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Hypertensive Crisis during Pregnancy Eric I. Rosenberg, MD, MSPH, FACP “I stopped taking medicine when I got pregnant” 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 History PMHx: Hypertension Meds: Preeclampsia x 2; 1 fetal demise Prenatal vitamins Allergies: Ø FH: Both parents hypertensive SH: Lives with 3 children. Smokes ½ ppd. Stopped EtOH. No drug abuse. ROS: Remarkably negative. 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 Studies 134 103 9 4.8 22 0.8 66 ECG: LVH 11 12 205 34 Urine: no protein What would you do next? 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? 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 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 Chronic BP >180/110 in 1st 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). 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 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? Do NOT use Immediate Release Nifedipine • No benefit • Not FDA approved for this purpose in any patient population • Associated with excessive reductions in BP Contraindicated Antihypertensives in Pregnancy • Nitroprusside (D) • Cyanide poisoining if > 4 hours use • ACE-inhibitors (D) • Teratogenic • Angiotensin Receptor Blockers (D) • Teratogenic 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 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 alphablocking properties ACOG Chronic hypertension in pregnancy. July 2001. Our Impression… “probable mild chronic hypertension now with poorly controlled gestational hypertension” 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 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 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