HYPERTENSIVE

DISEASE IN
PREGNANCY

A. Kurdi Syamsuri
INTRODUCTION
MMR : Indonesia 357/100000, Malaysia/Vitnam
160/100000, Singapore 6/100000.
Hypertensive disorders complicate 5-10%
pregnancies
 Contributes greatly to maternal morbidity and
mortality—along with hemorrhage and
infection
 Cause of MMR : Hemorrhage : 28%, Eclampsia :
24 %, Infection : 11%
HYPERTENSIVE DISEASE IN PREGNANCY

Hypertensive Disease
BP ≥ 140/90 mmHg

Chronic Gestational Preeclampsia- Superimposed

hypertension hypertension eclampsia preeclampsia

Before Gestational Chronic

pregnancy OR > 20 weeks hypertension hypertension +
before 20 weeks gestation + multi organ
gestation Multi organ involvement
involvement
CHRONIC HYPERTENSION
 CHTN is defined as either a history of
hypertension preceding the prenancy or a blood
pressure (BP) ≥140/90, < 20 weeks geastation.
 Severe CHTN -> BP ≥160/110
 High-risk CHTN -> BP ≥180/110

Risk Factors
• Renal disease
• Collagen vascular disease
• APS
• Hyperaldostreronisem,
pheochromocytoma
Management
similar with preeclampsia
Gestational Hypertension
Definition
GHTN : BP ≥ 140/90 after 20 weeks, without
proteinuria, other signs or symptoms of pre-
eclampsia, or a prior history of HTN. Severe
GHTN is defined similarly except that the
cutoffs are ≥ 160/110 mmHg.
Incidence : about 6% to 17% healthy nuliparous
women.
 Cont

Maternal-Fetal Evidence Based Guidelines Third Edition 2017

Complications
 Abruption
Similarly to severe
 PTB pre-eclampsia
 SGA

GHTN develops < 30 weeks or is severe, there is a

high (50%) rate of progression to preeclampsia.
Antenatal Management
 GHTN -> goods- outcomes similarly to low-risk
pregnant women.
 Before 37 weeks, no complications -> expectant
management.
 Outpatient : check proteinuria, laboratory test.
 Antihypertensive medications for BP <160/110
or bed rest are not recommended.
 BPP or modified BPP every weeks.
Cont
Severe GHTN -> admission to the hospital
Antihypertensive medications for BP ≥160/110
mmHg to avoid maternal complications (stroke,
cardiac failure , pulmonary edema, renal
impairment, and death).
Maternal-Fetal Evidence Based Guidelines Third Edition 2017
Maternal-Fetal Evidence Based Guidelines Third Edition 2017
Delivery
Pregnant women > 37 weeks with GHTN ->
delivery is recommended.
Magnesium sulfate : negative
There is no strict recommendation of when to
deliver women with severe GHTN in absence of
severe features.
If severe features positive -> deliver ≥34 for
weeks.
PREECLAMPSIA
 Is a pregnancy-specific syndrome that can affect
every organ system

Preeclampsia
Proteinuria Multi organ
BP ≥ 140/90
mmHg involvement

- Thrombocytopenia (PLT < 100,000/mcL

- Renal insufficiency (Creatinine >1.1 mg/dL)
- Liver involvement (AST or ALT 2x normal)
- Cerebral symptoms (Headache, visual disturbances, convulsions)
- Pulmonary edena
 PREECLAMPSIA SEVERITY
Abnormality Non Severe Abnormality Non Severe
severe severe
Systolic BP < 160 > 160 Convulsion (-) (+)
(eclampsia)
Diastolic BP < 110 > 110
Serum creatinine Normal 
Proteinuria (-)/(+) (-)/(+)
Thrombocytope (-) (+)
Headache (-) (+) nia
Serum Minimal Marked
Visual (-) (+) transaminase 
Disturbances
Fetal growth (-) Obvious
Upper (-) (+) restriction
Abdominal Pain
Pulmonary (-) (+)
Oliguria (-) (+) edema
 HELLP Syndrome

Maternal-Fetal Evidence Based Guidelines Third Edition 2017

Signs and Symptoms
 Right upper abdominal quadrant or apigastric
pain.
 Nausea
 Vomiting
 Headache
 Visual symptoms
Maternal-Fetal Evidence Based Guidelines Third Edition 2017
ECLAMPSIA
 Eclampsia =

 Preeclampsia + convulsion that cannot be attributed

to another cause
 Generalized seizures

 May appear before, during, or after labor

ETIOPATHOGENESIS
 Characterizedby abnormalities that result in
vascular endothelial damage with resultant
vasospasm, transudation of plasma, and ischemic
and thrombotic sequelae
 Fetusis NOT a requisite for preeclampsia to
develop
 Chronionic villi are essential and need NOT be
intrauterine  preeclampsia reported in 30%
extrauterine pregnancies >18 weeks gestation
 Abnormal trophoblastic invasion

Immunological maladaptive maternal

THEORIES tolerance to paternal & fetal tissues
OF
ETIOLOGY Maladaptation to changes of normal
pregnancy

Genetic factors
ABNORMAL
TROPHOBLASTIC INVASION
Normal Implantation Preeclampsia
- Extensive remodeling of - Incomplete trophoblastic
spiral arterioles within invasion
decidua basalis - Decidual vessels become lined
- Endovascular trophoblasts with endovascular
replace vascular endothelial trophoblasts
and muscular linings  - Deeper myometrial arterioles
enlarge vessel diameter do not lose endothelial lining
and musculoelastic tissue
- Mean external diameter ½ of
normal placenta vessels
 SPOT THE DIFFERENCES!

Vessel
diameter
larger

Vessel
diameter
smaller

Endothelial
Endothelial lining (+)
lining (-)
 IMMUNOLOGICAL
MALADAPTIVE TOLERANCE
 Loss of maternal immune tolerance to paternally-
derived placental and fetal antigens
 “Immunization” from previous pregnancy with the
same partner  decreased risk of preeclampsia
 First pregnancy, molar pregnancies, women with
trisomy-13 fetus  higher risk of preeclampsia
OTHER FACTORS
Nutritional factors
• Diet high of antioxidant 
decreased blood pressure

Genetic factors
• Result of interaction of
hundreds of inherited genes
PATHOPHYSIOLOGY
PREVENTION
• Low salt diet
• Calcium
supplementation
• Fish oil
• Exercise
Dietary & Anti
lifestyle hypertensive Anti oxidants
modification drug

• Aspirin 50-150
mg/day
• Heparin

Anti
thrombotic
agents
MANAGEMENT GOALS
Termination of
pregnancy with
minimal trauma

Complete
Birth of
restoration
infant who
of maternal
thrives
health

One of the most important clinical questions for successful

management is precise knowledge of fetal age
MANAGEMENT:
OUTPATIENT OR HOSPITALIZATION?
CLINICAL FINDINGS: Consider
- Overt hypertension hospitalization
- Proteinuria
- Headache Evaluate for early
- Visual disturbances identification of worsening
- Epigastric discomfort preeclampsia

EVALUATION: - Blood pressure (/4 hours)

- Clinical findings (daily) - Serum creatinine, hepatic
- Weight (daily) aminotransferase, platelet count
- Proteinuria OR protein:creatinine - Fetal size & well-being, amnionic
ratio (/2 days) fluid volume

Severe Preeclampsia

Plan for further management.

Depends on: (1) Preeclampsia severity, (2) gestational age,
(3) condition of cervix
MANAGEMENT
Control of • Magnesium sulfate
convulsions
Intermittent
antihypertensive
• Diuretics, except pulmonary edema

Avoidance of • Excessive IV fluid administration,

except excessive fluid loss
• Hyperosmotic agents

Delivery of fetus

Termination of pregnancy is the only cure

for preeclampsia
MANAGEMENT:
TERMINATE PREGNANCY Preeclampsia

OR NOT?
- > 37 wks, OR
- > 34 wks with:
- In labor or PROM Terminate
Yes
- Maternal or fetal distress pregnancy
- IUGR
- Placental abruption

No Yes

- < 37 wks
- > 37 wks
- Outpatient
- Maternal or fetal distress
- Maternal and fetal evaluation
- In labor or PROM
2x/wk
EXPECTANT
Severe preeclampsia
MANAGEMENT
- Evaluation in delivery room for 24-
48 hrs
Non severe preeclampsia - Corticosteroid for lung maturation,
prophylaxis MgSO4, anti HT
- Ultrasound, BPP, lab examination
- Expectant management
- Outpatient
- Close evaluation: Contraindication for expectant
- 2x/wk  Blood pressure, management:
ultrasound Yes:
- Eclampsia - Fetal distress
- 1x/wk  thrombocyte, - Lung edema - Abruptio placenta
Deliver after
liver function - DIC - IUFD stabilization
- Uncontrolled HT - Unviable fetus
Expectant management
- Available ICU & NICU
- Viable fetus Yes:
Complications:
- Hospitalization - Corticosteroid
- Stop MgSO4 in 24 hrs - Persistent symptoms - HELLP
for lung
- Evaluate mom & baby every day - Severe renal dysfunction - In labor
maturation
- Reversed end diastolic flow - PROM
- Deliver after
- Severe oligohydramnios - IUGR
48 hrs
- > 34 wks
- In labor or PROM
Yes:
- Maternal/fetal distress
- > 1 contraindication for expectant Terminate pregnancy
management
MANAGEMENT
Clinical management algorithm
for suspected severe
preeclampsia at <34 weeks

Note:
 HELLP = Hemolysis, elevated liver
enzyme levels, low platelet count
 L&D = Labor & delivery
 UOP = Urine output
MANAGEMENT
Indications for delivery in women <34 weeks’ gestation managed
expectantly

Corticosteroid therapy for lung maturation and delivery after maternal

stabilization:
- Uncontrolled severe hypertension - DIC
- Eclampsia - Nonreassuring fetal status
- Pulmonary edema - Fetal demise
- Placental abruption

Corticosteroid therapy for lung maturation; delay delivery 48 hr if

possible:

- PROM or in labor - Oligohydramnios

- Thrombocytopenia < 100,000/μL - Reversed end-diastolic doppler
- Hepatic transaminase 2x normal flow in umbilical artery
- Fetal growth restriction - Worsening renal dysfunction
MANAGEMENT:
ANTI CONVULSANT
 MgSO4 is recommended as 1st line eclampsia
treatment
 RCOG guideline:
 Loading dose: 4 g for 5-10 minutes

 Maintenance: 1-2 g/hr for 24 hrs after delivery or

after the last convulsion
 2 g bolus IV if convulsion re occur

 Monitor urine output, patella reflex, RR, O2

saturation
Maternal-Fetal Evidence Based Guidelines Third Edition 2017
MANAGEMENT:
ANTI HYPERTENSIVE
 Recommended for:
 BP systolic > 160 mmHg or diastolic > 110 mmHg
 BP target:

 Systolic < 160 mmHg and diastolic < 110 mmHg

 1st choice anti hypertensive:
 Short-acting oral nifedipine (10 mg tablet/15-30 minutes
max dose 30 mg)
 Other alternative: methyldopa
 250-500 mg per oral 2-3x/day, max dose 3 g/day
 250-500 mg/6 hrs IV, max dose 1 g/6 hrs for crisis HT