Contributor: Sharon Keiser, MD
Last Update: 5/30/14
1. Chronic Hypertension – SBP>140 or DBP>90 on 2 separate occasions at least 6 hours apart, prior to pregnancy or within 1st 20 weeks of pregnancy; or persists longer than 12 weeks postpartum
2. Gestational hypertension – SBP>140 or DBP>90 (severe if SBP >160 or DBP >110) x 2 separate occasions at least 4 hours apart after 20 weeks gestation in women known to be normotensive before pregnancy and before 20 weeks EGA, in the absence of proteinuria.
3. Preeclampsia-eclampsia – gestational hypertension plus new-onset proteinuria of >300mg/24 hours (alternatively, a timed collection that is extrapolated to this value, or a P:C ratio of at least 0.3, or 1+ on dip although this is to be used only if other quantitative methods not available). The diagnosis is not dependent on proteinuria, however. Without proteinuria, the diagnosis is considered when GHTN is present and any one of the following is also present:
- Persistent cerebral or visual disturbances
- Thrombocytopenia (Platelet count <100k/uL) and elevated liver enzymes (2x the ULN)
-Rate 2-7% in healthy nulliparous women; 14% in twin gestations; 18% in patients with a history of preeclampsia.
-Considered to result from endothelial disease similar to TTP and HUS.
-Risk factors: 1) Nulliparity; 2) Chronic hypertension; 3) Renal disease; 4) Prior preeclampsia; 5) Molar disease; 6) Multiple gestation;7) Obesity; 8) Other vasculopathies (pregestational DM, SLE); 9) Acquired thrombophilias (possibly); 10) Increase in anti-angiogenic substances (S-FLT, soluble endoglin) (possibly)
Severe features of preeclampsia include:
a. SBP > 160 or DBP > 110 on 2 separate occasions at least 4 hours apart
b. Persistent cerebral symptoms (including eclamptic seizures)
c. Pulmonary edema
d. Progressive renal insufficiency (serum creatinine concentration >1.1mg/dL or an unexplained doubling of creatinine)
e. Epigastric or right-upper-quadrant pain which is unexplained
f. AST or ALT (2x ULN)
g. Thrombocytopenia (<100,000/uL)
DIFFERENTIAL DIAGNOSIS includes:
a. Acute fatty liver of pregnancy (AFLP)
b. Thrombotic thrombocytopenic purpura (TTP)
c. Hemolytic uremic syndrome (HUS)
d. Immune thrombocytopenic purpura (ITP); e. Systemic lupus erythematosus (SLE)
f. Antiphospholipid syndrome (APS)
h. Fulminant viral hepatitis
i. Acute pancreatitis
j. Disseminated herpes simplex
k. Hemorrhagic or septic shock.
4. Superimposed Preeclampsia – chronic hypertension in association with preeclampsia
I. Gestational Hypertension (mild and severe)
A. Antepartum Management
1. > 37 weeks – The overall goal is to continue the pregnancy until 39 weeks gestation whenever possible, with continuation of twice-weekly testing and frequent office visits (as below). When the patient reaches 37 weeks gestation a reevaluation of quantitative urine protein should be done (either P:C ratio or 12- or 24-hour urine)
-Recommend delivery at 37 weeks if cervix very is favorable or if patient is scheduled for cesarean delivery for some other reason.
-If cervix is not favorable and cesarean delivery is not indicated, deliver by 39 weeks, or at any time after 37 weeks if cervix is favorable (Bishop score >6).
-Deliver at time of diagnosis after 39 weeks.
-Deliver at any time after diagnosis that severe features or preeclampsia develop.
-Document fetal lung maturity if poor dating criteria
2. >34 but <37 weeks gestation –
a. With progressive labor or PPROM, or nonreassuring fetal testing- deliver
b. Otherwise, outpatient management is reasonable if GHTN is mild and patient is compliant.
c. Fetal testing – daily kick counts and an initial ultrasound and NST followed by twice-weekly testing for the remainder of the pregnancy.
d. Maternal testing – (BP checks and urine dips twice-weekly), in addition to platelet counts, creatinine and LFTs weekly
– Evaluation for symptoms (severe headache, visual changes, altered mentation, RUQ/epigastric pain, nausea/vomiting, shortness of breath, oliguria) at each visit.
e. Strict bed rest not is not recommended but modified bed rest may be appropriate
f. Antihypertensives and diuretics – not recommended (risk masking severe disease; no improvement in perinatal outcome)
B. Intrapartum Management
1. Mode of delivery – Induction/augmentation of labor using standard methods. Reserve cesarean delivery for obstetric indications.
2. Magnesium sulfate (seizure prophylaxis) – indicated for severe gestational hypertension – see Medications for doses.
C. Postpartum management
1. If on MgSO4, continue for at least 6 hours postpartum. Discontinue when urine output >100cc/hour for >2 hours or 24 hours postpartum (whichever comes first).
2. Close monitoring of BP, symptoms and urine output – BP can be expected to normalize during the first week postpartum, however severe hypertension or severe preeclampsia may develop for the first time in the postpartum period. Education of these patients is essential.
3. Antihypertensives to keep BP below severe range (See Medications for options).
4. Patients discharged on an antihypertensive medication should be seen in clinic one week after discharge home for a BP check. Review preeclampsia precautions prior to discharge.
II. Preeclampsia without severe features
A. Antepartum Management
1. Remote from term:
Outpatient workup – mild hypertension (SBP<160 and DBP<110) AND no more than 2+ protein on dipstick urine AND no other symptoms. CBC, CMP; ultrasound (growth, BPP and Dopplers); 24-hour urine collection for protein and creatinine clearance (or a timed collection that is extrapolated to 24 hours, or a P:C ratio of >0.3. If laboratory findings are otherwise WNL and fetal testing reassuring, continued outpatient management with twice-weekly fetal testing, serial growth scans (q 3-4 weeks) and 2 doses of Celestone (if <34 weeks).
2. >37 weeks gestation – deliver (document fetal lung maturity if poor dating criteria)
B. Intrapartum Management
1. Continuous fetal monitoring
2. IV Magnesium Sulfate – Recommend intrapartum magnesium sulfate in light of the decreased rate of seizures from 2% to 0.6%. (The new taskforce recommendation of “No magnesium sulfate intrapartum” is recommended but theQuality of Evidence is low.
3. Checks q 2 hours by physician for evaluation of lungs, reflexes, urine output, patient mental status and labor progress
C. Postpartum Management
1. Close monitoring of BP, symptoms and urine output – BP can be expected to normalize during the first week postpartum, however severe hypertension or severe preeclampsia may develop for the first time in the postpartum period. Education of these patients is essential.
2. Magnesium sulfate – continue for at least 6 hours postpartum. Discontinue when urine output >100cc/hour for >2 hours or 24 hours postpartum (whichever comes first).
3. Antihypertensives to keep BP below severe range (See Medications for appropriate postpartum antihypertensives).
4. All Patients discharged on an antihypertensive medication should be seen in clinic one week after discharge home for a BP check.
III. Preeclampsia with severe features
A. Antepartum Management- hospitalize
1. >34 weeks gestation – Delivery is indicated.
a. Initiate magnesium sulfate upon diagnosis (see medications for dose).
b. Strict I/Os, BP checks, HELLP labs on admission.
2. 23-34 weeks gestation
a. Hospitalize for the remainder of the pregnancy. Initiate a course of Celestone. Initiate MgSO4 during initial assessment period if severe features are present (may discontinue at steroid window if managing conservatively)
b. Consider conservative management if:
i. Maternal and fetal status are reassuring AND patient agrees and understands the risks, AND
ii. Diagnosis of severe preeclampsia is made by BP criteria only, AND antihypertensives keep SBP<170 and DBP<110, as follows:
* Labetalol PO in doses every 6-8 hours, not to exceed a total daily dose of 2400mg
* Nifedipine PO up to 120mg/day
Labetalol and Nifedipine may be used separately or in combination to achieve the above BP goals. If BP cannot be controlled with both of these medications, delivery should be pursued.
c. Follow serial liver function tests, Hgb & platelet counts and daily NSTs or twice-weekly BPPs and weekly Dopplers. Growth scans every 3 weeks.
d. Conservative management is contraindicated with any of the following:
i. Maternal desire for delivery
ii. Oliguria (UOP<20cc/hour) or signs of renal failure
iii. Neurological symptoms (eclampsia, headache, visual change, seizure, stroke, blindness)
iv. Nonreassuring fetal assessment
v. Vaginal bleeding or other signs of abruption
vi. Hypertension uncontrolled with medication
vii. Development of hemolysis, elevated liver enzymes, thrombocytopenia (as described previously)
viii. IUGR is a relative contraindication for conservative management.
3. <23 weeks gestation (or fetus with estimated weight <400g with abnormal Dopplers regardless of EGA) – offer termination of pregnancy – continuation of the pregnancy places the patient at undue risk with essentially no benefit to the fetus.
B. Intrapartum management – delivery 48 hours after initiation of steroids or sooner
(at physician discretion based on patient status)
1. MgSO4 to start (or be restarted if stopped for conservative management) with induction of labor or cesarean delivery (See Medications).
2. Induction of labor may be considered for pregnancies > 31 weeks or prior to that if the patient’s cervix is favorable (Bishop score >6). Cesarean delivery is appropriate with nonreassuring fetal status or unfavorable cervix prior to 30 weeks.
3. Monitor every 2 hours: UOP with Foley catheter; Respirations; Deep tendon reflexes; Mental status
4. Monitor every 12 hours: CBC, Cr, AST, ALT, LDH, Uric acid
5. Antihypertensives should be utilized to keep SBP <170 and DBP<110. (See Medications for appropriate antihypertensives)
C. Postpartum Management
1. Continue MgSO4 for 24 hours (or 24 hours from last seizure activity if applicable).
2. Monitor I/O and daily weights for the entirety of the postpartum hospital stay.
3. Maintain BP <160mmHg systolic and <110 diastolic (see Medications).
4. Patient instructions: Contact a physician if any neurologic symptoms appear (headache, blurred vision, scotomata), urine output seems diminished or abdominal pain develops.
5. Follow-up in the OB clinic within 7 days of discharge for BP check if placed on antihypertensive postpartum, or if patient had seizure or otherwise at physician discretion.
a. intermittent use of small doses of systemic opioids.
b. Local inﬁltration anesthesia can be used for all vaginal deliveries in case of episiotomy or laceration repair.
c. Pudendal block is contraindicated in patients with thrombocytopenia because of the risk of bleeding and hematoma formation into this area.
d. Epidural/spinal anesthesia use at the discretion of anesthesiology (regional anesthesia should not be used with a platelet count <75-100k/uL; general anesthesia is the method of choice for C/S in such patients).
a. Corticosteroids for thrombocytopenia – Dexamethasone 10mg IV q12 hours is an option during the ante- and intra- partum period to facilitate improving thrombocytopenia so that the patient can have regional analgesia/anesthesia. Corticosteroid use postpartum (until plt count >100,000/uL) is also optional.
b. RBC transfusion may be necessary in patients with a low hemoglobin initially – add a crossmatch to the initial type and screen
c. Platelet transfusions –
i. intra- or postpartum in all patients with significant bleeding and/or a platelet count of less than 20,000/uL. Repeated platelet transfusions are not necessary because of the short half-life of the transfused platelets in such patients.
ii. Preoperatively – administration of 6 U of platelets in all patients with a platelet count <50,000/uL before intubation for cesarean delivery is appropriate.
3. Eclampsia – Antepartum and Intrapartum Management
a. Supportive care including elevation of bed rail with padding; padded tongue blade insertion, and physical restraints if needed.
b. Initiate supplemental O2 therapy by facemask and pulse oximetry
c. Alert anesthesia
d. After convulsions have ceased, begin magnesium sulfate (See medications).
e. About 10% of patients will develop a 2nd seizure; an additional 2 grams of magnesium sulfate can be given over 5 minutes. Rarely, a 3rd convulsion may occur; a short-acting barbiturate such as sodium amobarbital 250mg IV over 5 minutes may be given. Continue magnesium sulfate for 24 hours after the resolution of seizure activity.
f. Reduce blood pressure to safe range – systolic BP between 140 and 160 mmHg and diastolic BP between 90 and 110. (See medications for appropriate antihypertensives).
g. Electronic fetal monitoring should be initiated following convulsions. Fetal bradycardia, transient late decelerations and decreased variability are common. These changes usually resolve within 10 minutes of seizure activity or correction of maternal hypoxemia. If the FHR changes persist, cesarean section should be performed (suspect abruption).
h. Steroids for FLM – Not recommended to delay delivery
4. Postpartum preeclampsia and eclampsia precautions – For all women in the postpartum period (not just women with preeclampsia), it is suggested that discharge instructions include information about the signs and symptoms of preeclampsia as well as the importance of prompt reporting of this information to their health care providers.
Contraception – estrogen-containing contraception should not be given to any patient with a hypertensive disorder of pregnancy until hypertension has resolved. Patients can receive Micronor, Nexplanon or Depo Provera at discharge. Alternatively, if hypertension has resolved by the postpartum visit, estrogen-containing contraception can be considered at that time.
Antihypertensives during ante- and intra-partum period (use to maintain systolic BP 140-160 and diastolic BP 90-110)
a. Hydralazine 5 mg IV/15-20 minutes, not to exceed 30 mg/1 hour.
b. Labetalol 20 mg IV (followed by 40 mg IV, then 80 mg IV, then 80 mg IV if BP checked 15 minutes after each dose is not controlled). Max dose 220 mg IV. If BP not controlled after series, switch to another antihypertensive.
c. Nifedipine* 10-20 mg PO q 20-30 min (Max 4 doses)
Appropriate antihypertensives for postpartum use (or use during conservative management of severe preeclampsia):
a. Nifedipine* XL, 30 mg PO Qday or Q12 hours, not to exceed 120 mg/day
b. Labetalol 200 mg Q12 hours (may use q8 hours but compliance may be difficult) not to exceed 2400 mg/day.
c. HCTZ – 12.5-50 mg/day (not for use antepartum)
Fluorinated corticosteroids for fetal lung maturity
a. Betamethasone (Celestone) – 12 mg IM x 1; repeat after 24 hours. Maximum benefit occurs 48 hours after first dose.
b. Dexamethasone – 6 mg IM x 1; repeat q 12 hours x 4 doses. Maximum benefit occurs 48 hours after 1st dose.
a. 6g IV over 15-20 minutes followed by 2g/hour
b. If no IV access, 5g IM into each buttock, followed by 5g IM q 4 hours
c. For renal insufficiency (Cr >1.0mg/dL) – 6g IV over 15-20 minutes followed by 1g/hour. If Cr > 2.5mg/dL, use standard loading dose without a maintenance dose; monitor level periodically.
*Nifedipine – The contraindication for the use of nifedipine in conjunction with magnesium sulfate is relative and not absolute. There can be a synergistic hypotensive effect which is rare. Close monitoring is recommended.
1. Gabbe, Stephen, Obstetrics: Normal and problem pregnancies. Ch 33 – Hypertension
2. Epocrates – Magnesium sulfate drug monograph; Labetalol drug monograph; nifedipine drug monograph; hydralazine drug monograph
3. Sibai BM. “Diagnosis and management of gestational hypertension and preeclampsia”. Obstet Gynecol, 102(1):181-192, July2003.
4. Sibai BM. “Diagnosis, controversies and management of the syndrome of Hemolysis, Elevated Liver Enzymes and Low Platelet count”. Obstet Gynecol, 103(5, part 1):981-991, May 2004.
5. Sibai BM. “Diagnosis, prevention and management of Eclampsia”. Obstet Gynecol, 105(2):402-410, Feb 2005.
6. Fontenot MT, et al. “A prospective randomized trial of magnesium sulfate in severe preeclampsia; use of diuresis as a clinical parameter to determine the duration of postpartum therapy”. Am J Obstet Gynecol 2005 Jun;192(6):1788-93.
7. “Hypertension in Pregnancy” Report on the American College of Obstetricians and Gynecologists executive task force on hypertension in pregnancy. Obstet Gynecol 122(5): 1122-1131, November 2013