Gestational Hypertension: Pregnancy

Induced Hypertension (PIH)

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http://americanpregnancy.org/ (APAssociation)

Gestational hypertension, also referred to as pregnancy

induced hypertension (PIH) is a condition characterized
by high blood pressure during pregnancy. Gestational
hypertension can lead to a serious condition
called preeclampsia, also referred to as toxemia.
Hypertension during pregnancy affects about 6-8% of
pregnant women.

The Different Types Of Hypertension During

Pregnancy:
High blood pressure can present itself in a few different ways
during pregnancy.
The following are the 3 common types of gestational
hypertension:
 Chronic Hypertension– Women who have high blood pressure
(over 140/90) before pregnancy, early in pregnancy (before 20
weeks), or continue to have it after delivery.
 Gestational Hypertension– High blood pressure that develops after
week 20 in pregnancy and goes away after delivery.
 Preeclampsia – Both chronic hypertension and gestational
hypertension can lead to this severe condition after week 20 of
pregnancy. Symptoms include high blood pressure and protein in the
urine. This can lead to serious complications for both mom and baby
if not treated quickly.

Who Is At Risk For Gestational Hypertension?

The following women may have an increased risk of
developing gestational hypertension:
 First-time moms
 Women whose sisters and mothers had PIH
 Women carrying multiples
 Women younger than age 20 or older than age 40
  Women who had high blood pressure or kidney disease prior to
pregnancy

How Do I Know If I Have Gestational

Hypertension?
At each prenatal checkup, your healthcare provider will
check your blood pressure and urine levels. Your doctor may
also check your kidney and blood-clottingfunctions, order
blood tests, perform an ultrasound scan to check your baby’s
growth, and use a Doppler scan to measure the efficiency of
blood flow to the placenta.

How Is Gestational Hypertension Treated?

Treatment depends on how close you are to your due date. If
you are close to your due date and the baby is developed
enough, your health care provider may want to deliver your
baby as soon as possible.
If you have mild hypertension and your baby is not fully
developed, your doctor will probably recommend the
following:
 Rest, lying on your left side to take the weight of the baby off your
major blood vessels.
 Increase prenatal checkups.
 Consume less salt.
 Drink 8 glasses of water a day.
If you have severe hypertension, your doctor may try to treat
you with blood pressure medication until you are far enough
along to deliver safely.
How Does Gestational Hypertension Affect
My Baby?
Hypertension can prevent the placenta from getting enough
blood. If the placenta doesn’t get enough blood, your baby
gets less oxygen and food. This can result in low birth
weight. Most women still can deliver a healthy baby if
hypertension is detected and treated early.
If your hypertension is severe, it can lead to preeclmapsia,
which can have much more serious affects on mom and baby.

How Can I Prevent Gestational Hypertension:

Currently, there is no sure way to prevent hypertension.
Some contributing factors to high blood pressure can be
controlled, while others cannot. Follow your doctor’s
instruction about diet and exercise. Some ways you can help
prevent gestational hypertension include the following:
 Use salt as needed for taste.
 Drink at least 8 glasses of water a day.
 Increase the amount of protein you take in, and decrease the amount
of fried foods and junk food you eat.
 Get enough rest.
 Exercise regularly.
 Elevate your feet several times during the day.
 Avoid drinking alcohol.
 Avoid beverages containing caffeine.
 Your doctor may suggest you take prescribed medicine and
additional supplements.
Last Updated: 08/2015
Compiled using information from the following sources:
National Heart Lung and Blood
Institute, http://www.nhlbi.nih.gov/index.htm Mayo
Clinic, http://www.mayoclinic.com Medscape; Hypertension
and Pregnancy, http://www.emedicine.medscape.com
Medical Therapy
https://emedicine.medscape.com/article/261435-overview#a21Treatment of Acute
Hypertension in Pregnancy
Acute severe hypertension in pregnancy is a medical emergency requiring treatment to lower
blood pressures within 30 minutes of confirmation to reduce risk of maternal stroke.
According to the February 2015 ACOG Committee Opinion #623 “Emergent Therapy for
Acute-Onset, Severe Hypertension During Pregnancy and the Post-Partum Period,” first line
options for treatment include oral immediate-release nifedipine, IV labetalol, and IV
hydralazine. [4]
Bedrest and hospitalization
Women with worsening hypertension during pregnancy often are placed on bed rest or
restricted activity, although no scientific evidence demonstrates that this is beneficial in
prolonging gestation or reducing maternal or fetal morbidity/mortality.
Women with hypertension and suspected preeclampsia are typically admitted to a hospital for
close observation and investigation. Those with established preeclampsia must be observed
very closely, either in hospital or in a comprehensive home monitoring program under the
care of an obstetrician.
Pharmacologic considerations
Although the primary risk of chronic hypertension in pregnancy is development of
superimposed preeclampsia, no evidence suggests that pharmacologic treatment of mild
hypertension reduces the incidence of preeclampsia in this population. [20] A study by Magee
et al that analyzed 987 women at 14 to 34 weeks gestation to test the outcomes of less-tight
vs. tight control of hypertension found that although primary-outcome rates were similar,
severe hypertension (≥160/110 mm Hg) developed at a higher frequency in the less-tight
control group (40.6% vs. 27.5%). [21]
[21]

In normal pregnancy, women's mean arterial pressure drops 10-15 mm Hg over the first half
of pregnancy. Most women with mild chronic hypertension (ie, SBP 140-160 mm Hg, DBP
90-100 mm Hg) have a similar decrease in blood pressures and may not require any
medication during this period. Conversely, DBP greater than 110 mm Hg has been associated
with an increased risk of placental abruption and intrauterine growth restriction, and SBP
greater than 160 mm Hg increases the risk of maternal intracerebral hemorrhage. Therefore,
pregnant patients should be started on antihypertensive therapy if the SBP is greater than 160
mm Hg or the DBP is greater than 100-105 mmHg.
The goal of pharmacologic treatment should be a DBP of less than 100-105 mm Hg and an
SBP less than 160 mm Hg. Women with preexisting end- organ damage from chronic
hypertension should have a lower threshold for starting antihypertensive medication (ie,
>139/89) and a lower target blood pressure (< 140/90). [3]
If a pregnant woman's blood pressure is sustained greater than 160 mm Hg systolic and/or
110 mm Hg diastolic at any time, lowering the blood pressure quickly with rapid-acting
agents is indicated for maternal safety. [4] Anticonvulsant therapy may be undertaken in the
setting of severe preeclampsia (primary prophylaxis) or in the setting of eclamptic seizures
(secondary prophylaxis). The most effective agent is IV magnesium sulfate; phenytoin is an
alternative, although less effective, therapy.
Methyldopa has an established safety record, but it is a mild antihypertensive with a slow
onset of action, and associated fatigue may limit patient tolerability of this medication.
Labetalol has a more rapid onset of action, may be given orally or parenterally, and is
generally preferred as a first-line agent. [22] One retrospective case-control propensity-score
matched study evaluated the association between late trimester exposure to beta-adrenergic
blockade with labetalol, metoprolol, and atenolol. and neonatal bradycardia or hypoglycemia.
There was a small association between labetalol and neonatal hypoglycemia, the absolute rate
in the exposed group was 4.3% versus 1.2% in the nonexposed propensity-score matched
group. Labetalol is an effective well tolerated medication that can still be considered a first
line agent, and as with any maternal medication, maternal medications should be reviewed by
the pediatrician to determine proper neonatal monitoring. [23]
The association between these medications and neonatal hypoglycemia is limited by higher
respective prevalences of preexisting and gestational diabetes in the exposed vs. unexposed
groups (13.9% vs. 3.8% and 20.6% vs. 8.3%). In spite of a sensitivity analysis, women with
diabetes are more likely to have their infants screened for hypoglycemia, so a detection bias
cannot be totally excluded. [23]
Should other beta-blocking agents be required for the treatment of hypertension for cardiac
conditions, nadolol and metoprolol are reasonable options.
Nifedipine (Long Acting) is a reasonable medication to treat chronic hypertension.
ACE inhibitors should be avoided during pregnancy, as they are associated with fetal renal
dysgenesis or death when used in the second and third trimesters, as well as with increased
risk of cardiovascular and central nervous system malformations when used in the first
trimester. [24] In a retrospective cohort study, Li et al found that during the first trimester, the
risk of malformations with the use of ACE inhibitors is similar to the use of other
antihypertensives but that the apparent increased risk of malformations is due more to the
mother’s underlying hypertension rather than the medications. [25]
Angiotensin II receptor antagonists/blockers are not used during pregnancy, because they
have a mechanism of action that is similar to that of ACE inhibitors. Diuretics do not cause
fetal malformations but are generally avoided in pregnancy, as they prevent the physiologic
volume expansion seen in normal pregnancy. They may be used in states of volume-
dependent hypertension, such as renal or cardiac disease.
A healthy fetus depends on a healthy mother, so medications should be used when clear
benefit to the mother exists. The US Food and Drug Administration (FDA)categorization for
drug use during pregnancy is simplistic and sometimes misleading. To quote the FDA
descriptions, any medication in class A through D may be used "when the potential benefit
justifies the potential risk."
Available data suggest that all studied agents are excreted into human breast milk, but most
are excreted to a negligible degree. All antihypertensive medications are believed to be
compatible with breastfeeding, but using medications with a well-established record is
reasonable.
Consultations
Most internists do not have extensive exposure to diagnosing and treating medical disorders
during pregnancy and therefore feel some discomfort doing so. Women with chronic
hypertension in pregnancy should be monitored by an obstetrician. Women with moderate or
severe hypertension may benefit from referral to an experienced internist (obstetric medicine
specialist), hypertension subspecialist, and/or a specialist in maternal-fetal medicine
(perinatologist). The experience of these experts allows them to assess quickly which
treatments offer the best risk-benefit ratio. In most situations, the benefit of maximizing
maternal well-being with the usual therapies outweighs potential adverse effects on the fetus.
Diagnosis of secondary hypertension during pregnancy can be difficult; an internal medicine
consultation may be useful in the care of these women, as well as women with target organ
damage due to chronic hypertension and women in whom preeclampsia causes significant
organ failure.
Chronic hypertension
Women with mild chronic hypertension often do not require antihypertensive therapy during
most of pregnancy. Pharmacologic treatment of mild hypertension does not reduce the
likelihood of developing preeclampsia later in gestation and increases the likelihood of
intrauterine growth restriction. If maternal blood pressure exceeds 160/100 mm Hg, however,
drug treatment is recommended.
Three treatment options are available in cases of mild chronic hypertension in pregnancy.
Antihypertensive medication may be withheld or discontinued, with subsequent close
observation of blood pressure. Because blood pressure drops during normal pregnancy and no
data support the use of medication in patients with blood pressures less than 160/100 mm Hg,
the authors recommend this option most often.
If a woman is on pharmacologic treatment with an agent not recommended for use in
pregnancy, she may be switched to an alternative antihypertensive agent preferred for use in
pregnancy. If a woman is on pharmacologic treatment with an agent acceptable for use in
pregnancy, she may continue her current antihypertensive therapy.
Women with chronic hypertension in pregnancy should be monitored for the development of
worsening hypertension and/or the development of superimposed preeclampsia (the risk is
approximately 25%). Laboratory investigations for preeclampsia should be repeated if the
patient's blood pressure increases or if she develops signs or symptoms of preeclampsia (see
Routine Tests).
Preeclampsia
Women with suspected, mild, or diagnosed preeclampsia remote from term or labile blood
pressures due to chronic hypertension and/or gestational hypertension should be hospitalized
for close observation, bed rest, and frequent fetal monitoring. The severity of any
abnormalities on admission dictates the frequency of blood work. When diagnosed with
preeclampsia, delivering the baby is always in the mother's best interest. Any delay in
delivery should be due to uncertainty about the diagnosis or immaturity of the fetus.
Daily examination should include a funduscopic examination for retinal spasm or edema,
lung examination for signs of volume overload, cardiac examination for gallop rhythms,
abdominal examination for hepatic tenderness, extremities/sacrum examination for increasing
edema, and neurologic examination for clonus.
Women with preeclampsia remote from term (ie, < 34-36 weeks' gestation) should be
promptly transferred to a facility with adequate resources to care for premature newborn
infants. This is essential because worsening preeclampsia disease activity may require urgent
delivery at any time.
When preeclampsia develops remote from term (ie, < 34-36 weeks' gestation), attempts are
often made to prolong the pregnancy to allow for further fetal growth and maturation. In this
setting, both maternal and fetal status must be very closely monitored in a high-risk obstetric
center. Fetal testing should be performed at least twice weekly, using a combination of
biophysical profiles and nonstress testing supervised by an obstetrician (see Fetal
Monitoring). Facilitated delivery should occur if either maternal or fetal deterioration is
noted, with the mode of delivery decided by obstetric indications.
Treating hypertension secondary to preeclampsia with medications may reassure the clinician
falsely but does not slow progression of the process; therefore, if treatment with
antihypertensives is undertaken, clinicians must remain vigilant for all other symptoms, signs,
and laboratory evidence of worsening preeclampsia. Other symptoms and signs of worsening
preeclampsia must be sought routinely and delivery facilitated if the maternal or fetal
condition worsens.
Patients who are diagnosed with HELLP syndrome are typically delivered after
corticosteroids have been completed for fetal benefit. Occasionally, the patient may be too
unstable to wait for the full benefit of steroids, and immediate delivery should be considered.
Long-Term Monitoring
Women with preeclampsia require follow-up after hospital discharge to ensure normalization
of blood pressure and any noted laboratory abnormalities. This follow-up may be undertaken
via an internal medicine specialist (obstetric internist) and obstetrician or a family physician.
Hypertension due to preeclampsia may worsen or even present in the postpartum period.
After delivery, women with preeclampsia require ongoing close blood pressure monitoring.
Blood pressure sustained greater than 160/110 mm Hg should be urgently treated with IV
antihypertensives. Oral antihypertensive therapy should be undertaken for sustained pressures
above 155/105 mm Hg. As vasospasm resolves, these women may be weaned off their
antihypertensive therapy.
Blood pressure changes due to preeclampsia usually resolve within days to weeks after
delivery but may persist for 3 months. Persistent hypertension beyond this point probably
represents chronic hypertension.
Laboratory abnormalities related to preeclampsia (eg, proteinuria, thrombocytopenia, liver
enzyme elevations) should be followed until the abnormalities return to the reference range.
Failure to normalize warrants an evaluation for other acute or chronic medical disorders with
potential long-term consequences.
Preeclampsia and related disorders identify women at increase risk for future cardiovascular
disease. [26] These women should be screened for cardiovascular risk factors, including
cigarette smoking, glucose intolerance, low high-density lipoprotein cholesterol, elevated
triglycerides, and obesity. The presence of any of these risk factors should be addressed with
appropriate treatment and counseling regarding smoking cessation, diet, exercise, glucose
control, weight loss, and appropriate medical treatment.