Treatment of Hypertension in Pregnancy

Hypertension in pregnancy:

• Pre existing hypertension
• Pre eclampsia
• Eclampsia
• HELP syndrome
• Malignant hypertension

Pre existing hypertension:

When the hypertension is diagnosed before 20 weeks of gestation or even after 6 weeks of delivery then this is called pre existing hypertension.

Treatment of pre existing hypertension:

Methyldopa is the drug of choice in pre existing hypertension if methyldopa is not present the give labetalol and 3^rd option is dihydophyridine calcium channel blockers.

Pre eclampsia:

Pre eclampsia is

• Hypertension
• Pregnancy
• Proteinuria ( > 300g / 24h )

This condition is known as pre eclampsia.

Females are at greater risk of developing pre eclampsia when

• Who already suffer from hypertension
• Who have hypertension in previous pregnancy
• Have chronic kidney disease
• Suffer from diabetes mellitus
• Suffer from autoimmune diseases

Females are at intermediate risk of developing pre eclampsia when

• First pregnancy in 40 years
• 10 years gap between 2 pregnancies
• BMI > 35 kg / m2
• Multiple pregnancies
• Family history of pre eclampsia
• Obese females

Treatment of pre eclampsia:

Female should receive aspirin (62 – 150 mg) and calcium supplements (> 2.5 g).

Eclampsia:

• Severe hypertension
• Seizures
• Pregnancy
• Severe headache
• Severe abdominal pain
• Severe nausea and vomiting

This condition is known as eclampsia. This is life threatening condition for both mother and foetus and need treatment immediately.

Foetus risk in eclampsia:

• Intrauterine growth retardation of fetus
• Pre term birth ( birth before 37 weeks of pregnancy)
• Uterus damage
• Intrauterine death

Mother risk in eclampsia:

• Seizures
• Stroke
• Acute coronary syndrome
• Multiple organ failure
• Microangiopathy

Treatment of eclampsia:

Methyldopa / labetalol and magnesium supplements.

Magnesium supplements can prevent pre term birth and seizures.

Malignant hypertension:

When the blood pressure is more than or equal to 170 / 110 then this is malignant hypertension.  Should be reduced immediately.

Treatment of malignant hypertension:

We have to abruptly reduce the blood pressure give

IV labetalol and nicardipine (nicardipine should not given to out patients).

Initial dose is 20 mg loading dose (IV) and then give 1 – 2 mg / min infusion . Overall dose should not more than 300 mg .

HELP syndrome:

H = hypertension

E = elevated liver enzymes

L = low

P = platelets

When someone have HELP syndrome they are at the greater risk of developing pre eclampsia.

ACEIs and ARBs are strictly contraindicated in pregnancy.  Methyldopa should not be used after delivery because cause severe depression.

Propanolol , atenolol , nephidepine not use these in breast feeding because excreted in milk. CCB can given in breast feeding.

Hypertension crisis:

When sudden increase in blood pressure put you greater risk of organ damage then this is called hypertension crisis.

Hypertension crisis is of two types

1. Hypertension urgency
2. Hypertension emergency

Hypertension emergency and hypertension urgency is collectively called hypertension crisis.

Hypertension urgency:

No target organ damage occurred in hypertension urgency .

Clinical features of hypertension urgency:

• Hypertension
• Headache
• Nose bleeding
• Mental confusion
• Tachycardia

Treatment of hypertension urgency:

Hypertension urgency is treated by oral anti hypertensive. We should optimise oral regimens and if dose is low then we increase the doses or add oral antihypertensive if not present in previous treatment.  They are treated as out patients.

Hypertension emergency:

Target organ damage occurred in hypertension emergency.

Clinical features of hypertension emergency:

• Myocardial infarction
• Stroke
• Left ventricular hypertrophy
• Cardiac diseases
• Chronic kidney disease
• Nephropathy

Treatment of hypertension emergency:

Hypertension emergency is critical condition and the patients are treated as in patients in ICU or CCU .

Give labetalol

OR

Esimalol

OR

Nicardipine

If needed depend upon the condition.

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