Cardiovascular Management of
Hypertension during Pregnancy
Ma. Rosario Cruz Sevilla, MD, FPCP, FPCC
Asian Hospital and Medical Center
UPHDMC Heart and Vascular Institute, Las Pinas
Normal Physiologic Changes
23 May 2012
MRCSevilla MD
Normal Physiologic Changes
23 May 2012
MRCSevilla MD
Normal Physiologic Changes
LABOR AND DELIVERY
 Uterine contraction = 500 ml blood released – increased
CO & BP
 CO - >=50% above baseline at stage 2 labor
 Blood loss – 400 cc in NSD; 800 ml in CS
POSTPARTUM
 Abrupt increase in venous return due to:
 Autotransfusion from uterus – 24-72 hours
 Loss of fetal compression on IVC
23 May 2012
MRCSevilla MD
Hypertension in Pregnancy (ESC 2011)
Major cause of maternal, fetal, and neonatal
morbidity and mortality in developing and in
developed countries
•
• Hypertension is the most common medical
problem in pregnancy, complicating up to 15% of
pregnancies and accounting for about a quarter of
all antenatal admissions
23 May 2012
MRCSevilla MD
PHILIPPINE HEALTH STATISTICS
Total Number of Live Births
2008 : 1,920,098
2007: 1,858,361
2006: 1,770,735
23 May 2012
MRCSevilla MD
PHILIPPINE HEALTH STATISTICS
2006 Maternal Mortality Data
TOTAL: 1,721 deaths
CAUSES
1. Complications related to pregnancy occuring in the course of labor, delivery and
puerperium
N=732 (0.4/1000 Livebirths; 42.5%)
2. Hypertension complicating pregnancy, childbirth and puerperium
N=565 (0.3/1000 Livebirths; 32.8%)
N=510 (0.3/1000 livebirths; 29.4%) 2005
3. Postpartum Hemorrhage
N=261 (0.2/1000; 15.2%)
4. Pregnancy with abortive outcome
N=163 (0.1/1000; 9.5%)
5. Hemorrhage in early pregnancy
N=0
23 May 2012
MRCSevilla MD
Hypertension in Pregnancy (ESC 2011)
•These women are at higher risk for severe Cx
such as abruptio placentae, cerebrovascular
accident, organ failure, and disseminated
intravascular coagulation
• The fetus is at risk for intrauterine growth
retardation, prematurity, and intrauterine death
23 May 2012
MRCSevilla MD
Case 1:
 26/Female
 Known
hypertensive for 6 years
 On maintenance calcium channel
blockers
 usual BP = 130/80
23 May 2012
MRCSevilla MD
Case 1:




23 May 2012
26/Female
Known hypertensive for 6 years (diagnosed at age
20 – what was highest BP ever recorded? Was
secondary hypertension considered? What were the
results of any prior cardiovascular work-ups?)
On maintenance calcium channel blockers (which
CCB? What dose?)
usual BP = 130/80 (on meds?)
MRCSevilla MD
Case 1:




23 May 2012
26/Female
Known hypertensive for 6 years
G1 21-22 weeks
admitted due to severe HPN
 BP- 200/100mmHg
 PR-76/min
 RR-20/min
 T-36.5C.
MRCSevilla MD
Case 1:




26/Female
Known hypertensive for 6 years
G1 21-22 weeks (first consult or with prior prenatal
check-up? What was previous BP readings during
1st trime?)
admitted due to severe HPN




23 May 2012
BP- 200/100mmHg
PR-76/min
RR-20/min
T-36.5C.
MRCSevilla MD
Hypertension in Pregnancy (ESC 2011)
Basic lab exams recommended include:
• urinalysis (check for proteinuria)
• blood count, haematocrit,
• liver enzymes
• serum creatinine,
• serum uric acid
• Adrenal UTZ and urine metanephrine &
normetanephrine assays may be considered to exclude
pheochromocytoma w/c may be asymptomatic and, if not
diagnosed before labour, fatal.
•
23 May 2012
MRCSevilla MD
Hypertension in Pregnancy (ESC 2011)
•Definition and classification:
-based on absolute BP values
(SBP ≥140 mmHg or DBP ≥90 mmHg)
and distinguishes :
-Mildly elevated BP (140–159/90–109 mmHg)
or
-Severely elevated BP (≥160/110 mmHg)
in contrast to the grades used by the ESH/ESC,
or others
23 May 2012
MRCSevilla MD
Hypertension in Pregnancy (ESC 2011)
Hypertension in pregnancy - not a single entity
but is composed of:
•pre-existing hypertension
•gestational hypertension
•pre-existing hypertension plus superimposed
gestational hypertension with proteinuria
•antenatally unclassifiable hypertension
•
23 May 2012
MRCSevilla MD
Hypertension in Pregnancy (ESC 2011)
Hypertension in pregnancy - not a single entity
but is composed of:
•pre-existing hypertension
•gestational hypertension
•pre-existing hypertension plus superimposed
gestational hypertension with proteinuria
•antenatally unclassifiable hypertension
•
23 May 2012
MRCSevilla MD
Hypertension in Pregnancy (ESC 2011)
 Pre-existing
Hypertension
 1-5% of pregnancies
 BP>=140/90 that precedes or occurs
before 20 wks AOG
 Usually persists >42 days postpartum
 May be associated with Proteinuria
23 May 2012
MRCSevilla MD
Hypertension in Pregnancy (ESC 2011)

Gestational Hypertension
 Complicates 6-7% of pregnancies
 Develops after 20 wks AOG and resolves
within 42 days
 Pregnancy-induced hypertension +/proteinuria; If with proteinuria (>=0.3g/day in
24H urine collection or >=30mg/mmol urinary
creatinine in spot random urine sample), it is
known as Preeclampsia
23 May 2012
MRCSevilla MD
Hypertension in Pregnancy (ESC 2011)

Preeclampsia
 De novo onset of HPN w new onset significant
proteinuria >0.3gm/24H
 Complicates 5-7% of pregnancies but may go up to
25% in women w preexisting HPN
 Occurs usually in 1st pregnancy, multiple fetuses,
H.mole, Diabetes
 Causes placental insufficiency – IUGR, most
common cause of prematurity, accounting for 25% of
LBW infants
23 May 2012
MRCSevilla MD
Hypertension in Pregnancy (ESC 2011)
Severe Preeclampsia
– Signs & Symptoms
 RUQ/epigastric pain due to liver edema+/- hepatic
hemorrhage
 HA +/- visual disturbance (cerebral edema)
 Occipital lobe blindness
 Hyperreflexia +/- clonus
 Convulsions (cerebral edema)
 HELLP syndrome (hemolysis, elevated liver
enzymes, low platelet count)

23 May 2012
MRCSevilla MD
Hypertension in Pregnancy (ESC 2011)

Pre-existing Hypertension plus Superimposed
Gestational Hypertension with Proteinuria
 Worsening BP & proteinuria after 20 wks AOG

Antenatally Unclassifiable Hypertension
 When BP is first recorded after 20 wks AOG & HPN
is diagnosed; needs reassessment at or after 42 wks
pospartum
23 May 2012
MRCSevilla MD
Case 1:




23 May 2012
26/Female
Known hypertensive for 6 years (diagnosed at age
20 – was secondary hypertension considered? What
were the results of any prior cardiovascular workups?)
On maintenance calcium channel blockers
usual BP = 130/80
MRCSevilla MD
Hypertension (ESC/ESH 2007)

Secondary Hypertension
 suggested by:
 severe
blood pressure elevation
 sudden onset or worsening of hypertension
 blood pressure responding poorly to drug therapy
23 May 2012
MRCSevilla MD
Hypertension (ESC/ESH 2007)

Secondary Hypertension

23 May 2012
Etiologies:
 Renal Parenchymal Disease – most common
 Renovascular HPN – 2nd most common
 Phaeochromocytoma – rare (0.2-0.4%)
 Primary Aldosteronism – HPN w hypoK
 Cushing’s Syndrome – typical habitus
 Obstructive Sleep Apnea - overweight
 Coarctation of the Aorta - rare
 Drug-Induced HPN - licorice, oral contraceptives,
steroids, NSAIDS, cocaine & amphetamines,
erythropoietin, cyclosporins,
tacrolimus.
MRCSevilla MD
Case 1:




23 May 2012
26/Female
Known hypertensive for 6 years – probably
G1 21-22 weeks
admitted due to severe HPN
 BP- 200/100mmHg
 PR-76/min
 RR-20/min
 T-36.5C.
MRCSevilla MD
Hypertension in Pregnancy (ESC/ESH 2011)

Non-Pharmacological Management:
 Most women with pre-existing HPN in
pregnancy:
have mild to moderate hypertension (140–
160/90–109 mmHg)
are at low risk for cardiovascular
complications within the short time frame of
pregnancy.

23 May 2012
MRCSevilla MD
Hypertension in Pregnancy (ESC/ESH 2011)

Non-Pharmacological Management:
 Women with essential HPN & normal renal function
good maternal and neonatal outcomes
 candidates for non-drug therapy
 there is no evidence that pharmacological treatment
results in improved neonatal outcome.


23 May 2012
Some women with treated pre-existing hypertension
are able to stop their medication in the first half of
pregnancy because of the physiological fall in BP
during this period.
MRCSevilla MD
Hypertension in Pregnancy (ESC/ESH 2011)

Pharmacological Management:
 Drug treatment of severe HPN in pregnancy
is required and beneficial, yet treatment of
less severe hypertension is controversial.
 Although it might be beneficial for the mother
with hypertension to reduce her BP, a lower
BP may impair uteroplacental perfusion and
thereby jeopardize fetal development.
23 May 2012
MRCSevilla MD
Hypertension in Pregnancy (ESC/ESH 2011)

Pharmacological Management:
 Women with pre-existing HPN

may continue current meds except for ACE inhibitors,
ARBs, and direct renin inhibitors, which are strictly
contraindicated in pregnancy because of severe
fetotoxicity, particularly in the 2nd/3rd trimesters
a-Methyldopa is the drug of choice for long-term
treatment of HPN during pregnancy.
 The alpha & beta blocker labetalol has efficacy
comparable with methyldopa. If w severe HPN, it can
be given IV
 Metoprolol is also
recommended
23 May 2012
MRCSevilla MD

Hypertension in Pregnancy (ESC/ESH 2011)

Pharmacological Management:




23 May 2012
CALCIUM CHANNEL BLOCKERS such as nifedipine
(oral) or isradipine (i.v.) are drugs of second
choice for HPN treatment
 can be given in hypertensive emergencies or in
hypertension caused by pre-eclampsia.
Potential synergism with MAGNESIUM SULFATE
may induce maternal hypotension and fetal
hypoxia.
MAGNESIUM SULFATE IV -drug of choice for
treatment of seizures and prevention of
eclampsia.
Diuretics should be AVOIDED because they may
decrease blood flow in the placenta.
MRCSevilla MD
Hypertension in Pregnancy (ESC/ESH 2011)

Pharmacological Management:
 In Mild to Moderate HPN
 Current ESH/ESC guidelines recommend SBP = 140
mmHg or DBP = 90 mmHg as therapeutic thresholds
for treatment in women with:
 gestational HPN (+/- proteinuria)
 pre-existing HPN with superimposed gestational
HPN
 HPN with subclinical organ damage or symptoms
at anytime during pregnancy.
23 May 2012
MRCSevilla MD
Hypertension in Pregnancy (ESC/ESH 2011)

Pharmacological Management:
 Otherwise, ESH/ESC thresholds are SBP= 150
mmHg & DBP = 95 mmHg.
 In Severe hypertension
 SBP ≥170 mmHg or DBP≥110 mmHg in a
pregnant woman is an EMERGENCY, and
hospitalization is indicated.
 The selection of the antihypertensive drug and its
route of administration depend on the expected
time of delivery.
23 May 2012
MRCSevilla MD
Hypertension in Pregnancy (ESC/ESH 2011)

Pharmacological Management:
 Treatment of severe hypertension
 IV labetalol, or oral methyldopa, or nifedipine should
be initiated.
 IV HYDRALAZINE is no longer the drug of choice as
its use is associated with more perinatal adverse
effects than other drugs.
 drug of choice – NA NITROPRUSSIDE - but
Prolonged treatment with sodium nitroprusside is
associated with an increased risk of fetal cyanide
poisoning as nitroprusside is metabolized into
thiocyanate and excreted into urine.
23 May 2012
MRCSevilla MD
Hypertension in Pregnancy (ESC/ESH 2011)

Pharmacological Management:
 The drug of choice in PRE-ECLAMPSIA
ASSOCIATED WITH PULMONARY OEDEMA
- Nitroglycerine (glyceryl trinitrate),
given as an IV infusion of 5 mg/min and
gradually increased every 3–5 min to a
maximum dose of 100 mg/min.
23 May 2012
MRCSevilla MD
Hypertension in Pregnancy (ESC 2011)


Severe Preeclampsia – Management:
focuses on RECOGNITION of condition and,
ultimately, DELIVERY OF THE PLACENTA,
which is curative.
As proteinuria may be a late sign of preeclampsia, it should be suspected when de
novo HPN is accompanied by symptoms (HA,
visual disturbances, abdominal pain, or
abnormal laboratory tests - low platelet count
and abnormal liver enzymes; it is
recommended to treat such patients as having
pre-eclampsia.
23 May 2012
MRCSevilla MD
Long-Term Prognosis


Studies have shown that Women who
develop hypertension in pregnancy have
increased risk for future Cardiovascular
Morbidity and Mortality
Women must be informed about
appropriate preventive measures and
should be followed on the long term
23 May 2012
MRCSevilla MD
DRUG THERAPY FOR
HYPERTENSION IN PREGNANCY
(ESC2011)
Recommendation
Class
Level
Non-pharmacological
management for pregnant
women with SBP of 140-150
mmHg or DBP of 90-99 mmHg
is recommended.
I
C
23 May 2012
MRCSevilla MD
DRUG THERAPY FOR
HYPERTENSION IN PREGNANCY
(ESC2011)
Recommendation
Class
Level
In gestational HPN or preexisting HPN superimposed by
gestational HPN or with HPN &
subclinical organ damage or
symptoms at any time during
pregnancy, start drug Rx at BP140/90mmHg. Otherwise, start
drug treatment if SBP ≥150
mmHg or DBP ≥95 mmHg.
I
C
23 May 2012
MRCSevilla MD
DRUG THERAPY FOR
HYPERTENSION IN PREGNANCY
(ESC2011)
Recommendation
Class
SBP ≥170 mmHg or DBP
≥110 mmHg in a pregnant
woman is an emergency, &
hospitalization is
recommended.
I
23 May 2012
MRCSevilla MD
Level
C
DRUG THERAPY FOR
HYPERTENSION IN PREGNANCY
(ESC2011)
Recommendation
Class
Level
Induction of delivery is
recommended in
gestational HPN with
proteinuria with adverse
conditions such as visual
disturbances,coagulation
abnormalities, or fetal
distress.
I
C
23 May 2012
MRCSevilla MD
DRUG THERAPY FOR
HYPERTENSION IN PREGNANCY
(ESC2011)
Recommendation
Class
In pre-eclampsia
associated with pulmonary
oedema, nitroglycerine
given as an IV infusion, is
recommended.
I
23 May 2012
MRCSevilla MD
Level
C
DRUG THERAPY FOR
HYPERTENSION IN PREGNANCY
(ESC2011)
Recommendation
Class
Level
In severe HPN, drug
treatment with IV
labetalol or oral
methyldopa or
nifedipine is
recommended.
I
C
23 May 2012
MRCSevilla MD
DRUG THERAPY FOR
HYPERTENSION IN PREGNANCY
(ESC2011)
Recommendation
Class Level
Women with pre-existing
HPN should be considered to
continue their current
medication except for ACE
inhibitors, ARBs, and direct
renin inhibitors under close
BP-monitoring
IIa
23 May 2012
MRCSevilla MD
C
DRUG THERAPY FOR
HYPERTENSION IN PREGNANCY
Drug
Example
Comment
α2-adrenergic
blockers
Methyldopa
Most commonly used.
Safety is well established.
Drug of choice
Atenolol,
Beta-blockers Metoprolol
Appear safe.
W Case reports of fetal
bradycardia, growth
retardataion.
α, β blockers
Appears effacious.
Very scant safety data.
23 May 2012
Labetolol
MRCSevilla MD
DRUG THERAPY FOR
HYPERTENSION IN PREGNANCY
Drug
Example
Arteriolar
vasodilators
Hydralazine
ACE inhibitors
Captopril
Calcium
channel
blockers
Diltiazem
23 May 2012
MRCSevilla MD
Comment
Effacacious and safe
during pregnancy and
lactation.
Absolutely contraindicated
during pregnancy due to
fetal toxicity.
Appear safe, but not as
much data to support
their use.
DRUG THERAPY FOR
HYPERTENSION IN PREGNANCY
Drug
Diuretics
Example
Comment
Furosemide
Appears safe, but limited
efficacy.
Sodium
nitroprusside
Avoid in pregnancy due
to potential for fetal
thiocyanate toxicity
Magnesium
sulfate
Treatment of choice for
prevention of ecclamptic
seizures.
23 May 2012
MRCSevilla MD
DRUG THERAPY FOR
HYPERTENSION IN PREGNANCY
Drug
ACEI
23 May 2012
Use
Potential Side Effects Safe
Breast
feeding
HPN
Oligohydramnios,
IUGR, PDA,
prematurity,
neonatal
hypotension, renal
failure, anemia,
death,
musculoskeletal
abnormalities
OK
MRCSevilla MD
No
DRUG THERAPY FOR
HYPERTENSION IN PREGNANCY
Drug
Betablock
ers
23 May 2012
Use
Potential Side Effects
Breast
Safe feeding
HPN
Fetal bradycardia, low
birth weight,
hypoglycemia,
respiratory depression;
prolonged labor
Yes
MRCSevilla MD
Ok
DRUG THERAPY FOR
HYPERTENSION IN PREGNANCY
Drug
Use
Diuretics HPN
Na
Nitropru
sside
HPN
Nitrates
HPN
23 May 2012
Potential Side
Effects
Safe
Reduced uteroplacental perfusion
Unclear Ok
Fetal thiocyanate
toxicity
Potenti
ally
unsafe
No data
Yes
No data
Fetal distress with
maternal
hypotension
MRCSevilla MD
Breast
feeding
CRITICAL PERIODS
when caring for Gravidocardiacs
12-20 weeks AOG
28-4-36 weeks AOG
Labor
Postpartum Period
23 May 2012
MRCSevilla MD
Hypertension

Preeclampsia





23 May 2012
50% of patients w/ Gestational HPN
25% of patients with chronic HPN
More common in primipara & twin
pregnancies
Theory: endothelial dysfxn affecting
placental spiral arteries
HPN, vasospasm, reduced end organ
perfusion, activated coagulation
MRCSevilla MD