HYPERTENSIVE DISORDERS

IN PREGNANCY

Presenter: Joel Mwakisisile

FACILITATOR: DR. M. CHIDUO
FRIDAY 09th March 2007
 CONTENT
 1. Definition & Classification
 2. Background History
 3. Predisposing factors
 4. Pathophysiology
 5. Clinical Presentation
 6. Diagnosis & Management
 7. Complications
 8. Conclusion & References
 DEFINITIONS
 Gestational Hypertension: Occurs after 20
weeks of gestation.
 Systolic >140

 Diastolic>90

 No Proteinuria

 25% Develop Pre-eclampsia

 DEFINITIONS (Cont)
 Pre-eclampsia: Occurs after 20th week of
gestation.
 Systolic >140

 Diastolic>90

 Proteinuria

 Oedema
 DEFINITIONS (Cont)
 Chronic Hypertension: A rise in BP (>140/90) which
has been there before pregnancy or before 20weeks of
gestation age.
 Chronic Hypertension with superimposed Pre-
eclampsia-Eclampsia:
Hypertension and Proteinuria < 20 weeks:
 Sudden increase in Proteinuria
 Sudden increase in BP <20 weeks in pregnant woman
whose hypertension was well controlled
 Thrombocytopenia (platelet count <100,000 cells/mm3)
& rise in ALT and AST levels.
 CLASSIFICATION
 The hypertensive disorders in pregnancy are
classified as follows:
 Gestational Hypertension
 Pre-eclampsia-Eclampsia
 Mild
 Moderate
 Severe
 Chronic or Pre-existing Hypertension
 Chronic Hypertension with superimposed
Preeclampsia-Eclampsia
 Classification (cont…)
 Mild Pre-eclampsia: a diastolic BP of 90 to 99
mmHg and proteinuria +
 Moderate Pre-eclampsia: a diastolic BP of 100 to
109 mmHg and proteinuria ++
 Severe Pre-eclampsia: a diastolic BP of 110 or
more on 2 occasions 6 hours apart or 120 mmHg
or more on one occasion and proteinuria +++
 Imminent Eclampsia: this is eclampsia with risk of
developing eclamptic fits at any moment. The
diagnosis does not depend on the degree of HT or
amount of proteinuria present.
 BACKGROUND HISTORY
 According to Hippocrates who lived in the fourth
century, the fact that some pregnant women got Fits,
he termed this condition as “Eclampsia”.
 This is a Greek word which means “flash of light”, in
the sense of sudden onset of fits.
 However, it was not until early this century when the
sphygmomanometer was introduced, that it was
recognized as eclampsia associated with
Hypertension.
 BACKGROUND HISTORY
 The fact that albuminuria and hypertension
could precede the onset of fits, gave rise to the
concept of “Pre-eclampsia” as a clinical
condition.
 For many years it was thought that a toxin was
liberated from the pregnant uterus and later the
disorder became known as “Toxaemia of
pregnancy”.
 BACKGROUND HISTORY
 Later all efforts failed to demonstrate any
toxin, and the word “toxaemia” was avoided.
 The term Pre-eclampsia is criticized because
only a small proportion of women develop
eclampsia, and the term “Pregnancy Induced
Hypertension” is now used.
 PREDISPOSING FACTORS:
 1.Parity: Primigravida patients or in the first
pregnancy with a given partner. They are
liable to pre-eclampsia.
 2.Age: In patients < 20yrs or >35 yrs
 3.Family history of pre-eclampsia or
hypertension.
 4.Pre-existing HT
 PREDISPOSING FACTORS
 5.Multiple pregnancy
 6.Diabetes in pregnancy
 7.Obesity (BMI > 32)
 8.Hydatidiform Mole
 9.Polyhydramnions
 10.Severe rhesus sensitisation
PATHOPHYSIOLOGY

VASOSPASM

Vasoconstriction Damaged Damaged

vascular endothelium
endothelium

Increased Increased Increased

peripheral permeability permeability/
resistance filtration

HYPERTENSION OEDEMA PROTEINURIA

 CLINICAL PRESENTATION
 1. Gestational Hypertension;
 a) The patient will have raised BP (140/90) after 20
weeks of gestation age.
 b) Oedema will be absent.
 c) The hypertension disappears after delivery.
 d) On lab investigations Proteinuria will be
ABSENT.
CLINICAL PRESENTATION
(Cont)
 PRE-ECLAMPSIA
 1. mild pre-eclampsia
 a) the BP is usually 140/90mmHg, or any rise
in the basic BP by 30mmHg in systolic and by
15mHg in the diastolic blood pressure.
 b) there might be pedal edema
 c) Proteinuria is usually 1-3gm/L in 24hrs.
CLINICAL PRESENTATION
(Cont)
 2. Severe pre-eclampsia
 a) BP is usually 160/110mmHg,or any rise in
the basic BP by 60mmHg in systolic and by
30mmHg in diastolic blood pressure.
 b) there is generalized edema, i.e.
1. puffy face
2. Oedema of hands
CLINICAL PRESENTATION
(Cont)
 3. Pitting edema on abdominal wall
 4. Oedema of the lower limbs and the
genitalia.
 c) Proteinuria is usually > 3gm/L in 24hrs.
 Note: If the blood pressure is not controlled it
might lead to eclampsia and other
complications.
CLINICAL PRESENTATION
(Cont)
 IMMINENT ECLAMPSIA:
 This is a transient period which occurs just before
eclampsia.It is usually a warning sign preceding the
fits.
 It is identified by symptoms involving multiple
systems like:
 CNS: severe headache
 dizziness
 fever
CLINICAL PRESENTATION
(Cont)
 CVS: palpitations
 rise in BP
 GIT: Epigastric pain
 vomiting accompanied with nausea
 Renal System: Oliguria
Anuria
CLINICAL PRESENTATION
(Cont)
 These patients usually experience “aura” which
include:
 1. Visual disturbances like flashes of light
 2. Unpleasant taste and odour
 3. Severe headache
 4. Epigastric pain
 ECLAMPSIA: the pt starts fitting and is emergency.
 DIAGNOSIS
 Inorder to confirm the diagnosis of
hypertensive disorders in pregnancy, the
following measures should be done:
 Measure blood pressure in the sitting position,
with the cuff at the level of the heart. Inferior vena
cava compression by the gravid uterus while the
patient is supine can alter readings substantially,
leading to an underestimation of the blood pressure.
 DIAGNOSIS
After taking the first reading, sedate the
patient with diazepam 5mg or keep the
patient in a quiet room and then after 6hrs
recheck the BP.
If the BP is still high then it is suggestive of
hypertension in pregnancy, if not then it is
ruled out.
INVESTIGATIONS:
1.FBP: to check the platelet count
 DIAGNOSIS
 2. Urine for albumin (24hr urine collection)
 3. Plasma urate levels
 4. LFTs: check the levels of ALT &AST
 5. USS: check fetal well being
 Apart from the laboratory investigations, assessment
of fetal growth and well being must be checked
regularly by monitoring the fetal heart rate using
fetoscope or cardiotocography. Also one can use
biophysical profile to assess the fetal well being.

 MANAGEMENT
 1.Gestational & Chronic Hypertension
 This is associated with least complications and can be
easily controlled.
 Once the Dx is established, put the mother on anti
hypertensive medications like methyldopa 250mg bd
and monitor the blood pressure at each antenatal visit.
 Look out for any complication (s)
 MANAGEMENT
 Pre-eclampsia:
 Mild Pre-eclampsia:
a) Admit the patient
b) Tell the patient to rest more than her usual time of
resting.
c) Enquire about her profession during Hx taking as it
might help us to minimize the aggravating factors that
might lead to further rise in her BP.
 MANAGEMENT
d) If necessary then sedate the patient with diazepam
10mg I.V, and keep the patient in a quiet room and
also minimize the lights of the room.
e) Methyldopa 250mg bd
f) Monitor fetal well being
g) Advise the patient to come to clinic as soon as she
experiences any health problems or changes in her
usual self or her pregnancy.
 MANAGEMENT
 Severe Pre-eclampsia:
 1. Admit the patient.
 2. Stabilize the BP using Hydralazine I.V bolus 20mg
to be given over a period of 10-15min.
 3. Put drip 20mg Hydralazine in 500mls of normal
saline, 10 drops/min. Increase the drops by 5 until the
BP is <110mmHg diastolic.
 MANAGEMENT
 4. Monitor the BP regularly, once its
<110mmHg then give Hydralazine tabs 25mg
6hrly.
 5. Put the patient in a quiet room with
minimum lights, avoid any kind of disturbance
to the patient.
 MANAGEMENT
 4. Catheterize the patient and monitor urine
output.
 5.Monitor fetal heart rate on hourly basis.
 Other agents apart from Hydralazine include:
I.V Labetalol infusion 20mg or Nifedipine
10mg sublingually.
 MANAGEMENT
 Note: If the patient shows any warning signs
or signs of imminent eclampsia like severe
headache, epigastric churning (commonest), or
flashes of light e.t.c. then immediately take
action to prevent FITS (eclampsia).
 Give MgSO4, 4g I,.V. over a period of 10 min.
 MANAGEMENT
 This should be followed by maintenance
infusion of 1g per hour.
 Before giving MgSo4 check the RR, BP,Pulse
and Reflexes.
 All these must be checked 2hrly after the
infusion,. If there are reduced reflexes or
respiratory depression then give antidote I.e.
Calcium Gluconate I.v
 MANAGEMENT
 Eclampsia:
 1.Protect the tongue
 2.Protect her from injuries.
 3.Tie upper and lower limbs.
 4. Clear airway and give Oxygen.
 5. Give Hydralazine
 6. Catheterize the patient
 MANAGEMENT
 7.Put NGT for feeding
 8. Monitor the maternal and fetal well being at
regular intervals.
 9. Do renal function tests and check the
plasma levels of liver enzymes.
 MANAGEMENT
 DELIVERING THE PATIENT:
 Indications for Delivery in Preeclampsia*
 Maternal
 Gestational age 38 weeks
 Platelet count < 100,000 cells/mm3
 Progressive deterioration in liver and renal function
 Suspected abruptio placentae
 MANAGEMENT
 Persistent severe headaches, visual changes, nausea,
epigastric pain, or vomiting
 *Delivery should be based on maternal and fetal
conditions as well as gestational age.
 Fetal
 Severe fetal growth restriction
 No reassuring fetal testing results
 Oligohydramnios
 MANAGEMENT
 The “cure” for preeclampsia is delivery
 The “cure” is always beneficial for the mother,
although c-section might be needed
 The “cure” may be deleterious for the fetus.

 Route of Delivery
 Vaginal delivery is preferable.
 MANAGEMENT
 If the patient is 34 weeks of gestation age and
is in pre-eclampsia then induce labour by 5IU
of Oxytocin in 500ml of 5% dextrose with 10
drops per min.
 If the cervix is unfavorable then ripen the
cervix using Mesoprostol 25microgm.
 MANAGEMENT
 Mx during Labour:
 1.First stage:
 a) monitor blood pressure 1-2 hrly,give
Hydralazine I.V if the diastolic BP is >110mmHg.
 b) Careful fetal heart monitoring
 c) If pt develops imminent eclampsia prophylactic
MgSo4 must be given.
 MANAGEMENT
 d) Maintain systolic BP <170mmHg and
diastolic BP <110mmHg with hydralazine
Second stage:
. Assist second stage with vacuum extraction.
Third Stage:
Give Oxytocin I.M or in drip.
 MANAGEMENT
 Observe the patient’s BP 1-2 hrly for 4-6 hrs
before she is sent to the postnatal ward and
continue the anti hypertensive and sedatives
for 24-48hrs.
 Follow up the patient’s and the baby’s
condition before discharge.
 MANAGEMENT
•Indications for C-Section in such a patient:
• a)   in a woman with obstetric complications
• b) If vaginal examination reveal conditions totally
unfavorable for induction of labour.
• c) If labour does not begin promptly after induction.
 MANAGEMENT
 Note: Elective C-Section should not be undertaken
for a patient with continuing convulsions or for one
who is in coma
 •Under these circumstances the stress of such an
operative procedure may be lethal.
•Delivery by C-Section may be considered when
convulsions or coma have been absent for a period of
at least 12hrs.
 COMPLICATIONS
 Maternal complications:
 1.Cardiac failure
 2.Liver Failure
 3.Eclampsia
 4.Coma
 5.Renal Failure
 6.HELLP Syndrome
 COMPLICATIONS
 Fetal complications:
 1.Intra uterine fetal growth restriction
 2.Intra uterine fetal death
 3.Prematurity
 CONCLUSION
 Complicates 7-10% of pregnancies
 70% Preeclampsia-eclampsia

 30% Chronic hypertension

 Eclampsia 0.05% incidence

 20% of Maternal Deaths

 Cause of 10% of Preterm birth

 REFERENCES
 1.Lecture Notes
 2.Obstetrics Illustrated
 3.Obstetric and Gynecologic diagnosis and
treatment By Ralph C. Benson
 4.Textbook of Embryology By Kenneth
 5. Internet. www.Goggle.com
 6. management Guidelines of Common
Obstetrics and Gynaecological conditions, by
Dr. Charles R. Majinge et al
Thank you for
listening!