Chronic Hypertension HTN and Pregnancy

Defined as hypertension that antecedes pregnancy:

Mild: Systolic > 140 mm Hg and/or diastolic > 90 mm Hg Severe: Systolic > 160 mm Hg and/or diastolic > 110 mm Hg

If during pregnancy a chronic hypertensive patient's systolic blood pressure (BP) rises by 30 mm Hg or diastolic rises by 15 mm Hg, it is pregnancy-induced hypertension superimposed on chronic hypertension.

Diagnose HTN BP > 140/90 at rest, measured at least twice, and > 6 hours apart. (sustained T in BP)

History of HTN before pregnancy

Diagnose HTN BP > 140/90 at rest, measured at least twice, and > 6 hours apart. (sustained T in BP)

History of HTN before pregnancy

Check Baseline Labs

Chronic Hypertension

Check Baseline Labs

HTN onset prior to 24 weeks?

Chronic Hypertension

If conditions worsen, Like: Î HTN, Proteinuria, DIC, Î Fetal growth, other signs/symptoms

Deliver Baby

If conditions worsen, Like: Î HTN, Proteinuria, DIC, Î Fetal growth, other signs/symptoms

Chronic Hypertension Pregnancy

HTN onset prior to 24 weeks?

Check 24-hr Urine Protein

Deliver Baby

> 36 weeks' gestation

Check 24-hr Urine Protein

Consider Physical Exam

Epigastric Pain Cyanosis, HA, Oliguria

Conservative Management Follow Blood Pressure

Mild Preeclampsia e

< 36 weeks' gestation

FIGURE 9-1. Management of hypertension in pregnancy.

(Redrawn, with permission, from Lindarkis NM, Lott S. Digging Up the Bones: Obstetrics and Gynecology. New York: McGraw-Hill, 1998:60.)

Management

Mild: Early and serial ultrasounds, biophysicals Severe:

a Serial ultrasounds and biophysicals a Antihypertensives (methyldopa or nifedipine)

Pregnancy-Induced Hypertension (PIH)

Defined as hypertension during pregnancy in a previously normotensive woman (the patient had normal blood pressure prior to 20 weeks' gestation): Mild: Systolic > 140 mm Hg and/or diastolic > 90 mm Hg Severe: Systolic > 160 mm Hg and/or diastolic > 110 mm Hg (same as chronic HTN)

Subsets of PIH

2. Preeclampsia: Renal involvement leads to proteinuria.

3. Eclampsia: Central nervous system involvement leads to seizures.

4. HELLP syndrome: The clinical picture is dominated by hematologic and hepatic manifestations.

Complications a Heart failure a Cerebral hemorrhage a Placental abruption a Fetal growth restriction a Fetal death

Management

Mild: Observe, bed rest

Severe: Always hospitalize + antihypertensive pharmacotherapy (hydralazine or labetalol short term, nifedipine or methyldopa long term)

Generally, for all pregnancy-hypertensive states:

Plus the following:

a If > 36 weeks/fetal lung maturity: Induce labor.

a If < 34 weeks/fetal lung immaturity: Steroids plus expectant management a If fetal or maternal deterioration at any gestational age, induce labor Preeclampsia

Preeclampsia is pregnancy-induced hypertension with proteinuria +/- pathological edema. It is classified as mild or severe.

Preeclampsia rarely develops before 20 weeks and usually occurs in a first pregnancy.

Criteria for Mild Preeclampsia a BP: > 140 systolic or > 90 diastolic a Proteinuria: 300 mg to 5 g/24 hrs (norm: < 300 mg/24 hrs in pregnancy, < 150 mg/24 hrs in nonpregnant state)

Manifestations of Severe Disease a BP: > 160 systolic or > 110 diastolic

In PIH, you must monitor for intrauterine growth retardation (IUGR) and progression to superimposed preeclampsia (15 to 25% incidence).

Severe PIH usually occurs in the third trimester.

Symptoms of severe disease include:

■ Visual disturbances

■ Epigastric pain

The only definitive treatment for PIH is delivery.

Preeclampsia is usually asymptomatic; it is crucial to pick up during routine prenatal visits.

HTN may be absent in 20%% of women with HELLP and severely elevated in 50%.

Know what HELLP stands for.

Know which labs to order.

The prime objectives in severe cases are to forestall convulsions, prevent intracranial hemorrhage and serious damage to other vital organs, and deliver a healthy infant.

■ Elevated serum creatinine

■ Symptoms suggesting end organ involvement:

■ Visual disturbances

■ Epigastric/right upper quadrant pain

■ Pulmonary edema

■ Hepatocellular dysfunction (elevated aspartate transaminase [AST], alanine transaminase [ALT])

Thrombocytopenia

■ IUGR or oligohydramnios

■ Microangiopathic hemolysis

■ Grand mal seizures (eclampsia)

Predisposing Factors

■ Nulliparity

■ Family history of preeclampsia-eclampsia

■ Multiple fetuses

■ Chronic vascular disease

■ Renal disease

■ Hydatidiform mole

■ Fetal hydrops

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