2. Introduction
Most common medical complication of pregnancy
6 to 8 % of gestations in the US.
In 2000, the National High Blood Pressure
Education Program Working Group on High Blood
Pressure in Pregnancy defined four categories of
hypertension in pregnancy:
◦ Chronic hypertension
◦ Gestational hypertension
◦ Preeclampsia
◦ Preeclampsia superimposed on chronic hypertension
3.
4. Chronic Hypertension Defined
Chronic hypertension is hypertension
diagnosed prior to gestational week 20 or
presence of hypertension preconception, or
de novo hypertension in late gestation that
fails to resolve postpartum.
( CPG hypertension 4th edition)
- Persisting beyond 12 weeks postpartum
Causes
Primary = “Essential Hypertension”
Secondary = Result of other medical condition
(ie: renal disease
5. complication: severe HTN (HTN crisis,
risk of stroke), IUGR, abruptio placenta
(premature separation of the placenta
from the uterus) .
6. High risk factors indicating poor
outcome
Diastolic BP 85 or greater in repeated
observations 6hrs apart after 14weeks of
GA.
H/O severe HTN in previous pregnancies.
h/o abruption
h/o stillbirth or unexplained neonatal death.
h/o IUGR
AGE > 35yrs or chronic HTN of >15yrs
duration
Marked obesity
Secondary HTN
7. Prenatal Care for Chronic
Hypertensives
◦ Electrocardiogram should be obtained in
women with long-standing hypertension.
◦ Baseline laboratory tests
◦ Urinalysis, urine culture, and serum creatinine,
glucose, and electrolytes
◦ Tests will rule out renal disease, and identify
comorbidities such as diabetes mellitus.
◦ Women with proteinuria on a urine dipstick
should have a quantitative test for urine protein.
antenatal visits every 2 weekly until 32
wks & then every weekly.
8. Treatment for Chronic
Hypertension
Avoid treatment in women with
uncomplicated mild essential HTN as blood
pressure may decrease as pregnancy
progresses.
May taper or discontinue meds for women
with blood pressures less than 120/80 in 1st
trimester.
Reinstitute or initiate therapy for persistent
diastolic pressures >95 mmHg, systolic
pressures >150 mmHg, or signs of
hypertensive end-organ damage.
Excessively lowering blood pressure may
result in decreased placental perfusion and
9. Treatment of Chronic
Hypertension
Methyldopa , labetalol, and nifedipine most
common oral agents.
AVOID: ACEI and ARBs, atenolol, thiazide
diuretics
Women in active labor with uncontrolled
severe chronic hypertension require
treatment with intravenous labetalol or
hydralazine.
No other additional maternal/fetal
complications = wait until > 38w
10. Gestational HTN
Prevalence 6-15% in nulliparas & 2-4% in
multiparas
50% of women diagnosed with gestational
hypertension between 24 and 35 weeks develop
preeclampsia.
Gestational hypertension is defined as hypertension
detected for the first time after 20 weeks pregnancy.
The definition is changed to “transient” when pressure
normalizes postpartum.
( CPG hypertension 4th edition)
- absence of proteinuria
- returning to normal within 12 weeks after delivery.
11. Early : before 30wks, frequently
severe, advances to preeclampsia and
has a guarded perinatal prognosis.
Late : after 30wks, frequently in obese
women and multiple pregnancies, due
to poor maternal adaptation to
physiological changes in pregnancy.
12. Conti..
Criteria to identify high risk
women with gestational HTN :
1. BP > 150/100 mm Hg.
2. GA < 30wks
3. Evidence of end organ damage
4. Oligohydramnios
5. Fetal growth restriction
6. Nullipara, Age > 35yrs, BMI > 35
kg/m2
13. Management of Hypertension in
Pregnancy
Depends on severity of hypertension
and gestational age
Observational Management
Restricted activity
Close Maternal and Fetal Monitoring
BP Monitoring
S/S of preeclampsia
Fetal growth and well being (U/S)
Routine weekly or biweekly blood work =
platelets, LFTs, creatinine.
14. Management of Hypertension in
Pregnancy
Medical Management
Acute Therapy = IV Labetalol, IV Hydralazine
Expectant Therapy = Oral Labetalol, Methyldopa,
Nifedipine
Eclampsia prevention = MgSO4
Contraindicated antihypertensive drugs
ACE inhibitors
Angiotensin receptor antagonists
16. Proceed with Delivery
Vaginal Delivery VS Cesarean Section
Depends on severity of hypertension
May need to administer antenatal
corticosteroids depending on gestation
17. Chronic hypertension
superimposed preeclampsia
diagnosed in the presence of any of the
following, in a woman with chronic
hypertension:
i. De novo proteinuria after 20 week gestation
ii. A sudden increase in the severity of
hypertension
iii. Appearance of features of preeclampsia-
eclampsia
iv. A sudden increase in proteinuria in women
who have pre-existing proteinuria early in
18. Chronic Hypertension with Superimposed
Preeclampsia
Hypertension and new findings:
Without severe features:
- hypertension and proteinuria only
- proteinuria: new onset or worsening
With severe features
- hypertension +/- proteinuria + severe
features
19. CHTN with Superimposed Preeclampsia:
management
Without severe features
- stable maternal and fetal status
- delivery : > 37 w
With severe features
- magnesium sulfate is recommended
- delivery : < 34 w and stable maternal/fetal
status
- expectant management at tertiary center
20. CHTN with Superimposed Preeclampsia:
Delivery
Deliver if any of following at any gestational age
- uncontrollable severe hypertension
- eclampsia
- pulmonary edema
- abruption
- DIC
- nonreassuring fetal status
21. Key Points in Primary Care
Practice
Preconception counseling and adjustment of treatment in
women with chronic hypertension.
Women with chronic hypertension may require a change in
the type of antihypertensive agent used pre-pregnancy.
The drugs of choice in pregnancy are still methyldopa and
labetalol .
Atenolol has been shown to lead to fetal growth restriction.
The use of ARBs, ACEIs and thiazide diuretics are
associated with fetal anomaly and are therefore
contraindicated in pregnancy.
Pregnant women with uncomplicated chronic hypertension
should have their BP kept lower than 150/100 mmHg.
in the presence of target organ damage secondary to
chronic hypertension, the aim is to maintain the BP below
22. References
Hypertension in Pregnancy: Report of the American College of
Obstetricans and Gynecologists’ Task Force on Hypertension in
Pregnancy. ACOG, 2013.
Lockwood, CJ. ACOG task force on hypertension in pregnancy
(editorial). Contemporary Ob/Gyn. December 2013.
CPG hypertension 4th edition
