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Hypertension

Asymptomatic Hypertension

Management

Resistant Hypertension

Hypertensive Disease in Pregnancy

Chronic Hypertension

  • Aka Pre-existing Hypertension

  • 140/90 diagnosed prior to pregnancy or within the first 20 weeks of gestation

  • Increased risk of preeclampsia and eclampsia during antepartum, intrapartum, and immediate postpartum stages
    • 50% cesarean deliveries
  • Treatment
    • Deliver between 38-39+6 days
    • Begin treatment once ≥140/90
      • Improves pregnancy outcomes without increasing risk of small-for-gestational-age birth weight
      • CHAP Study
      • Labetalol
        • Starting dose 100-200mg BID, can be used TID if needed
        • Max 2400mg/day (1200mg BID or 800mg TID)
      • Nifedipine ER
        • Starting dose 30mg Qday, can be used BID
        • Max 120mg/day
      • Methyldopa
      • Amlodipine
        • Monitor for proteinuria, headache, upper abdominal pain, visual changes, acute renal or liver failure or intrauterine growth restriction (fetal growth deceleration)

Gestational Hypertension

  • BP >140/90 first found ≥ 20 weeks in a previously normotensive patient
    • 2 measurements 4 or more hours apart
    • Returns to baseline after pregnancy
    • No end organ damage
    • Usually resolved by 12 weeks postpartum
  • No protein in the urine
  • Mild ankle edema is normal in pregnancy
  • Increased risk of progression to preeclampsia, placental abruption
  • Treatment
    • Delivery if >37 weeks should be discussed
    • <160/110
      • Outpatient
        • Goal:
          • <155/105 if healthy
          • <140/90 if comorbid conditions
          • <130/90 if Gestational DM
    • ≥160/110
      • Inpatient
    • Medications
      • Nifedipine ER 20-30mg daily, Max 60mg BID
      • Labetalol 100-200mg BID, Max 300mg QID
      • Nifedipine = Labetalol > Hydralazine
      • Methyldopa 250-500mg BID, 500mg QID
      • 2nd line: Hydralazine, Thiazides
        • Acebutolol, metoprolol, pindolol, propranolol
        • Amlodipine is safe
      • Avoid ACEI and ARBs, Atenolol, Prazosin

Postpartum Hypertension

  • Physiology
    • BP peaks 3-6 days postpartum in both normotensive and hypertensive women
      • Avoid NSAIDs
  • Definition
    • Persistent: >6 weeks after delivery
    • Severe: ≥160/110
  • Etiology
    • Gestational Hypertension
    • Preeclampsia
    • Chronic Hypertension
    • Secondary Causes (10%)
  • W/U
    • Persistent or Pre-existing
      • UA, BMP, Fasting Lipids, EKG
    • Examine for HELLP
      • Hemolysis, Elevated LFTs, Low platelets
      • Urinalysis
    • Evaluate for Preeclampsia/Eclampsia
      • 5.7% of preeclampsia and eclampsia present de novo in the postpartum period (up to 6 weeks)
      • New onset persistent HA or visual changes
  • Treatment
    • Best Practices for Managing Postpartum Hypertension
    • Symptomatic (Eclampsia/Preeclampsia) or ≥160/110 (Severe)
      • Inpatient
        • Goal: <160 and <110
          • Labetalol 20mg IV q30 up to 80mg, Max 300mg then switch to oral
            • Onset 5min, peak 30min, 4hr duration
            • Avoid in asthma or HF
          • Nifedipine IR 5-10mg capsule q30
            • Onset 5min, peak 30min, 6hr duration
          • Hydralazine 5mg IV, q30min up to 10mg, Max 20 IV
            • Onset 5 min, peak 30min
          • Alternatively
            • IV Nitro, Oral Clonidine
            • IV Sodium Nitroprusside if refractory
    • Asymptomatic + ≤160/110
      • All drugs are safe for breastfeeding
      • Goal: <140 and <90 with Comorbidities (excluding gestational DM); <155/105 otherwise; Gestational DM: <130/80
      • Outpatient
        • F/u in 3-6 days for BP check
        • Nifedipine ER 20-30mg daily, Max 60mg BID
        • Labetalol 100-200mg BID, Max 300mg QID
        • Methyldopa 250-500mg BID, 500mg QID

Preeclampsia

  • Disorder of the Placenta
    • Extravillious trophoblast fails to penetrate myometrium
    • Abnormal remodeling of the spiral arteries (don’t expand) causing hypoperfusion and ischemia
    • Diffuse maternal endothelial dysfunction
    • Vasospasm and coagulation
    • Resolves with delivery
    • Result of placental hypoperfusion after 18-20 weeks of gestation
      • Usually in 3rd trimester
    • Usually resolved by 12 weeks
  • RF: Prior preeclampsia (#1), primiparous women, personal or family history, Pre-existing diabetes, chronic hypertension, obesity, renal insufficiency, CKD
    • BMI >30, Advanced maternal age, nulliparity
  • Symptoms
    • Typically after 34w
    • Peripheral edema is common
    • Cerebral or visual disturbances
    • Abdominal pain
  • Labs
    • Elevation of transaminases
    • Thrombocytopenia
    • Renal insufficiency
    • Elevated Urate
  • Diagnosis: New onset Hypertension (>140/90) and proteinuria (≥300mg protein in a 24h urine collection or a urine protein/creatinine > .0.3mg/g) or End-organ damage (renal failure, CNS, Liver failure, edema) at ≥ 20 weeks
    • Fibrinoid necrosis of vessels of placenta
    • CXR: Pulmonary Edema
  • Treatment
    • Preeclampsia: IV Magnesium sulfate, Antihypertensives for ≥160/110, Antenatal glucocorticoids
      • Labetalol IV, Hydralazine IV, Nifedipine PO
      • Target 130-150/80-100
      • No magnesium if Myasthenia gravis
        • Use Levetiracetam or valproate
      • Renal Damage: >1.2 can cause mg toxicity
        • Calcium gluconate
    • Severe: ≥34 weeks induce
    • W/o Severe: ≥37 weeks
    • Postpartum Thrombophylaxis should be considered

Severe Preeclampsia

  • Preeclampsia + hypertension >160/110 ± end-organ damage
    • Pick one:
      • Pulmonary edema, cerebral or visual symptoms, thrombocytopenia, renal insufficiency (>1.1 or 2x baseline), impaired liver function(2x normal), BP ≥160/110
  • Most likely to progress to eclampsia
  • Associated with myocardial damage or diastolic dysfunction (increased afterload)
  • Complications
    • HELLP Syndrome
  • Treatment
    • IV labetalol, IV hydralazine, of IR nifedipine
    • IV Magnesium Sulfate prophylaxis
    • Severe Preeclampsia + ≥34 weeks:
      • Delivery to reduce risk of maternal death

Eclampsia

  • Preeclampsia plus new onset tonic-clonic seizures, generalized, brief
    • Grand mal Seizures
  • RF: untreated preeclampsia
  • MCC of death: intracerebral hemorrhage and edma
    • PRES Syndrome
    • MRI w/ posterior cerebral hemisphere enhancement
  • Treatment/Prevention:
    • IV Magnesium Sulfate, anti-htn meds
      • Usually 4g IV then 1g/hr
      • Mg and Anti-HTNs given for 48 hours
        • 25% of seizures occur within 24hrs
      • ± diazepam, phenytoin
      • ± labetalol, hydralazine
      • Decreased DTRs:
        • Mag Toxicity: Give Calcium Gluconate
    • Acute: Airway, IV Magnesium Sulfate, Betamethasone, Induction
      • Betamethasone if <34 weeks only
    • Delivery is only cure

HELLP Syndrome

  • Thrombotic microangiopathy involving the liver
  • Symptoms
    • Manifestation of severe preeclampsia
    • Anemia, RUQ pain, bruising/bleeding, N/V
    • Hypertension, proteinuria also possible
  • Labs
    • Hemolysis
    • Moderately elevated liver enzymes
    • Low platelets (thrombocytopenia)
    • Low AT3
  • Complications:
    • Increased risk of acute hepatic and/or renal failure, abruptio placentae
    • Encephalopathy, renal insufficiency, DIC
  • Treatment
    • <30-32w + unfavorable cervix: C/S
    • <34w + Stable: Steroids + delivery

    • 34w: Prompt delivery of the neonate