Hypertensive Disorders of Pregnancy

Hypertensive Disorders
of Pregnancy
Learning Objectives
 Define chronic hypertension of pregnancy
 Define preeclampsia and eclampsia
 Discuss the etiologies of and risk factors for
hypertensive disorders of pregnancy
 Review the clinical management of
hypertensive disorders of pregnancy
Definitions
Chronic hypertension in pregnancy
 Mild – SBP>=140mmHg, DBP>=90mmHg
 Severe – SBP>=180, DBP>=110
 Using antihypertensives before pregnancy
 Onset before 20 weeks EGA
 Persistence beyond postpartum period (12
weeks)
Preeclampsia
 A clinical diagnosis defined by a classic triad:
 Hypertension (BP ≥ 140/90)
 Proteinuria (1+ dipstick or 300 mg/24 hr)
 Edema (especially non-dependent)]
 No longer considered a required component
 Mild preeclampsia meets the above criteria
Severe Preeclampsia
 Any one of the following:
 Blood pressure sustained above 160/110
 Proteinuria >2+ dipstick or > 5 gm/24 hr
 Headache/visual disturbances
 Epigastric pain
 Oliguria (< 500 mL/24 hours)
 HELLP syndrome
 Fetal growth restriction
Eclampsia
 Seizure activity unrelated to other central
nervous system disorders (epilepsy,
meningitis, mass lesion, intracranial
hemorrhage), with or without resultant
coma
 Associated with ~50,000 maternal deaths
(10% of total) worldwide each year
Incidence
 12 – 22% pregnancies – affected by hypertensive
diseases during pregnancy
 5% - chronic hypertension in pregnancy.
 5-8% - preeclampsia, 10% of whom develop
eclampsia
 Hypertensive diseases - responsible for 17.6% of
maternal deaths in the US. In 2003, there were 495
pregnancy-associated deaths, 68 (14%) due to
hypertension.
Risk Factors
 Nulliparity
 Previous pregnancy with preeclampsia
 Family history of preeclampsia
 Chronic hypertension (30%)
 Diabetes mellitus (30-50%)
Risk Factors
 Renal disease (30-50%)
 Multiple gestation
 Hydatidiform mole
 Age > 35
Pathophysiology
 Incompletely understood
 Thought to stem from inadequate invasion of
trophoblast into the myometrium
 This lack of invasion allows the myometrial
portion of the spiral arterioles to maintain
their muscular walls, preventing
development of the normal low-resistance
uteroplacental circulation.
Pathophysiology
 Increased vascular reactivity
 Increased platelet activation
 Altered prostanoid balance favoring
production of TXA2 and PGF2
(vasoconstrictors, platelet aggregators) over
PGI2 and PGE (vasodilators, platelet dis-
aggregators).
Pathophysiologic manifestations
 Alterations are seen in nearly every system:
 Hematologic
 Thrombocytopenia, hemolysis, increased
platelet activation
 Cardiovascular
 Vasospasm, hemoconcentration
 Renal
 Proteinuria, oliguria, ATN, acute renal failure
 Hepatic
 Elevated transaminases, hyperbilirubinemia,
hepatic hemorrhage
 Neurologic
 Headache, scotomata, blurred vision,
hyperreflexia, temporary blindness, seizures
 Fetoplacental
 IUGR, oligohydramnios, abruption, impaired
gas exchange, nonreassuring fetal status
HELLP Syndrome
 Occurs in up to 20% of women with severe
preeclampsia, more commonly in white
women and multigravid women
 H-Hemolysis
 EL-Elevated liver function tests
 AST> 72 IU; LDH > 600 IU
 LP-Low platelets
Chronic Hypertension - Evaluation
 Specialized testing, ideally prior to
pregnancy (ECHO, ECG, ophthlalmologic
exam, renal sonography)
 Rule out other medical etiologies
(pheochromocytoma, Cushing’s syndrome)
Chronic Hypertension -
Management
 Generally, deliver at term, unless
superimposed preeclampsia, HELLP
syndrome
 Avoid ACE inhibitors (renal failure,
oligohydramnios, pulmonary hypoplasia,
IUGR) and atenolol (IUGR)
Preeclampsia-Management
 Seizure prophylaxis
 Blood pressure control
 Delivery
Preeclampsia-Term Pregnancy
 Delivery is a short-term goal
 Induction of labor is appropriate after
maternal-fetal observation/stabilization
 Cesarean reserved for standard obstetric
indications
 Cesarean may be recommended in cases of
severe preeclampsia where delivery is remote
Preeclampsia-Preterm Pregnancy
 Expectant management of severe
preeclampsia at preterm gestational age:
 Hospitalization
 Magnesium sulfate for seizure prophylaxis, at
least during initial observation period
 Blood pressure control to range of 140-155/90-
105 (labetalol or nifedipine)
 Daily assessment of maternal-fetal condition
Preeclampsia-Preterm Pregnancy
 24-34 weeks – corticosteroids for fetal lung
maturation
 24-32 weeks – ongoing daily surveillance if
stable
 33-34 weeks – deliver after 48 hours
 Deliver for HELLP syndrome, severe
headache, uncontrolled hypertension,
eclampsia
Magnesium Sulfate
 Magnesium as the primary agent in the
treatment of eclampsia and suggested its use
for the prevention of eclampsia
 Has a direct vascular relaxant effect, but is
NOT an antihypertensive agent
Magnesium Sulfate
 Given IV (most commonly) or IM
 6 gram load followed by 2 grams per hour
 Therapeutic range 6-8 mg/dL
 Supratherapeutic levels lead to CNS
depression, cardiac arrythmias, possible
cardiac arrest (Mg level 15-20 mg/dL)
 Antidote - Calcium gluconate
Magnesium Sulfate
 Continued until about 24 hours post-partum,
depending on the patient’s condition
 While some argue the use of magnesium in
mild preeclampsia, most authorities
advocate its use in all women with
preeclampsia
Antihypertensive Agents
 Labetalol - alpha-1/beta blocker
 Hydralazine - direct arteriolar relaxation
 Nifedipine - calcium channel blockade
should be used with caution due to
synergistic hypotensive and negative
inotropic effect with MgSO4
 Sodium nitroprusside - severe hypertension
Antihypertensive Agents
 AVOID:
 Alpha-methyldopa - works too slowly
 ACE-inhibitors - fetal renal failure with
chronic use, not studied for acute use
 Diuretics - decrease uterine perfusion
 Calcium channel blockers (some would say)
Eclampsia
 Typical seizure lasts 75-90 seconds with 2
phases: 15-30 seconds of facial twitching
progressing to generalized rigidity, then
about 60 seconds of tonic-clonic activity
 Segmental constriction and dilatation of
cortical arterioles leads to decreased
perfusion and cerebral edema
 Reduced breathing, fetal bradycardia occur
Eclampsia - Treatment
 1. Protect airway
 2. Position in left lateral decubitus (prevent
aspiration, aid uterine perfusion)
 3. Prevent injury
 4. Oxygen
 5. Magnesium sulfate (after seizure has
terminated)
Preeclampsia - Recurrence
 Increased risk of recurrence in future
pregnancies (especially early onset or
severe) – up to 30-45%
 Increased lifetime risk of chronic
hypertension
 Increased risk of preeclampsia for the
patient’s sisters and daughters
Case 1
 18 yo G1, 37 weeks EGA presents to office
with headache, seeing spots. Gained 5 lbs in
past week. BP 140/90, 2+ protein in urine.
Case 1
 Appropriate tests include all except:
 24 hour urine collection
 liver enzymes, platelet count
 repeat blood pressure measurement
 fetal monitoring
 cord blood gases
Case 1
 You decide to admit the patient, as her
repeat blood pressure and other laboratory
results indicate mild preeclampsia. While
on the elevator down to the 2nd floor for
your fourth Cesarean delivery, you get
paged to see the patient because the family
thinks she had a seizure. You arrive to see
tonic-clonic activity.
Case 1
 The most appropriate next step is to:
 leave the patient downstairs to do an immediate
Cesarean
 quickly do the original Cesarean so you can attend to
the seizing patient
 assess maternal status, assess fetal status
 give Magnesium Sulfate
 wake up the chief and ask her what she would like in
her coffee before you ask her what to do, as you both
are likely to be up for a while
Sources
 2007 Compendium
 Williams Obstetrics
 Preeclampsia/Eclampsia presentation by C.
Chisholm, M.D.

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