectively, among all women (NNT = 11 and NNT = 20), women at high risk of hypertensive disorders (NNT = 2 and NNT = 6), and women with low calcium intake (NNT = 6 and NNT = 13). – A
slide54
Low-dose aspirin (75 to 81 mg daily) has small to moderate benefits for the prevention of preeclampsia (NNT = 72), preterm delivery (NNT = 74), and fetal death (NNT = 243). The benefit of aspirin is greatest (NNT = 19) for prevention of preeclampsia in women at highest risk (previous severe preeclampsia, diabetes, chronic hypertension, renal disease, or autoimmune disease). – B
  • For women with mild preeclampsia, delivery is generally not indicated until 37 to 38 weeks of gestation and should occur by 40 weeks. – C
slide55
Magnesium sulfate is the treatment of choice for women with preeclampsia to prevent eclamptic seizures (NNT = 100) and placental abruption (NNT = 100). – A
  • Intravenous labetalol or hydralazine may be used to treat severe hypertension in pregnancy because neither agent has demonstrated superior effectiveness. – B
slide56
For managing severe preeclampsia between 24 and 34 weeks of gestation, the data are insufficient to determine whether an "interventionist" approach (i.e., induction or cesarean delivery 12 to 24 hours after corticosteroid administration) is superior to expectant management. Expectant management, with close monitoring of the mother and fetus, reduces neonatal complications and stay in the newborn intensive care nursery. – B
  • Magnesium sulfate is more effective than diazepam (Valium; NNT = 8) or phenytoin (Dilantin; NNT = 8) in preventing recurrent eclamptic seizures. – A
slide57
Quiz
  • Which one of the following statements about preeclampsia is correct?

A. Magnesium sulfate is the treatment of choice to prevent eclamptic seizures.

B. Diazepam (Valium) is more effective than magnesium sulfate in preventing recurrent eclamptic seizures.

C. Low-dose aspirin is beneficial for the prevention of preeclampsia in low-risk women.

D. An "interventionist" approach is superior to expectant management for severe preeclampsia between 24 and 34 weeks of gestation.

slide58
Which of the following agents is/are used to treat a 30-year-old woman (gravida 1, para 0) at 19 weeks of gestation who has had a blood pressure measurement of 160/115 mm Hg on two occasions during her current pregnancy?

A. Methyldopa (Aldomet; brand no longer available in the United States).

B. Nifedipine (Procardia).

C. Labetalol.

D. Lisinopril (Prinivil).

slide59
Which of the following is/are part of the diagnostic criteria for severe preeclampsia?

A. Blood pressure measurement ≥ 160 mm Hg systolic or 110 mm Hg diastolic on two occasions at least six hours apart.

B. Blood pressure measurement ≥ 150 mm Hg systolic or 100 mm Hg diastolic on two occasions at least six hours apart.

C. Proteinuria ≥ 3 g in a 24-hour urine specimen.

D. Proteinuria ≥ 5 g in a 24-hour urine specimen.

references
References
  • Lawrence L, Fontaine P. Hypertensive Disorders in Pregnancy. American Family Physician. July 1, 2008.
  • Wagner L. Diagnosis and Management of Preeclampsia. American Family Physician. December 15, 2004.
  • ACOG Committee on Obstetric Practice. ACOG practice bulletin. Diagnosis and management of preeclampsia and eclampsia. No. 33, January 2002. American College of Obstetricians and Gynecologists. Obstet Gynecol 2002;99:159-67.
  • Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol. 2000;183(1):S1-S22.