Cardiovascular Medicine Book


Hypertension in Pregnancy

Aka: Hypertension in Pregnancy, Chronic Hypertension in Pregnancy, Gestational Hypertension
  1. See Also
    1. Pregnancy Induced Hypertension
    2. PIH Prophylaxis
    3. Mild PIH Management
    4. Severe PIH Management
    5. PIH Blood Pressure Management
  2. Definition
    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
  3. Complications: Pregnancy Related
    1. Superimposed Preeclampsia (20-50% of cases)
    2. Placental Abruption
    3. Intrauterine Growth Retardation
  4. 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
  5. 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
  6. 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
  7. 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. 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)
  8. Management: Anti-hypertensives
    1. See Blood Pressure Management in Pregnancy
    2. Goal: Lower Systolic Blood Pressure to <150/100 (much higher than non-pregnant goal)
    3. Anti-hypertensives are not indicated for mild to moderate Chronic Hypertension in Pregnancy
      1. Treatment of BP <150/100 does not reduce risk to fetus or prevent Preeclampsia
        1. Antihypertensives benefit mother only (these do not reduce pregnancy complications)
        2. van Dadelszen (2000) Lancet [PubMed]
      2. Aggressive lowering of Blood Pressure may result in adverse fetal outcomes (hypoperfusion)
      3. Severe chronic Hypertension (consistently >150-180/100-110) should be treated
      4. (2001) Obstet Gynecol 98(1 suppl): 177-85 [PubMed]
    4. Antihypertensive used in pregnancy
      1. Avoid contraindicated antihypertensives
        1. Avoid ACE Inhibitors and ARBs (despite 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)
      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
          2. May be continued if on pre-pregnancy - consult with local expert opinion
  9. 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
  10. 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]
  11. 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]

Hypertension induced by pregnancy (C0340274)

Definition (NCI) A blood pressure elevation after 20 weeks of gestation in the absence of either proteinuria or systemic findings like thrombocytopenia, impaired liver function, progressive renal insufficiency, pulmonary edema or the new-onset of cerebral or visual disturbances.(NICHD)
Definition (MSH) A condition in pregnant women with elevated systolic (>140 mm Hg) and diastolic (>90 mm Hg) blood pressure on at least two occasions 6 h apart. HYPERTENSION complicates 8-10% of all pregnancies, generally after 20 weeks of gestation. Gestational hypertension can be divided into several broad categories according to the complexity and associated symptoms, such as EDEMA; PROTEINURIA; SEIZURES; abnormalities in BLOOD COAGULATION and liver functions.
Concepts Pathologic Function (T046)
MSH D046110
ICD10 O13
SnomedCT 156106005, 156112000, 198969004, 267307002, 267306006, 308551004, 48194001, 30354006
LNC LA19981-2
English H/T - pregnancy, Hypertension induced by pregnancy, HYPERTENSION, PREGNANCY-INDUCED, HYPERTENSION PREGN IND, Hypertension of pregnancy NOS, pregnancy-induced hypertension, pregnancy-induced hypertension (diagnosis), PIH - Preg-ind hypertension, Induced Hypertension, Pregnancy, Pregnancy Induced Hypertension, Induced Hypertensions, Pregnancy, Hypertensions, Pregnancy Induced, gestational hypertension NOS, Hypertension, Pregnancy-Induced [Disease/Finding], PIH Pregnancy induced hypertension, Pregnancy induced hypertension, high blood pressure disorder caused by pregnancy, high blood pressure caused by pregnancy, hypertension in pregnancy, pregnancy induced hypertension, gestational hypertension, Hypertension of pregnancy, Hypertension induced by pregnancy (disorder), Hypertension of preg., Hypertension of pregnancy NOS (disorder), Pregnancy-Induced Hypertension, Hypertension gestational, Gestational hypertension, GH - Gestational hypertension, PIH - Pregnancy-induced hypertension, Gestational hypertension (disorder), Pregnancy-induced hypertension (disorder), Pregnancy-induced hypertension, pregnancy; hypertension, Pregnancy-induced hypertension, NOS, Gestational Hypertension, Hypertension, Gestational, Hypertension, Pregnancy Induced, Hypertension, Pregnancy-Induced, Pregnancy Associated Hypertension
Swedish Graviditetshypertoni
Czech hypertenze indukovaná těhotenstvím, Těhotenstvím indukovaná hypertenze, Gestační hypertenze
Spanish Hipertensión Inducida en el Embarazo, Hipertensión inducida por el embarazo, Hipertensión gestacional, hipertensión durante el embarazo, SAI, hipertensión durante el embarazo, SAI (trastorno), Hypertension of pregnancy NOS, Hipertensión Gestacional, hipertensión gestacional (trastorno), hipertensión gestacional, hipertensión gestacional [dup] (trastorno), hipertensión inducida por el embarazo, hipertensión inducida por el embarazo (trastorno)
Finnish Raskauteen liittyvä kohonnut verenpaine
Japanese 妊娠中毒症, 妊娠中毒, 妊娠高血圧, 妊娠誘発性高血圧, 高血圧-妊娠誘発性, 高血圧症合併妊娠, 妊娠性高血圧, 高血圧症-妊娠, 妊娠高血圧症, ニンシンコウケツアツ, ニンシンコウケツアツショウコウグン, 妊娠高血圧症候群, 高血圧-妊娠性
Dutch zwangerschapsgeinduceerde verhoogde bloeddruk, zwangerschapshypertensie, zwangerschap; hypertensie, Hypertensie, zwangerschaps-, Zwangerschapshypertensie
Portuguese Hipertensão gestacional, Hipertensão induzida pela gravidez, Hipertensão arterial induzida pela gravidez, Hipertensão Gestacional, Hipertensão Induzida por Gravidez, Hipertensão Induzida pela Gravidez
Italian Ipertensione gestazionale, Ipertensione gravidica (PIH), Ipertensione da gravidanza, Ipertensione gravidica
German Bluthochdruck in der Schwangerschaft, schwangerschaftsbedingte Hypertonie, PIH schwangerschaftsbedingte Hypertonie, Gestationshypertonie, Hypertonie, schwangerschaftsinduzierte, Schwangerschaftsinduzierte Hypertonie
French Gestational hypertension, Hypertension gestationnelle (HG), Hypertension artérielle gravidique, Hypertension gestationnelle, Hypertension liée à la grossesse, Hypertension induite par la grossesse, Hypertension de la grossesse
Polish Nadciśnienie wywołane ciążą, Nadciśnienie ciążowe
Hungarian Terhesség által kiváltott hypertonia, Gestationalis hypertonia, PIH terhesség által kiváltott hypertonia
Norwegian Svangerskapshypertoni, Graviditetsblodtrykk, Graviditetshypertoni
Derived from the NIH UMLS (Unified Medical Language System)

Pre-existing hypertension complicating pregnancy, childbirth and puerperium (C0348859)

Concepts Pathologic Function (T046)
ICD10 O10
SnomedCT 199005000
English Pre-ex hypten cmp prg brth+pue, Pre-exist hypertension compl preg childbirth and puerperium, Pre-existing hypertension complicating pregnancy, childbirth and the puerperium, Pre-existing hypertension complicating pregnancy, childbirth and puerperium, Pre-existing hypertension complicating pregnancy, childbirth and puerperium (disorder)
German Vorher bestehende Hypertonie, die Schwangerschaft, Geburt und Wochenbett kompliziert
Korean 임신, 출산 및 산후기에 합병된 선재성 고혈압
Spanish hipertensión preexistente que complica el embarazo, parto y puerperio (trastorno), hipertensión preexistente que complica el embarazo, parto y puerperio
Dutch Reeds bestaande hypertensie als complicatie van zwangerschap, bevalling en kraambed
Derived from the NIH UMLS (Unified Medical Language System)

Unspecified maternal hypertension (C0495183)

Concepts Pathologic Function (T046)
ICD10 O16, O16.9
English Unspecified maternal hypertension, Unspecified maternal hypertension, unspecified trimester
German Nicht naeher bezeichnete Hypertonie der Mutter
Korean 상세불명의 모성 고혈압
Dutch Niet gespecificeerde hypertensie van moeder
Derived from the NIH UMLS (Unified Medical Language System)

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