Hypertension in pregnancy - Revision history

Aidan at 19:24, 21 October 2021

2021-10-21T19:24:48Z

← Older revision		Revision as of 19:24, 21 October 2021
Line 6:		Line 6:
	* Use the muffling of Karotkoff sounds rather than disappearance		* Use the muffling of Karotkoff sounds rather than disappearance

	== Classification ==		=== Classification ===

	* Pre-existing or chronic hypertension (<20 weeks; 1%), either primary or secondary		* Pre-existing or chronic hypertension (<20 weeks; 1%), either primary or secondary
Line 22:		Line 22:
	** White coat		** White coat

	== Pathophysiology ==		=== Pathophysiology ===

	* BP in pregnancy naturally decreases to a nadir at 20 weeks		* BP in pregnancy naturally decreases to a nadir at 20 weeks

		⚫	=== Epidemiology ===
		⚫	* Affects 8% of all pregnancies
		⚫	** Pre-existing in 1%
		⚫	** Gestational in 5-6%
		⚫	** Preeclampsia in 1-2%
		⚫	** Other
		⚫	* A major cause of maternal and perinatal morbidity and mortality
		⚫	** Preeclampsia/eclampsia is the second leading direct cause of maternal mortality in developed world

	== Differential Diagnosis ==		== Differential Diagnosis ==
Line 49:		Line 58:
	**** Excessive shedding of syncitiotrophoblasts into maternal circulation in women with preeclampsia, which presents late and mildly		**** Excessive shedding of syncitiotrophoblasts into maternal circulation in women with preeclampsia, which presents late and mildly
	**** Increased concentrations of soluble receptor for angiogenic factors (VEGF agonists, including s-Flt and PLGF)		**** Increased concentrations of soluble receptor for angiogenic factors (VEGF agonists, including s-Flt and PLGF)

⚫	== Epidemiology ==

⚫	* Affects 8% of all pregnancies
⚫	** Pre-existing in 1%
⚫	** Gestational in 5-6%
⚫	** Preeclampsia in 1-2%
⚫	** Other
⚫	* A major cause of maternal and perinatal morbidity and mortality
⚫	** Preeclampsia/eclampsia is the second leading direct cause of maternal mortality in developed world

	== Management ==		== Management ==

Aidan: /* Management */

2021-10-21T19:24:10Z

Management

← Older revision		Revision as of 19:24, 21 October 2021
Line 1:		Line 1:
	== ~~Definition~~ ==		== Background ==

			=== Definition ===

	* SBP ≥140 or DBP ≥90, with severe ≥160/110		* SBP ≥140 or DBP ≥90, with severe ≥160/110
Line 34:		Line 36:
	**** Outcomes are fine		**** Outcomes are fine
	*** Severe gestational hypertension		*** Severe gestational hypertension
	**** Very high risk for preeclampsia within 5 weeks if presents <34 weeks		**** Very high risk for [[preeclampsia]] within 5 weeks if presents <34 weeks
	** Proteinuria or end-organ dysfunction (preeclampsia)		** Proteinuria or end-organ dysfunction ([[preeclampsia]])
	*** Two-stage model		*** Two-stage model
	**** 1. Failure of maternal spiral arteries to re-model		**** 1. Failure of maternal spiral arteries to re-model
	**** 2. Multi-system process characterized by hypertension and end-organ dysfunction due to a dysfunctional endothelium		**** 2. Multi-system process characterized by hypertension and end-organ dysfunction due to a dysfunctional endothelium
	***** Cardiorespiratory: hypertension, myocardial dysfunction		***** Cardiorespiratory: [[hypertension]], [[myocardial dysfunction]]
	***** CNS: eclampsia, TIA/stroke, PRES		***** CNS: [[eclampsia]], [[TIA]]/[[stroke]], [[PRES]]
	***** Renal: glomerular endotheliosis, proteinuria, ATN, AKI		***** Renal: glomerular endotheliosis, proteinuria, [[ATN]], [[AKI]]
	***** Hepatic: HELLP, hepatic dysfunction		***** Hepatic: [[HELLP]], hepatic dysfunction
	***** Hematologic: mAHA, thrombocytopenia, DIC		***** Hematologic: mAHA, [[thrombocytopenia]], [[DIC]]
	*** Two leading theories		*** Two leading theories
	**** Excessive shedding of syncitiotrophoblasts into maternal circulation in women with preeclampsia, which presents late and mildly		**** Excessive shedding of syncitiotrophoblasts into maternal circulation in women with preeclampsia, which presents late and mildly
Line 60:		Line 62:
	== Management ==		== Management ==

	=== Chronic ~~hypertension~~ ===		=== Chronic Hypertension ===

	* First-line antihypertensives: labetalol, methyldopa, nifedipine, hydralazine		* First-line antihypertensives: [[labetalol]], [[methyldopa]], [[nifedipine]], [[hydralazine]]
	* Second-line is hydrochlorothiazide, but it has a theoretical risk of decreasing placental perfusion		* Second-line is [[hydrochlorothiazide]], but it has a theoretical risk of decreasing placental perfusion
	* Third-line includes clonidine, prazosin		* Third-line includes [[clonidine]], [[prazosin]]
	* Fourth-line: nitrates (short term use)		* Fourth-line: [[nitrates]] (short term use)
	* Antihypertensives often need to be titrated throughout pregnancy		* Antihypertensives often need to be titrated throughout pregnancy
	* Avoid: ACEi and ARBs		* Avoid: ACEi and ARBs
Line 79:		Line 81:

	* Prevention		* Prevention
	** ASA 75-100mg daily prior to 16 weeks		** [[ASA]] 75-100mg daily prior to 16 weeks
	** Calcium 1000mg daily		** Calcium 1000mg daily
	* Severe HTN >160/109		* Severe HTN >160/109
	** Treat if symptomatic, monitor if not		** Treat if symptomatic, monitor if not
	** Target <155/95 for maternal safety while allowing placental perfusion to continue		** Target <155/95 for maternal safety while allowing placental perfusion to continue
	* Labetalol, nifedipine, hydralazine IV		* [[Labetalol]], [[nifedipine]], [[hydralazine]] IV
	** Labetalol 20mg IV x1 repeated q30min up to 300mg then switch to oral		** [[Labetalol]] 20mg IV x1 repeated q30min up to 300mg then switch to oral
	** Nifedipine 5-10mg PO q30min		** [[Nifedipine]] 5-10mg PO q30min
	** Hydralazine 5-10mg IV q30min up to 20mg		** [[Hydralazine]] 5-10mg IV q30min up to 20mg
	* ~~MgSO4~~ 4-6g in 100mL D5W over 15 minutes, then 1-2g/h for 24h		* MgSO<sub>4</sub> 4-6g in 100mL D5W over 15 minutes, then 1-2g/h for 24h
	** Beware toxicity, especially if oliguric		** Beware toxicity, especially if oliguric
	*** CNS depression, decreased reflexes		*** CNS depression, decreased reflexes
	*** Respiratory depression, bradycardia, hypotension		*** Respiratory depression, bradycardia, hypotension
	* Deliver if cannot control blood pressure, they develop symptoms, of they have evidence of end-organ involvement		* Deliver if cannot control blood pressure, they develop symptoms, of they have evidence of end-organ involvement
	** HELLP, ~~renal~~ ~~failure~~, DIC, pulmonary edema, neurologic events		** [[HELLP]], [[acute kidney injury]], [[DIC]], [[pulmonary edema]], neurologic events
	** If you can stabilize BP, though, can get better fetal outcomes		** If you can stabilize BP, though, can get better fetal outcomes
	* Postpartum: AVOID NSAIDs		* Postpartum: AVOID [[NSAIDs]]

	=== Postpartum ===		=== Postpartum ===

	* If breastfeeding, can use same meds as above, with addition of captopril or enalapril and hydrochlorothiazide		* If breastfeeding, can use same meds as above, with addition of [[captopril]] or [[enalapril]] and [[hydrochlorothiazide]]

	== Further Reading ==		== Further Reading ==

Maintenance script: Imported from text file

2020-07-04T01:17:39Z

Imported from text file

New page

== Definition ==

* SBP ≥140 or DBP ≥90, with severe ≥160/110
* Use the muffling of Karotkoff sounds rather than disappearance

== Classification ==

* Pre-existing or chronic hypertension (<20 weeks; 1%), either primary or secondary
** Often the first time they're seeing a doctor for blood pressure
** Consider if there is an underlying secondary cause
** Can have superimposed preeclampsia in 15-20% of these patients
*** Highest risk in patients who started hypertensive and have been trending upwards over the first and second trimesters
* Gestational (>20 weeks; 5%)
** Mild
** Severe: BP ≥160/110
* Preeclampsia (1-2%): also have proteinuria or end-organ damage
* Other
** Transient
** Masked
** White coat

== Pathophysiology ==

* BP in pregnancy naturally decreases to a nadir at 20 weeks

== Differential Diagnosis ==

* Spurious or transient (white coat hypertension)
* Pre-existing (especially if in first trimester)
* Gestational (>20 weeks gestation)
** No proteinuria
*** Mild gestational hypertension
**** Presents late ≥37 weeks
**** Outcomes are fine
*** Severe gestational hypertension
**** Very high risk for preeclampsia within 5 weeks if presents <34 weeks
** Proteinuria or end-organ dysfunction (preeclampsia)
*** Two-stage model
**** 1. Failure of maternal spiral arteries to re-model
**** 2. Multi-system process characterized by hypertension and end-organ dysfunction due to a dysfunctional endothelium
***** Cardiorespiratory: hypertension, myocardial dysfunction
***** CNS: eclampsia, TIA/stroke, PRES
***** Renal: glomerular endotheliosis, proteinuria, ATN, AKI
***** Hepatic: HELLP, hepatic dysfunction
***** Hematologic: mAHA, thrombocytopenia, DIC
*** Two leading theories
**** Excessive shedding of syncitiotrophoblasts into maternal circulation in women with preeclampsia, which presents late and mildly
**** Increased concentrations of soluble receptor for angiogenic factors (VEGF agonists, including s-Flt and PLGF)

== Epidemiology ==

* Affects 8% of all pregnancies
** Pre-existing in 1%
** Gestational in 5-6%
** Preeclampsia in 1-2%
** Other
* A major cause of maternal and perinatal morbidity and mortality
** Preeclampsia/eclampsia is the second leading direct cause of maternal mortality in developed world

== Management ==

=== Chronic hypertension ===

* First-line antihypertensives: labetalol, methyldopa, nifedipine, hydralazine
* Second-line is hydrochlorothiazide, but it has a theoretical risk of decreasing placental perfusion
* Third-line includes clonidine, prazosin
* Fourth-line: nitrates (short term use)
* Antihypertensives often need to be titrated throughout pregnancy
* Avoid: ACEi and ARBs
** ACE inhibitors cause fetal anuria and oligohydramnius in T2-3
*** Unclear teratogenicity in T1
** ARBs may be worse
** Stop these medications when patient starts trying to conceive
* Target
** No comorbidities: 130-155/80-105
** With comorbidities 130-139/80-89

=== Preeclampsia ===

* Prevention
** ASA 75-100mg daily prior to 16 weeks
** Calcium 1000mg daily
* Severe HTN >160/109
** Treat if symptomatic, monitor if not
** Target <155/95 for maternal safety while allowing placental perfusion to continue
* Labetalol, nifedipine, hydralazine IV
** Labetalol 20mg IV x1 repeated q30min up to 300mg then switch to oral
** Nifedipine 5-10mg PO q30min
** Hydralazine 5-10mg IV q30min up to 20mg
* MgSO4 4-6g in 100mL D5W over 15 minutes, then 1-2g/h for 24h
** Beware toxicity, especially if oliguric
*** CNS depression, decreased reflexes
*** Respiratory depression, bradycardia, hypotension
* Deliver if cannot control blood pressure, they develop symptoms, of they have evidence of end-organ involvement
** HELLP, renal failure, DIC, pulmonary edema, neurologic events
** If you can stabilize BP, though, can get better fetal outcomes
* Postpartum: AVOID NSAIDs

=== Postpartum ===

* If breastfeeding, can use same meds as above, with addition of captopril or enalapril and hydrochlorothiazide

== Further Reading ==

* Magee LA ''et al''. [https://doi.org/10.1016/j.preghy.2014.01.003 Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy]. ''Pregnancy Hypertens''. 2014;4(2):105-145.
* CHIPS. [https://doi.org/10.1056/NEJMoa1404595 Less-Tight versus Tight Control of Hypertension in Pregnancy]. ''N Engl J Med''. 2015; 372:407-417.

[[Category:Obstetrical medicine]]
[[Category:Cardiology]]