Management of Hypertensive Disorders of Pregnancy
Gestational HTN
The diagnosis of gestational hypertension is made if hypertension without proteinuria or other signs of organ dysfunction first appears after 20 weeks’ gestation or within 48 to 72 hours of delivery and resolves by 12 weeks postpartum. Formerly called PIH (pregnancy-induced HTN).
Chronic Hypertension
The diagnosis of chronic hypertension requires at least one of the following: known hypertension before pregnancy or the development of hypertension before 20 weeks’ gestation.
General Principles
Delivery is the only definitive treatment for preeclampsia.
regarding HELLP Immediate delivery
Management of Chronic HTN
The primary goals of management of chronic hypertension are to control hypertension and detect the development of superimposed preeclampsia in the mother and IUGR in the fetus. As a general rule, the safest antihypertensive medication should be used at the lowest possible dose needed to keep blood pressure at about 130/80 mm Hg to 140/90 mm Hg.
Antihypertensive Medications in Pregnancy
Methyldopa is considered to be the safest antihypertensive medication in pregnancy, but calcium channel blockers and labetalol are also considered to be safe. ; methyldopa may increase potentiation of postpartum depression
Angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, an-giotensin II receptor blockers, renin inhibitors, and mineralocorticoid blockers should be avoided at all stages of pregnancy because of potential fetal toxicity. Beta blockers should be used with caution because they may cause fetal growth restriction and may affect the interpretation of the NST. -
Timing and Route of Delivery
The timing of delivery in the patient with chronic hypertension depends on the clinical circumstances. For patients without evidence of fetal growth restriction or superimposed preeclampsia, in whom blood pressure is well controlled and who have no other indications for delivery, pregnancy may be allowed to progress until at least 38 weeks’ gestation.
The route of delivery should be vaginal in the absence of other obstetric reasons for cesarean delivery.
Management of Gestational HTN
- No hospitalization.
- Delivery at 37 weeks.
- Monitor for preeclampsia or complications.
- The route of delivery should be vaginal in the absence of other obstetric reasons for cesarean delivery.
Management of Preeclampsia
Should be delivered by the time she reaches 37 weeks, or earlier if she develops signs or symptoms of worsening disease or if there is evidence of fetal compromise.
Management of Severe Preeclampsia
If the initial evaluation is consistent with the diagnosis of severe preeclampsia, the patient should remain hospitalized for the remainder of the pregnancy. After 34 weeks’ gestation, stabilization and delivery are appropriate for most patients. For those patients at less than 34 weeks’ gestation who have severe preeclampsia, the decision regarding delivery needs to be individualized after carefully considering the risks to the neonate of prematurity versus the potential maternal and fetal risks of continuing the pregnancy.
Monitoring
Both the mother and fetus require very close monitoring with maternal labor parameters and fetal assessment testing repeated daily or more often if necessary. This includes stabilization of the patient with severe preeclampsia with magnesium sulfate prophylaxis, along with medical control of severe hypertension and corticosteroids for fetal lung maturity.