Hypertensive disorders of

pregnancy
about 10% of pregnant women
Definitions & Classification
(HT – BP >140 or 90 mmHg)

Hypertensive disorders of pregnancy

The National Institute for Health and Care Excellence _ NICE 2019

• Chronic hypertension (without or with overlapped pre-eclampsia)

• Gestational hypertension
• Pre-eclampsia

BMJ 2019;366:l5119 doi: 10.1136/bmj.l5119 (Published 9 September

2019)
Chronic hypertension
• HT present at:
• the booking visit or
• before 20 weeks’ gestation, or
• the woman is already taking antihypertensive medication
when starting maternity care.
• Etiology of HT can be primary (essential) or secondary
• It can be overlapped by pre-eclampsia (clinical signs of pre-
eclampsia appear after 20 weeks of pregnancy superimposed on
already existing HT)

Gestational hypertension
Hypertension presenting
• after 20 weeks of pregnancy
• without significant proteinuria
BMJ 2019;366:l5119 doi: 10.1136/bmj.l5119 (Published 9 September
2019)
Pre-eclampsia
New onset hypertension after 20 weeks of pregnancy and coexistence of one or both of the
following new-onset conditions:
• Proteinuria – proteinuria > 300mg or protein/creatinine ratio ≥30 mg/mmol, or albumin/
creatinine ratio ≥8 mg/mmol, or ≥1 g/L [2+] on dipstick testing)
• And /or Other organ dysfunction
• Thrombocytopenia < 100000 and / or
• ASAT, or ALAT >2x normal and / or
• AKI - SCr > 1,1mg/dl or dubling of baseline SCr (no other kidney disease) and / or
• Ac.P.E and/ or
• Neurological or visual disorders and /or
• Uteroplacental dysfunction (such as fetal growth restriction, abnormal umbilical artery
Doppler waveform analysis, or stillbirth)

BMJ 2019;366:l5119 doi: 10.1136/bmj.l5119 (Published 9 September

2019)
Clinical forms
1. Mild to moderate Pre-eclampsia
2. Severe Pre-eclampsia (any of the following):
1. SBP ≥ 160 and/or DBP ≥ 110mmHg in 2 measurements at 4h interval (bed rest) , if
no hypotensive administered
2. Thrombocytopenia <150000/µl
3. Severe abdominal pain (epigastric or right hypochondrium), no reaction to therapy,
and / or
4. Elevated liver enzymes > 2x the normal value
5. Progressive increase of SCr ( >1,1mg/dl ) and /or doubling of baseline SCr
6. Ac PE
7. Neurologic or visual disorders

A.C.O.G. Task Force on Hypertension in Pregnancy 2013

 ECLAMPSIA

• Eclampsia is a severe complication of pre-eclampsia

• It’s a rare but serious condition where high blood pressure results in
seizures, loss of consciousness, agitation during PRE-ECLAMPSIA
• Sometimes preceded by severe head ache or hyperreflectivity
• It may appear before or after delivery
• Severe complications are frequent: cerebral / meningeal hemorrhage, Ac.
P.E., AKI, Shock
• Eclampsia may affect 1/200 of pre eclampsia patients

A.C.O.G. Task Force on Hypertension in Pregnancy 2013

 • First pregnancy COMT gene anomalies Degradation of catecholamines
• Multiple fetuses catechol-O-methyl-transferase
• 13 trisomy
• Endothelial disfunction: Angiogenesis inhibitor
2ME
HT, DM, Obesity, CKD 2-methoxyestradiol PRE-ECLAMPSIA

Oxidative stress AT1-Agon. Disfunction /

Auto Ab Ischemia of placenta
HO Heme
oxygenase
Antiangiogenic factors Increased anti angiogenic factors
sFlt1 Soluble fms-like tyrosine kinase-1
sEng Increased cleavage of TGF-βr by soluble endoglin Decreased trophoblastic
development
• Pl GF Phosphatidylinositol-glycan class F protein
• VEGF Decreased pro angiogenic factors

ROS NO AT1-AA Proteinuria

Systemic endothelium dysfunction Thrombotic microangiopathy

HT, Puria, Edema, H EL LP (HEmolysis, Liver Enzymes, Low Platelet count}

Maynard SE J Am Soc Nephrol 20: 14-22, 2009
 Pre-eclampsia risk factors
1. Primiparous
2. History of pre-eclampsia in previous pregnancies
3. Chronic HT
4. CKD
5. Thrombophilia history
6. Twin pregnancies
7. In vitro fertilization
8. Family history of pre-eclampsia
9. DM
10. Obesity
11. SLE
12. Pregnancy over > 40 years

A.C.O.G. Task Force on Hypertension in Pregnancy 2013

 Screening for pre-eclampsia
1. Decrease PI GF (Phosphatidyl inositol-glycan class F protein) synthesis – first 3 months
2. Increased sFlt1 si sEng – the second half of months 3-6
3. Doppler US of uterine artery
4. Decreased PP-13 (placenta protein 13)– decreased in pre-eclampsia and in stop of IU
fetal growth

1. Doppler US of uterine artery

Increased resistance in the UA generating a pathological uni or
bilateral wave form
• Low predictive value.
• If it corelates with prediction, when pre-eclampsia appears –
no outcome benefit

Maynard SE J Am Soc Nephrol 20: 14-22, 2009

A.C.O.G. Task Force on Hypertension in Pregnancy 2013
 Prevention in pre-eclampsia

•Aspirine – improves prostacyclin / thromboxane ratio

• 2 Meta A – small but significant effect in high risk patients

•Arginine – with the aim to increase NO levels – promising results

• Ca and Folic acid – obs. studies with some promising results NO RCTs
• Angiogenic therapies
•VEGF 121 recombinant – pilot studies, promising results NO PROOFS
•PI GF
•MAB anti sFlt1
•Antioxidants – Vit C si Vit E – 3 RCT – NO EFFECT
Low Na diet – NO PROFILACTIC EFFECT

Maynard SE J Am Soc Nephrol 20: 14-22, 2009

 TREATMENT
Chronic hypertension Gestational hypertension
Diet • Regular monitoring, to ensure that blood
• Weight management pressure control is maintained and that there
• Exercise is no progression to pre-eclampsia.
• Healthy eating • The blood pressure target 135/85 mm Hg (in
• Lowering the amount of salt in the diet line with that for chronic hypertension),
Antihypertensive treatment. • Drug choices aligned to those used in chronic
Initiate if hypertension
• Sustained systolic blood pressure ≥140 mm Hg or
• Sustained diastolic blood pressure ≥90 mm Hg.
Target BP 135/85 mm Hg.
Drugs
• labetalol to treat chronic hypertension
• nifedipine for women in whom labetalol is not suitable, or
• methyldopa if both labetalol and nifedipine are not suitable.
Prevention of PE aspirin 75-150 mg once daily from 12 weeks.
 Pre-eclampsia
• Initiation of antihypertensive medication in women with a blood pressure
measurement of 140/90 mm Hg
• Target blood pressure for those taking antihypertensive medication is now
135/85 mm Hg
A.C.O.G. Task Force on Hypertension in Pregnancy 2013
Pre-eclampsia
Timing of birth in women with pre-eclampsia

• Before 34 weeks’ pregnancy

• Continue surveillance unless there are indications for planned early birth (see
recommendation).
• Offer IV magnesium sulfate and a course of antenatal corticosteroids in line with the
NICE guideline on preterm labor and birth
• From 34 to 36+6 weeks
• Continue surveillance unless there are indications for planned early birth (see
recommendation).
• When considering planned early birth, take into account
• the woman’s and baby’s condition,
• risk factors (such as maternal comorbidities, multi-fetal pregnancy), and availability of
neonatal unit beds.
• Consider a course of antenatal corticosteroids in line with the NICE guideline on preterm
labour and birth
• From 37 weeks onwards
• Initiate birth within 24-48h
 Pre-eclampsia
Maternal and fetal thresholds for planned early birth before 37 weeks in women with pre-
eclampsia

Thresholds for considering planned early birth could include (but are not limited to) any of the
following known features of severe pre-eclampsia:.
• Inability to control maternal blood pressure despite using three or more classes of
antihypertensives in appropriate doses
• Maternal pulse oximetry <90%
• Progressive deterioration in liver function, renal function, haemolysis, or platelet count
• Ongoing neurological features, such as severe intractable headache, repeated visual
scotomata, or eclampsia
• Placental abruption
• Reversed end-diastolic flow seen in umbilical artery Doppler velocimetry,
• Non-reassuring cardiotocograph,
• Stillbirth.
Other features not listed above may also be considered in the decision to plan early birth.

Offer intravenous magnesium sulfate and a course of antenatal corticosteroids if indicated, if early birth
is
planned for women with preterm pre-eclampsia,
 Postnatal care for women with hypertension during
• pregnancy
HT may persist after delivery for variable period.

• HT therapy should be adapted to breastfeeding – some drugs have a very low passage to breast milk with
no significant effect on the newborn
• Offer enalapril to treat hypertension in women during the postnatal period, with appropriate
monitoring of maternal renal function and maternal serum potassium
• For women of black African or Caribbean family origin treat with: Nifedipine or Amlodipine
• For women with hypertension in the postnatal period, if blood pressure is not controlled with a single
medicine consider a combination of nifedipine (or amlodipine) and enalapril. If this combination is not
tolerated or is ineffective, consider:adding atenolol or labetalol

• When possible, avoid using diuretics or angiotensin receptor blockers to treat hypertension in women in
the postnatal period who are breastfeeding or expressing milk.

• Treat women with hypertension in the postnatal period who are not breastfeeding and who are not planning
to breastfeed in line with the guideline on hypertension in adults.

.
Relative risk* of future cardiovascular morbidity in women with hypertension
in previous or current pregnancy

Increased risk for FSGS and or CKD

Prevalence of hypertensive disorder in a future pregnancy in women with
hypertension in previous or current pregnancy