Hypertensive Disorders in Pregnancy

At the end of my presentation, we should be able to :

Outline diagnostic features of pre-eclampsia
Classify pre-eclampsia according to severity
Outline risk factors for pre-eclampsia
Outline maternal and fetal complications of pre-eclampsia.
Describe the management of pre-eclampsia and eclampsia.
Definition
• Definition
• Hypertension
• Raised in blood pressure recorded at least
on two occasions at six hours apart, it may be
either:
•  Diastolic BP greater than 90 mmHg or,
•  Systolic BP greater than 140 mmHg
•  Measurement
• Should be measured in a sitting position or
semi recumbent position (450 head up)
•  T h e right arm should be used consistently
• A r m should be in a horizontal position at
the level of the heart
•  Phase V us used in pregnancy
• Phase IV is more difficult to detect and
has limited reproducibility
• Definition
• Proteinuria
•  Screening test is by dipstick
•  Have a sensitivity >90% using ≥ 1+
• However, the accuracy of dipstick compared
to 24 hours urine protein is highly variable
•  Miss >300 mg/24 hours in up to 1:8 patients
•  False negative up to 20%
•  Significant if ≥ 2+
•  Trace of ≥ 1+ should be regarded as equivocal
•  24 hour urine collection and quantification
•  Significant if 24 hour urine protein > 300 mg
•  Gold standard
•  Labour intensive and slow
•  Spot urinary protein:creatinine ratio
•  Significant if > 30mg/mmol
•  Good compromise
 • Definition
• Severity of Hypertension
•  Mild hypertension
•  Moderate hypertension
•  Severe hypertension

• Mild hypertension
• B P is 140 to 149 mmHg systolic and/or 90 to 99 mmHg diastolic
• Moderate hypertension
• B P is 150 to 159 mmHg systolic and/or 100 to 109 mmHg diastolic.
• Severe hypertension
• B P is ≥160 mmHg systolic and/or ≥110 mmHg diastolic
Classifications

• Four Categories
•  Gestational hypertension
• Pre-eclampsia / eclampsia
•  Chronic hypertension
•Pre-eclampsia / eclampsia
superimposed on chronic hypertension
• Gestational hypertension
• H P T that developed after 20th week of
pregnancy, in labour or within 48 hours of
delivery without significant proteinuria
•  Resolved by 12 weeks postpartum
•  I f persist beyond 12 weeks  chronic
hypertension
• Pre-eclampsia / eclampsia
• Pre-eclampsia - New onset of HPT after
20th weeks of pregnancy, in labour or within
48 hours of delivery, where the BP was
previously normal, accompanied by
significant proteinuria (>300 mg/24 hrs)
•  Eclampsia – Occurrence of tonic-clonic
convulsion not cuased by coincidental
neurological disoreders in a patient with
pre-eclampsia
• Chronic hypertension
• Presence of persistent
hypertension, of whatever cause,
before the 20th week of pregnancy
(in the absence of hydatiform
mole), or persistent hypertension
beyond six weeks postpartum.
• Pre-eclampsia / Eclampsia
superimposed on chronic
hypertension
• Usually difficult to make, but is
usually associated with worsening of
the hypertension and the
development of worsening
proteinuria
Investigations
May be repeated at interval
 Urine test

 Urine dipstick – if positive, do MSU to rule out UTI

 24 hrs urine protein > 300mg/day significant
 Spot urinary protein:creatinine ratio >30 significant
 Blood test

 Full blood count – platelets and haematocrits

 Renal function – urea, creatinine
 Plasma uric acid

 GFR and creatinine clearance decreases  increase uric acid

 Liver function test – AST & ALT
 Should be less than 70

 Coagulation profile

 Assess fetal well being

 CTG

 Ultrasound – AFI, umbilical artery doppler

Diagnosis Modality Frequency
Gestational 1 – 2x per week Weekly
hypertension
Urine analysis for protein Pre-eclampsia blood
investigations

Pre-eclampsia Urine analysis for protein At time of diagnosis. Do not repeat

Twice weekly or more frequent if unstable

Pre-eclampsia blood
investigations
Chronic Each visit
hypertension
Urine analysis for protein Pre-eclampsia blood
investigations If sudden increase in BP or
new proteinuria
Management

• General principle
•
In patient vs. out patient


Gestational HPT (mild / moderate) – out patient



Gest HPT (severe) & Pre-eclampsia – in patient



Advise on signs & symptoms of impending eclampsia



Control of blood pressure to protect mother from severe hypertension



•
Maternal evaluation


•
PET chart


•
Investigations


•
Fetal evaluation


•
Serial ultrasound for growth


•
AFI 

•
Doppler

•
CTG 

•
FKC 

•
 Plan for delivery – delivery will cure pre-eclampsia & gestational hypertension
Pre-Eclampsia - Diagnosis Pre-Eclampsia - Risk factors

Diagnosis
 When systolic BP > 140 mmHg, DBP > 90mmHg in a woman known to be
normotensive prior to pregnancy
 The diagnosis requires 2 such abnormal blood pressure measurements recorded at
least 6 hours apart
 Significant proteinuria

Symptom and signs of pre-eclampsia

 May be asymptomatic
 Severe headache
 Problems with vision e.g. blurring of vision or flashing before the eyes
 Severe pain just below the ribs (epigastric pain)
 Nausea, vomitting
 Sudden swellingof the face, hands or feet
Pre-Eclampsia - Classification
According to Severity
Mild Pre-eclampsia
Blood pressure ≥ 140/90 - 2 occasions 6
hrs apart (not more than 1 wk apart)
Proteinuria - ≥ 300mg/24-h sample
OR
≥ 2+ on 2 urine samples 6 hrs apart (not
more than 1 wk apart)
Absent of 
Severe Pre-eclampsia
Blood Pressure ≥ 160/110 - 2 occasion
at least 6 h apart (not more than 1 wk
apart)
Proteinuria - ≥ 5g/24-h sample
OR
≥ 3+ on 2 urine samples 6 hrs apart
(not more than 1 wk)
Oliguria - <500mL/24 h
Thrombocytopenia - <100,000/mm3
Epigastric or right upper quadrant pain
Pulmonary edema
Persistent cerebral or visual
disturbances
Management
Investigations – What and how frequent?
Test for proteinuria
 Investigations – What and how frequent?
Blood test
Pre eclampsia blood test
• FBC, kidney function test, LFT, DIVC

Mild Moderate Severe

(140/90 to 149/99) (150/100 to 159/109) (160/110 or higher)
Pre-eclampsia
blood investigations
Gestational HPT Only those for Test at presentation
routine antenatal Do not do further and then monitor
care test if no weekly
proteinuria at Pre-eclampsia blood
subsequent visit investigations

2x per week blood 3x per week Pre-

Pre-eclampsia 3x per week blood
Pre-eclampsia
Pre-eclampsia eclampsia
investigations blood investigations
investigations
 Management
Fetal Monitoring – What and how frequent?

Mild Moderate Severe

(140/90 to 149/99) (150/100 to 159/109) (160/110 or higher)
Gestational HPT US for fetal growth, US for fetal growth, US for fetal growth,
AFI &UA doppler AFI &UA doppler AFI &UA doppler
• At diagnosis and 3 • At diagnosis and • At diagnosis and
- 4 weekly 3 – 4 weekly not more than
CTG CTG every 2 week
• Only if fetal • Only if fetal CTG
activity is activity is • At diagnosis
abnormal abnormal • Do not repeat
more than weekly
if fetal
activity is normal

Pre-eclampsia Same as severe

gestational HPT Same as severe
gestational HPT Same as severe
gestational HPT
 Admission – to admit or not to admit?

Mild Moderate Severe

(140/90 to 149/99) (150/100 to 159/109) (160/110 or higher)
Yes
(until BP is
Gestational HPT No No
159/100 or lower)

Pre-eclampsia Yes Yes Yes

How often to measure BP?

Mild Moderate Severe

(140/90 to 149/99) (150/100 to 159/109) (160/110 or higher)

Gestational HPT Not more than 1x

per week At least 2x per week At least 4x per day

Pre-eclampsia At least 4x per day At least 4x per day More than 4x per
day, depending on
circumstances
 Management
Treatment – To treat or not?

Mild Moderate Severe

(140/90 to 149/99) (150/100 to 159/109) (160/110 or higher)
Gestational HPT No With oral labetalol as With oral labetalol as
1st line Rx 1st line Rx
Keep Keep
• Diastolic between • Diastolic between 80
80 – 100 mmHg – 100 mmHg
• Systolic less than
• Systolic less than 150 150 mmHg
mmHg
Pre-eclampsia No Same as above Same as above

Only offer antihypertensive Rx other than labetalol after considering side effect profiles for women, fetus and newborn baby
Alternative includes methyldopa and nifedipine
 Management
Treatment – Drugs commonly used

Drugs Dosages
Labetalol Up to 1200 mg/day
Methyldopa (Aldomet) Up to 2250 mg/day

Nifedepine Up to 120 mg/day

Prazocin Up to 15 mg/day

• Aim for BP <150 mmHg systolic & between 80 to 100 mmHg diastolic
• Combination therapy of drugs from different classes is possible
• Eg. Aldomet + Beta blocker
• Do not use:
• Thiazide diuretics – reduce plasma volume
• Highly selective beta blockers – causes IUGR
• ACE inhibitors – may cause IUFD
 Management
Drugs used for acute hypertension
 I V Hydralazine:
 5mg IV bolus with additional 5mg
increments up to 20 mg every 20 – 30
mins.
 I V Labetalol:
 20-50mg over 2 mins.
 Repeat after 15-30 mins.
 Sublingual Nifedipine:
 5mg sublingually
 Usually starts working within 10 mins.
 Can be repeated after 30 mins.
 I V Diazoxide:
 15 – 45 mg bolus
 Repeat after 5 mins to a maximum of
300 mg.
 Management
Prophylaxis against convulsion?
 Consider giving intravenous magnesium sulphate to women with severe pre- eclampsia who are in a
critical care setting if birth is planned within 24 hours
 Features of severe pre-eclampsia

 severe hypertension and proteinuria OR

 mild or moderate hypertension and proteinuria with one or more of the following:
 symptoms of severe headache

 problems with vision, such as blurring or flashing before the eyes

 severe pain just below the ribs or vomiting
 Papilloedema

 signs of clonus (≥3 beats)

 Liver tenderness

 HELLP syndrome

 Platelet counts falling below 100 x 109 per litre

 Abnormal liver enzymes (ALT or AST rising to above 70 iu/litre
 loading dose of 4 g should be given intravenously over 5 minutes, followed by an infusion of 1 g/hour
maintained for 24 hours
 Management
Who requires delivery?
General Principle – Manage conservatively
 Pre-eclampsia > 36 completed week
 Uncontrollable hypertension
 Deteriorating renal, hepatic or haematological
state
 Eclampsia or imminent eclampsia
 Fetus is compromised
 Abruptio placenta
Gestational Hypertension - When to deliver?
 Manage women with gestational
hypertension conservatively
 A i m for delivery after 37 weeks
 Indications for early delivery
 Refractory hypertension – deliver earlier
after a course of steroids (if required)
Pre-eclampsia - When to deliver?
 Manage women with pre-eclampsia
conservatively until 34 weeks (earlier if
develops maternal / fetal complications)
 Severe pre-eclampsia
 Offer delivery at 34 weeks
 i f BP well controlled and
corticosteroids has been given
 Offer delivery before 34 weeks
 Severe hypertension develop
refractory to treatment
 Maternal of fetal complications
How to deliver?
 Induction of labour or Caesarean section?
 Deliver vaginally if > 37 weeks and
the cervix is favourable (or can be
ripen)
 Caesarean section only if the above is
not met
 Epidural anaesthesia is encouraged
where there is no clotting abnormalities
 Deliver in an environment that can
cope with a severe multisystem
disease
Intrapartum Care
 Maternal monitoring
 B P, PR, Temp, Urine output
 B P monitoring:
 hourly in women with mild or moderate
hypertension
 continually in women with severe
hypertension
 Fetal monitoring
 Monitoring preferably by continuous CTG
 Alternatively, intermittent auscultation
every 15 minutes during 1st stage and after
each contractions in 2nd stage
 Continue use of antenatal antihypertensive
treatment during labour.
 Assess convulsive risk and consider
prophylactic MgSO4
 Strict I/O
 Pain control – epidural preferable
Intrapartum Care
 2nd Stage
 D o not routinely limit 2nd stage of labour
 i n women with stable mild or moderate
hypertension or
 i f blood pressure is controlled within
target ranges in women with severe
hypertension
 Assist 2nd stage
 f o r women with severe hypertension
whose hypertension has not responded
to initial treatment
 3rd stage
 Withhold prophylactic ergometrine
 U s e oxytocin instead

Postpartum Care
 1/3 of eclamptic fits occurs in postpartum
 B P frequently at its highest 3-4 days after
delivery
intensive monitoring required especially 1st 48
hours
 although eclampsia has been reported
beyond 48 hours, but it is unlikely to be
associated with serious morbidity
 continue anti-hypertensive after discharge if
necessary
 F / U postnatal clinic for review of BP
 residual disease  refer physician
Gestational hypertension

Gestational hypertension in future
pregnancy ranges from 1 in 6 (16%) to 1 in
2 (47%)
 Pre-eclampsia in future pregnancy
ranges from 1 in 50 (2%) to about 1 in 14
(7%) pregnancies
Pre-eclampsia
 Gestational hypertension in future
pregnancy ranges from about 1 in 8 (13%)
pregnancies to about 1 in 2 (53%)
pregnancies
 Pre-eclampsia in future pregnancy is
up to about 1 in 6 (16%) pregnancies
 Pre-eclampsia in future pregnancy is
about 1 in 4 (25%) pregnancies if their
pre- eclampsia was complicated by
severe pre-eclampsia, HELLP syndrome
or eclampsia and led to birth before 34
weeks, and about 1 in 2 (55%)
pregnancies if it led to birth before 28
weeks.
Cardiovascular Risk

 Women with pre-eclampsia:

 4 fold risk of developing hypertension
 2 fold increase risk IHD, stroke and venous
thrombosis
 Women developing early pre-eclampsia at
highest risk
 possible need for earlier cardiovascular
risk assessment and commencement of
preventive therapies at an earlier age
 f/u for at least 6 months postpartum 
earlier identification of cardiovascular risk
and the potential for lifestyle
modifications
Eclampsia
 Eclampsia – Occurrence of tonic-clonic convulsion not  Phase 3: Clonic phase.
caused by coincidental neurological disorders in a patient  violent contraction and relaxation of the muscles
with pre- eclampsia  increased saliva causes foaming at the mouth and there is a risk of
 Eclampsia and pre-eclampsia are part of the same inhalation
disorder with eclmapsia being the severe form  deep, noisy breathing
 h o w e v e r not all cases follow an orderly prigression  face looks congested and swollen
from mild to severe disease  lasts 1- 2 minutes
 some develop severe pre-eclampsia and eclampsia  Phase 4: Recovery.
very suddenly  the convulsive movements subsides slowly, respiration resumes,
 M a y occur during antepartum, intrapartum, or postpartum cyanosis fades but face may still be swollen and congested.
 some patients passes into a coma of variable duration.
 further fits may occur
• 4 Phase
•  Phase 1: Initial of prodromal phase (Premonitary).

•  there may be an aura, followed by convulsive movements that begin around

the mouth
•  eyes rool or stare
•  face and hand muscles may twitch
•  Lasts 10 – 20 seconds
•  Phase 2: Tonic phase
•  muscles go into violent spasm
•  fists are clenched and arms and legs are rigid
•  diaphragm is in spasm  breathing stops and the colour of the skin
becomes cyanosed
•  back may be arched
•  teeth are clenched
•  eyes bulge
•  lasts up to 30 secs.
Effects on mother Effects on fetus
 respiratory problems – asphyxia, aspiration of vomitus, pulmonary oedema,  reduction in maternal placental blood flow 
bronchopneumonia  hypoxia
 cardiac  heart failure  severe cases  IUD
 brain  haemorrhage, thrombosis, oedema  hypoxia may cause brain damage if severe or prolonged 
 liver cirrhosis
 physical disability
 HELLP syndrome
 mental disability
 coagulopathy  clotting, coagulation failure
 visual  temporary blindness due to oedema of the retina
 injuries during convulsion – fractures
main cause of maternal death during eclampsia are:
 intracerebral hemorrhage
 pulmonary complications
 kidney failure
 liver failure
 failure of more than one organs
 Eclampsia - Treatment
Anticonvulsant
General measures  Anticonvulsant of choice – Magnesium sulfate
 Causes relaxation of smooth muscle by competing wtih calcium for entry into the
 Individualised nursing care in an isolated room with adequate monitoring
facility cells at the time of cellular depolarization
 Kept in railed cot  Causes CNS depression and suppressing neuronal activities
 Nursed in left lateral position and oropharyngeal suction o t clear secretions  Regime (WHO)
 loading dose of 4 g of 20% MgSO4 should be given intravenously over 5
 Establised IV lines with two large bore canulae – use Ringer’s lactate
minutes
 CBD
 followed immediately with 10g of 50% MgSO4 solution, 5g in each
 Strict I/O chart
buttocks as deep IM injections (with 1ml of 2% lignociane in the same
 Emergency investigations – FBC, platelets, LFT, renal function test, serum
syringe)
electrolytes, coagulation profile, arterial blood gas
 if convulsion recur after 15 minutes
 Blood GXM
 give 2g of 50% MgSO4 IV over 5 minutes
 Monitor O2 saturation
 Anticonvulsants
Anticonvulsant - MgSO4 Anticonvulsant - MgSO4
 Maintenance dose  Monitoring
 5g of 50% solution MgSO4 together with 1 ml lignocaine 2% in the same  all patients should have pulse oxymeter, ECG and automated BP monitoring (recorded
every 15 minutes)
syringe every 4 hours into alternate buttocks
 Monitor respiratory rate
 o r 1g hourly IV infusion
 every 5 – 10 minutes during 1st 2 hours of therapy
 c o nt in u e the treatment for 24 hours after delivery of h
te last convulsions,  every 15 minutes thereafter
whichever occurs last  if RR < 16/min  stop infusion
 Monitor patellar reflexes
 every 5 to 10 minutes during 1st 2hours
 every 15 minutes thereafter
 absent or decrease reflexes  withhold or decrease infusion
Anticonvulsant - MgSO4 Anticonvulsant - MgSO4
 Monitoring  Antidote
 Monitor urine output  In cases of respiratory arrest:
 measure every hourly  give calcium gluconate 1g (10ml of 10% solution) V I slowly over 2 – 3
 oliguria <25mls/hr  decrease infusion minutes
 Monitor serum Mg level  assist ventilation using mask and bag, anaesthetics apparatus or intubation
 frequent monitoring of serum Mg level important ni presence of oliguria
 keep serum Mg level between 2-4 mmol/l
 loss of patellar reflexes occurs when Mg > 5 mmol/l
 respiratory depression Mg > 6 mmol/l
 muscle paralysis and respiratory arrest Mg > 63
. mmol/l
 cardiac arrest Mg > 12.5 mmol/l
 Treatment
Anticonvulsant
 Alternative anticonvulsants
 Diazepam
 Loading dose of 10mg IV over 2
mins, repeated of convulsion MgSO4 is more effective than diazepam or phenytoin in
preventing or reducing the number of eclamptic fits

recurred
 Followed by IV infusion of
40mg in 500ml normal saline for
24 hours
 Rate of titration adjusted
according to patient’s level of
consciousness
 Phenytoin therapy
 Phenytoin is only recommended
for prevention of convulsion. So
diazepam 10mg is to be given as
required for immediate control of
seizures
 When to deliver?
 a s soon as the woman’s condition
has stabilized, regardless of
gestational age
 suggested within 12 hours of the
onset of convulsions
How to deliver?
 methods of delivery taking into Indications for caesarean
section
account the period of gestation and 1. unfavourable cervix
2. fetal heart rate
the state of the cervix abnormalities
3. if vaginal delivery is

 assess the cervix not

anticipated within 12 hours
ensure coagulopathy has been
 cervix favourable  rupture excluded before performing a
caesarean section
membranes and induce using
oxytocin or prostaglandin
 cervix unfavourable 
caesarean section