Hypertension in pregnancy: Difference between revisions
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+ | == Background == |
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+ | === Definition === |
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* SBP ≥140 or DBP ≥90, with severe ≥160/110 |
* SBP ≥140 or DBP ≥90, with severe ≥160/110 |
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* Use the muffling of Karotkoff sounds rather than disappearance |
* Use the muffling of Karotkoff sounds rather than disappearance |
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− | == 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 |
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** White coat |
** White coat |
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− | == Pathophysiology == |
+ | === Pathophysiology === |
* BP in pregnancy naturally decreases to a nadir at 20 weeks |
* BP in pregnancy naturally decreases to a nadir at 20 weeks |
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== Differential Diagnosis == |
== Differential Diagnosis == |
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**** Outcomes are fine |
**** Outcomes are fine |
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*** Severe gestational hypertension |
*** Severe gestational hypertension |
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− | **** 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 |
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**** 1. Failure of maternal spiral arteries to re-model |
**** 1. Failure of maternal spiral arteries to re-model |
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**** 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 |
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− | ***** 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 |
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**** 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 |
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**** 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) |
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== Management == |
== Management == |
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− | === Chronic |
+ | === 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 |
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* Avoid: ACEi and ARBs |
* Avoid: ACEi and ARBs |
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* Prevention |
* Prevention |
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− | ** ASA 75-100mg daily prior to 16 weeks |
+ | ** [[ASA]] 75-100mg daily prior to 16 weeks |
** Calcium 1000mg daily |
** Calcium 1000mg daily |
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* Severe HTN >160/109 |
* Severe HTN >160/109 |
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** Treat if symptomatic, monitor if not |
** Treat if symptomatic, monitor if not |
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** Target <155/95 for maternal safety while allowing placental perfusion to continue |
** Target <155/95 for maternal safety while allowing placental perfusion to continue |
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− | * 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 |
− | * |
+ | * 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 |
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*** CNS depression, decreased reflexes |
*** CNS depression, decreased reflexes |
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*** Respiratory depression, bradycardia, hypotension |
*** Respiratory depression, bradycardia, hypotension |
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* 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 |
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− | ** HELLP, |
+ | ** [[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 |
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− | * Postpartum: AVOID NSAIDs |
+ | * Postpartum: AVOID [[NSAIDs]] |
=== Postpartum === |
=== Postpartum === |
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− | * 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 == |
Latest revision as of 15:24, 21 October 2021
Background
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
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
- 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
- Mild gestational hypertension
- 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)
- Two-stage model
- No proteinuria
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
- ACE inhibitors cause fetal anuria and oligohydramnius in T2-3
- 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
- Beware toxicity, especially if oliguric
- Deliver if cannot control blood pressure, they develop symptoms, of they have evidence of end-organ involvement
- HELLP, acute kidney injury, 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. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. Pregnancy Hypertens. 2014;4(2):105-145.
- CHIPS. Less-Tight versus Tight Control of Hypertension in Pregnancy. N Engl J Med. 2015; 372:407-417.