Hypertension in Pregnancy: Classification, Risk Factors, and Management
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This document discusses hypertension in pregnancy, including classifications of hypertensive disorders, epidemiology and risk factors, predicting and diagnosing preeclampsia, assessing severity, chronic hypertension, gestational hypertension, management of preeclampsia and HELLP syndrome, and preconceptual counseling. It covers diagnostic criteria, monitoring, treatment including antihypertensive therapy and magnesium sulfate, timing of delivery, and postpartum care. Prevention strategies like low-dose aspirin are also reviewed.
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Hypertension in Pregnancy: Classification, Risk Factors, and Management
- 1. Hypertension in Pregnancy Dr.Rafi Rozan Obstetrician & Gynecologist Specialist in Comprehensive Family Medicine Medical Technologist
- 2. Classification of Hypertensive disorders • Preeclampsia-Eclampsia • Chronic Hypertension • Chronic Hypertension with Superimposed Preeclampsia • Gestational hypertension
- 3. Epidemiology and Risk factors • 1st degree relative (2-4x) • Previous pregnancy (7x) • Multiple gestation • AMA, DM, obesity, preexhisting HTN • IVF • History of thrombocytopenia • SLE
- 4. Predicting preeclampsia • Uterine artery doppler velocimetry -increased resistance to flow abnormal waveforms(increased resistance or pulsatility indices with persistence of diastolic notch) -low predicitve value alone • Biomarkers (angiogenesis related and placental protein 13)- none currently recommended. Future studies needed • Screening to predict preeclampsia beyond obtaining an appropriate medical history to evaluate for risk factors is not recommended
- 5. Preeclampsia-Eclampsia • Pregnancy specific hypertensive disease with multisystem involvement • >20w of gestation • Most common: HTN + Proteinuria • Without Protein: thrombocytopenia, impaired LFTs, the new development of renal insufficiency, pulmonary edema, cerebral or visual disturbances
- 7. Preeclampsia-Eclampsia • Hypertension: mild >140/90. at least 2 readings 4h apart. Severe >160/110 diagnosis can be confirmed within shorter interval to facilitate timely antihypertensive therapy • Proteinuria: 300mg in 24h, Protein:Creatinine ratio >0.3 on random void, 1+ dipstick • Eclampsia: convulsive phase • “mild preeclampsia” and “severe preeclampsia” are not specific classifications and should be replaced by preeclampsia with or without severe features
- 8. Assessing the severity of Preeclampsia
- 9. Establishing the diagnosis • Taking a BP -patient seated, legs uncrossed, back and arm supported -middle of the cuff on the upper arm at the level of the right atrium (midpoint of sternum) -pt to relax and not talk for 5 minutes prior to BP reading -wait several minutes before repeating if elevated -BP taken in upper arm with woman in left lateral position will be falsely low
- 10. Prediagnostic findings warranting increased surveillance • New onset headache, visual disturbance, RUQ pain, epigastric pain • New onset proteinuria in second half of pregnancy • Fetal growth restriction • Biochemical markers (uric acid) value of management of specific patients. Associated with poorer outcomes. Should not be used to support the initiation of specific interventions by themselves • Edema or rapid weight gain: nondiagnostic
- 11. Eclampsia • New onset grand mal seizures in woman with preeclampsia • Can occur before, during, or after labor • Differential: bleeding AV malformation, ruptured aneurysm, idiopathic seizure disorder • Alternative diagnosis may be more likely if seizures occur after 48-72h postpartum or when new seizures occur during use of antiepileptic therapy with magnesium sulfate
- 12. Chronic Hypertension • High BP known to predate conception • High BP detected before 20w
- 13. Chronic Hypertension with superimposed preeclampsia • Incidence preeclampsia 4-5x that in nonhypertensive pregnant women • Women with HTN who develop proteinuria after 20w and women who have proteinuria before 20w who: -Need to escalate antihypertensive treatment -increased LFTs -Plts <100,000 -RUQ pain or HA -Pulmonary edema -Cr >1.1 or doubled -sudden increase in proteinuria
- 14. Gestational Hypertension • New elevations in BP in the absence of proteinuria • Failure of BP to normalize postpartumchange diagnosis to chronic hypertension • Women with BP elevation to severe level have similar outcomes to women with preeclampsia • Require enhanced surveillance
- 15. Management of preeclampsia and HELLP syndrome • Initial Evaluation • CBC, Cr, LFTs • 24h urine protein collection or protein:creatinine ratio • Evaluate for symptoms • Fetal evaluation: EFW, AFI, NST • Continued evaluation: • Daily kick count • Fetal growth US q3w • AFI q week • NST q week (gHTN), NST twice weekly (Preeclampsia without severe features) • Twice weekly BP • Assess for proteinuria weekly (gHTN) • Weekly labs
- 16. Management of preeclampsia and HELLP syndrome • Antihypertensive Therapy: • Decrease progression to severe range BP • Increase fetal growth restriction • No effect on development of preeclampsia, eclampsia, pulmonary edema, fetal or neonatal death, preterm birth
- 17. Management of preeclampsia and HELLP syndrome • Intrapartum management • Timing of delivery 37w0d IOL -Lower risk of new onset severe features, HELLP syndrome, eclampsia -No difference neonatal morbidities or cesarean • Magnesium Sulfate -studies not powered to demonstrate signifcant reduction in eclampsia -routine magnesium sulfate not indicate in Preeclampsia without severe features • Antihypertensive therapy: BP>160/110. decrease CV, renal, cerebrovascular events -Labetalol or hydralazine -Nifedipine controversial: theoredical risk if on mag. Excessive hypotension and neuromuscular blockade
- 19. Management of preeclampsia and HELLP syndrome • Severe Preeclampsia • Progressive deterioration of maternal and fetal conditions if delivery not pursued • Delivery at 34w0d • Prompt delivery in pulmonary edema, renal failure, abruptio placenta, severe thrombocytopenia, DIC, persistent cerebral symptoms, nonreassuring fetal testing or fetal demise irrespective of GA less than 34w • Corticosteroids for fetal lung maturity: for women <34w, decrease RDS and IVH • Severe Proteinuria: resolution of renal dysfunction by 3 months. no difference in rates of eclampsia, placental abruption, pulmonary edema, HELLP, neonatal death/morbidity • Previable Preeclampsia should not be expectantly managed • Mode of delivery should be determined by fetal GA, fetal presentation, cervical status, maternal-fetal condition
- 20. Management of preeclampsia and HELLP syndrome • Eclampsia • Magnesium sulfate superior to phenytoin and diazepam • Continue mag for 24h after last convulsion • Loading 4-6g followed by 1-2g/hr • HELLP (hemolysis, abnormal LFTs, thrombocytopenia) • Delivery delayed for fetal steroids • Cochran review demonstrating inprovement of platelet levels following steroids, no improvement of morbidity/mortality
- 21. Management of preeclampsia and HELLP syndrome • Postpartum • BP decrease within 48h • BP increases again 3-6d PP • NSAIDs can raise BP suggest replacing if BP persistently elevated for 1d PP • Recommend BP monitoring for 72h PP and again 7- 10d PP • Antihypertensive therapy if BP> 150/100 on 2 occasions 4-6h apart • 24h mag for women with HTN and severe features
- 23. Chronic hypertension in pregnancy and superimposed preeclampsia • Uncomplicated cHTN higher rates of cesarean and PP hemorrhage • Superimposed preeclampsia 13-40% pregnancies with cHTN • Avoid ACEi, ARBs mineralicorticoids and statins • Initial eval: • baseline HELLP labs and urinalysis • ECHO if cHTN >4y • Home BP monitoring suggested. Ambulatory monitoring good to rule out white coat HTN
- 24. Chronic hypertension in pregnancy and superimposed preeclampsia • Initiate antihypertensive therapy for BP >160/105 • Suggested to maintain BP 120-160/80-105 • 10mmHg decrease in mean arterial pressure has been shown to decrease fetal weight by 145g • Medications in pregnancy: labetalol, nifedipine, methyldopa • Incidence SGA 8-15.5% (growth US, doppler PRN) • Deliver at 38w
- 25. Chronic hypertension in pregnancy and superimposed preeclampsia • Superimposed Preeclampsia • Without severe features: new proteinuria or increasing BP • Does not require antihypertensive therapy if BP <160/105 • Avoid mag • Superimposed preeclampsia with severe features • Expectantly managing <34w steroids • Magnesium for seizure prophylaxis(2.4%)
- 26. Prevention of Preeclampsia • Alterations in systemic prostacyclin-thromboxane balance • Inflammation increased • Meta-analysis 30,000 women from 31 trials: ASA modest benefit with RR 0.9 • Cochran review 59 trials and 37,000 women: 17% reduction with significant reduction in high risk patients • High risk women: cHTN, DM, previous preterm preeclampsia (number needed to treat=50) • Initiate in late 1Trimester for women with a medical history of early onset preeclampsia and preterm delivery less than 34w or Preeclampsia in more than 1 pregnancy
- 27. Prevention of Preeclampsia • Calcium supplementation (1.5-2g) may be considered in pregnant women from populations with low baseline calcium intake (less than 600mg/d) • Dietary salt should not be restricted. Meta analysis of 7,000 patients suggest diuretics do not reduce preeclampsia • Oxidative stress contributes to Preeclampsia: Vitamin C and Vitamin E with no benefit in prevention • Bedrest not recommended: further studies need examining exercise
- 28. References • ACOG task force: Hypertension in pregnancy • ACOG Committee opinion 623: Emergent therapy for acute onset, severe hypertension during pregnancy and the postpartum period