CHRONIC HYPERTENSION

IN PREGNANCY
OUTLINE
01 INTRODUCTION

02 LITERATURE REVIEW

03 CASE REPORT

04 DISCUSSION

05 CONCLUSION
INTRODUCTION
• Hipertension in pregnancy
is one of complication triad
beside bleeding and infecti
on.
• About 7-10% of pregnancy accompani
ed byhipertension.
• Hipertension in pregnancy is second c
ause of maternal death after thromboe
mboli
• Medication for hypertension in pregna
ncy become challenge to medical prof
essional, because medication need to
be safe, effective and rational
LITERATURE
REVIEW
DEFINITION

High blood presure >20 weeks gestation

No history of high blood pressure before

gestation.

03 Blood Pressure ≥140/90 mmHg

Increased systolic pressure 30 mmHg an

d diastolic pressure 15 mmHg above nor
mal value.
EPIDEMIOLOGY

• Complication of 7%-10
% pregnancy
• High mortality and morb
idity in Indonesia
• Often happen in Primigr
avide
• In women age >35 Year
s old and <20 years old
CLASSIFICATION
The National High Blood Pressure Education Program Working Group on High Blood
Pressure in Pregnancy (NHBPEP)

Preeklamsia Superimposed
Chronic hypertension
Preeklamsia
01 Hypertension before 20
02 Hypertension ≥ 20 week 03 Chronic Hypertension +
s gestation
weeks gestation + Proteinuria proteinuria
.

Gestasional
Hypertension
04 Hypertension ≥ 20 week
s gestation
• RISK FACTOR

MATERNAL FACTOR PREGNANCY FACTOR

Mothers age<20 YO, or >35YO
Primigravide Mola Hidatidosa
Family history of hypertension Gemelli Pregnancy
Past history of Hypertension in pregnancy
High Body mass index
Kidney Disease
PHATOPHYSIOLOGY
In Hypertension in pregnancy, there is no invasion
of trophoblast cell in spiralis artery

Spiral artery unable to dilate, thus causing spiralis

artery to constrict and failure of spiral artery remo
delling.

Decresed Blood flow of uteroplacenta

Ischemia of placenta
Produce of oksidan -> causing destruction of bloo
d vessel

Endothelial disfunction causing :

1. Decreased production of PGE2
2. Platelet aggregation
3. Production of thromboxane
4. Production of endotelin
PHATOPHYSIOLOGY OF CHRONIC HYPERTENSION IN
PREGNANCY

• In Chronic Hypertension in pregnancy the the pat

hophysiology basically the same with Hypertensi
on in adult
• Primary hypertension : idiopathic
• Secondary Hypertension : Renal, Endocrine, or
Cardiovascular origin
 CLINICAL MANIFESTATION
Chronic Hypertension
• Blood Pressure ≥140/90 mmHg before gesta
tion, or before 20 weeks of gestation
• Hypertension stay in 12 weeks post partum
• Primer : - Idiopatik (90-95%)
• Secondary : Caused by kidney disease, endo
krin, or cardiovascular
• 13-40% developed to superimposed preekla
msia

• Severe : ≥ 160/110
• Mild to moderate : Systolic of 140-159, a
nd Diastolyc of 90-109 mmHg
CLINICAL MANIFESTATION

Superimposed Preeklamsia

• Chronic hypertension with proteiunuria after

24 weeks gestation
CLINICAL MANIFESTATION

Gestational hypertension

• Blood Pressure ≥140/90 mmHg after 20 wee

ks of gestation
• Without Proteinuria
CLINICAL MANIFESTATION

Preeklampsi

• Blood pressure ≥140/90 mmHg after 20 wee

ks of gestation
• With proteinuria and/or edema
• Proteinuria : protein concentration of 300 mg
on urin sample or 30 mg/dl (+1 dipstic)
 Degree of Preeklamsia
Ringan Berat

1. Hipertensi ≥ 140/90 mmHg 1. Hipertensi ≥ 160/110 mmHg

2. Proteinuria ≥ 300 mg/24 jam 2. Proteinuria ≥ 500 mg/24 jam
atau ≥ +1 dipstik atau > +3 disptik
3. Oliguria kurang dari 500
ml/24 jam
4. Gangguan penglihatan dan
serebral
5. Edema paru dan sianosis
6. Nyeri epigastrium atau
kuadran kanan atas
7. Trombositopenia
8. Pertumbuhan janin terganggu
 DIAGNOSIS

01 ANAMNESIS 02 PHYSICAL EXAMINATION

Symptom : headache, blurry visi Blood pressure examination two

on, nausea, vomiting, chest pain,
dispneu
Past History : Kidney disease, co
ntraception, history of high blood
pressure
Social history: smoking, alcohol
consumption
times or more
Precaution : No comsumption of
coffe, or medication related to ad
renergic stimulation. No physical
activity 30 minute before examin
ation
LABORATORY EXAMINATION

1 2 3 4

URINANALYSIS Kidney Function Test USG urology Electro Cardiography

Proteinuria
+1 = 0,3 – 0,45 g/L Creatinin, Ureum If abnormality in kidne To exclude cardiac ab
+2 = 0,45 – 1 g/L y suspected normality
+3 = 1 – 3 g/L .
+4 = > 3 g/L.
When to suspect secondary cause
in Chronic Hypertension?

• Hipertensi Refrakter
• UL : Proteinuria
• Serum Creatin : >1,1 mg/dl
• Hipokalemia : <3.0 mEq/l
 AIM
To prevent acute complication,
and keep pregnancy healthy as
long as possible

To minimize the risk of compilc

ation from hypertension

MANAGE To minimize the risk of complic

ation to the fetus due to usage
MENT of antihypertension medication
which can cause hypoperfusion
to uteroplacental.
MANAGEMENT
NON FARMAKOLOGIS TR
EATMENT
• Mild to moderate physical activity is rec
ommended by researcher in patient wit
hout obstetric problem.
• Dietary nutrition restriction in patient wit
h chronic hypertension in general is the
same with adult patient.
• Daily nutrition allowance for natrium is r
estricted to 2,4 gram/day
FARMAKOLOGIS TREATM
ENT
• Consideration :
• Lowering acutely, severe hypertension in hos
pital setting (≥160/110)
• To maintain blood pressure stay in the target t
hat desired
• Blood pressure goal (NICE Guideline):
• <150/100 for chronic hypertension without co
mplication or without target organ damage,
• <140/90 mmHg for chronic hypertension with
target organ damage
SEVERE HYPERTENSION
MILD TO MODERATE
HYPERTENSION
DRUG OF CHOICE

Methyldopa Labetalol

• alpha-2 adrenergik agonis

• First choice therapy, because conside
red safe to be used in pregnant woma
n and children
• No adverse reaction related to fetal a
nd uteroplacenta hemodynamic
• Not effective in lowering sever chronic
hypertenision if compared to labetalol
and nifedipine.
• Adverse effect : Hepatic disfunction, n
ecrosis dan anemia hemolitik
• Non selective beta blocker that also act
on alfa reseptor in vascular
• Adverse effect : lethargy, malaise, slee
p disturbance, and bronchoconstriction
• Contraindication in asthma, congestif h
eart failure
DRUG OF CHOICE

Calcium Channel Blocker Diuretik

• Work by blocking calcium channel, and cau
sing vasodilatation
• Not many research had been done regardin
g safety of nifedipine in pregnancy
• But, nifedipine is one of the most prescribed
medication to maintain blood pressure in pr
egnant women
• There are no perinatal adverse effect report
ed regarding the use of nifedipine and other
calcium channel blocker medication in pregn
ant women
• Nifedipine didn’t cause any effect in uterin bl
ood flow
• Theoritically, researcher afraid of adv
erse effect of diuretics that can cause
depletion of blood volume that can fur
ther causing fetal growth restriction
• But according to research and meta a
nalisis systematic review that had bee
n done, those adverse effect was not
proven
• Adverse effect : hipokalemia
DRUG OF CHOICE

ACE Inhibitor and ARB

• Kohort restropektif studi in america on baby that have been born from years 1985 to 2000 show that
from 209 baby, 18 were having congenital malformation. (RR: 2,71; 95% CI 1,72 - 4,27).
• FDA research : From 108 cases,88.9 % having adverse effect on fetal such as fetal death,and abort
us. In Preganancy that occur until 16 weeks, 32.5% experience congenital malformation. In pregnan
cy that occur until 20 weeks, 50% experience IUGR
• Systematic review identified the used of ARB in pregnancy. From 64 case, 58% experienced mild a
dverse effect, and 42% case experienced severe adverse effect including congenital malformation a
nd lungs abnormality.
• From 27 pregnancy that experienced congenital malformation, 10 pregnancy exposed from valsarta
n, 9 pregnancy exposed losartan, 6 pregnancy exposed by candesartan, and 2 pregnancy exposed
by irbesartan.
Prevention of Superimposed Preeklamsia

• Aspirin 1 x (60-80mg)
• Calcium Supplementation 1 gram
Drug Route of Administration Adverse Effect
Methyldopa Oral - Mild hipotensi in first 2 days of b
aby life
- Not associated with congenital
malformation

Labetalol Oral/ Intra vena - Not associated with congenital

malformation
- Hipotension on first 24 hours of
baby life

Atenolol Oral - Not associated with congenital

malformation
- Low birth weight
- Decreased fetal heart beat

Metoprolol Oral - Not associated with congenital

malformation
Drug Route of Administration Adverse Effect

Prazosin (Alpha Bloker) Oral - Not associated with congenital

malformation
Nifedipin Oral - Not associated with congenital
malformation

Amlodipin Oral No data available

Verapamil Oral/ Intra vena - Not associated with congenital
malformation
Chlorotiazide Oral - Associated with congenital
malformation
- Trombositopenia neonatal
- Hipoglikemia/hypovolemia neo
natal
- Electrolyte Imbalance
Drug Route of Administrati Adverse Effect
on
Furosemide Oral/IV - No significant side effect

Hidralazine Intra Vena - Not associated with cong

enital malformation
- Maternal Hipotension
- Headache
- Fetal Distress
 CASE
REPORT
 PATIENT IDENTITY
• Name : PSD
• MR : 52373
• Sex : Female
• Age : 32 tahun
• Address : Asrama Brimob Tohpati
• Nationality : Indonesia
• Race : Jawa
• Religion : Islam
• Occupation : Brigadir
• Status : Married
• Date of examination : 7 Agustus 2018
ANAMNESIS
• Chief Complaint: High Blood Pressure
• Medical History:
• The patient is said to be 4 months pregnant and has regularly performed an obstetr
ic examination to a gynecologist.
• At the last examination at the obstetrician, high blood pressure of 160/100 was fou
nd
• Previously the patient claimed to have no complaints regarding the high blood pres
sure. Complaints of headache, chest tightness, intense epigastric pain, swelling in t
he legs and body and visual disturbances are denied by the patient.
• From 4 times visit to an obstetrician, high blood pressure was only obtained during
the last visit.
• The first day of the patient's last menstruation was said on April 19, 2018.
• In the second visit patients had a complaint of blood spots / brown spots and lower
abdominal pain,the doctor said the patient had a weak uterus and the patient was
diagnosed with imminent abortion, then the patient was given uterine strengthening
medication.
ANAMNESIS
• Past History:
• A history of high blood pressure in pregnancy was
suffered by a patient in the fourth month of pregna
ncy for the first child.
• Blood pressure at that time reached 140/90.
• There were no symptoms of swelling in the legs, h
eartburn, visual disturbances, and seizures in the
previous pregnancy. After birth, blood pressure is
said to return to normal.
ANAMNESIS
• Obstetric History:
• Female, 8 years old, born with Sectio Cesarean, birth weight 3300 gr
am
• This Pregnancy
• Family History:
• The father and grandfather of the patient are said to have a history of high
blood pressure. A family history of heart and kidney disease is denied by the patie
nt.
• Social History:
• History of smoking and alcohol consumption are denied by patie
nts.
PHYSICAL EXAMINATION

Status Present
General Appearance : Good
Level Conciousness : Compos mentis (GCS : E4V5M6 )
VAS : 0/10
Blood Pressure : 150/90 mmHg
Pulse : 88x/ menit
RR : 18x/mnt
Temperature : 36,5º C
Body height : 165 cm
Body weight : 80 kg
Body mass index : 29
PHYSICAL EXAMINATION
Head
Eye : an ( -/ -); ict ( -/ -); pupil reflex ( +/ + ); Ø ( 3 mm / 3mm)
ENT : Ear : within normal limit
Nose : secret (-/-), concha edema (-/-)
Throat : T1/T1 hiperemia (-/-), Pharynx hiperemia (-)

Neck
Communis carotid artery : bruit ( - / - )
Lymph nodes : not palpable

Thorax
Cor : S1 S2 normal regular; murmur ( - )
Pulmo : Vesicular ( + / + ); ronchi ( - / - ) wheezing ( - / - )
PHYSICAL EXAMINATION

Abdomen : tenderness (-), bowel sounds (+) N,

liver/spleen not palpable
Genitalia : not evaluated
Skin : cyanosis ( - )
Extremity : warm +/+ ; edema -/-
+/+ -/-
Laboratory Examination

• Kidney Function Test(7 Agustus 2018)

Parameter Hasil Nilai rujukan Remarks

Creatinine 0,47 0,5-0,9 Rendah

Urea UV 10 15-40 Rendah

 Parameter Hasil Nilai rujukan Remarks
Berat Jenis 1,020 -

Laboratory pH 6,0 -
Kejernihan Agak Keruh -

Examination Warna
Protein
Kuning
Negatif
-
Negatif
Reduksi Negatif Negatif
Bilirubin Negatif Negatif
Urine Analysis(7 Agustus 2018)
Urobilinogen Negatif Negatif
Nitrit Negatif Negatif
Keton Negatif Negatif
Eritrosit 0-1 0-2
Leukosit 2-4 0-5
Epitel 5-7 0-2
Kristal Negatif - `
Silinder Negatif -
Bakteri Positif + -
Lain-lain Negatif -
 Laboratory Examination
EKG (7 Agustus 2018)

• Rythm : Sinus
• Heart Rate : 120 x per minute
• Axis : Normal
• P Wave : Normal
• P-R Interval : Normal
• QRS Complex : Normal
• R/S in V1 : <1
• RV5 + SV2 : <35
• St-T Wave : Normal
• Conclusion : Sinus Takikardi
DIAGNOSIS & MANAGEMENT

DIAGNOSIS MANAGEMENT

• G2P1001 T/H UK 15-16 m • Nifedipine 2x10 mg

inggu • Low salt diet
• Chronic Hypertension in p • Mild to moderate activity
regnancy • Routine ante natal care in
Obstetrician
DISCUSSION
 DISCUSSION
CASE THEORY

• Female 32 Years old, second pregnanc • Hipertension in pregnancy happen in 5

y,
• History of hypertension on the first pre • The risk increasing in patient with histo
gnancy
• Father and grandfather have history of
Hypertension
• Anamnesis & Physical examination
• -> Blood pressure 150/100
• -> 15-16 weeks pregnant
-7% of pregnancy.
ry of hypertension in pregnancy, and fa
mily history of hypertension
• Chronic hypertension in pregnancy defi
ned by hypertension that occur in <20
weeks gestation
• Severe : ≥160/110
• Mild to moderate : Systolic of 140-159,
and Diastolyc of 90-109 mmHg
 DISCUSSION
CASE
• Laboratory Examination :
• Urin analysis : proteinuria (-)
• Creatinin : 0,47
• ECG : Sinus Takikardia
THEORY
• In Chronic hypertension it is important to det
ermined wether the cause is primary or
secondary.
• Secondary Chronic Hypertension cause : ren
al impairment, hyper aldosterism, cushing s
yndrome, cardiovascular
• Lab result indicating secondary cause :
• Hipertensi Refrakter
• UL : Proteinuria
• Serum Creatin : >1,1 mg/dl
• Hipokalemia : <3.0 mEq/l
DISCUSSION
CASE
• Management :
• Non farmakologis : Low salt diet, mild
to moderate physical activity
• Farmakologis : Nifedipine 2x10 mg
THEORY
• Aim of treatment :
• To prevent acute complication, and ke
ep pregnancy healthy as long as poss
ible
• Non faramkologis treatment : mild to
moderate activity for patient without o
bstetric problem
• Farmakologis treatment :
• Methyldopa, Nifedipine, Labetalol
• Contraindicated : Ace Inhibitor and A
RB
CONCLUSION
 CONCLUSION
• Chronic hypertension in pregnancy is increased blood pregnancy in pregn
ancy less than 200 weeks gestation
• Hypertension in pregnancy is complication that happen to 7-10% of pregn
ancy
• The aim of management of hypertension in pregnancy is to prevent acute
complication, and keep pregnancy healthy as long as possible
• The choice of medication aimed to minimize the risk of complication to th
e fetus due to usage of antihypertension medication
THANK YOU
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MANAGEMENT
NON FARMAKOLOGIS TR
EATMENT
• Mild to moderate physical activity is rec
ommended by researcher in patient wit
hout obstetric problem.
• Dietary nutrition restriction in patient wit
h chronic hypertension in general is the
same with adult patient.
• Daily nutrition allowance for natrium is r
estricted to 2,4 gram/day
FARMAKOLOGIS TREATM
ENT
• Consideration :
• Lowering acutely, severe hypertension in hos
pital setting (≥160/110)
• To maintain blood pressure stay in the target t
hat desired
• Blood pressure goal (NICE Guideline):
• <150/100 for chronic hypertension without co
mplication or without target organ damage,
• <140/90 mmHg for chronic hypertension with
target organ damage
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You can simply impress You can simply impress
your audience and add a your audience and add a
unique zing. unique zing.
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 DIAGNOSIS

01 ANAMNESIS 02 PHYSICAL EXAMINATION

Symptom : headache, blurry visi Blood pressure examination two

on, nausea, vomiting, chest pain,
dispneu
Past History : Kidney disease, co
ntraception, history of high blood
pressure
Social history: smoking, alcohol
consumption
times or more
Precaution : No comsumption of
coffe, or medication related to ad
renergic stimulation. No physical
activity 30 minute before examin
ation
SEVERE HYPERTENSION
 Thank you
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