Hypertension in Pregnancy

N.L. Meyer, M.D.

Hypertension in Pregnancy
Most common medical disorder during pregnancy
Gestational hypertension preeclampsia
70 % of HTN in pregnancy
Wide spectrum
Mild elevation in BP vs severe hypertension
with organ dysfunctions
Acute gestational hypertension
Preeclampsia
Eclampsia
HELLP

Hypertension in Pregnancy
Chronic
Hypertension

Gestational
Hypertension

< 20 weeks

Third
trimester

20 weeks

Mild or severe

Mild

Mild or severe

Absent

Absent

Usually present

Uric acid > 5.5 mg/dl

Rare

Absent

Usually present

Hemoconcentration

Absent

Absent

Severe disease

Thrombocytopenia

Absent

Absent

Severe disease

Hepatic dysfunction

Absent

Absent

Severe disease

Clinical Findings
Onset
Degree
Proteinuria

Preeclampsia

Gestational Hypertension
Systolic BP 140 and /or diastolic 90 on at
least 2 occasions at least 6 hours apart after 20
weeks in women known to be normotensive
before pregnancy and before 20 weeks
gestation
BP recordings should be no more than 7 days
apart
Severe gestational hypertension
Sustained elevations in systolic BP 160
and /or diastolic BP 110 for 6 hours

Gestational Hypertension
Most frequent cause of HTN during
pregnancy
6 -17% in healthy nulliparous patients
2 - 4% in multiparous patients
Rates increase
Previous preeclampsia
Multifetal gestations

Gestational Hypertension
Progression
Gestational age at diagnosis
50% progression with diagnosis prior to 30
weeks
Severe hypertension
Preeclampsia
Eclampsia
Undiagnosed hypertension

Gestational Hypertension
Most cases develop 37 weeks
Overall outcome similar to or better than
normotensive pregnancies
Higher gestational age at delivery
Higher birth weight
Higher rates of induction
Higher cesarean section rates

Mild Gestational Hypertension

Gestational age

Kuinst
(n = 396)
NR

Hauth
Barton
(n = 715) (n = 405)
39.7
37.4

Sibai
(n = 186)
39.1

< 37 (%)

5.3

7.0

17.3

5.9

< 34 (%)

1.3

1.0

4.9

1.6

Birth weight (gm)

NR

3303

3038

3217

SGA (%)

1.5

6.9

13.8

7.0

< 2500 g (%)

7.1

7.7

23.5

NR

Abruption (%)

0.5

0.3

0.5

0.5

Perinatal death (%)

0.8

0.5

Mild Gestational Hypertension

Management
Increased risks for progression
Close maternal and fetal assessment

Mild Gestational Hypertension

Maternal Evaluation
Weekly prenatal visits
Reporting preeclamptic symptoms
Laboratory evaluation
CBC
Platelets
LFT's

Mild Gestational Hypertension

Fetal Evaluation
Amniotic fluid
Estimated weight
Weekly nonstress testing

Mild Gestational Hypertension

Management
Salt restriction not indicated
Restricted activity not indicated
Antihypertensive medication not indicated
Continue to term
Absence of progression
Seizure prophylaxis not indicated

Severe Gestational Hypertension

Increased maternal and perinatal morbidity
Outcomes similar to severe preeclampsia
Abruptio placentae
Preterm delivery
< 37 weeks
< 35 weeks
SGA infants
Manage as if they had severe preeclampsia

Severe Gestational HTN vs Severe Preeclampsia

Outcome

Relative risk

95% CI

Delivery <37 wk

0.81

0.53-1.24

Delivery <35 wk

0.7

0.32-1.56

SGA infant

1.83

0.56-5.71

Abruption

0.63

0.07-5.69

LGA infant

1.87

0.28-12.49

NICU admissions

0.55

0.23-1.31

RDS

0.75

0.21-2.63

Buchbinder et al AJOG 2002;186:66-71

Preeclampsia
Hypertension unique to human pregnancy
Rarely reported in primates
Incidence
3 - 7 % in nulliparas
0.8 - 5 % in multiparas
Significantly increased in multigestations

Risk Factors
Nulliparity

Preexisting medical conditions

Family history

CHTN

Obesity

Renal disease

Multifetal gestation

Diabetes

Previous preeclampsia

Thrombophilias

Previous poor outcome

APAS

IUFD

Protein S deficiency

IUGR

Protein C deficiency

Abruption

Factor V Leiden
Abnormal dopplers

Preeclampsia
Gestational hypertension plus proteinuria
300 mg / 24 hours
Classic triad
Hypertension
Proteinuria
Edema

Hypertension
Systolic blood pressure of 140 mm or diastolic
blood pressure of 90 mm after 20 weeks in a
previously normotensive women
"30 x 15" rule
30 mm SBP or 15 mm DBP over baseline
No longer used
Gradual rise in BP is seen in most normal
pregnancies
73% of primigravidas demonstrate >15 mm
increase in DBP during pregnancy
67% with SBP > 30 mm over baseline

Hypertension

Sensitivity

PPV

DPB 15 mm

39%

32%

SBP 30 mm

22%

33%

Villar and Sibai AJOG 1989;60:419

Hypertension
Korotkoff phase V
Appropriate size cuff
Length 1.5 x upper arm circumference
Bladder encircles > 80% of the arm
Upright position after 10 minutes rest
Hospitalized
Either sitting up or LLR position
Arm level with heart
No tobacco or caffeine x 30 minutes
Mercury sphygmomanometer preferred

Edema
No longer considered part of the diagnosis
Neither sufficient nor necessary to confirm
Common finding in normal pregnancies
1/3 of eclamptic women do not develop
edema

Proteinuria
300 mg / 24 hours
30 mg/dL or 1+ on dipstick on at least 2 random
samples at least 6 hours apart but < 7 days apart
Dipstick correlates poorly with protein in a 24-hr
collection*
1+ has PPV of 92% for 300 mg / 24-hr
Negative to trace has a NPV of only 34%
66% have > 300 mg / 24-hrs
Cannot exclude significant proteinuria
3+ to 4+ have PPV of 36%
Cannot confirm significant proteinuria
* Meyer et al AJOG 1994;170:137-41

Proteinuria

Urine protein / 24hrs

Neg

Tr

1+

2+

3+

4+

< 300

21

21

300 - 4999

37

44

42

38

22

24

5000

10

17

Meyer et al AJOG 1994;170:137-41

Proteinuria

Dipstick mg / 24-hrs Sensitivity Specificity PPV

NPV

> 1+

300

67

74

92

34

> 3+

5000

75

81

36

96

Meyer et al AJOG 1994;170:137

-41
1994;170:137-41

Proteinuria
Can preeclampsia occur without
proteinuria?
Consider preeclampsia when gestational
hypertension is associated with other
symptoms
Persistent cerebral symptoms
Epigastric or right upper quadrant pain
with nausea and vomiting
Thrombocytopenia
Abnormal liver enzymes
IUGR

Severe Preeclampsia
Severe gestational hypertension
associated with abnormal proteinuria
SBP 160 mm or DBP 110 mm on 2
occasions > 6 hours apart at bed rest
Hypertension in association with severe
proteinuria
5 g / 24 hours

Severe Preeclampsia
Multiorgan involvement
Pulmonary edema
Seizures
Oliguria
< 500 mL / 24 hours
Thrombocytopenia
< 100,000 / mm33
Abnormal LFT with persistent RUQ or
epigastric pain
Persistent severe CNS symptoms

Superimposed Preeclampsia
New onset proteinuria complicating
hypertension prior to 20 weeks gestation
Sudden increase in proteinuria
Sudden increase in hypertension
HELLP syndrome
CHTN with HA, scotomata or epigastric
pain

Management
Delivery is the only cure
Primary considerations
Safety of mother
Delivery of a live, mature newborn
Immediate delivery vs expectant management
Severity of disease process
Maternal / fetal status at initial evaluation
Gestational age
Labor
Bishop score
Maternal desire

Mild Preeclampsia - Management

Mild preeclampsia at term with favorable cervix
Delivery
Unfavorable cervix 37 weeks - ? Cervical ripening
Delivery 34 weeks
Progressive labor
ROM
Abnormal testing
IUGR
Deliver by 40 weeks even with unfavorable
conditions

Mild Preeclampsia - Management

Management < 37 weeks remains controversial
Maternal and fetal evaluation?
Hospitalization vs ambulatory management?
Antihypertensive medications?
Bed rest?

Maternal Evaluation
Frequent evaluation for progression of disease
Lab evaluation
Platelet count
LFT's
Renal function
Urine protein
Repeat weekly mild disease, no progression

Fetal Evaluation
Weekly antepartum fetal evaluation
Twice weekly testing with IUGR or oligohydramnios
Daily fetal movement assessment
Fetal growth evaluation

Outpatient Management
SBP 150mm / DBP 100mm
Urine protein 1000 mg/24 hours
Asymptomatic
Normal LFT's
Platelets 1000/mm3
Daily BP and urinalysis
Twice weekly evaluation
Growth and fluid assessment q 3 weeks
Hospitalize with disease progression

Antihypertensive Medication
Mask diagnosis of severe disease
Lower rates of progression to severe disease
No demonstrated impact on perinatal outcome
No difference in GA at delivery*
Reduction in BP has not been associated with a
reduction in antepartum days*
*Sibai

et al AJOG 1992;167:879

Bed Rest
No evidence that bed rest improves outcome
No randomized trials
Increased risk of thromboembolism

Magnesium Sulfate Prophylaxis

> 70 years of use
Intramuscular (Pritchard) and intravenous (Sibai)
regimes
"Standard of care" in the US
10 % progression to severe disease with
prophylaxis or placebo in 135 women at term*
12.8 % vs 16.8 % progression in a recent
controlled trial of MgSO44 vs placebo**
*Witlin, Friedman, Sibai AJOG 1997;176:623-7
**Livingston et al Ob Gyn 2003;101:217-220

Severe Preeclampsia
SBP 160mm or DBP 110mm on 2 occasions 6
hours apart at bed rest
Significant proteinuria ( 5 g/24 hr)
Oliguria < 500 mL / 24-h
Cerebral / visual disturbances
Epigastric pain, nausea, vomiting
Pulmonary edema, cyanosis
Abnormal LFT's
Thrombocytopenia
IUGR

Severe Preeclampsia
Hospitalization
MgSO4 prophylaxis
Antihypertensive medication
Maintain SBP 140-155mm and DBP 90-105mm
24-34 weeks
Steroids for lung maturity
Maternal assessment
Fetal assessment

Antihypertensive Medication
Hydralazine

Labetalol
Nifedipine

5 mg IV or 10 mg IM. Repeat at 20 min

intervals pending response. Repeat prn
when controlled (usually 3 hrs). Max dose
20 mg IV or 30 mg IM.
20 mg IV bolus initially, then 40, 80, 80 mg
every 10 minutes for max 220 mg. Caution
with asthma, CHF.
10 mg po. Repeat in 30 min if necessary.

HTN unresponsive to other drugs or

hypertensive encephalopathy. 0.25
Sodium Nitroprusside
g/kg/min to max 5 g/kg/min. Fetal
cyanide toxicity if used > 4 hrs.
National
National High
High Blood
Blood Pressure
Pressure Education
Education Program
Program Working
Working Group
Group on
on High
High Blood
Blood
Pressure
Pressure in
in Pregnancy.
Pregnancy. AJOG
AJOG 2000;183:S1-S22.
2000;183:S1-S22.

Antihypertensive Therapy
Prevent potential cerebrovascular and cardiovascular
complications
Encephalopathy, hemorrhage, CHF
No randomized trials to determine what level to treat
to prevent complications
Recommendations vary
SBP 180mm and DBP 110mm
SBP 160 mm or DBP 105mm
MABP 130mm
Sibai Ob Gyn 2003;102:181
Intrapartum SBP 170mm or DBP 110mm
Postpartum or thrombocytopenia SBP 160mm
or DBP 105mm

Severe Preeclampsia
Progressive deterioration in both maternal and
fetal conditions
Deliver with onset after 34 weeks
Increased rate of maternal morbidity/mortality
Significant fetal risk
Delivery prior to 34 weeks
Imminent eclampsia
Multiorgan dysfunction
Severe IUGR
Suspected abruption
Non-reassuring fetal testing

Severe Preeclampsia < 34 Weeks

Considerable disagreement
Delivery is definitive therapy
Delivery may not be optimal for the premature
fetus
34 weeks deliver
< 23 weeks offer termination
33 - 34 weeks steroids with delivery after 48-hrs
23 - 32 weeks gestation
Individualized treatment based on clinical
response during the initial 24 hours
observation

Chronic Hypertension
5 % of pregnant women
Hypertension before the 20thth week or before
pregnancy
Antihypertensive medication prior to pregnancy
Persistence beyond the usual postpartum period
Mild chronic hypertension
140 / 90 mm Hg
Severe chronic hypertension
180 / 110 mm Hg

Chronic Hypertension
Essential hypertension (90%)
Secondary hypertension (10%)
Renal
Connective tissue
Endocrine
Vascular

Chronic Hypertension
Risks
Superimposed preeclampsia
4.7 52% incidence
Abruption
Poor perinatal outcome
IUGR
IUFD
PTD

Low Risk Chronic HTN

Mild essential hypertension without organ
involvement
Blood pressure at initial visit regardless of
medication
BP < 180 / 110 mmHg
No previous perinatal losses

Low Risk Chronic HTN

Usually good perinatal outcome irrespective of
antihypertensive drugs
49% MAP
34% with no change in MAP
Most poor outcomes were related to superimposed
preeclampsia
Discontinue antihypertensive meds
Treat BP > 160 / 110 mmHg to keep DBP 105 mmHg
In absence of superimposed preeclampsia, pregnancy
may continue
Favorable cervix
Labor
Completion of 40 weeks

High Risk Chronic HTN

Secondary hypertension
Maternal age > 40
Duration HTN > 15 years
Target organ damage
Previous perinatal loss
BP 180 / 110 mmHg

High Risk Chronic HTN

Antihypertensive medication
Absent target organ damage
Maintain BP 140-150/90-100 (140-160/90-105)
Target organ damage
BP <140/90
Close monitoring
Fetal evaluation at 28 (as early as 26) weeks
Superimposed preeclampsia
Hospitalization
Delivery with GA 34 weeks

Medication for BP 180/110

Drug

Starting dose

Max dose

Acute treatment
Hydrazaline

5-10 mg IV q 20 min

30 mg

Labetalol

20-40 mg IV q 5-10 min 220 mg

Nifedipine

10-20 mg po q 30 min

50 mg

Methyldopa

250 mg bid

4 g/d

Labetalol

100 mg bid

2400 mg/d

Nifedipine

10 mg bid

120 mg/d

Thiazide diuretic

12.5 mg bid

50 mg/d

Long-term treatment

Superimposed Preeclampsia
Incidence 4.7 - 52% depending on initial BP
Exacerbation of HTN
At least 30 mm systolic or 15 mm diastolic
Development of proteinuria
500mg / 24 h
Exacerbation of preexisting proteinuria
5 g / 24 h
LFT's
platelets
uric acid > 6 mg / dL
Development of symptoms