HYPERTENSION IN PREGNANCY

- Occurs in 6-8% of pregnancies, and is the most common medical complication in pregnancy
- Also a leading cause of premature delivery
o Because treatment is delivery
- General:
o HPN is >=140/90 on 2 separate measurements at least 4 hours apart
o HPN Crisis: >=160/110 that persists for >=15 mins
Etiology
- Recall: In the trimesters:
o Decreased SVR in the latter half of first trimester
o Nadir in the midsecond trimester
§ If seen here, t/c hydatidiform mole or previously undiagnosed chronic HPN
o BP slowly increase back to baseline at third trimester (but not higher than pre-pregnancy
BP) à where HPN is most commonly seen
- Risk Factors
o Manifestations of the disease
§ Chronic HPN
§ Renal Disease
§ African-American à likely to develop chronic HPN, obesity, T2DM
§ APLS
§ Collagen vascular disease
§ Pregestational diabetes
§ Extremes of maternal age
o Immunogenic nature of preeclampsia
§ Nulliparity
§ Previous preeclampsia
§ Multiple gestation
§ Abnormal placentation
§ FHx in the parturient
§ Parental ethnic discordance
§ Cohabitation with partner (“Tolerance effect”)
§ Paternity à if new father: risk increases to that of nulliparous woman
o Smoking: decreased incidence, unexplained
- Pathogenesis
o Involves both maternal and fetal factors resulting in abnormal development of placental
vasculature and maternal systemic endothelial dysfunction
1. Fetal Effects: due to placental vascular development
a. Acute Placental underperfusion
i. Placental infarct and/or abruption
ii. Intrapartum fetal distress
iii. Stillbirth
b. Chronic Placental underperfusion
i. Asymmetric and symmetric SGA fetuses
ii. IUGR
c. Oligohydramnios
2. Maternal Effects: due to endothelial dysfunction c/o circulating antiangiogenic factors
a. Vascular permeability
b. Activation of coagulation cascade
c. Microangiopathic hemolysis
d. Vasoconstriction à seizure and stroke (affects brain), oliguria and renal
failure (kidneys), pulmonary edema (lungs), edema and subcapsular
hematoma and periportal hemorrhagic necrosis at periphery à increased
serum liver enzymes (liver), and thrombocytopenia and DIC (small blood
vessels)
e. = Obstetric complications (Premature deliveries, CS deliveries)
Classifications

Minimum Labs to order

- CBC with platelet count
- Clotting studies
- Liver enzymes
- Creatinine
- Uric Acid

Indications for Admissions

- Unreliable patient
- >2 episodes of 150/100
- Heavy proteinuria
- Persistent maternal symptoms
- All patients newly diagnosed with preeclampsia

If outpatient, monitor for the following at least once weekly:

- BP at each visit
- Platelet count and liver enzymes at regular intervals
- NST at regular intervals
- Fetal growth every 2-3 weeks

Indications for Expectant Management

- Remote from term (preeclampsia, gestational, chronic)
- Stable BP, normal labs, no concern about fetal well being
Antihypertensives Used
Maintenance
- Methyldopa: DOC
- Beta blockers: May decrease uteroplacental flow, increase risk for growth restriction in first or
second trimester, may cause neonatal hypoglycemia at higher doses
o Labetalol: assoc with UGR, avoid in asthmatics and with CHF
- Nifedipine: may inhibit labor
- Hydrochlorothiazide: May be useful with methyldopa to mitigate compensatory fluid retention;
WOF volume contraction and electrolyte disorders

Urgent
- Hydralazine: DOC to NGBEP
- Nifedipine
- Nicardipine
- Labetalol

Route of Delivery
- CS if need to expedite delivery due to fetomaternal compromise or with OB indications
o Induction of labor if there is a need to deliver
- Assisted vaginal delivery if no need to expedite delivery
- Preferred anesthesia: epidural or spinal anesthesia

PREECLAMPSIA

• Gestational HPN
o Always take BP in a seated position à supine position lowers their BP
o Rule out preeclampsia, monitor closely with
§ Twice weekly BP checks
§ Weekly lab testing and antenatal fetal testing
o Should be delivered at 37 weeks AOG
• Preeclampsia, (-) Severe Features
o WOF: Peripheral edema (especially of the face, hands, and feet)
o Diagnosed prior to 37 weeks, (-) comorbidities à manage as outpatient
o Should be delivered at 37 weeks AOG
§ ACOG: no recommendation for MgSO4 seizure prophylaxis

• Preeclampsia, (+) Severe Features

o Clinical manifestations are explained by vasospasm leading to necrosis and hemorrhage of
organs
o Deliver at 34 weeks
§ Manage expectantly until 34 weeks
§ Administer betamethasone for fetal lung maturity thru 36 seeks
§ NOT AN INDICATION for CS
o Treat with MgSO4 for seizure prophylaxis
o If BP is greater than 160/110 à manage with antihypertensives
o Severe features
§ SBP 160/110 or higher while on bed rest, 4h apart
§ Thrombocytopenia (less than 100k/ul)
§ Impaired liver function (twice the normal AST/ALT)
§ Progressive renal insufficiency (SCr>1.1 mg/dL)
§ Pulmonary edema
§ New onset cerebral or visual disturbances
• HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count) syndrome
o Develops in 10% of patients with preeclampsia with severe features
o Hypertension and proteinuria may be minimal or even absent in these patients à just
presents with RUQ (Epigastric pain due to liver capsule distention à can lead to hepatic
rupture)
o Diagnosis
§ Hemolytic anemia: Schistocytes on PBS, Elevated LDH, Elevated total bilirubin
 § Elevated liver enzymes: Increased AST and ALT
§ Low platelets
o Screen for AFLP if presenting with frank hepatic failure
o Management
§ If diagnosed after 34 0/7, deliver soon after maternal stabilization
§ If diagnosed prior to 34 weeks, deliver 24-48 hours after administration of
betamethasone for fetal lung maturity and stabilized fetomaternal conditions
§ Give MgSO4 for seizure prophylaxis thru 24h postpartum
§ Discharge after 4-8 days hospitalization, if platelet count is >100000/mm3 and no
evidence of end organ damage

• AFP (Acute Fatty Liver of Pregnancy)

o Difficult to distinguish from HELLP
o Exhibits evidence of liver failure
§ Elevated ammonia levels
§ Blood glucose <50 mg/dL
§ Elevated fibrinogen and antithrombin III levels
o Management: Maternal stabilization and prompt delivery regardless of gestational age

Management Goals
- Reduce severity and prevent progression
- Control severe HPN (NOT to normalize, recommends tx only for BP over 160/110)
o 110/80 below will run risk of uteroplacental insufficiency
- Deliver fetus at optimum time and with the least trauma
- Treat end organ damage
- Completely restore the health
Prevention: Low dose aspirin after 12 weeks to help reduce the risk of preeclampsia
ECLAMPSIA
- Occurrence of grand mal seizures in the preeclamptic patient; can’t be attributed to other cases
- Etiology: Breakdown in autoregulatory system of cerebral circulation due to:
o Hyperperfusion
o Endothelial dysfunction
o Brain edema
- Clinical Manifestations
o Tonic clonic seizures, (+/-) aura
o Fetal bradycardia
- Diagnosis: Clinical, treat promptly upon recognition
- Management
o Seizure management: ABCs (Airway, Breathing, Circulation)
o BP Control: Hydralazine or Labetalol, goal: less than 160/110
o Prophylaxis against further convulsions: MgSO4 at time of diagnosis, continued for 12-24
hours after delivery (goal: 4.8-8.4 mg/mL serum conc)
§ Mechanism: Decreases hyperreflexia and raises the seizure threshold
§ If refractory to MgSO4: Lorazepam and Phenytoin
§ Antidote: Calcium gluconate or calcium chloride
o Initiate delivery after seizures are controlled and patient is stabilized
§ Establish adequate maternal oxygenation and cardiac output
§ If FHR abnormalities does not resolve à emergent CS
- Complications
o Cerebral hemorrhage
o Aspiration pneumonia
o Hypoxic encephalopathy
o Thromboembolic events

CHRONIC HPN
- Since at risk for other complicationsà order baseline labs
o CBC
o CMP
o 24-h urine collection for CrCl and protein
§ Differentiate superimposed preeclampsia from CRD
§ If 24 hour urine protein is elevated, diagnosis is superimposed preeclampsia à if
not, manage with increasing dosages of medications
o ECG
§ No current cardiac compromise
- Postpartum Management
o Stage 1: Thiazide type diuretics
o Stage 2: Add ACEi/ARB OR Beta blocker OR CCB
- Prophylaxis: Low dose aspirin after 12 weeks to help reduce the risk of preeclampsia