Hypertension EAC

Hypertensive Disorders in
Pregnancy
Hypertensive Disorders in Pregnancy

OBJECTIVES
To know the:
• Terminologies and diagnosis
• Incidence and risk factors
• Ethiopathogenesis and pathophysiology
• Prediction and prevention
• Management
• Long term consequences

Case
• M.M., a 25 year old, G1P0, came in at 18
weeks for prenatal check up. BP was
140/100mmHg, HR 85, RR 18
• FHT: 152/min
• What is your diagnosis?

Case
A.G., 30 years old, G1P0, 32 weeks, sought
consult due to bipedal edema.
V/S: BP: 160/110, CR: 88, RR: 18
FH: 30 cm, FHT: 140’s
What is your diagnosis at this time?

Basis of your diagnosis?

Classification of Hypertensive Disorders complicating pregnancy
(Working Group of the NHBPEP 2000):
• Gestational Hypertension
• Preeclampsia and eclampsia syndrome
• Chronic Hypertension of any etiology
• Preeclampsia superimposed on Chronic
hypertension

>140 mm Hg systolic
or
90 mm Hg diastolic

Case: a 35 y/o G1P0, had these
record at your clinic
• Weeks of gestation blood pressure
12 weeks 90/60 mm Hg

DELTA HYPERTENSION

Gestational Hypertension
• BP ≥ 140/90mmHg for the first time after
midpregnancy
• No proteinuria
• BP returns to normal <12 weeks’ postpartum
• Transient hypertension

Preeclampsia syndrome
• Preeclampsia
– Proteinuria
• 24 hour urine protein >300 mg
• Urine protein-creatinine ratio >/- 0.3
• Persistent random urine protein 30mg/dl or +1 on
dipstick
– Evidence of multiorgan involvement

• Thrombocytopenia, renal dysfunction, hepatocellular
necrosis, CNS perturbations or pulmonary edema
Eclampsia
• Seizures that cannot be attributed to other

causes in a woman with preeclampsia

CHRONIC HYPERTENSION
• BP ≥140/90 mm Hg before pregnancy or diagnosed before 20

weeks' gestation not attributable to gestational trophoblastic
disease; or hypertension first diagnosed after 20 weeks
gestation and persistent after 12 weeks postpartum

SUPERIMPOSED PREECLAMPSIA
(ON CHRONIC HYPERTENSION)
• New-onset proteinuria 300 mg/24 hours in hypertensive

women but no proteinuria before 20 weeks' gestation
• A sudden increase in proteinuria or blood pressure or platelet

count < 100,000/mm3 in women with hypertension and
proteinuria before 20 weeks' gestation

Classification of Preeclampsia
Mild “ non-severe” “ less severe”
Severe = preeclampsia + ≥ 1 of a
series of complications

Indicator or preeclampsia severity
abnormality nonsevere severe
Diastolic BP <110 mmHg >/- 110 mmHg
Systolic BP <160 mm Hg ≥160 mmHg
Proteinuria None to positive Present
Headache Absent Present
Visual disturbances Absent Present
Upper abdominal pain Absent Present
Oliguria Absent Present
Convulsion Absent Present
Serum creatinine Normal Elevated
Thrombocytopenia Absent Present
Serum transaminase elevation Minimal Marked
Fetal growth restriction Absent Obvious

Pulmonary edema Absent Disorders in Pregnancy present
Hypertensive
Criteria for the Diagnosis of Severe Preeclampsia
• Symptoms of central nervous

system dysfunction
• Blurred vision, scotomata,
altered mental status, severe
Symptoms headache
• Symptoms of liver capsule
distention or rupture
• Persistent right upper quadrant
and/ or epigastric pain
Norwitz. Expectant management of severe preeclampsia remote from term. Am J Obstet Gynecol 2008 .

• Blood pressure criteria≥ 160/110

• Eclampsia
• Pulmonary edema or cyanosis
• Cerebrovascular accident
Signs • Cortical blindness
• IUGR (EFW < 5th percentile for age or
< 10th percentile with evidence of
fetal compromise

Laboratory findings
• > 300 mg per 24 hours or persistent 30 mg/dl on

Proteinuria dipstick
Oliguria and/ • Urine output < 500 mL per 24 hours and/ or serum
creatinine > 1.2 mg/ dL
or renal failure
• Evidence of hemolysis (abnormal peripheral smear,
HELLP total bilirubin >1.2 mg/ dL, LDH >600 U/L)
• Elevated liver enzymes (ALT >70 U/L)
syndrome • Low platelets (<100,000 platelets/ mm3 )

Laboratory findings
Hepatocellular
• Liver enzymes ≥ 2x normal
injury
Thrombocytopenia • < 100,000 platelet / mm3
• Prolonged PT
Coagulopathy • Low platelet count
• Low fibrinogen

Case
C.G., 30 years old, G1P0, 32 weeks, sought
consult due to bipedal edema.
V/S: BP: 160/110, CR: 88, RR: 18
FH: 30 cm, FHT: 140’s
What is your diagnosis at this time?

Basis of your diagnosis?

Case
C.G. asked you this question
WHY ME?

Risk factors
• Primigravid
• Multifetal gestation or hydatidiform mole
• Diabetes, renal or cardiovascular disease
• Genetic predisposition
• Obesity
• Maternal age

Normal pregnancy In preeclampsia
no trophoblastic proliferation
Ingrowth of trophoblastic cells into the
walls of spiral arterioles
Vasoconstriction
cause thinning and dilation of blood

increase resistance to blood flow in
vessels
uteroplacental units
resistance to blood in uteroplacental

units decreased decreased uteroplacental
perfusion
increase in uteroplacental perfusion
placental ischemia
produce agents into systemic

circulation which will induce damage to
endothelial cell

Pathophysiology of hypertension in pregnancy
absent trophoblastic invasion of the uterine artery
vasospasm hepatic hepatic

ischemia infarction
endothelial damage hematoma
edema platelet hemolysis liver

consumption rupture

BLOOD VESSELS
vasoconstriction vas permeability
BP of at least 160/110mmHg edema

UTERO-PLACENTAL UNIT
vasospasm
decreased placental perfusion
IUGR fetal death

KIDNEYS
glomerular cap decreased renal

endotheliosis blood flow
proteinuria oliguria
5gm/24 hrs < 400cc/day

BRAIN
cerebral edema
hyperemia
focal anemia
thrombosis
hemorrhages
headache blurred vision stroke / coma

ENDOTHELIAL CELL DAMAGE
CARDIOVASCULAR SYSTEM
increased afterload from hypertension

diminished preload
extravasation into extravascular space
pulmonary edema cyanosis

LIVER
hepatocellular edema / necrosis
Right upper or epigastric pain

(subcapsular hematoma / liver rupture )
Elevated liver enzymes

BLOOD
thrombin platelet activation red cell

activation destruction
platelet adhesion
fibrin deposition
DIC decreased platelet hemolysis

• Can you predict if I will develop Preeclampsia?

• Can I prevent Preeclampsia?

PREVENTION of Preeclampsia
1. dietary manipulation
(high dose calcium, fish oil,
low salt diet)
2. Antithrombotic drugs
3. antioxidants
4. Exercise
5. Cardiovascular drugs

Case
C.G. asked another question
WHAT IS THE DEFINITIVE

TREATMENT?

Delivery is the only
cure for preeclampsia

Conservative
Immediate Delivery
Management
Advantages
Safety of the
mother
Disadvantages
Complications of
Prematurity
- RDS - NEC
- IVH - Sepsis

MANAGEMENT OBJECTIVES
• Termination of pregnancy with the least possible

trauma to mother and fetus
• Birth of an infant who subsequently thrives
• Complete restoration of health to the mother
*PRECISE KNOWLEDGE OF GESTATIONAL AGE*

Main Objectives in the Management of Severe
Preeclampsia
Safety of the mother
Forestall convulsion
Prevent intracranial hemorrhage
Avoid serious damage to vital organs
Deliver a healthy infant

EARLY PRENATAL DETECTION
• scheduled intervals of every 4 weeks until 28 weeks,
then every 2 weeks until 36 weeks and weekly
thereafter
• Increased surveillance for women with ;

1. diastolic BP 81-89 mmHg
2. sudden abnormal weight gain (>2lbs/wk)
• Hospitalization for assessment of severity of disease

for new onset hypertension

For NEW ONSET Hypertension :
(esp. with persistent or worsening hypertension
or development of proteinuria)
• Detailed examination followed by daily
scrutiny for clinical findings as headache,
visual disturbances, epigastric pain and rapid
weight gain
• Weight on admittance & q day thereafter
• Analysis for proteinuria on admittance and at
least q 2 days thereafter

For NEW ONSET Hypertension :
(esp. with persistent or worsening hypertension
or development of proteinuria)
• Blood pressure readings in the sitting position with

an appropriate-size cuff q 4 hours, except between
midnight and morning
• Measurements of plasma or serum creatinine,

hematocrit, platelets, and serum liver enzymes, the
frequency to be determined by the severity of
hypertension
• Frequent evaluation of fetal size and AFV either

clinically or with sonography
• Case
– S.L, 30 year old, G1P0, 32 weeks AOG
– BP 160/ 110 mmHg
– FHR- 140’s
– (+) proteinuria

Admit
Maternal and fetal assessment
Consider MgSO4
Treat dangerous hypertension
Contraindications to conservative
management
• Persistent symprtoms of severe hypertension
• Eclampsia, pulmonary edema, HELLP syndrome
• Renal dysfunction, coagulopathy
• Abruption
• Fetal compromise

Initial 24-48 hours observation
• Corticosteroids for lung maturation
• Frequent evaluation
• Daily lab evaluation for HELLP Syndrome
On going in patient management

daily maternal assessment
Serial lab evaluation
Daily fetal assessment, serial growth evaluation, amnionic fluid
Deliver at 34 weeks
EXPECTANT MANAGEMENT
• Justified ONLY in MILD Preeclampsia

where there is hesitation to deliver because of
PREMATURITY
• Frequent antepartum surveillance is

mandatory (BPS, NST, doppler velocimetry)

• Reduced physical activity
• Absolute bed rest, sedatives & tranquilizers are

NOT necessary
• Ample but not excessive protein & calories
• Sodium and fluid intakes should not be limited or

forced
• Further management depends on ;
1. severity of preeclampsia, determined by

presence or absence of conditions cited
2. duration of gestation
3. condition of the cervix

Anticonvulsants
• Magnesium sulfate
A,Continuous Intravenous Infusion ;
1. Give 4-6 g loading dose diluted in 100 ml

of IV fluid administered over 15-20 min.
2. Begin 2 g/hr in 100 ml of IV maintenance
infusion
3. Measure serum Mg level at 4-6 hr and
adjust infusion to maintain levels
between 4-7 mEq/L (4.8-8.4 m/dL)
4. Magnesium sulfate is discontinued 24 hrs
after delivery
Anticonvulsants
• MgSO4·7H2O USP
B,Intermittent Intramuscular Injection ;
1. Give 4g of magnesium sulfate as a 20% solution IVP

at a rate not exceeding 1g/min
2. Follow promptly with 5g of 50% solution, deep IM
on each buttocks thru 3-inch long, 20-gauge needle.
3. Every 4 hrs thereafter, give 5g of 50% solution injected
deeply on alternate buttocks, but only after ensuring that ;
a. the patellar reflex is present
b. respirations are not depressed
c. urine output the previous 4 hrs exceeded 100ml
4. Magnesium sulfate isHypertensive
discontinued
Disorders 24 hrs after delivery.
in Pregnancy
Anticonvulsants
• Phenytoin (Dilantin)
- 1000 mg IV over 1 hour

- followed by 500 mg PO 10 hours later;
- not to exceed 1500 mg/24 hours;
- rate of infusion not to exceed 50 mg/min
to avoid hypotension and arrhythmias
- higher recurrent convulsions & maternal
mortality compared to MgSO4

Anticonvulsants
• Diazepam (valium)
- 10 mg slow IVP esp. for acute episodes

- favored because of shorter half-life
- higher recurrent convulsions & maternal
mortality compared to MgSO4

Antihypertensive drug therapy:
• Aim is to lower diastolic BP to 90 – 100 mm Hg

otherwise uteroplacental perfusion may be
compromised

• vasodilators
- hydralazine (Apresoline)
- BP >160/105 mmHg: 5 – 10 mg IV every 15 – 20
minutes until satisfactory response ( defined as
decrease in diastolic BP to 90 or 100 mmHg)
- nitroprusside (Nitropress)
- continuous infusion begun with 0.25µg/kg/min
increased 5µg/kg/min
- given ONLY when hydralazine,& Nifedipine fail
Antihypertensive drug category:
• calcium channel blockers

- nifedipine (Calcibloc)
– for BP > 170/110 mmHg:
10 mg PO initial, repeat dose
may be administered in 30 minutes prn
alpha adrenergic inhibitors

- methyldopa (Aldomet) – 250 mg PO BID/TID
not to exceed 3 gms/day
Antihypertensive drug category:
• beta adrenergic receptor blockers
- labetalol (Normodyne) 20 mg IV bolus initially
followed by 40mg if not effective in 10 min
80 mg in another 10 minutes ; not to exceed 220mg
total dose per episode
- metoprolol (Neobloc, Betaloc) – 50-400 mg/day PO
centrally acting alpha-adrenergic agonists

- clonidine (Catapres) – initial: 0.1 mg PO BID
- maintenance: 0.2-1.2 mg/day BID to QID PO
(not to exceed 2.4 mg/day)
• diuretics
* not commonly used to treat
hypertension in pregnancy
a. hydrochlorothiazide
– 25-100 mg PO/day
(not to exceed 200 mg/kg/day)
b. furosemide (Lasix)
– 10 mg IV as initial dose
- 20-80 mg/day PO / IV / IM
- titrate up to 600 mg/day for severe
edematous states
For Eclampsia
• Control convulsions using IV magnesium sulfate,
followed by IM loading dose / continuous infusion of
magnesium sulfate
• Intermittent IV or oral antihypertensives to keep

diastolic pressure < 100 mmHg
• Diuretics and hyperosmotic agents are avoided. IVF’s

are limited.
• Delivery
LONG TERM CONSEQUENCES
• Recurrence rates are higher in;
- earlier onset preeclampsia
- prior singletons with preeclampsia
- multiparous preeclamptics
• At higher risk for chronic hypertension ;

-Those with recurrent preeclampsias
-Those with longer persistent
hypertension postpartum
THANK YOU

Hypertension EAC

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Hypertensive Disorders in

Hypertensive Disorders in Pregnancy

Hypertensive Disorders in Pregnancy

• What is your diagnosis?

Hypertensive Disorders in Pregnancy

What is your diagnosis at this time?

Hypertensive Disorders in Pregnancy

Hypertensive Disorders in Pregnancy

Hypertensive Disorders in Pregnancy

Hypertensive Disorders in Pregnancy

Hypertensive Disorders in Pregnancy

Hypertensive Disorders in Pregnancy

– Evidence of multiorgan involvement

• Seizures that cannot be attributed to other

Hypertensive Disorders in Pregnancy

• BP ≥140/90 mm Hg before pregnancy or diagnosed before 20

Hypertensive Disorders in Pregnancy

• New-onset proteinuria 300 mg/24 hours in hypertensive

• A sudden increase in proteinuria or blood pressure or platelet

Hypertensive Disorders in Pregnancy

Mild “ non-severe” “ less severe”

Hypertensive Disorders in Pregnancy

Fetal growth restriction Absent Obvious

• Symptoms of central nervous

Hypertensive Disorders in Pregnancy

• Blood pressure criteria≥ 160/110

Hypertensive Disorders in Pregnancy

• > 300 mg per 24 hours or persistent 30 mg/dl on

Hypertensive Disorders in Pregnancy

Thrombocytopenia • < 100,000 platelet / mm3

Hypertensive Disorders in Pregnancy

What is your diagnosis at this time?

Hypertensive Disorders in Pregnancy

Hypertensive Disorders in Pregnancy

Hypertensive Disorders in Pregnancy

cause thinning and dilation of blood

resistance to blood in uteroplacental

produce agents into systemic

Hypertensive Disorders in Pregnancy

absent trophoblastic invasion of the uterine artery

vasospasm hepatic hepatic

endothelial damage hematoma

edema platelet hemolysis liver

Hypertensive Disorders in Pregnancy

vasoconstriction vas permeability

BP of at least 160/110mmHg edema

Hypertensive Disorders in Pregnancy

decreased placental perfusion

IUGR fetal death

Hypertensive Disorders in Pregnancy

glomerular cap decreased renal

Hypertensive Disorders in Pregnancy

headache blurred vision stroke / coma

increased afterload from hypertension

pulmonary edema cyanosis

Hypertensive Disorders in Pregnancy

hepatocellular edema / necrosis

Right upper or epigastric pain

Elevated liver enzymes

Hypertensive Disorders in Pregnancy

thrombin platelet activation red cell

DIC decreased platelet hemolysis

Hypertensive Disorders in Pregnancy

PRECISE KNOWLEDGE OF GESTATIONAL AGE