EMERGENCY #32 HYPERTENSION IN PREGNANCY

Definition/Manifestations/Diagnosis
1. Hypertension the most common medical complication of pregnancy. It is one of the leading
causes of maternal and perinatal morbidity and mortality.
2. Gestational hypertension is SBP >140 or DBP of >90 noted for the first time after 20 weeks
AOG not associated with proteinuria. It returns to normal usually 12 weeks postpartum.
3. Chronic hypertension is BP of >140/90 before pregnancy or before 20 th week AOG and is
persistent after 12 weeks postpartum.
4. Preeclampsia and eclampsia syndrome is SBP >140 mmHg or DBP >90mmHg after 20
weeks AOG at two separate occasions at least 4 hours apart. This is associated with
proteinuria of >300mg in 24 hours, protein creatinine ratio of >0.5, or protein dipstick of +1.
In the absence of proteinuria, this is still considered if serum creatinine >1.1mg/dL, platelet
count of <100 000, serum transaminase level twice the normal, pulmonary edema, and
cerebral symptoms. Eclampsia is noted when there is new onset grandma seizures or
coma.
5. Preeclampsia with severe features manifests as BP of >160/110, thrombocytopenia,
elevated liver enzymes, renal insufficiency, pulmonary edema, and new onset cerebral
symptoms.
6. Superimposed preeclampsia on chronic hypertension is chronic hypertension with new
onset proteinuria after the 20th week AOG.

Pathophysiology
1. Normally, trophoblastic invasion is characterized by extensive remodeling of the spiral
arterioles within the decidua basalis. Endovascular trophoblasts replace the vascular
endothelial and muscular linings to enlarge the vessel diameter.
2. In preeclampsia, there is incomplete trophoblastic invasion and only the decidual vessels
are lined by endovascular trophoblasts. This results with narrow-caliber vessels leading to
impairment in placental blood flow and placental necrosis.

Management
1. The goals of treatment are to prevent convulsions, control hypertension, and delivery at an
optimum time and mode.
2. Magnesium sulfate is the anti-convulsant of choice to prevent eclampsia. It reduces cerebral
vasoconstriction and ischemia. Loading dose is 4g SIVP over 20 minutes then 5g IM on
each buttock. Maintenance dose if 5g IM on each buttock every 6 hours. We should
monitory for toxicity which manifests as loss of patellar reflex at 10mEq/L, respiratory
depression at 12mEq/L, altered conduction or heart block at 15mEq/L, and cardiac arrest at
>25mEq/L. Toxicity is treated with calcium gluconate 1g IV.
3. For control of hypertension >160/110, labetalol and hydralazine are the first line agents.
Labetalol is given 20mg IV over 2 minutes while hydralazine is given 5mg IV over 2 minutes.
We monitor the patient for improvement and provide follow up dose if BP target is not
reached.
4. We determine if the patient has severe features; if none, we deliver >37 weeks; if present
and the patient is already >34 weeks AOG, we can terminate pregnancy via assisted
vaginal delivery. If <34 weeks, we observe. CS delivery is reserved for unfavorable cervix,
failure of progression after induction, absence of imminent vaginal delivery, and fetal
compromise.
5. Corticosteroids must be given to enhance fetal lung maturation before 34 weeks.
Betamethasone 12mg IM 2 doses 24 hours apart or dexamethasone 6mg IM 4 doses 12
hours apart may be given.