Spreading Emergency Medicine Across the Globe ..
emmedonline
Dr. Ajith Kumar J MD
Dept. of Emergency Medicne
Travancore Medicity, Kollam
India
editor
Hypertensive disorders of pregnancy affect about 10% of all pregnant women.
Hypertension in pregnancy is classified as
Chronic hypertension
Chronic hypertension with superimposed preeclampsia
Gestation hypertension
It is an important cause for morbidity , long term disability and death among mothers and baby
Gestational Hypertension
Gestational hypertension is characterized most often by new onset elevations of BP After 20 weeks of gestation often near term, in the absence of accompanying proteinuria.
Chronic Hypertension in Pregnancy
Chronic hypertension in pregnancy is defined as hypertension present before pregnancy or before 20 weeks of gestation.
For pregnant women with persistent chronic hypertension with SBP>160mmHg or DBP >105mmHg antihypertensive therapy is recommended.
Chronic hypertension treated with antihypertensive medication, it is suggested that BP levels be maintained between 120 mmHg systolic and 80 mmHg diastolic and 160 mmHg systolic and 105 mmHg diastolic.
Women with chronic hypertension with increased risk of adverse pregnancy outcomes initiate low dose aspirin 60 -80mg beginning in the late first trimester .
Antihypertensive agents used for urgent blood pressure control in pregnancy
Drug | Dose | Comment |
Labetalol | 10 -20mg IV, then 20 -80mg every 20 -30 min to a maximum dose of 300mg or Constant infusion 1 -2mg/min IV | Considered a first line agent. Tachycardia is less common and fewer adverse effect. Contraindicated in patients with asthma, heart disease or CCF. |
Hydralazine | 5mg IV or IM, then 5- 10 mg IV every 20 -40 min or Constant infusion 0.5- 1.0 mg/hr | Higher or frequent dosage assosciated with maternal hypotension, headache and fetal distress. |
Nifedipne | 10 – 20 mg orallyrepeated in 30 min ; then 10 -20mg every 2-6 hrs | May observe reflex tachycardia and headaches. |
Common oral antihypertensive agents in pregnancy
Drug | Dosage | Comments |
Labetalol | 200 – 2400 mg/d orally in 2-3 divided doses | Well tolerated Potential bronchoconstrictive effects Avoid in patients with asthma and CCF |
Nifedipine | 30 -120 mg/d orally of a slow release preparation | Do not use sublingual form |
Methyldopa | 0.5 -3 gm/day 2-3 divided doses | May not be effective in controlling severe hypertension. |
Thiazide diurectics | Depends on agent | Second line agent |
ACE Inhibitors and ARB are contraindicated in pregnancy.
Diuretics are second line agents . Theoretical concern has been raised regarding intravascular volume depletion and thereby lead to fetal growth restriction.
Superimposed Preeclampsia
Superimposed preeclampsia refers to women with chronic hypertension who develop preeclampsia.
Superimposed preeclampsia is likely when
A sudden increase in BP that was previously well controlled or escalation of antihypertensive medications to control BP.
New onset of proteinuria or a sudden increase in proteinuria in a women with known proteinuria before or early in pregnancy.
Superimposed preeclampsia with severe features
Severe range BP despite escaltion of antihypertensive
Thrombocyopenia
Elevated transaminases
New onset or worsening of renal function
Pulmonary edema
Persistent cerebral or visual disturbances
For women with chronic hypertension and superimposed preeclampsia with severe features, the administration of intrapartum-postpartum parenteral magnesium sulfate to prevent eclampsia is recommended.
Timing of Delivery
Women with chronic hypertension and no additional maternal or fetal complication, delivery before 38 weeks of gestation is not recommended.
For women with chronic hypertension and superimposed preeclampsia without severe features and stable maternal and fetal conditions, expectant management until 37 weeks of gestation is suggested.
For women with superimposed preeclampsia who receive expectant management at less than 34 weeks of gestation, the administration of corticosteroids for fetal lung maturity benefit is recommended.
Delivery soon after maternal stabilization is recommended irrespective of gestational age or full corticosteroid benefit for women with superimposed preeclampsia that is complicated.
HELLP Syndrome
Hemolysis, abnormal liver function tests and thrombocytopenia have been recognized as complications of preeclampsia and eclampsia for many years & the term HELLP syndrome is the acronym for the same.
It can develop during antepartum or postpartum.
For women with HELLP syndrome and before the gestational age of fetal viability, it is recommended that delivery be undertaken shortly after initial maternal stabilization.
For women with HELLP syndrome at 34 weeks or more of gestation, it is recommended that delivery be undertaken soon after initial maternal stabilization.
For women with HELLP syndrome from the gestational age of fetal viability to 33 6/7 weeks of gestation, it is suggested that delivery be delayed for 24 – 48 hrs if maternal and fetal condition remain stable to complete a course of corticosteroids for fetal benefit.
Updated on 26/6/2014
Reference
Hypertension in pregnancy ; The American college of Obstetricians and Gynecologist 2013
Copyright 2020. emmedonline. All rights reserved.
Website is designed for desktop. Mobile user are advised use firefox for best results.
emmedonline
Dr. Ajith Kumar J MD
Dept. of Emergency Medicne
Travancore Medicity, Kollam
India
editor