Hypertension in Pregnancy

Aka: Hypertension in Pregnancy, Chronic Hypertension in Pregnancy, Gestational Hypertension

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II. Definitions

  1. Chronic Hypertension in Pregnancy
    1. Chronic Hypertension (140/90 mmHg) that extends into pregnancy without Preeclampsia
    2. Onset of Hypertension before 20 weeks gestation or persisting beyond 12 weeks after delivery
  2. Gestational Hypertension
    1. Hypertension in Pregnancy with onset beyond 20 weeks gestation and NO Proteinuria

III. Complications: Pregnancy Related

  1. Superimposed Preeclampsia (20-50% of cases)
  2. Placental Abruption
  3. Intrauterine Growth Retardation

IV. Risk Factors: Superimposed Preeclampsia Risk Factors

  1. Age 35 years or higher
  2. Antihypertensive needed for Blood Pressure control
  3. History of prior pregnancy complications
    1. Preeclampsia
    2. Untrauterine growth retardation
    3. Intrauterine Fetal Demise
  4. Comorbid conditions
    1. Diabetes Melllitus
    2. Systemic Lupus Erythematosus
    3. Chronic cardiopulmonary disease
    4. Renal disease
  5. Abnormal labs
    1. Serum Creatinine >1.0 mg/dl
    2. Proteinuria >300 mg/24 hours
    3. Phopholipid Antibody positive

V. Labs

  1. Baseline Hypertension labs may be obtained prior to pregnancy or during pregnancy
  2. Standard Hypertension testing
    1. Complete Blood Count
    2. Serum Electrolytes
    3. Serum Creatinine and Blood Urea Nitrogen
    4. Spot Urine Protein to Creatinine Ratio
    5. Thyroid Stimulating Hormone (if not recently obtained, typically part of Prenatal Labs)
    6. Consider baseline Electrocardiogram (EKG)
  3. Other labs
    1. Serum transaminases

VI. Monitoring

  1. Initial evaluation (at time of diagnosis)
    1. Estimate Fetal Growth
    2. Estimate amniotic fluid index (AFI)
    3. Non-Stress Test (NST)
    4. Biophysical Profile (BPP) if NST not reactive
    5. Further evaluation if BPP <8
  2. Repeat Testing
    1. Ultrasound every 4 weeks starting at 28 weeks gestation
    2. Other testing as indicated for significant maternal status changes

VII. Management: General

  1. See PIH Blood Pressure Management
  2. See Anti-Hypertensive Medications in Pregnancy
  3. Despite early studies, Aspirin DOES lower Preeclampsia risk and Intrauterine Growth Retardation risk
    1. See Preeclampsia Prevention
    2. Aspirin 81 mg orally daily starting at 12-28 weeks and continuing until delivery
  4. Hypertension therapy during pregnancy does not reduce pregnancy complications
    1. However, persistent Hypertension does have adverse effects on maternal health and is treated as below
    2. Evidence supports medication management of mild Chronic Hypertension in Pregnancy
      1. Antihypertensives appropriate for pregnancy are not associated with fetal or maternal pregnancy complications
      2. See Antihypertensives below
    3. Low Sodium Diet shows no benefit
    4. Minimizing weight gain shows no benefit
    5. Exercise restriction offers no benefit
  5. Delivery timing
    1. Recommended at 37-39 weeks for those on Antihypertensives (38-39 weeks if not)

VIII. Management: Anti-hypertensives

  1. See Blood Pressure Management in Pregnancy
  2. Goal: Lower Systolic Blood Pressure to <140/90
    1. New goal as of 2022 (prior goal had been <150-160/100-110 mmHg, much higher than non-pregnant goal)
    2. ACOG Practice Advisory
      1. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2022/04/clinical-guidance-for-the-integration-of-the-findings-of-the-chronic-hypertension-and-pregnancy-chap-study
  3. Anti-hypertensives are now indicated for mild to moderate Chronic Hypertension in Pregnancy
    1. Chronic Hypertension and Pregnancy (CHAP) Study found goal <140/90 benefits both mother and fetus
      1. Tita (2022) N Engl J Med 386(19):1781-92 +PMID: 35363951 [PubMed]
    2. Original studies found treatment of BP <150/100 did not reduce risk to fetus or prevent Preeclampsia
      1. Antihypertensives benefitted mother only (these do not reduce pregnancy complications)
      2. Based on these findings, only severe chronic Hypertension (>150-160/100-110) was previously treated
      3. References
        1. van Dadelszen (2000) Lancet [PubMed]
        2. (2001) Obstet Gynecol 98(1 suppl): 177-85 [PubMed]
  4. Precautions
    1. Aggressive lowering of Blood Pressure may result in adverse fetal outcomes (hypoperfusion)
  5. Antihypertensive used in pregnancy
    1. Avoid contraindicated Antihypertensives
      1. Avoid ACE Inhibitors and ARBs (serious fetal risk in second half of pregnancy, mixed data in first trimester)
      2. Avoid Atenolol and Beta Blockers in general (other than Labetalol) due to IUGR risk
      3. Avoid Spironolactone, Eplerenone and Aliskiren
    2. Most commonly used Antihypertensives in pregnancy
      1. Labetolol 200 mg orally twice daily (up to 1200 mg twice daily)
      2. Nifedipine XL 30 mg orally twice daily (up to 120 mg daily)
      3. Alpha Methyldopa 500 mg orally twice daily (up to 3000 mg daily in divided doses)
        1. Long safety record, but weak Antihypertensive and less tolerated (Fatigue, Dizziness)
        2. Also, as of 2023, indefinitely unavailable
    3. Other Antihypertensives used in pregnancy (less safety data)
      1. Felodipine 5 mg PO daily (up to 20 mg daily)
      2. Hydralazine 10 mg PO tid (up to 25 mg tid)
      3. Hydrochlorothiazide
        1. Not usually initiated in pregnancy due to volume depletion (esp. in first few weeks of starting)
        2. May be continued if on pre-pregnancy - consult with local expert opinion

IX. Precautions: Chronic Hypertension in Pregnancy

  1. Observe for superimposed Preeclampsia on chronic Hypertension
  2. High index of suspicion if maked Blood Pressure increase or new onset Proteinuria

X. Precautions: Gestational Hypertension

  1. Preeclampsia will develop in 50% of those with Gestational Hypertension onset 24-35 weeks
    1. Barton (2001) Am J Obstet Gynecol 184(5): 979-83 [PubMed]
  2. Severe Gestational Hypertension is associated with worse outcomes than mild PIH
    1. Treat with same management protocol as Severe Preeclampsia
    2. Buchbinder (2002) Am J Obstet Gynecol 186:66-71 [PubMed]

XI. References

  1. (2019) Am Fam Physician 100(12): 782-3 [PubMed]
  2. (2012) Obstet Gynecol 119:396-407 [PubMed]
  3. (2001) Obstet Gynecol 98(1 suppl): 177-85 [PubMed]
  4. Leeman (2008) Am Fam Physician 78: 93-100 [PubMed]
  5. Leeman (2016) Am Fam Physician 93(2):121-7 [PubMed]

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