ANTHIPERTENSIVOS EN EL EMBARAZO

Dra. Blanca N. Rodríguez Grijalva R1 Ginecología y obstetricíaHospital del Niño y la Mujer - HGO

METILDOPA

Ha demostrado beneficio a largo plazo en el feto

Es solo un antihipertensivo medio y tiene un inicio de accion lento (3 a 6 horas)

Muchas mujeres no logran el efecto deseado con esto medicamento solo.

Final report of study on hypertension during pregnancy: the effects of specific treatment on the growth and development of the children.

Cockburn J, Moar VA, Ounsted M, Redman CW

Lancet. 1982;1(8273):647.

BETABLOQUEADORES

Labetalol (accion beta y alfa) (1-2 hrs) Pindolol y Metoprolol aceptados Propanolol (reporta APP, apnea neonatal,

RCIU bradicardia e hipoglucemia). Chronic hypertension in pregnancy.

Sibai BM, Obstet Gynecol. 2002;100(2):369.

Atenolol and fetal growth in pregnancies complicated by hypertension. Lydakis C, Lip GY, Beevers

M, Beevers DG Am J Hypertens. 1999;12(6):541.

BLOQUEADORES DE LOS CANALES DE CALCIO

Nifedipino (30-60mg c/24hrs), no se utiliza por que causa un descenso rápido en la TA

Amlodipino, verapamilo y diltiazem aun no hay reportes significativos

Oral beta-blockers for mild to moderate hypertension during pregnancy. Magee LA, Duley L Cochrane Database Syst Rev. 2003;

Nifedipine in pregnancy. Smith P, Anthony J, Johanson R BJOG. 2000;107(3):299. McMaster University, Hamilton, Ontario, Canada.

Exposure to amlodipine in the first trimester of pregnancy and during breastfeeding.

Ahn HK, Nava-Ocampo AA, Han JY, Choi JS, Chung JH, Yang JH, Koong MK, Park CT Hypertens

Pregnancy. 2007;26(2):179.

HIDRALAZINA

Tiene un efecto hipotensor poco predecible

Causa taquicardia refleja, retención de líquidos.

American College of Obstetricians and Gynecologists. Diagnosis and management of preeclampsia and eclampsia. ACOG practice bulletin #33. American College of Obstetricians and Gynecologists, Washington, DC 2002. Obstet Gynecol 2002.

Committee Opinion no. 514: emergent therapy for acute-onset, severe hypertension with preeclampsia or eclampsia.

Committee on Obstetric Practice

Obstet Gynecol. 2011;118(6):1465.

DIURETICOS TIAZIDICOS

Controversiales Sin embargo no son utilizados hasta

que hay EAP

Overview of randomised trials of diuretics in pregnancy. Collins R, Yusuf S, Peto R Br Med J (Clin Res Ed). 1985;290(6461):17.

ACOG Practice Bulletin No. 125: Chronic hypertension in pregnancy. American College of Obstetricians and Gynecologists Obstet Gynecol. 2012;119(2 Pt 1):396.

INDICACIONES DE TERAPIA ANTIHIPERTENSIVA

No tratamiento para TA < 150/100 Bajar la TA no afecta el curso de la

preeclampsia, debido a que la causaprincipal es una anormalidad en la vascularidad placentaria que resulta en una hipoperfusión placentaria , que lleva a una disfunción multiorganica.

No iniciar terapia hasta TA >160/100mmHg

Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Abalos E, Duley L, Steyn DW, Henderson-Smart DJ Cochrane

Database Syst Rev. 2007

ELECCIÓN DEL MEDICAMENTO

COMMITTEE OPINION NO. 514: EMERGENT THERAPY FOR ACUTE-ONSET, SEVERE HYPERTENSION WITH PREECLAMPSIA OR ECLAMPSIA. COMMITTEE ON OBSTETRIC PRACTICESO OBSTET GYNECOL.

2011;118(6):1465.

LABETALOL HIDRALAZINA

Begin with 20 mg intravenously over 2 minutes followed at 10-minute intervals by doses of 20 to 80 mg up to a maximum total cumulative dose of 300 mg. As an example, give 20 mg, then 40 mg, then 80 mg, then 80 mg, then 80 mg. A constant infusion of 1 to 2 mg/min can be used instead of intermittent therapy. The fall in blood pressure begins within 5 to 10 minutes and lasts from 3 to 6 hours. Continuous cardiac monitoring is not necessary routinely, but should be used in patients with relevant co-morbidities (eg, coronary artery disease).

Begin with 5 mg intravenously over 1 to 2 minutes; if the blood pressure goal is not achieved within 20 minutes, give a 5 to 10 mg bolus depending upon the initial response. The maximum bolus dose is 20 mg. If a total dose of 30 mg does not achieve optimal blood pressure control, another agent should be used. The fall in blood pressure begins within 10 to 30 minutes and lasts from 2 to 4 hours.

Fase aguda

BLOQUEADORES DE LOS CANALES DE CALCIO

Con experiencia limitada No se utiliza como primera linea por el

resigo de una hipotensión precipitada, asociada a seriasmorbilidades cardiovasculares.

Nicardipine for the treatment of severe hypertension in pregnancy: a review of the literature. Nij Bijvank SW, Duvekot JJ Obstet Gynecol Surv. 2010;65(5):341.

NITROGLICERINA

Tratamiento para hipertensiona sociada a edema pulmonar en infusion IV de 5mcg/min e incrementar cada 3 a 5 minutos hasta un máximo de 100 mcg/min

ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of

Cardiology (ESC).European Society of Gynecology (ESG), Association for European Paediatric Cardiology (AEPC), German

Society for Gender Medicine (DGesGM), Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, Cifkova R, Ferreira R, Foidart JM, Gibbs JS, Gohlke-Baerwolf C, Gorenek B, Iung B, Kirby M, Maas AH,

Morais J, Nihoyannopoulos P, Pieper PG, Presbitero P, Roos-Hesselink JW, Schaufelberger M, Seeland U, Torracca L, ESC Committee for Practice Guidelines Eur Heart J. 2011;32(24):3147

TERAPIA A LARGO PLAZOMANAGEMENT OF HYPERTENSIVE DISORDERS DURING PREGNANCY: SUMMARY OF NICE GUIDANCE.

VISINTIN C, MUGGLESTONE MA, ALMERIE MQ, NHERERA LM, JAMES D, WALKINSHAW S, GUIDELINE DEVELOPMENT GROUP BMJ. 2010;341:C2207

OBJETIVOSCOMPLICACIONES DE ANTIHIPERTENSIVOS

Sistólica <130-150 Diastólica <80-100 No reducir ala TA mas

del 25% dentor de dos horas, alcanzando los objetivos

Isquemia al miocardio inferto

GESTATIONAL HYPERTENSION

Total blood and plasma volumes are significantly lower in women with preeclampsia (mean 2660 mL/m2 and 1790 mL/m2, respectively) than in women with gestational hypertension (3139 mL/m2 and 2132 mL/m2, respectively)

La preeclampsia se desarrolla en un 15-25%

Comparison of total blood volume in normal, preeclamptic, and nonproteinuric gestational hypertensive pregnancy by simultaneous measurement of red blood cell and plasma volumes.

Silver HM, Seebeck M, Carlson R Am J Obstet Gynecol. 1998;179(1):87

MILD GESTATIONAL HYPERTENSION ASA Reposo Patient education and counseling Fetal assessment No antihypertensive therapy No antenatal glucocorticoids No se administra sulfato de magnesio a menos que

se demuestre proteinuria

Does admission to hospital for bed rest prevent disease progression or improve fetal outcome in pregnancy complicated by non-proteinuric hypertension? Crowther CA, Bouwmeester AM, Ashurst HM Br J Obstet Gynaecol. 1992;99(1):13

Placental morphometrical and histopathology changes in the different clinical presentations of hypertensive syndromes in pregnancy. Corrêa RR, Gilio DB, Cavellani CL, Paschoini MC, Oliveira FA, Peres LC, Reis MA, Teixeira VP, Castro EC Arch

Gynecol Obstet. 2008;277(3):201.

SEVERE GESTATIONAL HYPERTENSION

CHRONIC (PREEXISTENT) HYPERTENSION

MILD Superimposed preeclampsia — 10 to 25 percent

(versus 3 to 5 percent in the general obstetrical population)

Abruptio placentae — 0.7 to 1.5 percent (versus ≤1 percent in the general obstetrical population)

Fetal growth restriction — 8 to 16 percent (versus 10 percent in the general obstetrical population)

Chronic hypertension in pregnancy Sibai BM Obstet Gynecol. 2002;100(2):369.

SEVERE Superimposed preeclampsia — 50

percent Abruptio placenta — 5 to 10 percent Preterm birth — 62 to 70 percent Fetal growth restriction — 31 to 40

percent

LABORATORIOS

Urinalysis Urine culture Creatinine Glucose Electrolytes Quantitative analysis of urine protein  

COMPLICATED AND SECONDARY HYPERTENSION

Secondary, rather than essential, hypertension

Target-organ damage (eg, left ventricular hypertrophy, microalbuminuria, retinopathy)

Dyslipidemia Maternal age over 40 years old History of stroke Previous perinatal loss Diabetes

SEVERE HYPERTENSION 

The United States National High Blood Pressure Education Program (NHBPEP) Working Group on High Blood Pressure in Pregnancy states that anti-hypertensive therapy is indicated for women with chronic hypertension and blood pressures exceeding 150 to 160 mmHg systolic or 100 to 110 mmHg diastolic or the presence of target organ damage (eg, renal insufficiency, left ventricular hypertrophy) [1]. They also recommend treatment of “dangerously high” blood pressure in women with preeclampsia; they do not define a specific level, but suggest a diastolic pressure greater than 100 to 110 mmHg be considered depending on patient-specific risk factors, such as baseline blood pressure.

The Society of Obstetricians and Gynaecologists of Canada (SOGC) guideline recommends anti-hypertensive treatment for new onset systolic blood pressure >160 mmHg or diastolic blood pressure >110 mmHg, with goal blood pressure <160/110 mmHg [33]. For women with chronic hypertension without comorbid conditions and blood pressure of 140 to 159/90 to 109 mmHg, antihypertensive drug therapy should be used to keep systolic blood pressure at 130 to 155 mmHg and diastolic blood pressure at 80 to 105 mmHg. For women with chronic hypertension with comorbid conditions, antihypertensive drug therapy should be used to keep systolic blood pressure at 130 to 139 mmHg and diastolic blood pressure at 80 to 89 mmHg.

The National Institute for Health and Clinical Excellence (NICE) recommends that for pregnant women with uncomplicated chronic hypertension the goal is to keep blood pressure lower than 150/100 mmHg [34]. In women with gestational hypertension or preeclampsia, treatment is initiated at blood pressures ≥150/100 mmHg with the goal of systolic blood pressures <150 mmHg and diastolic blood pressures of 80 to 100 mmHg. They also recommend use of low dose aspirin (75 mg/day) from 12 weeks of gestation to reduce the risk of preeclampsia. (See "Prevention of preeclampsia", section on 'Approach to therapy'.)

The American College of Obstetricians and Gynecologists (ACOG) recommends treatment of severe hypertension and suggests labetalol as first-line therapy [16]. They also suggest avoiding atenolol, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers.

THE TASK FORCE ON THE MANAGEMENT OF CARDIOVASCULAR DISEASES DURING PREGNANCY OF (ESC) RECOMMENDS THE FOLLOWING [23]:

Nonpharmacological management for pregnant women with systolic blood pressure of 140 to 150 mmHg or diastolic blood pressure of 90 to 99 mmHg

In women with gestational hypertension or preexisting hypertension superimposed by gestational hypertension or with hypertension and subclinical organ damage or symptoms at any time during pregnancy, initiation of drug treatment is recommended at blood pressure of 140/90mmHg. In any other circumstances, initiation of drug treatment is recommended if systolic blood pressure is ≥150 mmHg or diastolic blood pressure is ≥95 mmHg.

Systolic blood pressure ≥170 mmHg or diastolic blood pressure ≥110 mmHg in a pregnant woman is an emergency, and hospitalization is indicated

POSTPARTUM HYPERTENSION 

One guideline suggests avoiding methyldopa postpartum because of the risk of postnatal depression

ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during

Pregnancy of the European Society of Cardiology (ESC). European Society of Gynecology (ESG), Association for European Paediatric Cardiology (AEPC),

German Society for Gender Medicine (DGesGM), Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, Cifkova R, Ferreira R, Foidart JM, Gibbs JS, Gohlke-

Baerwolf C, Gorenek B, Iung B, Kirby M, Maas AH, Morais J, Nihoyannopoulos P, Pieper PG, Presbitero P, Roos-Hesselink JW, Schaufelberger M, Seeland U,

Torracca L, ESC Committee for Practice GuidelinesEur Heart J. 2011;32(24):3147