Hypertension
in
Pregnancy
Ramon M. Gonzalez, MD
Professor
UST Medicine and Surgery
A 26y/o G1 21-22 weeks known hypertensive
for 6 years was admitted because of severe
hypertension VS- BP-200/100mmHg,
PR- 76/min, RR-20/min, T-36.5C. She was
taking calcium channel blockers for her HPN
which she was taking regularly.
Hypertensive Disorders Complicating
Pregnancy
• Gestational Hypertension
– Systolic BP≥ 140 or diastolic ≥ 90 mmHg for the
first time after 20 weeks gestation
– No proteinuria
– BP returns to normal before 12 weeks postpartum
– Final diagnosis made only postpartum
– May have other signs or symptoms of
preeclampsia
Hypertensive Disorders Complicating
Pregnancy
• Preeclampsia
– Minimum criteria
• BP ≥ 140/90 mmHg after 20 weeks gestation
• Proteinuria ≥ 300mg/24 hours or ≥ 1+ dipstick
– Severe preeclampsia
•
•
•
•
•
BP ≥ 160/110 mmHg
Proteiunuria 2.0gms/24 hrs or ≥ 2+ dipstick
Serum creatinine > 1.2mg/dl
Platelets < 100,00/ul
Elevated LDH, ALT or AST
Hypertensive Disorders Complicating
Pregnancy
• Eclampsia
– Seizures that cannot be attributed to other causes in
women with preeclampsia
• Chronic Hypertension
– BP ≥ 140/90 mmHg before pregnancy or diagnosed
before 20 weeks gestation
– Hypertension first diagnosed after 20 weeks gestation
and persistent after 12 weeks postpartum
Hypertensive Disorders Complicating
Pregnancy
• Superimposed Preeclampsia
– New onset proteinuria ≥ 300mg/24 hrs in
hypertensive women but no proteinuria before 20
weeks gestation
Pregnancy 20-21 weeks,
Chronic Hypertension
Maternal Assessment
• Duration of
hypertension
• Current therapy
• Degree of BP
control
• Other medical
complications
Maternal Assessment
• Serum creatinine
• Quantification of
urine proteins
• ECG
• Echocardiography
• Blood chemistry
1. What are the effects of chronic
hypertension on pregnancy?
2. What is the management of chronic
hypertension during pregnancy?
3. Can we prevent superimposition of
preeclampsia ?
4. What is the management of chronic
hypertension with superimposed
preeclampsia?
What are the effects of chronic
hypertension on pregnancy?
ORs for Fetal Complications: 1995-2008
Pregestational Diabetes
------------------------------------------------------------------------------------------Variable
With Chronic HPN
W/O Chronic HPN
________________________________________________________
Stillbirth
4.30(3.81-4.85)
3.05(2.88-3.23)
Poor fetal growth
2.66(2.40-2.94)
1.20(1.14-1.27)
Spontaneous delivery
<37weeks
4.88(4.63-5.15)
2.90(2.83-2.90)
ORs for Maternal Complications: 1995-2008
Pregestational Diabetes
-------------------------------------------------------------------------------------------Variable
With Chronic HPN
W/O Chronic HPN
__________________________________________________________
Preeclampsia
CVA
13.96 (13.29-14.66)
3.80 (3.69-3.91)
7.14 (4.90-10.40 )
1.85 (1.41-2.44)
Acute renal failure
35.41 (28.39-44.16)
4.43 (3.57-5.48)
Pulmonary edema
11.97 (7.86-18.24)
4.01 (3.07-5.25)
Ventilation
11.87 (9.22-15.26)
3.34 (2.89-4.00)
5.75 (5.46-6.05)
3.33 (3.26-3.41)
6.02 (2.71-13.40)
2.58 (1.59-4.17)
Cesarean delivery
In- hospital mortality
ORs for Fetal Complications: 1995-2008
Chronic Renal Disease
------------------------------------------------------------------------------------------Variable
With Chronic HPN
W/O Chronic HPN
________________________________________________________
Stillbirth
7.29(5.59-9.52)
1.74(1.51-2.02)
Poor fetal growth
7.94(6.67-9.44)
2.29(2.12-2.49)
Spontaneous delivery
<37weeks
8.60(7.64-9.67)
2.25(2.15-2.35)
ORs for Maternal Complications: 1995-2008
Chronic Renal Disease
--------------------------------------------------------------------------------------------Variable
With Chronic HPN
W/O Chronic HPN
__________________________________________________________
Preeclampsia
27.87(24.85-31.25)
3.28(3.10-3.47)
13.73(6.63-28.44)
3.53(2.34-5.31)
Acute renal failure
253.4(199.5-321.9)
62.40(54.37-71.63)
Pulmonary edema
23.29(10.32-52.56)
9.06(5.84-14.06)
Ventilation
19.29(11.36-32.76)
8.25(6.43-10.60)
5.73(5.03-6.53)
1.74(1.68-1.81)
27.02(8.72-83.73)
6.88(3.56-13.29)
CVA
Cesarean delivery
In- hospital mortality
ORs for Fetal Complications: 1995-2008
Collagen Vascular Disease
------------------------------------------------------------------------------------------Variable
With Chronic HPN
W/O Chronic HPN
________________________________________________________
Stillbirth
7.42(5.37-10.25)
2.74(2.35-3.20)
Poor fetal growth
7.99(6.44-9.91)
3.87(3.55-4.22)
Spontaneous delivery
<37weeks
7.19(6.22-6.30)
3.15(2.98-3.33)
ORs for Maternal Complications: 1995-2008
Collagen Vascular Disease
--------------------------------------------------------------------------------------------Variable
With Chronic HPN
W/O Chronic HPN
__________________________________________________________
Preeclampsia
17.41 (15.09-20.09)
2.96 (2.76-3.18)
CVA
23.00 (11.47-46.14)
7.60 (5.26-10.97)
Acute renal failure
191.5 (141.4-259.4)
12.60 (8.88-17.88)
Pulmonary edema
15.52 (4.92-48.90)
6.08 (3.46-10.69)
Ventilation
26.29 (15.04-45.63)
11.09 (8.46-14.52)
4.38 (3.74-5.12)
1.89 (1.80-1.98)
88.81 (41.90-188.2)
23.81 (14.67-38.66)
Cesarean delivery
In- hospital mortality
What is the management of
chronic hypertension during pregnancy?
Management
• Blood pressure control
• Fetal antepartum surveillance
• Prevention of preeclampsia
• Detection of preeclampsia
Blood Pressure Control
• Ca Channel Blockers
• Adrenergic Blocking
Agents
• Vasodilators
• Diuretics
• ACE Inhibitors/ARB
– contraindicated
A randomized trial of tight vs. less tight control of mild
essential and gestational hypertension in pregnancy
• El Guindy, A.A. and Nabhan, A.F. (2008)
• Journal of Perinatal Medicine
• Women in the tight control group
– Were less likely to develop severe hypertension (RR 0.32,
95% CI 0.14 to 0.74)
– Delivered babies with older gestational ages (36.6 ±2.2
weeks vs 35.8 ± 2.2 weeks: P<0.05)
– Fewer preterm deliveries (RR 0.52, 95%CI 0.28 to 0.99)
– No significant differences between groups regarding
stillbirth or IUGR
Fetal Antepartum Surveillance
• Fetal biometry
• Nonstress test
• Contraction stress test
• Biophysical profile
• Doppler velocimetry
Can we prevent superimposition
of preeclampsia?
Preeclampsia
• Pregnancy specific syndrome that can affect
virtually every organ system.
• Disorder of unknown etiology affecting 5-10%
of all pregnancies.
• In developed countries 16% of maternal
deaths were due to hypertensive disorder.
• POGS (2006)- 26.24% maternal deaths were
due to hypertensive disorder.
Pathogenesis
• Vasospam
– Increased resistance → hypertension
– Endothelial cell damage → leakage of blood
constituents, including platelets and
fibrinogen
– Decreased blood flow → ischemia of tissues
→ necrosis, hemorrhage and other end
organ disturbances
Pathogenesis
• Endothelial cell activation
– Increased pressor responses
• Increased sensitivity to angiotensin II
– Prostaglandin
• Prostacyclin: thromboxane A2 ratio decreases
– Nitric oxide
• Decreased nitric oxide synthase expression
– Endothelins
• Potent vasoconstrictor which is increased in preeclampsia
Cardiovascular System
• ↑ Cardiac afterload
– hypertension
• ↑Cardiac preload
– Diminished hypervolemia
– ↑ intravenous crystalloids
• Extravasation of
intravascular fluid into the
extracellular space
– Pulmonary edema
Blood Volume and Coagulation
• Hemoconcentration
– Hallmark of preeclampsia
– Vasospasm and endothelial
leakage
• Thrombocytopenia
• Hemolysis
– Endothelial disruption
• HELLP syndrome
Kidneys
• ↓ Glomerular filtration rate
and renal plasma flow
• ↑ Serum creatinine
• ↑ Uric acid
• Proteinuria
• Oliguria
• “Glomerular capillary
endotheliosis”
• Acute renal failure
Liver
• Hepatic infarction
• Periportal hemorrhage
• Hepatocellular necrosis
• Elevations of AST/ALT
• Hepatic hematoma
• HELLP syndrome
Brain
• Headaches, visual
symptoms
• Convulsions
• Intracerebral
hemorrhage
• Cortical and subcortical
petechial hemorrhages
• Subcortical edema
Uteroplacental Perfusion
Vasospasm
↓
Decreased uteroplacental
perfusion
↓
Increased perinatal
morbidity and mortality
Prevention of Superimposed Preeclampsia
• Systematic Review by Duley et al
• 59 trials with 37,560 women given Aspirin
– 17% reduction in the risk of preeclampsia (RR 0.83,
077-0.89), especially in high risk patients
– 8% reduction in the relative risk of preterm birth
(RR 0.92, 0.88-0.97)
– 14% reduction in fetal and neonatal deaths (RR
0.86, 0.76-0.98)
– 10% reduction in SGA babies (0.90, 0.83-0.98)
Detection of Preeclampsia
• BP monitoring
• 24 hour urine
proteins
What is the management of chronic
hypertension with superimposed
preeclampsia?
Management
• Termination of
pregnancy with the
least possible trauma to
mother and baby
• Birth of an infant who
subsequently thrives
• Complete restoration of
health to the mother
Severe Preeclampsia
• Clinical course is progressive
deterioration in both maternal and fetal
condition
• Associated with high rates of maternal
and perinatal morbidity and mortality
Management of Severe Preeclampsia
• Aggressive
- High neonatal mortality
and morbidity due to
prematurity
- Prolonged NICU stay
- Long term disability
• Expectant
- Fetal death
- Asphyxial damage in
utero
- Increased maternal
morbidity
Odendaal and associates
•
•
•
•
•
Aggressive vs expectant management
58 patients, 20 were delivered w/in 48 hours
20 aggressive, 18 expectant
28-34 weeks
Betamethasone, MgSO4, Antihypertensive
drugs
• Maternal and fetal testing
Sibai and colleagues
•
•
•
•
•
Aggressive vs expectant management
28-32 weeks
95 patients
Aggressive (n=46); expectant (n=49)
Bed rest, antihypertensives, MgSO4,
betamethasone, maternal and fetal testing,
laboratory exams
Expectant Management
•
•
•
•
•
•
Prolongs pregnancy
Higher gestational age
Higher birth weight
Lower incidence of admission to NICU
Lower incidence of neonatal complication
No difference in the incidence of CS,
abruptio placenta, HELLP syndrome and
postpartum stay
Guidelines for Expectant Management
• Hospitalization in a tertiary hospital
- Good facilities to monitor the mother and fetus
- NICU facilities
- Trained personnels
• MgSO4
• Antihypertensives
• Corticosteroids
Maternal Assessment
Maternal Assessment
• Blood pressure measurement
- Systolic – 140 – 155 mmHG
- Diastolic – 90 – 105 mmHG
• Daily 24 hour urine volume
• Maternal symptoms
• Search for imminent signs of eclampsia
Sibai et al AmJOG 2007
Maternal Assessment
• CBC with platelet counts
• Serum creatinine
• Liver function test
– AST/ALT
– Lactate dehydrogenase
Sibai et al AmJOG 2007
Fetal Assessment
Fetal Assessment
• Fetal kick counts
• NST
• Biophysical profile
scoring
• Umbilical artery
Doppler studies
• Assessment of fetal
growth
Maternal Indications for Delivery in
Women With Severe Preeclampsia
• Persistent severe headache or visual changes;
eclampsia
• Pulmonary edema
• Uncontrolled severe HPN
• Epigastric pain/RUQ pain with AST or ALT >2
times the upper limit of normal
Sibai et al AmJOG 2007
Maternal Indications for Delivery in
Women With Severe Preeclampsia
•
•
•
•
Oliguria (<500ml/24hr)
HELLP syndrome
Platelet counts <100,000/mm3
Deterioration of renal function
(serum creatinine >/=1.5 mg/dl)
• Suspected abruptio placenta, progressive labor,
and/or rupture of membranes
Sibai et al AmJOG 2007
Fetal Indications For Delivery In Women
With Severe Preeclampsia
• Repetitive late or severe variable deceleration
• Biophysical profile </=4 on 2 occasions at 6 hours
apart
• IUGR (Estimated fetal weight <5th percentile)
• Umbilical artery Doppler with reverse end
diastolic flow
• Severe oligohydramnios
Sibai et al AmJOG 2007
Mode of Delivery
• Vaginal delivery
- Inducible cervix
- No fetal distress
• Cesarean section
Thank You