Transcript The Internist as Consultant

Hypertensive Crisis
during Pregnancy
Eric I. Rosenberg, MD, MSPH, FACP
“I stopped taking
medicine when I got
pregnant”
Hypertensive and Pregnant
• 28 year old woman, G4P2
• 29 week IUP
• BP 233/125 mmHg
• Admitted by High-Risk Obstetrical
Service
• Internist asked to advise on optimal
antihypertensive regimen
History
PMHx:
Hypertension
Meds:
Preeclampsia x 2; 1 fetal demise
Prenatal vitamins
Allergies: Ø
FH:
Both parents hypertensive
SH:
Lives with 3 children. Smokes ½ ppd.
Stopped EtOH. No drug abuse.
ROS:
Remarkably negative.
Exam
• P 88, BP 233/125 mmHg
• BP 210/105 mmHg after 40mg Labetalol
• Normal exam
– Alert, asymptomatic
– No papilledema
– Clear lungs
– No S3 or S4
– No edema
Studies
134
103
9
4.8
22
0.8
66
ECG: LVH
11
12
205
34
Urine: no protein
What would
you do next?
Key Issues for the Medical
Consultant
• How quickly should BP be normalized?
• Which medications are most
efficacious?
• Which medications are safe in
pregnancy?
• Is this preeclampsia?
Severe Asymptomatic
Hypertension
• Consistent with chronically untreated and
uncontrolled hypertension
• Rapid correction associated with morbidity
and no proven benefit
–May induce cerebral or myocardial ischemia
–Goal: < 160/100 mmHg over hours to days
–Keep patient (and staff) calm
Hypertensive Disorders in
Pregnancy
• Preeclampsia
– New onset hypertension (>140/90 mmHg)
– Gestational age > 20 weeks
– Proteinuria (>300mg in 24-hours)
• Gestational Hypertension
– New onset, IUP > 20 weeks, no proteinuria
• Chronic Hypertension
– Antedates pregnancy
Chronic BP >180/110 in 1st Trimester
is Strongly Associated with Fetal
Demise
• Preeclampsia: 50%
• Placental abruption: 5 – 10%
• Delivery < 37 weeks: 70%
• Growth restriction: 35%
Obstet Gynecol 2002 Aug;100(2).
Keep BP <140/90 During
Pregnancy
• Mild chronic hypertension (>140/90)
associated with up to 25% risk preeclampsia
• Perform same evaluation as all other newly
dx’d HTN patients
– ECG
– UA
– Ophthalmologic exam
– Creatinine
• Close fetal surveillance by obstetrician
Key Issues for the Medical
Consultant
• How quickly should BP be normalized?
• Which medications are most
efficacious?
• Which medications are safe in
pregnancy?
• Is this preeclampsia?
Do NOT use Immediate Release
Nifedipine
• No benefit
• Not FDA approved for this purpose in
any patient population
• Associated with excessive reductions in
BP
Contraindicated
Antihypertensives in Pregnancy
• Nitroprusside (D)
• Cyanide poisoining if > 4 hours use
• ACE-inhibitors (D)
• Teratogenic
• Angiotensin Receptor Blockers (D)
• Teratogenic
Options for Acute Therapy
• Labetalol (C)
– Probably the safest option
– No reports of teratogenicity
• Hydralazine (C)
– May be teratogenic
– Associated with impaired uteroplacental perfusion
– Possible maternal hepatoxicity during
preeclampsia
• Clonidine (C)
– Case reports of birth defects if used throughout
pregnancy
– Should probably be avoided
Options for Chronic Therapy
• Methyldopa (C) (Aldomet ®)
–Commonly used, but no teratology studies
–Mild; may not control BP adequately
–Has sedative effects
• Labetalol (C)
–Most widely used beta-blocker
–May preserve uteroplacental flow better
than beta-blockers that don’t have alphablocking properties
ACOG Chronic hypertension in pregnancy. July 2001.
Our Impression…
“probable mild chronic hypertension
now with poorly controlled
gestational hypertension”
Recommendations
• Labetalol 200mg po twice daily
• Clonidine 0.1 to 0.2mg every 15
minutes for SBP > 200mmHg
• Monitor BP every 1 to 2 hours
• Goal: 160/100mmHg over several hours
• Labetalol gtt if symptomatic
And a sad ending…
• BP remained 150 – 200 / 83 – 119
mmHg
• Patient left against advice the next day
• Prescribed Labetalol 300mg twice daily
• Given appointment for f/u in 3 days
• Presented 2 weeks later to clinic with no
fetal heart tones, BP 190/92
Take-Home Points
• This is an obstetrical area of expertise
• But you may be asked for input on optimal
control of newly discovered chronic
hypertension during pregnancy
• Educate patients on risks of all
antihypertensive medications during
pregnancy
• Risks of uncontrolled hypertension outweigh
risks of Category C medications