Therapy in High-risk Pregnancy

Abraham Simatupang
Dept. of Pharmacology & Therapy
Faculty of Medicine
Universitas Kristen Indonesia
 Conditions evaluated or treated:
(After John Hopkins, Dept. of Obs. & Gynecology)
• Maternal conditions or diseases, including:
– Hypertension (high blood pressure)
– Preeclampsia (toxemia)
– Maternal metabolic diseases, including diabetes (both pregestational and
gestational types)
– Infectious diseases (to include parvovirus, toxoplasmosis, hepatitis, HIV, and
AIDS)
– Platelet alloimmunization (NAIT or FMAIT) (e.g. Rh negative mother sensitized
to an Rh positive fetus)
– Maternal lupus (collagen vascular disorder)
– Poor past obstetrical history (e.g. past preterm deliveries, preterm labor,
preterm cervical dilatation, premature rupture of membranes, repetitive
pregnancy loss)
• Multiple gestation (twins and higher order multiples)
• A known/suspected fetal anomaly
– Suspected abnormal fetal growth
– Macrosomia (a baby that is too large)
– Fetal growth restriction (a baby that is too small)
• Maternal family history of:
– Cardiac disease
– Renal disease
– Gastrointestinal disease
– Cystic fibrosis

• Prenatal genetic testing and consultation. Our genetic counselors and

Maternal-Fetal Medicine specialists work side by side to diagnose and
provide comprehensive care for the following:
– AFP (alpha fetoprotein) blood test (including the suspicion of a neural tube
defect)
– Antenatal serum screening (triple screen/quad screen) with an increased
risk/suspicion of a chromosomal abnormality such as Trisomy 21 [Down
syndrome], Trisomy 13 or Trisomy 18
– The need for invasive fetal testing procedure(s) or other in utero therapeutic
techniques (i.e., blood sampling/transfusion, platelet infusion, fetal bladder
stent placement, chorionic villus sampling (CVS) or amniocentesis (amnio) for
maternal age or other factors
After University of California San Francisco
(UCSF)Medical Center
A pregnancy may be considered high-risk for a variety of
reasons. Some of these include:
• The mother has medical conditions that began before
pregnancy, such as diabetes
• The mother develops a medical condition during
pregnancy, such as preeclampsia
• The mother experienced problems in a previous pregnancy,
such as miscarriage
• Problems are detected in the developing baby
• Complications occur during pregnancy, such as premature
labor
• The mother is pregnant with multiples (twins or more)
 Hypertension in pregnancy
• chronic hypertension
• gestational hypertension
• pre-eclampsia
 BP classification: JNC-7 vs NHBPEP
JNC-7 BP Classification NHBPEP BP Classification
(Nonpregnant, mmHg) (Pregnant, mmHg)
Normal Normal/acceptable in pregnancy
SBP < 120 and DBP < 80 SBP < 140 and DBP < 90
Prehypertension
SBP 120 to 139 or DBP 80 to 89
Stage 1 hypertension Mild hypertension
SBP 140 to 159 or DBP 90 to 99 SBP 140 to 150 or DBP 90 to 109
Stage 2 hypertension Severe hypertension
SBP 160 to 179 or DBP 100 to > 160 systolic or > 110 diastolic
110
Stage 3 hypertension
SBP 180 to 209 or DBP 110 to
119
 Pre- and Eclampsia
• Preeclampsia-eclampsia is a syndrome that
manifests clinically as new-onset hypertension in
later pregnancy (any time after 20 weeks, but
usually closer to term), with associated
• proteinuria: 1 on dipstick and, officially, 300 mg
per 24-hour urine collection
• This syndrome occurs in 5% to 8% of all
pregnancies and is thought to be a consequence
of abnormalities in the maternal vessels
supplying the placenta.
• Both ACE inhibitors and ARBs are fetotoxic but
there are no data to support teratogenicity
Adverse events ACE-I & ARBs:
• Oligohydramnious
• IUGR
• joint contractures
• pulmonary hypoplasia
• hypocalvaria (incomplete ossification of the fetal
skull)
• fetal renal tubular dysplasia and neonatal renal
failure
 Drugs for gestational hypertension
Drug Dose Concerns or Comments
Preferred agent
Methyldopa (B) 0.5 to 3.0 g/d in 2 divided Drug of choice according to
dose NHBEP; safety after
trimester well
documented, including 7
years follow-up off-spring
Second line agents†
Labetalol © 200-1200 mg/d in 2-3 May be associated with
divided doses fetal growth restriction
Nifedipine © 30 to 120 mg/d of a slow May inhibit labour and
release preparation have synergistic action
with MgSO4 in BP
lowering; little experience
with other Ca channel
blockers
Drug Dose Concerns or Comments
Preferred agent
Hydralazine © 50 to 300 mg/d in 2 to 4 Few controlled trials, long
divided doses experience with few
adverse events
documented; useful in
combination with
sympatholytic agent; may
cause neonatal
thrombocytopenia
Beta receptor blockers (C) Depends on specific agent May decrease
uteroplacental blood flow;
may impair fetal response
to hypoxic stress; risk of
growth restriction when
started in first or second
trimester (atenolol); may
be associated with
neonatal hypoglycemia at
higher doses
Drug
Preferred agent
Hydrochlorothiazide (C)‡
Contraindicated ACE-Is and
angiotensin type 1 receptor
antagonists (D)‡
Dose Concerns or Comments
12.5 to 25.0 mg/d Majority of controlled studies in
normotensive
pregnant women rather than
hypertensive
patients; can cause volume
contraction and
electrolyte disorders; may be useful in
combination with methyldopa and
vasodilator to
mitigate compensatory fluid retention
Leads to fetal loss in animals; human
use
associated with cardiac defects,
fetopathy,
oligohydramnios, growth restriction,
renal
agenesis and neonatal anuric renal
failure,
which may be fatal