1. Chronic Hypertension in Pregnancy
Dr. M. Barekat
February 2013
Bushehr-Iran

2. n engl j med 365;5 nejm.org august 4, 2011
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5. National Institute for Health and Clinical Excellence(NICE)
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7. Alabama Perinatal Excellence Collaborative 10/17/2012
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10. The Journal of Lancaster General Hospital • Fall 2008 •
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11. Classification of Hypertension in Pregnancy
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12. Incidance HTN occurs in up to 22% of women of childbearing age
1% of pregnancies are complicated by chronic hypertension
5-6% by gestational hypertension (without proteinuria)
1-2% by preeclampsia.
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13. Definition
BP of at least 140 mm Hg systolic or 90 mm Hg diastolic pressure before pregnancy or
For women who first present for care during pregnancy, before 20 weeks of gestation Or
persistent after 12 weeks’ postpartum
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15. Grading Mild (140–159/90–109 mmHg) Severe (≥160/ 110 mmHg)
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16. Prevalence As high as 3% Primarily attributable to
Increased prevalence of obesity
Delayed childbearing
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17. Complications Most have good pregnancy outcomes
Increased frequency of preeclampsia (17 to 25%, vs. 3 to 5% in the general population)
Placental abruption two times more(1.56% vs. 0.58%) and even more if associated with preeclampsia
Fetal growth restriction (SGA), specially when associated with preeclampsia(10 to 20% and even 50% in a Danish report)
Preterm birth
Cesarean section
The risk of superimposed preeclampsia increases with an increasing duration of hypertension
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18. Clinical course
Most have a decrease in BP during pregnancy, similar to that observed in normotensive women
BP falls toward the end of the first trimester and rises toward prepregnancy values during the third trimester
As a result, antihypertensive medications can often be tapered
7 to 20% of women have worsening of hypertension during pregnancy without the development of preeclampsia
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19. Prepregnancy Evaluation
Assessment of target-organ damage
Blood glucose, hematocrit, serum potassium, creatinine, calcium, and lipoprotein profile, as well as urinalysis
ECG
24-hour quantification of urine protein to facilitate the identification of subsequent superimposed preeclampsia
The presence of end-organ manifestations of hypertension may worsen the prognosis
Dr.M.Barekat
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20. Prepregnancy Evaluation
The evaluation of identifiable causes of hypertension is generally limited to women with hypertension that is resistant to therapy or that requires multiple medications or to those who have symptoms or signs that suggest a secondary cause
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21. Monitoring for Preeclampsia
Superimposed preeclampsia should always be considered when the blood pressure increases in pregnancy or when there is a new onset of or an increase in baseline proteinuria
An elevated uric acid level may help to distinguish the two conditions (some overlaps)
Presence of thrombocytopenia or elevated values on liver-function testing may also support a diagnosis of preeclampsia
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22. Goal Of Therapy
A primary reason for treating hypertension in pregnancy is to reduce maternal morbidity
Meta-analysis including 28 randomized trials comparing antihypertensive treatment either with placebo or with no treatment showed that:
Antihypertensive treatment significantly reduced the risk of severe hypertension.
However, treatment did not reduce:
Risks of superimposed preeclampsia
Placental abruption
Growth restriction
Nor did it improve neonatal outcomes
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23. Antihypertensive Medications
The only trial of treatment of hypertension in pregnancy with adequate infant follow-up (7.5 years) was performed years ago with a-methyldopa
No adverse developmental effect
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24. Antihypertensive Medications
Methyldopa is considered to be a first-line therapy in pregnancy by many guidelines
Frequently causes somnolence, which may limit its tolerability
Adult Dose: 250 mg PO bid/tid; increase q2d prn; not to exceed 3 g/d.
Contraindications: acute liver disease
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25. Beta-blockers
Use of beta-blockers resulted in fewer episodes of severe hypertension than the use of methyldopa
Labetalol, a combined alpha- and beta-receptor blocker, is often recommended as another first-line or second-line therapy
mg/day in 2-3 divided doses
Association between atenolol and fetal growth restriction
Not been reported with the use of other beta-blockers or labetalol
Dr.M.Barekat
2/17/2019

26. Other Antihypertensive Medications
Long-acting calcium-channel blockers also appear to be safe in pregnancy, although experience is more limited than with labetalol
Diuretics were long considered contraindicated in pregnancy because of concern about volume depletion
Review of nine randomized trials showed no significant difference in pregnancy outcomes
continuation of diuretic therapy during pregnancy
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27. The only drugs that are contraindicated First trimester exposure:
Angiotensin-converting–enzyme inhibitors and angiotensin-receptor blockers
The only drugs that are contraindicated
First trimester exposure:
Potential teratogenic effects including cardiovascular and CNS defects
Second half of pregnancy exposure:
Oligohydramnios (probably resulting from impaired fetal renal function) and neonatal anuria and renal failure, growth abnormalities, skull hypoplasia, and fetal death
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29. Lifestyle modifications
Weight reduction and increased physical activity, have been shown to improve BP control in nonpregnant women
The American College of Obstetrics and Gynecology recommends weight reduction before pregnancy in obese women
However, data are lacking to inform whether such measures improve pregnancy outcomes specifically in women with hypertension
Normal diet without salt restriction is advised, particularly close to delivery, as salt restriction may induce low intravascular volume
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30. Blood-Pressure Goals in Pregnancy
Various professional guidelines provide disparate recommendations regarding indications for starting therapy (ranging from a blood pressure of >159/89 mm Hg to one of >169/109 mm Hg) and for blood-pressure targets for women who are receiving therapy (ranging from <140/90 mm Hg to <160/110 mm Hg).
Our recommendation: start medication with BP>169/109 and keep it<150/100
Dr.M.Barekat
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31. Starting Medical RX
Medscape, Feb 24, 2012: SBP >160 mm Hg or the DBP > mmHg.
Braunwald 2012: Only if diastolic pressures remain above 100 mm Hg
Royal College of OB and GYN 2011: BP>150/100
ESC Guidelines 2011:SBP 150> mmHg and a DBP > 95 mmHg.
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32. Blood-Pressure Goals in Pregnancy
Some experts recommend stopping antihypertensive agents during pregnancy, as long as blood pressures fall below such thresholds.
Meta-analysis showed greater magnitude of blood pressure lowering was associated with an increased risk of fetal growth restriction
So prepregnancy doses of antihypertensive agents may need to be reduced, particularly in the second trimester
Dr.M.Barekat
2/17/2019

33. Prevention of Preeclampsia
No significant reduction in the risk of preeclampsia associated with the use of low-dose aspirin, calcium supplementation, or antioxidant supplementation with vitamins C and E
Although antihypertensive medications are effective in treating chronic hypertension that has worsened during pregnancy, they are not effective in preventing preeclampsia
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34. NICE Guidelines on hypertension in Pregnancy January 2011
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35. Fetal Surveillance More frequent prenatal visits
Measuring blood pressure and urine protein
Evaluation of fetal growth
Regular evaluation of fundal height with ultrasonographic estimation of fetal weight, beginning in the early third trimester and continuing at intervals of 2 to 4 weeks
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36. Time of Delivery
Weigh the risks of fetal morbidity associated with delivery before term against the risks of maternal and fetal complications from continued expectant management
At 39 weeks and no later than 40 weeks
Not before 37 weeks if BP<160/110 mmHg, with or without antihypertensive treatment
Dr.M.Barekat
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37. Breast-feeding Breast-feeding should be encouraged
Although most antihypertensive agents can be detected in breast milk, levels are generally lower than those in maternal plasma
Most antihypertensive agents, including ACE inhibitors, as “usually compatible” with breast-feeding
Data are lacking with respect to the use of ARBs and breast-feeding
Dr.M.Barekat
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38. Breast-feeding
Case reports have described lethargy and bradycardia in newborns who are breast-fed by mothers taking atenolol
No such cautions are noted for other beta-blockers, such as metoprolol
Use of long-acting nifedipine, labetalol, methyldopa, captopril, and enalapril is acceptable during breastfeeding
Dr.M.Barekat
2/17/2019

39. Postpartum
Careful monitoring for at least 48h after delivery as they are at increased risk of renal failure , pulmonary edema and hypertensive encephalopathy
Measure blood pressure:
Daily for the first 2 days after birth
At least once between day 3 and day 5 after birth
As clinically indicated if antihypertensive treatment is changed after birth
Dr.M.Barekat
2/17/2019

40. Postpartum Continue antenatal antihypertensive treatment.
Review long-term antihypertensive treatment 2 weeks after the birth.
If a woman has taken methyldopa to treat chronic hypertension during pregnancy, stop within 2 days of birth because of the risk of post-natal depression and restart appropriate antihypertensive treatment
Dr.M.Barekat
2/17/2019

41. Areas of Uncertainty
Whether women with mild-to-moderate hypertension should receive antihypertensive treatment
which target blood pressure should be used for treatment
Which antihypertensive agents are superior
Dr.M.Barekat
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44. Take home message
primary reason for treating hypertension in pregnancy is to reduce maternal morbidity
Before attempting to conceive, the patient should replace the ACE inhibitor (methyldopa, labetalol, or a long-acting calcium-channel blocker
prepregnancy doses of antihypertensive agents may need to be reduced, particularly in the second trimester
Dr.M.Barekat
2/17/2019

45. Take home message
Although some guidelines recommend the first-line use of methyldopa on the basis of its long safety record, we would generally use labetalol first
Start medication with BP>169/109
Adjust medications to maintain blood pressure between 130/80 mm Hg and 150/100 mm Hg
Dr.M.Barekat
2/17/2019

46. Thank you for attention
Dr.M.Barekat
2/17/2019