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COMPANY NAME
Hypertension in Pregnancy
นพ.สิทธิพงศ์ ถวิลการ
กลุ่มงานสูตินรีเวชกรรม รพ.ขอนแก่น
Contents
Classification
HT
In
Pregnancy
Pathogenesis and Risk factors
Diagnosis
Prediction and prevention
Management
Introduction
 Hypertensive disorders of pregnancy remain a major
health issue for women and their infants worldwide
 The ACOG convened a task force of experts in the
management of HT in pregnancy to review available
data and publish evidence-based recommendations for
clinical practice
 Preclampsia is a dynamic process, by nature is
progressive
Classification
Preeclampsia-eclampsia:
BP elevation after 20 weeks of gestation with
proteinuria or any of the severe features of
preeclampsia
Chronic hypertension
BP elevation before 20 weeks of gestation or
before pregnancy
Chronic hypertension with
superimposed preeclampsia
Gestational hypertension :
evidence for the preeclampsia not
develop and HT resolves by 12 weeks
postpartum
Previous classification
p
Classification
Avoid use of term mild preeclampsia
>> replace with preeclampsia without
severe features
Severe preeclampsia
>> preeclampsia with severe features
Pathogenesis
Abnormal
trophoblastic
invasion
Pathogenesis
of
Endothelial cell
injury
Preeclampsia
Genetic
factors
Vasospasm
Pathophysiology
Risk factors
Young and
Nulliparous
Incidence 3-10%
Older women : Chronic
HT with superimposed
precclampsia
 4.3% in BMI < 20
 13.3 % in BMI > 35
 Twins 13% vs
Singleton 5%
Obesity
Multifetal gestation
Previous
Preeclampsia
Diagnosis : Preeclampsia
Diagnosis : Preeclampsia
with severe feature
Diagnosis : Preeclampsia
with severe feature
 The diagnosis of severe preeclampsia is no longer
dependent on the presence of proteinuria
 Do not delay management of preeclampsia in the
absence of proteinuria
 Massive proteinuria (> 2 g) has been eliminated from
consideration of preeclampsia as severe
 Fetal growth restriction has been removed as a
finding indicative of severe preeclampsia
Prediction of preeclampsia
 Screening to predict preeclampsia beyond obtaining
an appropriate medical history to evaluate for risk
factors is not recommended
TVS of a cervix and funneling
Prevention of preeclampsia
 Antioxidants: vitamins C and E are not effective.
 Calcium: may be useful in populations with low
calcium intake (not in the USA).
 Low-dose aspirin (60 to 80 mg/day): beginning in the
late first trimester may have slight effect to reduce
preeclampsia and adverse perinatal outcomes.
>> suggest in women with Hx of early onset
preeclampsia and preterm delivery less than 34 wks
or preeclampsia in more than one prior pregnancy
TVS of a cervix and funneling
 Bed rest or salt restriction: no evidence of benefit.
Management
Basic
manage
ment
objective
Important
Current
clinical
issues
 Termination of pregnancy with the least possible
trauma to mother and fetus
 Birth of infants who subsequently thrives
 Complete retroration of health to mother
 Early diagnosis of preeclampsia
 Precise gestational age
 Timing of delivery
 Antihypertensive drugs
 Magnesium sulfate
Management
 Hospitalization for women with new
onset HT
 Daily assessment of maternal symptoms,
weight gain and fetal movement
 Analysis for proteinuria
 BP every 4 hours
 Measurement of serum Cr, Hepatic enzymes,
CBC (some recommend uric acid, LDH,
coagulogram)
 Evaluation of fetal size, amniotic volume,
well-being
Management
 Timing of delivery :
 Preeclampsia without severe features; 37 weeks
 Severe preeclampsia ;
• < 34 weeks of gestation with stable maternal and
fetal conditions, it is recommended that continued
pregnancy be undertaken only at facilities with
adequate maternal and neonatal intensive care
resources
• ≥ 34 weeks of gestation, and in those with
unstable maternal or fetal conditions irrespective
of gestational age, delivery soon after maternal
stabilization is recommended
 Chronic hypertension; 38 weeks
Management
Management
Management
 Antihypertensive drugs ;
 preeclampsia with severe hypertension during
pregnancy (sustained systolic BP of at least 160 or
diastolic of at least 110)
 persistent chronic hypertension with systolic BP of at
least160 or diastolic BP of at least105
Management
 Antihypertensive drugs ;
 IV labetalol
• bolus doses 20-40 mg (max 300/hr)
• continuous IV infusion (1-2 mg/min)
 IV bolus doses of hydralazine
• 5, 10, 10 mg q 20 min (max 25 mg)
 Oral nifedipine
• 10-20 mg q 20 min (max 60 mg)
 IV Sodium nitroprusside
Management
 Magnesium sulfate prevent seizure;
Preeclampsia without severe feature do not need
magnesium sulfate
(risk for eclampsia = 1/100)
Management : MgSO4 dosage
Management : MgSO4 dosage
TASK FORCE RECOMMENDATIONS
Close monitoring of women with gestational HT or
preeclampsia without severe features with
 serial assessment of maternal symptoms and fetal
movement (daily by the woman)
 serial measurements of BP (twice weekly)
 assessment of platelet counts and liver enzymes
(weekly) is suggested
 US to assess fetal growth and antenatal testing to
assess fetal status
 If evidence of fetal growth restriction is found in,
fetoplacental assessment that includes umbilical
artery Doppler velocimetry as an adjunct antenatal
test is recommended
TASK FORCE RECOMMENDATIONS
For women with preeclampsia, it is suggested that
a delivery decision should not be based on the
amount of proteinuria or change in the amount of
proteinuria
For women with preeclampsia, it is suggested that
the mode of delivery need not be cesarean
delivery. The mode of delivery should be
determined by fetal gestational age, fetal
presentation, cervical status, and maternal
and fetal conditions
TASK FORCE RECOMMENDATIONS
For women with HELLP syndrome;
 before the gestational age of fetal viability, it is
recommended that delivery be undertaken shortly
after initial maternal stabilization
 ≥34 weeks of gestation, it is recommended that
delivery be undertaken soon after initial maternal
stabilization
 gestational age of fetal viability to <34 weeks of
gestation, it is suggested that delivery be delayed
for 24-48 hours if maternal and fetal conditions
remain stable to complete a course of
corticosteroids for fetal benefit
TASK FORCE RECOMMENDATIONS
Post partum period;
 BP be monitored in the hospital or that equivalent
outpatient surveillance be performed for at least 72
hours postpartum and again 7-10 days after
delivery or earlier in women with symptoms
 discharge instructions include information about
the signs and symptoms of preeclampsia as well
as the importance of prompt reporting of this
information to their health care providers
TASK FORCE RECOMMENDATIONS
Post partum period;
 new-onset hypertension associated with
headaches or blurred vision or preeclampsia with
severe hypertension, the parenteral administration
of magnesium sulfate is suggested
 persistent postpartum hypertension, BP of 150
systolic or 100 diastolic or higher, on at least two
occasions that are at least 4-6 hours apart,
antihypertensive therapy is suggested
 Persistent BP of 160 systolic or 110 diastolic or
higher should be treated within 1 hour
References
American College of Obstetricians and
Gynecologists: Hypertension in pregnancy
Executive summary, November 2013
Williams Obstetrics, 24ed
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