cardiovascular management of hypertension during pregnancy

Cardiovascular Management of Hypertension during Pregnancy

Ma. Rosario Cruz Sevilla, MD, FPCP, FPCCAsian Hospital and Medical Center

UPHDMC Heart and Vascular Institute, Las Pinas

23 May 2012 MRCSevilla MD

Normal Physiologic Changes


Normal Physiologic ChangesLABOR AND DELIVERY Uterine contraction = 500 ml blood released – increased CO &

BP CO - >=50% above baseline at stage 2 labor Blood loss – 400 cc in NSD; 800 ml in CS

POSTPARTUM Abrupt increase in venous return due to:

Autotransfusion from uterus – 24-72 hours Loss of fetal compression on IVC


Hypertension in Pregnancy (ESC 2011)

• Major cause of maternal, fetal, and neonatal morbidity and mortality in developing and in developed countries

• Hypertension is the most common medical problem in pregnancy, complicating up to 15% of pregnancies and accounting for about a quarter of all antenatal admissions


PHILIPPINE HEALTH STATISTICS

Total Number of Live Births 2008 : 1,920,0982007: 1,858,361 2006: 1,770,735


PHILIPPINE HEALTH STATISTICS2006 Maternal Mortality Data

TOTAL: 1,721 deaths

CAUSES1. Complications related to pregnancy occuring in the course of labor, delivery and puerperium N=732 (0.4/1000 Livebirths; 42.5%)2. Hypertension complicating pregnancy, childbirth and puerperium

N=565 (0.3/1000 Livebirths; 32.8%)N=510 (0.3/1000 livebirths; 29.4%) 2005

3. Postpartum Hemorrhage N=261 (0.2/1000; 15.2%)

4. Pregnancy with abortive outcome N=163 (0.1/1000; 9.5%)

5. Hemorrhage in early pregnancyN=0



•These women are at higher risk for severe Cx such as abruptio placentae, cerebrovascular accident, organ failure, and disseminated intravascular coagulation

• The fetus is at risk for intrauterine growth retardation, prematurity, and intrauterine death


Case 1:

26/FemaleKnown hypertensive for 6 yearsOn maintenance calcium channel

blockersusual BP = 130/80


Case 1:

26/Female Known hypertensive for 6 years (diagnosed at age

20 – what was highest BP ever recorded? Was secondary hypertension considered? What were the results of any prior cardiovascular work-ups?)

On maintenance calcium channel blockers (which CCB? What dose?)

usual BP = 130/80 (on meds?)


Case 1: 26/Female Known hypertensive for 6 years G1 21-22 weeks admitted due to severe HPN

BP- 200/100mmHgPR-76/minRR-20/minT-36.5C.


Case 1: 26/Female Known hypertensive for 6 years G1 21-22 weeks (first consult or with prior prenatal

check-up? What was previous BP readings during 1st trime?)

admitted due to severe HPN BP- 200/100mmHg PR-76/min RR-20/min T-36.5C.



• Basic lab exams recommended include:• urinalysis (check for proteinuria)• blood count, haematocrit, • liver enzymes• serum creatinine,• serum uric acid

• Adrenal UTZ and urine metanephrine & normetanephrine assays may be considered to exclude pheochromocytoma w/c may be asymptomatic and, if not diagnosed before labour, fatal.



•Definition and classification: -based on absolute BP values

(SBP ≥140 mmHg or DBP ≥90 mmHg) and distinguishes :-Mildly elevated BP (140–159/90–109 mmHg) or -Severely elevated BP (≥160/110 mmHg)in contrast to the grades used by the ESH/ESC, or others



• Hypertension in pregnancy - not a single entity but is composed of:

•pre-existing hypertension•gestational hypertension•pre-existing hypertension plus superimposed gestational hypertension with proteinuria•antenatally unclassifiable hypertension



Pre-existing Hypertension1-5% of pregnanciesBP>=140/90 that precedes or occurs

before 20 wks AOGUsually persists >42 days postpartumMay be associated with Proteinuria



Gestational HypertensionComplicates 6-7% of pregnanciesDevelops after 20 wks AOG and resolves within

42 daysPregnancy-induced hypertension +/- proteinuria;

If with proteinuria (>=0.3g/day in 24H urine collection or >=30mg/mmol urinary creatinine in spot random urine sample), it is known as Preeclampsia



PreeclampsiaDe novo onset of HPN w new onset significant

proteinuria >0.3gm/24HComplicates 5-7% of pregnancies but may go up to

25% in women w preexisting HPNOccurs usually in 1st pregnancy, multiple fetuses,

H.mole, DiabetesCauses placental insufficiency – IUGR, most

common cause of prematurity, accounting for 25% of LBW infants



Severe Preeclampsia – Signs & Symptoms

RUQ/epigastric pain due to liver edema+/- hepatic hemorrhage

HA +/- visual disturbance (cerebral edema)Occipital lobe blindnessHyperreflexia +/- clonusConvulsions (cerebral edema)HELLP syndrome (hemolysis, elevated liver

enzymes, low platelet count)



Pre-existing Hypertension plus Superimposed Gestational Hypertension with ProteinuriaWorsening BP & proteinuria after 20 wks AOG

Antenatally Unclassifiable HypertensionWhen BP is first recorded after 20 wks AOG & HPN

is diagnosed; needs reassessment at or after 42 wks pospartum


Case 1:

26/Female Known hypertensive for 6 years (diagnosed at age

20 – was secondary hypertension considered? What were the results of any prior cardiovascular work-ups?)

On maintenance calcium channel blockers usual BP = 130/80


Hypertension (ESC/ESH 2007)

Secondary Hypertensionsuggested by:

severe blood pressure elevation sudden onset or worsening of hypertension blood pressure responding poorly to drug therapy


Hypertension (ESC/ESH 2007)

Secondary Hypertension Etiologies:

Renal Parenchymal Disease – most common Renovascular HPN – 2nd most common Phaeochromocytoma – rare (0.2-0.4%) Primary Aldosteronism – HPN w hypoK Cushing’s Syndrome – typical habitus Obstructive Sleep Apnea - overweight Coarctation of the Aorta - rare Drug-Induced HPN - licorice, oral contraceptives, steroids, NSAIDS,

cocaine & amphetamines, erythropoietin, cyclosporins, tacrolimus.


Case 1: 26/Female Known hypertensive for 6 years – probably G1 21-22 weeks admitted due to severe HPN

BP- 200/100mmHgPR-76/minRR-20/minT-36.5C.


Hypertension in Pregnancy (ESC/ESH 2011)

Non-Pharmacological Management:Most women with pre-existing HPN in

pregnancy: have mild to moderate hypertension (140–

160/90–109 mmHg)are at low risk for cardiovascular

complications within the short time frame of pregnancy.



Non-Pharmacological Management:Women with essential HPN & normal renal function

good maternal and neonatal outcomes candidates for non-drug therapy there is no evidence that pharmacological treatment results

in improved neonatal outcome. Some women with treated pre-existing hypertension are

able to stop their medication in the first half of pregnancy because of the physiological fall in BP during this period.



Pharmacological Management:Drug treatment of severe HPN in pregnancy

is required and beneficial, yet treatment of less severe hypertension is controversial.

Although it might be beneficial for the mother with hypertension to reduce her BP, a lower BP may impair uteroplacental perfusion and thereby jeopardize fetal development.



Pharmacological Management:Women with pre-existing HPN

may continue current meds except for ACE inhibitors, ARBs, and direct renin inhibitors, which are strictly contraindicated in pregnancy because of severe fetotoxicity, particularly in the 2nd/3rd trimesters

a-Methyldopa is the drug of choice for long-term treatment of HPN during pregnancy.

The alpha & beta blocker labetalol has efficacy comparable with methyldopa. If w severe HPN, it can be given IV

Metoprolol is also recommended



Pharmacological Management: CALCIUM CHANNEL BLOCKERS such as nifedipine

(oral) or isradipine (i.v.) are drugs of second choice for HPN treatment

can be given in hypertensive emergencies or in hypertension caused by pre-eclampsia.

Potential synergism with MAGNESIUM SULFATE may induce maternal hypotension and fetal hypoxia.

MAGNESIUM SULFATE IV -drug of choice for treatment of seizures and prevention of eclampsia.

Diuretics should be AVOIDED because they may decrease blood flow in the placenta.



Pharmacological Management: In Mild to Moderate HPNCurrent ESH/ESC guidelines recommend SBP = 140

mmHg or DBP = 90 mmHg as therapeutic thresholds for treatment in women with:

gestational HPN (+/- proteinuria)pre-existing HPN with superimposed gestational

HPNHPN with subclinical organ damage or symptoms

at anytime during pregnancy.



Pharmacological Management:Otherwise, ESH/ESC thresholds are SBP= 150

mmHg & DBP = 95 mmHg. In Severe hypertension

SBP ≥170 mmHg or DBP≥110 mmHg in a pregnant woman is an EMERGENCY, and hospitalization is indicated.

The selection of the antihypertensive drug and its route of administration depend on the expected time of delivery.



Pharmacological Management: Treatment of severe hypertension

IV labetalol, or oral methyldopa, or nifedipine should be initiated.

IV HYDRALAZINE is no longer the drug of choice as its use is associated with more perinatal adverse effects than other drugs.

drug of choice – NA NITROPRUSSIDE - but Prolonged treatment with sodium nitroprusside is associated with an increased risk of fetal cyanide poisoning as nitroprusside is metabolized into thiocyanate and excreted into urine.



Pharmacological Management: The drug of choice in PRE-ECLAMPSIA

ASSOCIATED WITH PULMONARY OEDEMA - Nitroglycerine (glyceryl trinitrate), given as an IV infusion of 5 mg/min and gradually increased every 3–5 min to a maximum dose of 100 mg/min.



Severe Preeclampsia – Management:focuses on RECOGNITION of condition and, ultimately, DELIVERY OF THE PLACENTA, which is curative.

As proteinuria may be a late sign of pre-eclampsia, it should be suspected when de novo HPN is accompanied by symptoms (HA, visual disturbances, abdominal pain, or abnormal laboratory tests - low platelet count and abnormal liver enzymes; it is recommended to treat such patients as having

pre-eclampsia.


Long-Term Prognosis Studies have shown that Women who

develop hypertension in pregnancy have increased risk for future Cardiovascular Morbidity and Mortality

Women must be informed about appropriate preventive measures and should be followed on the long term


DRUG THERAPY FOR HYPERTENSION IN PREGNANCY

(ESC2011)

Recommendation Class LevelNon-pharmacological management for pregnant women with SBP of 140-150 mmHg or DBP of 90-99 mmHg is recommended. I C



(ESC2011)

Recommendation Class LevelIn gestational HPN or pre-existing HPN superimposed by gestational HPN or with HPN & subclinical organ damage or symptoms at any time during pregnancy, start drug Rx at BP-140/90mmHg. Otherwise, start drug treatment if SBP ≥150 mmHg or DBP ≥95 mmHg. I C



(ESC2011)

Recommendation Class LevelSBP ≥170 mmHg or DBP ≥110 mmHg in a pregnant woman is an emergency, & hospitalization is recommended. I C



(ESC2011)

Recommendation Class LevelInduction of delivery is recommended in gestational HPN with proteinuria with adverse conditions such as visual disturbances,coagulation abnormalities, or fetal distress. I C



(ESC2011)

Recommendation Class LevelIn pre-eclampsia associated with pulmonary oedema, nitroglycerine given as an IV infusion, is recommended. I C



(ESC2011)

Recommendation Class LevelIn severe HPN, drug treatment with IV labetalol or oral methyldopa or nifedipine is recommended. I C



(ESC2011)

Recommendation Class LevelWomen with pre-existing HPN should be considered to continue their current medication except for ACE inhibitors, ARBs, and direct renin inhibitors under close BP-monitoring IIa C


Drug Example Comment

α2-adrenergic blockers Methyldopa

Most commonly used.Safety is well established.Drug of choice

Beta-blockersAtenolol, Metoprolol

Appear safe. W Case reports of fetal bradycardia, growth retardataion.

α, β blockers LabetololAppears effacious. Very scant safety data.




Arteriolar vasodilators Hydralazine

Effacacious and safe during pregnancy and lactation.

ACE inhibitors Captopril

Absolutely contraindicated during pregnancy due to fetal toxicity.

Calcium channel blockers Diltiazem

Appear safe, but not as much data to support their use.




Diuretics FurosemideAppears safe, but limited efficacy.

Sodium nitroprusside

Avoid in pregnancy due to potential for fetal thiocyanate toxicity

Magnesium sulfate

Treatment of choice for prevention of ecclamptic seizures.



Drug Use Potential Side Effects SafeBreastfeeding

ACEI HPN

Oligohydramnios, IUGR, PDA, prematurity, neonatal hypotension, renal failure, anemia, death, musculoskeletal abnormalities No OK



Drug Use Potential Side Effects SafeBreastfeeding

Beta-blockers HPN

Fetal bradycardia, low birth weight, hypoglycemia, respiratory depression; prolonged labor Yes Ok



Drug UsePotential Side Effects Safe

Breastfeeding

Diuretics HPNReduced uteroplacental perfusion Unclear Ok

Na Nitroprusside HPN

Fetal thiocyanate toxicity

Potentially unsafe No data

Nitrates HPN Fetal distress with maternal hypotension

Yes No data



CRITICAL PERIODSwhen caring for Gravidocardiacs

12-20 weeks AOG28-4-36 weeks AOG

LaborPostpartum Period


Hypertension

Preeclampsia 50% of patients w/ Gestational HPN 25% of patients with chronic HPN More common in primipara & twin

pregnancies Theory: endothelial dysfxn affecting

placental spiral arteries HPN, vasospasm, reduced end organ

perfusion, activated coagulation

cardiovascular management of hypertension during pregnancy

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