Nihan Kahya Eren, MDIzmir Ataturk Education and Research Hospital

Cardiology Department

Hypertensive Disorders of Pregnancy

Definition: 

Systolic bld pressure ≥

140 mm Hg or 

Diastolic bld pressure ≥

90 mm Hg on at least 2 

seperate measurements

Prevalance: 6‐10% of all pregnancies

Major cause of maternal, fetal and neonatal 

morbidity and mortality  

16%of maternal deaths in developed countries

Hemodynamic Changes During Pregnancy 

Plasma volume expansion (50%)

Heart rate increase (20%)

Cardiac output increase (50%)

Peripheral vascular resistance decrease

Systemic blood pressure decrease

Hypertensive Disorders of Pregnancy  Classification: 

Gestational hypertension: 

HT w/o proteinuria after 20 weeks of gestation

Preeclampsia

HT and proteinuria after 20 weeks of gestation

Preexisting hypertension (Chronic HT)

HT before 20 weeks of gestation or persisting >12 weeks 

postpartum

Preexisting HT with superimposed preeclampsia

Transient HT of pregnancy

Retrospective diagnosis

Preexisting (Chronic) Hypertension

•

HT before 20 weeks of gestation or persisting >12  weeks postpartum

•

Prevelance: 1‐5%

•

Mild‐moderate HT:

Sistolic 140‐159 mm Hg;  diastolic 90‐105/109 mmHg

•

Severe HT:

Sistolic  ≥

160 mm Hg

Diastolic ≥

105‐110 mm Hg

Preexisting HypertensionAdverse outcomes related to chr. HT in 

pregnancy:

Placental abruption

Low birth weight

Premature birth

Perinatal mortality

Preeclampsia 

Preexisting Hypertension: Management 

Optimal blood pressure during pregnancy?

Medical tx of mild‐moderate HT during  pregnancy improves maternal outcomes?

Fall in mean arterial pressure may lead to   decreased uteroplacental perfusion?

Preexisting Hypertension:Management Cochrane Metaanalysis 

Role of antihypertensive drug therapy in pregnant women  with mild‐moderate HT (either chronic or gestational)

28 trials, n=3200

Antihypertensive therapy vs placebo/no therapy:

Decresed the risk of developing severe HT

No effect on the risk of preeclampsia

No improvement in perinatal outcomes (perinatal death, preterm 

birth) 

No effect on birth weight 

Cochrane Database of Systematic Reviews 2007, Issue 1.

Preexisting Hypertension:Management JNC, NHBPEP

Women with stage 1 HT (<160/100): Non‐pharmacologic 

treatment:

Limitation of activities

ASA for high risk for preeclampsia

Drug therapy: SBP ≥

160; DBP ≥

100 mm Hg

Medications can be tapered during pregnancy

Reinstitude if systolic BP150‐160; diastolic 100‐110 mm Hg

TOD (+), or a previous requirement of multiple medications:  continue therapy

ESC

SBP≥

150, DBP ≥

95 mm Hg: Drug treatment

HT+ subclincal organ damage: drug tx if BP ≥

140/90 mm Hg

Preexisting Hypertension:Management Methyldopa:

Long‐term follow‐up studies supporting

safety

Maintain stable uteroplacental blood flow

Beta blockers:

Labetalol:

Β‐blocking agent with some α‐blocking activity

As effective as methyldopa, less adverse effects

IUGR (atenolol) when used during first trimester

Atenolol and metoprolol safe and effective in late 

pregnancy

Preexisting Hypertension:Management Calsium antagonists:

Limited data 

No increase in major teratogenicity with exposure

Diuretics:

No increase in adverse fetal events

May potentiate volume depletion in preeclampsia

ACEI and ARB are contraindicated

Medications in Hypertension of Pregnancy

Drug Dose Adverse events in pregnancyMethlydopa 500 mg–3 g in 2

divided dosesPeripheral edema, anxiety, nightmares, drowsiness, dry-mounth, maternal hepatitis

Labetalol 200-1200 mg/dayİn 2-3 divided doses

Persistent fetal bradycardia, hypotension, neonatal hypoglycemia

Hydrochlorothiazide 12,5-25 mg/day Fetal malformations, electrolyte abnormalities,

volume depletion

Nifedipine 30-120 mg/day Inhibition of labor particularly if used with Mg sulphate

Metoprolol 25-200 mg/day Possible association with fetal growth restriction

Management of Acute Severe HT Labetalol 10-20 mg iv, then 20 to 80 mg

every 20 to 30 minutes, up to 220 mg

Low incidence ofhypotension andadverse events

Hydralazine 5 mg iv or im, then 5-10 mg every 20-40 min, up to 20 mg iv, 30 mg im

More maternal and perinatal adverse effects

Nifedipine 10-30 mg PO, repeat in 45 min if needed

İntermediate or long acting preperations

Nitroprusside(relatively contraindicated)

Constant infusion of 0.25 to 5.00 g/kg per minute

Possible cyanide toxicty if used for> 4 hr ; agent of last resort

Preeclampsia Superimposed on  Preexisting HT

20‐25% of women with preexisting HT 

New onset proteinuria after 20 weeks in a woman with  chronic hypertension

In a woman with hypertension and proteinuria prior to 20  weeks gestation:

Sudden 2‐

to 3‐fold increase in proteinuria

Sudden increase in BP

Thrombocytopenia

Elevated AST or ALT

Hypertensive Disorders of Pregnancy

Gestational HT:

HT w/o proteinuria after 20 weeks of gestation

Preeclampsia:

Multiorgan disease process characterized by the 

development of hypertension and proteinuria  (>300mg/day) after 20 weeks of gestation

Up to 50% of women with gestational HT develop 

preeclampsia

Hemodynamics in Preeclampsia

Plasma volume and CO decrease

İncrease in systemic vascular resistance

Preeclampsia : Pathophysiology

Abnormal placentation•Abnormal trophoblast invasion

•Inadequate vascular remodelling of spiral arteries into low resistance vessels

•Reduced blood flow to the feto-placental unit

Poor placental perfusion

Circulating factors triggering endothelial dysfunction and generalised hyperinflammatory

state

Altered placental angiogenesisAngiogenic factors: Decreased placental GF,VEGFIncreased anti-angiogenic factors

Maternal

sx of preeclampsia

Multiorgan System Involvement in  Preeclampsia

Preeclampsia

CNS:Severe headache

Visual disturbances,Hyperreflexia

Cerebral hemorhageKidney:Decreased filtration rate

ARF

Lung:Pulmonary edema

ARDS

Liver: Elevated transaminase levels

Subcapsular hemorrhage

Hematological:Trobocytopenia

HemolysisDIC

Placental abruptionIUGR

Preeclampsia : Risk Factors

•Nulliparity•Preeclampsia in a previous pregnancy•Elevated BMI (>30)•Multiple gestation•Maternal age > 40 years•Antiphospholipid antibody syndrome•Chronic renal disease•Diabetes mellitus•Chronic hypertension

Diagnostic Criteria for Severe Preeclamsia:

Blood pressure ≥

160 mm Hg systolic or 110 mm Hg 

diastolic (during bed rest)  or

Proteinuria ≥

5g/day or

Any of the following associated signs and symptoms:

Cerebral or visual disturbances

Epigastric or right upper quadrant pain

Impaired liver function

Oliguria < 500 mL in 24 hours

Pulmonary edema

Thrombocytopenia

Fetal growth restriction

HELLP Syndrome

A variant of severe preeclampsia 

Hemolysis + Elevated Liver enzymes + Low  Platelet count

Occurs in 20%of pregnancies with severe  preeclampsia

Management of Preeclampsia:

Delivery is the only cure for preeclampsia

Decion to deliver:

Risk of worsening preeclamsia

Risk of prematurity

Treatment of Mild Preeclampsia

Delivery is generally not indicated until 37 to 38 

weeks of gestation 

Maternal monitoring:

Measure BP twice/week

CBC, platelet count, ALT, AST, LDH, uric acid, creatinine (1/week)

Assess for proteinuria: screen with dipstick or spot 

protein/creatinine ratio and obtain periodic 24‐hour urine  collections

Fetal monitoring

Nonstress test (2/week)

Measure amniotic fluid index (1‐2/ week)

Perform ultrasonography for fetal growth every 3‐4 weeks

Management of Mild Gestational Hypertension or Preeclampsia

Maternal and fetal evaluation:

•≥

40 weeks of gestation•≥37 weeks and

•Bishop score ≥

6•Noncompliant patient

•<37 weeks and•Worsening maternal and fetal condition

•≥

34 weeks •Labor or rupture of membranes•Abnormal fetal testing results•Intrauterine growth restriction?

Delivery

Management of Severe Preeclampsia

Hospital admission, bed rest 

Maternal and fetal evaluation for 24 hours

Magnesium sulphate for 24 hours

Antihypertensive tx if:

Sistolic BP ≥160 mm Hg

Diastolic BP ≥110 mm Hg

Mean arterial pressure > 125 mm Hg

Management of Severe Preeclampsia:  Antihypertensive treatment:

BP >160/110 mm Hg

Goal of tx: sistolic 140‐155 mm Hg, 

diastolic 90‐105 mm Hg

Acute management:

İv. hydralazine :

5 mg IV, 5–10mg every 20–40 min up to 30 mg

iv. labetalol:

20 mg IV, 40‐80 mg every 10‐15 min. up to 220 mg

For patients undergoing expectent management remote  from term oral labetalol and nifedipine acceptable  

Management of Severe Preeclampsia

•≥34 weeks of gestation or

•Maternal distress (Ecclampsia, trombocytopenia,pulmary edema, hemolysis and elevated liver enzymes)

•Nonreassuring fetal status

•Severe IUGR•Labor or rupture of membranes

Maternal and fetal evaluation:

DeliveryWithin 24 hours

<23 weeks of gestation

Termination of pregnancy

24-33 weeks of gestation

SteroidsAntihypertensives if neededDelivery

Preeclampsia: Postpartum  Management

Most patients respond promptly to delivery with  decreased BP and clinical improvement

Eclampsia may occur postpartum

greatest risk within 48 hours

Mg sulphate continued for 12‐24 hours 

Postpartum Management:

Antihypertensive treatment during lactation:

Methyldopa, labetolol, nifedipine, captopril,  enalapril, quinapril

Atenolol may cause bradycardia and lethargy in  newborns

Diuretics may reduce milk volume

Thank You

HELLP Syndrome

A variant of severe preeclampsia 

Hemolysis + Elevated Liver enzymes + Low Platelet count

Occurs in 20%of pregnancies with severe

preeclampsia

Clinical presentation is variable:12‐18% are normotensive13% proteinuria (‐)At diagnosis 30% postpartum, 18% term, 52% preterm

Common presenting sx: Right upper quadrant pain or epigastric pain, nausea, vomitting,

non 

spesific sxSigns and sx: CBC, plt count and liver enzyme should be evaluated

Management of Mild Gestational Hypertension or Mild Preeclampsia

Antihypertensive treatment:

No compelling studies showing prolonged gestational 

age or improved outcomes with antihypertensive tx 

ESC Antihypertensive tx >140/90 mm Hg

NHBPEP Antihypertensive tx >160/105-110 mm Hg