1. Hypertension in Pregnancy
Ramon M. Gonzalez, MD
Professor
UST Medicine and Surgery

2. A 26y/o G weeks known hypertensive for 6 years was admitted because of severe hypertension VS- BP-200/100mmHg, PR- 76/min, RR-20/min, T-36.5C. She was taking calcium channel blockers for her HPN which she was taking regularly.

3. Hypertensive Disorders Complicating Pregnancy
Gestational Hypertension
Systolic BP≥ 140 or diastolic ≥ 90 mmHg for the first time after 20 weeks gestation
No proteinuria
BP returns to normal before 12 weeks postpartum
Final diagnosis made only postpartum
May have other signs or symptoms of preeclampsia

4. Hypertensive Disorders Complicating Pregnancy
Preeclampsia
Minimum criteria
BP ≥ 140/90 mmHg after 20 weeks gestation
Proteinuria ≥ 300mg/24 hours or ≥ 1+ dipstick
Severe preeclampsia
BP ≥ 160/110 mmHg
Proteiunuria 2.0gms/24 hrs or ≥ 2+ dipstick
Serum creatinine > 1.2mg/dl
Platelets < 100,00/ul
Elevated LDH, ALT or AST

5. Hypertensive Disorders Complicating Pregnancy
Eclampsia
Seizures that cannot be attributed to other causes in women with preeclampsia
Chronic Hypertension
BP ≥ 140/90 mmHg before pregnancy or diagnosed before 20 weeks gestation
Hypertension first diagnosed after 20 weeks gestation and persistent after 12 weeks postpartum

6. Hypertensive Disorders Complicating Pregnancy
Superimposed Preeclampsia
New onset proteinuria ≥ 300mg/24 hrs in hypertensive women but no proteinuria before 20 weeks gestation

7. Pregnancy 20-21 weeks, Chronic Hypertension

8. Maternal Assessment Duration of hypertension Current therapy
Degree of BP control
Other medical complications

9. Maternal Assessment Serum creatinine Quantification of urine proteins
ECG
Echocardiography
Blood chemistry

10. What are the effects of chronic hypertension on pregnancy?
What is the management of chronic hypertension during pregnancy?
Can we prevent superimposition of preeclampsia ?
What is the management of chronic hypertension with superimposed preeclampsia?

11. What are the effects of chronic hypertension on pregnancy?

13. ORs for Fetal Complications: 1995-2008
Pregestational Diabetes Variable With Chronic HPN W/O Chronic HPN ________________________________________________________ Stillbirth 4.30( ) 3.05( ) Poor fetal growth 2.66( ) 1.20( ) Spontaneous delivery 4.88( ) 2.90( ) <37weeks

14. ORs for Maternal Complications: 1995-2008
Pregestational Diabetes
Variable With Chronic HPN W/O Chronic HPN
__________________________________________________________
Preeclampsia ( ) ( )
CVA ( ) ( )
Acute renal failure ( ) ( )
Pulmonary edema ( ) ( )
Ventilation ( ) ( )
Cesarean delivery ( ) ( )
In- hospital mortality ( ) ( )

15. ORs for Fetal Complications: 1995-2008
Chronic Renal Disease Variable With Chronic HPN W/O Chronic HPN ________________________________________________________ Stillbirth 7.29( ) 1.74( ) Poor fetal growth 7.94( ) 2.29( ) Spontaneous delivery 8.60( ) 2.25( ) <37weeks

16. ORs for Maternal Complications: 1995-2008
Chronic Renal Disease
Variable With Chronic HPN W/O Chronic HPN
__________________________________________________________
Preeclampsia ( ) ( )
CVA ( ) ( )
Acute renal failure ( ) ( )
Pulmonary edema ( ) ( )
Ventilation ( ) ( )
Cesarean delivery ( ) ( )
In- hospital mortality ( ) ( )

17. ORs for Fetal Complications: 1995-2008
Collagen Vascular Disease Variable With Chronic HPN W/O Chronic HPN ________________________________________________________ Stillbirth 7.42( ) 2.74( ) Poor fetal growth 7.99( ) 3.87( ) Spontaneous delivery 7.19( ) 3.15( ) <37weeks

18. ORs for Maternal Complications: 1995-2008
Collagen Vascular Disease
Variable With Chronic HPN W/O Chronic HPN
__________________________________________________________
Preeclampsia ( ) ( )
CVA ( ) ( )
Acute renal failure ( ) ( )
Pulmonary edema ( ) ( )
Ventilation ( ) ( )
Cesarean delivery ( ) ( )
In- hospital mortality ( ) ( )

19. What is the management of chronic hypertension during pregnancy?

20. Management Blood pressure control Fetal antepartum surveillance
Prevention of preeclampsia
Detection of preeclampsia

21. Blood Pressure Control
Ca Channel Blockers
Adrenergic Blocking Agents
Vasodilators
Diuretics
ACE Inhibitors/ARB
contraindicated

22. El Guindy, A.A. and Nabhan, A.F. (2008) Journal of Perinatal Medicine
A randomized trial of tight vs. less tight control of mild essential and gestational hypertension in pregnancy
El Guindy, A.A. and Nabhan, A.F. (2008)
Journal of Perinatal Medicine
Women in the tight control group
Were less likely to develop severe hypertension (RR 0.32, 95% CI 0.14 to 0.74)
Delivered babies with older gestational ages (36.6 ±2.2 weeks vs 35.8 ± 2.2 weeks: P<0.05)
Fewer preterm deliveries (RR 0.52, 95%CI 0.28 to 0.99)
No significant differences between groups regarding stillbirth or IUGR

23. Fetal Antepartum Surveillance
Fetal biometry
Nonstress test
Contraction stress test
Biophysical profile
Doppler velocimetry

24. Can we prevent superimposition of preeclampsia?

25. Preeclampsia
Pregnancy specific syndrome that can affect virtually every organ system.
Disorder of unknown etiology affecting 5-10% of all pregnancies.
In developed countries 16% of maternal deaths were due to hypertensive disorder.
POGS (2006) % maternal deaths were due to hypertensive disorder.

26. Pathogenesis Vasospam Increased resistance → hypertension
Endothelial cell damage → leakage of blood constituents, including platelets and fibrinogen
Decreased blood flow → ischemia of tissues → necrosis, hemorrhage and other end organ disturbances

27. Pathogenesis Endothelial cell activation Increased pressor responses
Increased sensitivity to angiotensin II
Prostaglandin
Prostacyclin: thromboxane A2 ratio decreases
Nitric oxide
Decreased nitric oxide synthase expression
Endothelins
Potent vasoconstrictor which is increased in preeclampsia

28. Cardiovascular System
↑ Cardiac afterload
hypertension
↑Cardiac preload
Diminished hypervolemia
↑ intravenous crystalloids
Extravasation of intravascular fluid into the extracellular space
Pulmonary edema

29. Blood Volume and Coagulation
Hemoconcentration
Hallmark of preeclampsia
Vasospasm and endothelial leakage
Thrombocytopenia
Hemolysis
Endothelial disruption
HELLP syndrome

30. Kidneys ↓ Glomerular filtration rate and renal plasma flow
↑ Serum creatinine
↑ Uric acid
Proteinuria
Oliguria
“Glomerular capillary endotheliosis”
Acute renal failure

31. Liver Hepatic infarction Periportal hemorrhage Hepatocellular necrosis
Elevations of AST/ALT
Hepatic hematoma
HELLP syndrome

32. Brain Headaches, visual symptoms Convulsions Intracerebral hemorrhage
Cortical and subcortical petechial hemorrhages
Subcortical edema

33. Uteroplacental Perfusion
Vasospasm ↓ Decreased uteroplacental perfusion Increased perinatal morbidity and mortality

34. Prevention of Superimposed Preeclampsia
Systematic Review by Duley et al
59 trials with 37,560 women given Aspirin
17% reduction in the risk of preeclampsia (RR 0.83, ), especially in high risk patients
8% reduction in the relative risk of preterm birth (RR 0.92, )
14% reduction in fetal and neonatal deaths (RR 0.86, )
10% reduction in SGA babies (0.90, )

35. Detection of Preeclampsia
BP monitoring
24 hour urine proteins

36. What is the management of chronic hypertension with superimposed preeclampsia?

37. Management
Termination of pregnancy with the least possible trauma to mother and baby
Birth of an infant who subsequently thrives
Complete restoration of health to the mother

38. Severe Preeclampsia
Clinical course is progressive deterioration in both maternal and fetal condition
Associated with high rates of maternal and perinatal morbidity and mortality

39. Management of Severe Preeclampsia
Aggressive
High neonatal mortality and morbidity due to prematurity
Prolonged NICU stay
Long term disability
Expectant
- Fetal death
- Asphyxial damage in
utero
- Increased maternal
morbidity

41. Odendaal and associates
Aggressive vs expectant management
58 patients, 20 were delivered w/in 48 hours
20 aggressive, 18 expectant
28-34 weeks
Betamethasone, MgSO4, Antihypertensive drugs
Maternal and fetal testing

43. Sibai and colleagues Aggressive vs expectant management 28-32 weeks
95 patients
Aggressive (n=46); expectant (n=49)
Bed rest, antihypertensives, MgSO4, betamethasone, maternal and fetal testing, laboratory exams

47. Expectant Management Prolongs pregnancy Higher gestational age
Higher birth weight
Lower incidence of admission to NICU
Lower incidence of neonatal complication
No difference in the incidence of CS, abruptio placenta, HELLP syndrome and postpartum stay

48. Guidelines for Expectant Management
Hospitalization in a tertiary hospital
- Good facilities to monitor the mother and fetus
- NICU facilities
- Trained personnels
MgSO4
Antihypertensives
Corticosteroids

49. Maternal Assessment

50. Maternal Assessment Blood pressure measurement
- Systolic – 140 – 155 mmHG
- Diastolic – 90 – 105 mmHG
Daily 24 hour urine volume
Maternal symptoms
Search for imminent signs of eclampsia
Sibai et al AmJOG 2007

51. Maternal Assessment CBC with platelet counts Serum creatinine
Liver function test
AST/ALT
Lactate dehydrogenase
Sibai et al AmJOG 2007

52. Fetal Assessment

53. Fetal Assessment Fetal kick counts NST Biophysical profile scoring
Umbilical artery Doppler studies
Assessment of fetal growth

54. Maternal Indications for Delivery in Women With Severe Preeclampsia
Persistent severe headache or visual changes; eclampsia
Pulmonary edema
Uncontrolled severe HPN
Epigastric pain/RUQ pain with AST or ALT >2 times the upper limit of normal
Sibai et al AmJOG 2007

55. Maternal Indications for Delivery in Women With Severe Preeclampsia
Oliguria (<500ml/24hr)
HELLP syndrome
Platelet counts <100,000/mm3
Deterioration of renal function
(serum creatinine >/=1.5 mg/dl)
Suspected abruptio placenta, progressive labor, and/or rupture of membranes
Sibai et al AmJOG 2007

56. Fetal Indications For Delivery In Women With Severe Preeclampsia
Repetitive late or severe variable deceleration
Biophysical profile </=4 on 2 occasions at 6 hours apart
IUGR (Estimated fetal weight <5th percentile)
Umbilical artery Doppler with reverse end diastolic flow
Severe oligohydramnios
Sibai et al AmJOG 2007

57. Mode of Delivery Vaginal delivery - Inducible cervix
- No fetal distress
Cesarean section

58. Thank You