HYPERTENSION

in
PREGNANCY
• Maternal Personal Risk
Factors
• Primiparity
• Primipaternity
• History of preeclampsia
(risk of recurrence 14%)
• Obesity (BMI ≥ 30 kg/m2)
• Family history of preeclampsia • Placental/Fetal Risk Factors
• Black ethnicity
• Maternal age ≥ 40 (2x risk)
• Maternal Medical Risk
Factors
• Underlying medical conditions
• Diabetes mellitus
• Antiphospholipid antibody
syndrome
• Renal disease
• Maternal infection
• Multiple pregnancy
• Molar pregnancy
 HYPERTENSION
SBP ≥ 140 mmHg SBP ≥ 160 mmHg
or or
DBP ≥ 90 mmHg DBP ≥ 110 mmHg

• 2 occasions • Confirmed within

• at least 4 hours apart minutes
 HYPERTENSIVE DISORDERS
IN PREGNANCY
• Chronic hypertension
• Gestational hypertension
• Preeclampsia
• Eclampsia
• Chronic hypertension with superimposed preeclampsia
HYPERTENSIVE DISORDERS IN PREGNANCY
 SEVERE FEATURES
SBP ≥ 160 mmHg or DBP ≥ 110 mmHg
Thrombocytopenia • Platelet <100,000/uL

• Serum creatinine > 1.1 mg/dl

Renal Insufficiency • Serum creatinine 2x elevated

• Transaminases 2x normal
Impaired liver function test • Epigastric or right upper quadrant pain
unresponsive to medications

• Dyspnea
Pulmonary edema • Cough with pinkish frothy sputum

• Headache unresponsive to analgesia

Cerebral or visual symptoms • Visual disturbances (e.g. scotomas,
blindness)
 Gestational Hypertension

Develops proteinuria,
Preeclampsia/Eclampsia severe features, or
convulsions

Transient Hypertension of Hypertension resolves

after 12 weeks postpartum
Pregnancy
Hypertension persists after
Chronic Hypertension 12 weeks postpartum
 Prevention of
Preeclampsia
• Recommended
• Aspirin
• 150 mg at bedtime
• start <16wks AOG
• Calcium
• 1500-2000 mg/day
 MANAGEMENT
• Outpatient versus inpatient
• Referral to a higher level health care facility
• Maternal and fetal monitoring
• Antiplatelet therapy
• Antihypertensive drugs
• Prevention and control of convulsions
• Timing and route of delivery
• Postpartum Care
 Acute-Onset Severe Hypertension
Drug Dose and route
10-20mg IV, then 20-80mg every 20-30 minutes, maximum
Labetalol
of 300mg; 1 to 2mg/min IV
5mg IV or IM, then 5-10mg every 20-40 minutes; once BP
controlled repeat every 3 hours; for infusion: 0.5 to 10.0
Hydralazine mg/hr.
If no success with 20mg IV or 30mg IM, consider another
drug
10-20mg orally, repeat in 30 minutes if needed;
Nifedipine then 10-20mg PO every 2-6 hours
Max dose: 120mg/day
D5W 90ml + Nicardipine 10mg in soluset (0.1mg/ml)
Start drip at 10ugtts/min (equivalent to 1mg/hr)
IV Nicardipine
Titrate every hour (increments of 1 mg/hr)
Maximum dose 10mg/hr
 Oral Hypertensive Agents
Drug Dose and route

Labetalol 200-2,400 mg/daily orally 2-3 divided doses

Tablets recommended only

Nifedipine 10-20mg/tab PO q6H
Max dose: 120mg/day

Methyldopa 0.5-3g/day orally in 2-3 divided doses

 Magnesium Sulfate
Continuous intravenous
infusion
Loading Dose 4-6g in 100ml intravenous
fluid over 15-20 min
Maintenance 20g in 1000ml D5W or
Dose D5NM at 100ml/hr (2g/hr)
via infusion pump or soluset, buttocks until 24 hours
may be reduced to 1g/hr
until 24 hours postpartum
Intermittent intramuscular
injections
4g of 20% solution IV
then 5g of 50% solution
IM each buttocks
5g of 50% solution IM
every 4 hours alternate on
postpartum
 Magnesium Sulfate
 Monitoring  Levels
• Blood pressure • 4-7 meq/L – prevents eclamptic
• Patellar reflexes ++ convulsions

• RR > 12 cpm • 8-10meq/L – patellar reflexes

disappears
• UO > 100ml/4H (>30ml in 1
hour) • 12meq/L – respiratory
depression

• Serum magnesium level

Expectant Management

versus

Labor Induction
 Indications for Delivery
• Maternal Indications
• Recurrent severe hypertension
• Recurrent symptoms of severe
preeclampsia
• Progressive renal insufficiency
• Persistent thrombocytopenia or HELLP
syndrome
• Pulmonary edema
• Eclampsia
• Suspected abruptio placenta
• Progressive labor or rupture of membranes
• Fetal Indications
• Gestational age of 34 weeks
• Severe fetal growth restriction (<5th
percentile by ultrasound)
• Persistent oligohydramnios (maximum
vertical pocket <2cm)
• Biophysical profile (BPP) of 4/10 or less
on at least 2 occasions 6 hours apart
• REDF on umbilical artery Doppler
studies
• Recurrent variable or late decelerations
during NST
• Fetal death
TERMINATION OF PREGNANCY

IS THE ONLY CURE FOR

PREECLAMPSIA-ECLAMPSIA
 POSTPARTUM CARE
• Family planning
• BP and symptom monitoring
• Counselling
• Antihypertensive drug
• Review of medical care plan every 2-4 weeks
   BP ≥ 140/90 but < 160/110   BP ≥ 160/110
No severe feature Severe feature
No Convulsion Convulsion
  Outpatient   Inpatient
(admit if in labor)

Referral to higher Refer Referral to higher Refer Immediately

level care level care
Monitoring Maternal Monitoring Maternal
   BP 2-3x/week (if admitted, at least 4x/day); target < 135/85    BP every 15-30 minutes until <160/110, then at least 4x/day while
 Laboratory: CBC, renal function, liver function at presentation admitted; target < 135/85
then 1-2x/week  Monitor symptoms of severe hypertension at least every 8 hours
Fetal  Laboratory: CBC, renal function, liver function at presentation then
 FHT every visit 3x/week
 CTG if indicated Fetal
 UTZ at diagnosis, repeat every 2-4 weeks if indicated  FHT at least 1x every shift while admitted
 CTG at diagnosis then repeat if indicated
Advise to seek medical care immediately if severe features or  UTZ at diagnosis, repeat every 2 weeks
convulsions develop

Antihypertensive Labetalol PO> Nifedipine PO > Methyldopa PO

Antihypertensive Labetalol IV >Hydralazine IV/IM; Nicardipine drip
Drug Do not give ACEI/ARBS/Atenolol during pregnancy
Drug Nifedipine PO > Methyldopa PO
Do not give ACEI/ARBS/Atenolol during pregnancy
Anticonvulsant Not routinely given
Anticonvulsant Give MgSO4 until 24 hours postpartum
Antiplatelet therapy Moderate – high risk
Antiplatelet therapy Moderate – high risk
Timing and route of  Expectant management vs. Labor Induction Timing and route of  Expectant management vs. Labor Induction
delivery  Vaginal delivery vs. Cesarean Delivery
delivery  Vaginal delivery vs. Cesarean delivery

Postpartum Care  Counselling, family planning
 BP at least 4x/day while admitted, the 2-3x/week at home
 Advise to seek medical care immediately if with headache,
chest pain, dyspnea, abdominal pain, convulsion, BP ≥ 160/90
 Review medical care plan every 2-4 weeks
 Reduce or discontinue antihypertensive drug if
BP ≤ 130/90
 If still with proteinuria > 3mos postpartum – refer for a
specialist kidney assessment
Postpartum Care  Counselling, family planning
 BP at least 4x/day while admitted, the 2-3x/week at home
 Advise to seek medical care immediately if with headache, chest
pain, dyspnea, abdominal pain, convulsion, BP ≥ 160/90
 Review medical care plan every 2-4 weeks
 Reduce or discontinue antihypertensive drug if
BP ≤ 130/90
 If still with proteinuria > 3mos postpartum – refer for a specialist
kidney assessment
 REFERENCES
• Cummingham et al. Williams Obstetircs 25th edition. Copyright 2018. p
710-745
• Philippine Obstetrical and Gynecological Society (Foundation), Inc.
Clinical Practice Guidelines on Hypertension in Pregnancy, Third
Edition. Copyright 2015. ISBN 978-971-94602-6-8
• National Institute for Health and Care Excellence. Hypertension in
pregnancy: diagnosis and management. 2019
• Leeman L, Dresang L, Fontaine P. Hypertensive Disorders of Pregnancy.
Copyright 2016 American Academy of Family Physicians.
• The American College of Obstetricians and Gynecologist. Gestational
Hypertension and Preeclampsia. ACOG Practice Bulletin. 2019.