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Hypertensive disorders of pregnancy affect about 10% of all pregnant women.

• Hypertension in pregnancy is classified as

1. Preeclampsia- eclampsia

2. Chronic hypertension

3. Chronic hypertension with superimposed preeclampsia

4. 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

Common oral antihypertensive agents in pregnancy

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