Hypertension in Pregnancy and Preeclampsia

Definition:
Hypertension (HTN) is BP>140/90
Preeclampsia – HTN with proteinuria (protein >300mg in 24-hour urine specimen) after 20 weeks gestation
May be transient with gestation
May also be superimposed on chronic HTN, presenting with acute proteinuria
If preeclampsia is unresolved, it may lead to a more serious condition – eclampsia, which involves generalized
seizures which may be life-threatening

Classification:
Considered severe if:
• BP>160/110 on 2 occasions
• Proteinuria >5 grams/24hour
• Cerebral or visual disturbances (including headache)
• Epigastric or right upper quadrant pain
• Fetal growth restriction
• Impaired hepatic function
• Oliguria (<500ml over 24 hours)
• Pulmonary edema
• Thrombocytopenia
• Cyanosis

Incidence:
Increases with increasing gestation
Preeclampsia occurs in approximately 5-8% of US pregnancies (most common pregnancy complication)
• <1% are severe preeclampsia

Pathophysiology
Etiology appears to be unclear, although abnormal placental implantation, platelet activation, angiogenic
factors, genetic factors, and immunologic issues between fetus and parent are all considered possible
Risk factors for developing preeclampsia:
• Maternal age >40
• Family history of preeclampsia
• Pre-existing hypertension, diabetes, or renal dysfunction
• Obesity (BMI>35)
• Antiphospholipid antibodies
• Multiple gestations
• Nulliparity
Fetus and childhood complications
• Intrauterine grown restriction, oligohydramnios (low levels of amniotic fluid which may lead to
congenital malformations), preterm birth, or even fetal death
• Potential increase in rate of epilepsy in children born at normal term
Complications to mothers may include:
• Stroke
• Pulmonary edema
• ARDS
• Oliguria
• Renal/liver dysfunction
 • Coagulation abnormalities
Increases risk of developing further complications such as HTN, diabetes, VTE, stroke

Clinical Presentation

Treatment
• Hospitalization if severe hypertension of preeclampsia
o Consider delivery if gesational age >34 weeks
• If mild-moderate, monitor closely
o Bed rest and inactivity is often recommended in these cases, although data is inconclusive
o Minimizing excess fluid amounts is recommedned
• Medication management may be recommended if diastolic BP >105
o Mild-moderate:
 methyldopa 0.5-3 g/day in 2 divided doses
 labetalol 200-1,200 mg/day in 2-3 divided doses
 other beta blockers (except atenolol)
 nifedipine 30-120 mg/day of slow-release preparation
 hydralazine 50-300 mg/day in 2-4 divided doses
 hydrochlorothiazide 25 mg/day
o Acute severe hypertension
 hydralazine 5-10 mg IV every 20 minutes as needed
 labetalol 20 mg IV bolus, then 40 mg in 10 minutes if needed, then 80 mg every 10
minutes (maximum 220 mg)
 nifedipine 10-30 mg orally, repeat in 45 minutes if needed
 last resort - sodium nitroprusside 0.5-10 mcg/kg/minute (risk of fetal cyanide toxicity if
used > 4 hours)
o ACEIs and ARBs are contraindicated in pregnancu
o Severe preeclampsia or eclampsia may require magnesium sulfate
 most studied dose is loading dose 14 g (4 g IV plus 5 g intramuscularly in each buttock)
then either 1 g/hour IV infusion or 4 g intramuscularly every 4 hours for 24 hours
o Antenatal corticosteroids must be considered if between 24-34 weeks gestation to hasten fetal
maturation if delivery is planned within 7 days
 Generally betamethasone is used IM 12mg once daily for two days
 Benefit greatest >24 hours after therapy initiation, although delivery may be required
sooner
• Course should be attempted even if a partial course is anticipated given that some benefit is likely

Monitoring

References: