Jun 11, 2020
In this podcast, Matt Bigos, MD, FACOG an obstetrician/gynecologist with OB-GYN West, presented at Ridgeview Medical Center's Live Friday CME Series on March 13, 2020. At the event, Dr. Bigos talked about hypertension in the OB patient.
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Hypertension in pregnancy is one of the worldwide leading causes of mortality, affecting 2-8% globally. That's 76,000 maternal and 500,000 infant deaths per year in the world.
Exact mechanisms is unknown, but probably due to the placenta itself. Many theories exist, and there is a familial component.
Physiology changes with pre-eclampsia. With pregnancy in general, blood volume increases by 50%. Most of which is serum. In preeclampsia, oncotic pressure in the blood vessels decreases, and fluid leaking occurs, hence edema. Kidneys also lose protein which aids in losing intravascular volume. Be cautious with IV hydration in preeclampsia. Intense vasospasm also occurs. Thrombocytopenia occurs due to overuse of platelets. Hemolysis occurs as well. Look for elevations of LDH and bilirubin. Schistocytes can be seen if you can find a microscope. Periportal necrosis leads to elevated AST>ALT. Coagulation factors won't produce as well either. In the kidney, protein leaks through porous glomeruli. Urine output will decrease due to intrarenal vasospam. Uric acid levels can help differentiate chronic vs new HTN in pregnancy. Less amniotic fluid and smaller fetus size occurs. Placental abruption may happen, in addition.
Gestational HTN is a BP of 140/90 (either or both) or greater. These must be noted on two separate occasions at least four hours apart. Diagnosed after 20 weeks of gestation in a woman with previously normal BP.
Preeclampsia is the same criteria, along with proteinuria. 24-hour urine collection for protein is the historic best way to check. Protein: Creatinine ration is the easiest to do, though. 2+ protein on the urine dipstick may also suffice.
Preeclampsia with severe features: BP 160/110 or both (= or >) on 2 occasions, 4 hrs apart. Or if you move to treating the BP, this would signify "severe" feature. Other features include: Mild HTN with platelets <100. Transaminases twice normal w/ or w/o RUQ/epig pain. Creatinine elevation, which must be double the baseline normal. Pulmonary edema, headache. Headache should be treated more aggressively than merely Tylenol if it isn't going away. Visual disturbances of any sort.
HELLP: Hemolysis, Elevated LFTs, Low platelets. Some patients only have two of the three. This can even show up postpartum.
Eclampsia is all of the above with onset, focal, multifocal or tonic/clonic seizures. HA, vision change, hyperreflexia and PRES (posterior reversible encephalopathy syndrome) on head imaging may be seen as well. Preeclampsia may not always precede eclampsia. It's not necessarily a steady progression.
Acute HTN in pregnancy is BP 160/110, persistent over 15 minutes or more. Treatment should ensure promptly. Complications such as CHF, MI, stroke and kidney injury may develop quickly.
Three major drugs are used, and most of these have been used for many years. Labetalol, Hydralzine and Ca++ channel blockers. All are equally efficacious. Labetalol can be given PO and IV and has a quick onset. Avoid contraindications to B-blockers though.
Hydralazine is given IV or IM, and lasts a little longer than labetalol. Nifedipine is an oral medication and can be started easily in the office or while awaiting hospitalization and preparing for an IV, etc. Ridgeview has specific treatment algorithms in our order sets along with dosing for these medications.
Thanks so much to Dr. Bigos for his time and expertise on the topic of hypertensive disorders in pregnancy.