Hypertension in Pregnancy

• Complicate 10-20% of pregnancies

• Elevation of BP ≥140 mmHg systolic and/or ≥90 mmHg diastolic, on two occasions at least 6 hours apart.

• Categories for Hypertensive Disorders;

– Preeclampsia

– Chronic Hypertension

– Preeclampsia superimposed on Chronic Hypertension

– Gestational Hypertension

Preeclampsia

• “Pregnancy Induced Hypertension”

• New onset of hypertension and proteinuria after 20 weeks gestation.

– Systolic blood pressure ≥140 mmHg OR diastolic blood pressure ≥90 mmHg

– Proteinuria of 0.3 g or greater in a 24-hour urine specimen

– **Preeclampsia before 20 weeks, think MOLAR PREGNANCY!

• Classified as;

– Mild Preeclampsia

– Severe Preeclampsia

• Eclampsia

– Occurrence of generalized convulsion and/or coma in the setting of preeclampsia, with no other neurological condition.

• Severe Preeclampsia must have one of the following;

– Symptoms of central nervous system dysfunction

• Blurred vision, scotomata, altered mental status, severe headache

– Symptoms of liver capsule distention

• Right upper quadrant or epigastric pain

– Nausea, vomiting

– Hepatocellular injury

• Serum transaminase concentration at least twice normal

– Severe blood pressure elevation

• Systolic blood pressure ≥160 mm Hg or diastolic ≥110 mm Hg on two occasions at least six hours apart

– Thrombocytopenia

• Less than 100,000 platelets per cubic milimeter

– Proteinuria

• 5 or more grams in 24 hours

– Oliguria

• <500 mL in 24 hours – Severe fetal growth restriction – Pulmonary edema or cyanosis – Cerebrovascular accident 


Chronic Hypertension • “Preexisting Hypertension” • Systolic pressure ≥ 140 mmHg, diastolic pressure ≥90 mmHg, or both. • Present before 20th week of pregnancy or persists longer then 12 weeks postpartum. • 
Chronic Hypertension caused by; – Primary (Essential Hypertension). – Secondary from medical disorders. 

Preeclampsia superimposed upon Chronic Hypertension • Preexisting Hypertension with the following additional signs/symptoms; – New onset proteinuria – Hypertension and proteinuria beginning prior to 20 weeks of gestation. – A sudden increase in blood pressure. – Thrombocytopenia. – Elevated aminotransferases. 

Gestational Hypertension • Mild hypertension without proteinuria or other signs of preeclampsia. • Develops in late pregnancy. • Resolves by 12 weeks postpartum. • Can progress onto preeclampsia. • Usually when gestational hypertension develops before 30 weeks gestation.

Risk Factors for Hypertension in Pregnancy 

• Nulliparity • Preeclampsia in a previous pregnancy • Age >40 years or <18 years

• Family history of pregnancy-induced hypertension

• Chronic hypertension

• Chronic renal disease

• Antiphospholipid antibody syndrome or inherited thrombophilia

• Vascular or connective tissue disease

• Diabetes mellitus (pregestational and gestational)

• Multifetal gestation

• High body mass index

• Male partner whose previous partner had preeclampsia

• Hydrops fetalis

• Unexplained fetal growth restriction

Evaluation of Hypertension in Pregnancy

• History;

• ID and Complaint

• HPI (S/S of Preeclampsia)

• Past Medical Hx, Past Family Hx

• Past Obstetrical Hx, Past Gyne Hx

• Social Hx

• Medications, Allergies

• Prenatal serology, blood work

• Assess for Hypertension in Pregnancy risk factors

• Physical;

• Vitals

• HEENT

– Vision (blurry, scotomata), Headache

• Cardiovascular

• Respiratory

• Abdominal

– Epigastric pain, RUQ pain

• Neuromuscular and Extremities

– Reflex, Clonus, Edema

• Fetus

– Leopold’s, FM, NST

• Laboratory Investigations;

• CBC (Hg, Plts)

• Renal Function (Cr, UA, Albumin)

• Liver Function (AST, ALT, ALP, LD)

• Coagulation (PT, PTT, INR, Fibrinogen)

• Urine Protein (Dipstick, 24 hour)

Management of Hypertension in Pregnancy

• Depends on severity of hypertension and gestational age!!!!

• Observational Management

• Restricted activity

• Close Maternal and Fetal Monitoring

– BP

– S/S of preeclampsia

– Fetal growth and well being (NST, U/S)

• Routine weekly blood work

• Medical Management

• Acute Therapy = IV Labetalol, IV Hydralazine, SR Nifedipine

• Expectant Therapy = Oral Labetalol, Methyldopa, Nifedipine

• Eclampsia prevention = MgSO4

• Contraindicated antihypertensive drugs;

• ACE inhibitors

• Angiotensin receptor antagonists

• Proceed with Delivery

• Vaginal Delivery VS Cesarean Section

• Depends on severity of hypertension!

• May need to administer antenatal corticosteroids depending on gestation!

• Only cure is DELIVERY!!!