hypertensive disorders of pregnancy · bps≥ 160/110 mm hg: tx with iv labetolol or hydralazine,...

Hypertensive disorders of pregnancyElyse Watkins, DHSc, PA-C, DFAAPA

Epidemiology

Occurs in about 10% of pregnancies

Non-Hispanic black women had higher incidence of chronic hypertension

Non-Hispanic black women had higher odds of developing

mild, severe, or superimposed preeclampsia compared to

non-Hispanic white women

Hispanic women and Asian/Pacific Islanders had higher odds

of remaining normotensive

https://www.researchgate.net/publication/6659868_Racial_Disparity_in_Hypertensive_Disorders_of_Pregnancy_in_New_York_State_A_

10-Year_Longitudinal_Population-Based_Study

Source: Centers for Disease Control and Prevention. “Racial/Ethnic Disparities in Pregnancy-Related Deaths—United States, 2007-

2016.” September 6, 2019.

Centers for Disease Control and Prevention. “Racial/Ethnic Disparities in Pregnancy-Related Deaths—United States, 2007-2016.”

September 6, 2019.

https://www.nature.com/articles/s41371-018-0113-7

Pathophysiology

*soluble fms-like tyrosine kinase 1 (sFlt1)

https://hcup-us.ahrq.gov/reports/statbriefs/sb222-Preeclampsia-Eclampsia-Delivery-Trends.jsp

https://www.bmj.com/content/347/bmj.f6564

Risk Factors

BMI, anemia, and lower education appear to be modifiable

risk factors

Maternal age, primiparity, multiple gestation, HDP in previous

pregnancy, GDM, preexisting HTN, preexisting T2DM,

preexisting UTI, and family history of HTN, T2DM, and

preeclampsia may be nonmodifiable risk factors

Genetic variants such as a single-nucleotide polymorphism

in the angiotensinogen gene may be nonmodifiable risk

factors

Definitions

Hypertensive disorders of pregnancy

Gestational hypertension

New onset HTN (SBP ≥140 mm Hg and/or DBP ≥90 mm Hg) at ≥20 weeks in a previously normotensive woman and in the absence of proteinuria or new signs of end-organ dysfunction.

If the BP is ≥140 mm Hg and/or DBP ≥90 mm Hg, but <160 mm Hg systolic and/or 110 mm Hg diastolic, BP readings should be documented on at least TWO occasions at least FOUR hours apart.

(An aside)

How do you check blood pressure?


Considered severe when SBP ≥160 mm Hg and/or DBP ≥110 mm Hg.

Can be differentiated from preeclampsia if:

there is no proteinuria, platelet dysfunction (platelets <100,000 cells per microliter), renal dysfunction (serum creatinine >1.1 mg/dL) or doubling of liver transaminases.


Gestational hypertension

Up to 50% of patients develop preeclampsia

All pts with new onset HTN should have a CBC with platelets, liver transaminases, LDH, creatinine, bilirubin, and uric acid.

Low-dose ASA at 12 wks is recommended to help decrease the risk of preeclampsia.

BPs <160/105 mm Hg are generally not tx’d with meds but should have twice-weekly BP and urine protein checks*

Non-stress tests (NSTs) and serial ultrasounds weekly.


BPs≥ 160/110 mm Hg: tx with IV labetolol or

hydralazine, delivery considered for patients > 34

weeks.

Most will start meds when diastolic is ≥ 105 mm

Hg.

Recommended in pregnancy: labetolol,

nifedipine, hydralazine, and methyldopa.

A course of betamethasone with close

monitoring of fetal health for patients <34 weeks.


Preeclampsia

New onset HTN in a previously

normotensive pt with proteinuria or other

end-organ damage (elevated liver

transaminases, serum creatinine, and platelet

dysfunction).


Most preeclampsia will manifest after 20

weeks.

The presence of preeclampsia prior to 20 wks

requires molar pregnancy be ruled out!


Ask about the severe symptoms of

preeclampsia, such as epigastric or right upper quadrant pain, visual changes, swelling, or headaches.

PE: peripheral edema, pulmonary edema,

papilledema.


Preeclampsia is classified as either

“without severe features” or “with

severe features.”

BP >160/110 mm Hg is a hypertensive emergency and patients must be managed expeditiously.

Preeclampsia without severe features:BPs greater than 140/90 mm Hg on two occasions four hours apart (or 160/110 mm Hg on one occasion) AND proteinuria > 300 mg/24 hours with a urine protein/creatinine ratio > 0.3 mg/dl.

Preeclampsia with severe features:

Thrombocytopenia, increase in creatinine concentration to >1.1 mg/dL, and doubling of hepatic transaminases.

Platelet count <100,000 cells/microliter, liver transaminase elevation, serum creatinine > 1.1 mg/dL (or doubling of a previous serum creatinine), pulmonary edema, and visual or cerebral changes.

Quantified proteinuria of >5 g in 24 hours is no longer required.


Management depends on GA and presence or

absence of severe features.

Pregnancies at <34 weeks gestation with severe features:

Admit to L&D for continuous fetal monitoring,

maternal BP and urine output monitoring,

corticosteroids, and evaluation of renal function

and development of HELLP.

If BP <160/110 mm Hg and without severe features, delivery is indicated once the patient

reaches 37 weeks.


Magnesium sulfate (MgSO4) is

neuroprotective.

Is not an antihypertensive therapy.

Helps protect against the development

of eclampsia.

The standard dose is 4 gm loading,

followed by 1 gm/hour.

Must check DTRs, VS, LOC regularly


Patients at 34w0d and later:

Consider for delivery after a course of

antenatal corticosteroids ([two doses of

betamethasone 12 mg IM 24 hours apart] if

not already done)

Immediate delivery if:

Evidence of fetal distress, ROM, oliguria,

serum creatinine ≥1.5 mg/dL, pulmonary

edema, HELLP syndrome, eclampsia,

platelets <100,000 cells/mL, coagulopathy,

and placental abruption

Preeclampsia without severe

features

Preeclampsia with severe

features

BPs greater than 140/90 mm

Hg on two occasions four

hours apart

OR

160/110 mm Hg on one

occasion

AND

Proteinuria > 300 mg/24

hours with a urine

protein/creatinine ratio > 0.3

mg/dl

Platelet count <100,000

cells/microliter

Liver transaminase elevation

Pulmonary edema

Visual or cerebral changes

Serum creatinine > 1.1

mg/dL

OR

Doubling of a previous

serum creatinine


HELLP Syndrome

Hemolysis, elevated liver enzymes, and low

platelets.

Occurs in 0.1%-0.6% of all pregnancies

Occurs in 4%-12% of patients with preeclampsia

Typically manifests between 27 wks and delivery, or

immediately postpartum in 15%-30% of cases

May originate from abnormal placental

development = coagulopathy and hepatic

inflammation.

Delivery!


All pts should have a BP check at 72 hours

postpartum and again at 7 – 10 days as

preeclampsia and eclampsia can develop during

the postpartum period.

Most women will become normotensive within 12

weeks postpartum.

If not: chronic hypertension

https://n.neurology.org/content/92/4/e305

The EndThank you!

hypertensive disorders of pregnancy · bps≥ 160/110 mm hg: tx with iv labetolol or hydralazine,...

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