1. Hypertensive Crisis during Pregnancy Eric I. Rosenberg, MD, MSPH, FACP

2. “I stopped taking medicine when I got pregnant”

3. Hypertensive and Pregnant 28 year old woman, G4P2 29 week IUP BP 233/125 mmHg Admitted by High-Risk Obstetrical Service Internist asked to advise on optimal antihypertensive regimen

4. History PMHx:Hypertension Preeclampsia x 2; 1 fetal demise Meds:Prenatal vitamins Allergies:Ø FH:Both parents hypertensive SH:Lives with 3 children. Smokes ½ ppd. Stopped EtOH. No drug abuse. ROS:Remarkably negative.

5. Exam P 88, BP 233/125 mmHg BP 210/105 mmHg after 40mg Labetalol Normal exam –Alert, asymptomatic –No papilledema –Clear lungs –No S3 or S4 –No edema

6. Studies 134 4.8 103 22 9 0.8 66 11 34 12 205 ECG: LVH Urine: no protein

7. What would you do next?

8. Key Issues for the Medical Consultant How quickly should BP be normalized? Which medications are most efficacious? Which medications are safe in pregnancy? Is this preeclampsia?

9. Severe Asymptomatic Hypertension Consistent with chronically untreated and uncontrolled hypertension Rapid correction associated with morbidity and no proven benefit –May induce cerebral or myocardial ischemia –Goal: < 160/100 mmHg over hours to days –Keep patient (and staff) calm

10. Hypertensive Disorders in Pregnancy Preeclampsia –New onset hypertension (>140/90 mmHg) –Gestational age > 20 weeks –Proteinuria (>300mg in 24-hours) Gestational Hypertension –New onset, IUP > 20 weeks, no proteinuria Chronic Hypertension –Antedates pregnancy

11. Chronic BP >180/110 in 1 st Trimester is Strongly Associated with Fetal Demise Preeclampsia: 50% Placental abruption: 5 – 10% Delivery < 37 weeks: 70% Growth restriction: 35% Obstet Gynecol 2002 Aug;100(2).

12. Keep BP <140/90 During Pregnancy Mild chronic hypertension (>140/90) associated with up to 25% risk preeclampsia Perform same evaluation as all other newly dx’d HTN patients –ECG –UA –Ophthalmologic exam –Creatinine Close fetal surveillance by obstetrician

13. Key Issues for the Medical Consultant How quickly should BP be normalized? Which medications are most efficacious? Which medications are safe in pregnancy? Is this preeclampsia?

14. Do NOT use Immediate Release Nifedipine No benefit Not FDA approved for this purpose in any patient population Associated with excessive reductions in BP

15. Contraindicated Antihypertensives in Pregnancy Nitroprusside (D) Cyanide poisoining if > 4 hours use ACE-inhibitors (D) Teratogenic Angiotensin Receptor Blockers (D) Teratogenic

16. Options for Acute Therapy Labetalol (C) –Probably the safest option –No reports of teratogenicity Hydralazine (C) –May be teratogenic –Associated with impaired uteroplacental perfusion –Possible maternal hepatoxicity during preeclampsia Clonidine (C) –Case reports of birth defects if used throughout pregnancy –Should probably be avoided

17. Options for Chronic Therapy Methyldopa (C) (Aldomet ®) –Commonly used, but no teratology studies –Mild; may not control BP adequately –Has sedative effects Labetalol (C) –Most widely used beta-blocker –May preserve uteroplacental flow better than beta-blockers that don’t have alpha- blocking properties ACOG Chronic hypertension in pregnancy. July 2001.

18. Our Impression… “probable mild chronic hypertension now with poorly controlled gestational hypertension”

19. Recommendations Labetalol 200mg po twice daily Clonidine 0.1 to 0.2mg every 15 minutes for SBP > 200mmHg Monitor BP every 1 to 2 hours Goal: 160/100mmHg over several hours Labetalol gtt if symptomatic

20. And a sad ending… BP remained 150 – 200 / 83 – 119 mmHg Patient left against advice the next day Prescribed Labetalol 300mg twice daily Given appointment for f/u in 3 days Presented 2 weeks later to clinic with no fetal heart tones, BP 190/92

21. Take-Home Points This is an obstetrical area of expertise But you may be asked for input on optimal control of newly discovered chronic hypertension during pregnancy Educate patients on risks of all antihypertensive medications during pregnancy Risks of uncontrolled hypertension outweigh risks of Category C medications