Emilio Aguinaldo College Medical Center- Cavite

DEPARTMENT OF OBSTETRICS AND

GYNECOLOGY

HYPERTENSION
IN PREGNANCY
BIRADAR RISHAB
BYANJANKAR, RAMITA
CABALZA, MARY ANNE
HIPOL, BERNADINE NICOLE
ORLEANS, KRISTIAN KOLEN

Moderator: Dr. Aidelenn Bajandi

September 21, 2020

OBJECTIVES
General Specific
⮚ To present and
⮚ To discuss its presentation, diagnosis
discuss a case of and management
⮚ To appraise a journal article regarding
Hypertension in hypertension in pregnancy
Pregnancy
CASE PRESENTATION
CASE#5

17 G1P0 at 37 5/7 weeks AOG was seen at the ER

due to labor pains and bloody show.
PHYSICAL EXAMINATION

Vital signs:
◼BP: 180/110mmHg ▪ Fundic Height: 32cm
◼HR: 91bpm ▪ Fetal heart tone: 143bpm
◼RR: 20cpm
(right lower quadrant)
◼Temp: 36.2C.
PHYSICAL EXAMINATION
LEOPOLD’S MANEUVER Internal examination:
LM 1: soft round mass at the fundic area ▪ Cervix 2cm dilated
LM 2: concavity at the right and small ▪ 50% effaced
fetal parts at the left
▪ (+) Bag of water
LM 3: hard ballotable mass at the pubic
area ▪ Station (-) 3
LM 4: the hard ballotable mass is movable Extremities:
▪ Grade II pitting bipedal edema
UPON ADMISSION

◼Anti-hypertensive was given

◼BP was repeated after 30 minutes. However BP was still elevated at
160/100 mmHg.
◼Urinalysis showed +2 proteinuria.
INITIAL IMPRESSION

17 G1P0 Pregnancy Uterine 37 5/7 weeks

Age of Gestation, Cephalic not in labor;
Young Primigravida; To consider Pre-
eclampsia, probably severe
BASIS

▪ Primigravida 17 G1P0
▪ Labor pains, Bloody show
▪ BP: 180/110 mmHg (37 5/7 weeks AOG)
▪ Proteinuria +2 dipstick
▪ IE: 2cm dilated, 50%effaced,St-3
DIFFERENTIAL DIAGNOSIS
Rule in Rule out Remarks
Gestational BP of 180/110 mmHg (-) Proteinuria Px history for first time increase
Hypertension 17 Primigravida BP.
Final Diagnosis made only
postpartum
Eclampsia BP systolic 180-160 mmHg (-) Convulsion Signs such as epigastric pain,
diastolic 110-100 mmHg headache, blurring of vision
(+) Proteinuria, 2+ dipstick should be elicit.

Chronic Hypertension BP of 180/110 mmHg 17 Prenatal History should be noted.

Primigravida BP of more than 140/90 mmHG
before pregnancy or before 20
weeks AOG should be ask
DISCUSSION
QUESTION#1
IS THE BABY ENGAGED OR NOT ENGAGED?
LEOPOLD’S MANEUVER Physical Examination Remarks
LM 1: Fundal grip Soft round mass at the Cephalic
fundic area
LM 2: Umbilical grip Concavity at the right Fetal back at the right
and small fetal parts at Small fetal parts at the
the left left

LM 3: Pawlick’s grip Hard ballotable mass at Not engaged

the pubic area

LM 4: Pelvic grip The hard ballotable Fetal attitude not

mass is movable determined
QUESTION#2
ESTIMATED FETAL WEIGHT

▪ JOHNSON’S RULE: ▪ Fundic Height: 32cm

EFW= (FH-n) X 155 ▪ Baby is not engaged
n is 11 if engaged
▪ n=12
n is 12 if not engaged
▪ (32-12) x 155=
▪ EFW is 3100g
Baby’s Presentation: Vertex
 QUESTION#3
CLASSIFICATION OF HYPERTENSIVE D/O COMPLICATING PREGNANCY
Gestational Hypertension BP ≥ 140/90 mmHg without Proteinuria occurring after 20 weeks
gestation
BP returns to normal <12 weeks Postpartum
Confirmed only after 12 weeks delivery (postpartum)
Pre eclampsia
Eclampsia Presence of convulsions with underlying pre-eclampsia
Seizures that cannot be attributed to other causes
Chronic Hypertension BP ≥ 140/90 mmHg before Pregnancy or Diagnosed before 20
weeks AOG not attributable to Gestational Trophoblastic Disease
or Hypertension first diagnosed after 20 weeks gestation and
persistent after 12 weeks postpartum.
Multiparity and HPN in previous pregnancy help support the
diagnosis.
Superimposed pre- New onset of Proteinuria ≥ 300 mg/24 hrs in hypertensive women
eclampsia on Chronic but No proteinuria before 20 weeks gestation;
Hypertension Sudden increase in proteinuria/BP/platelet count <100,000mm³
PRE ECLAMPSIA
Increased Certainty of Preeclampsia:
Minimum Criteria: ▪ BP ≥ 160/110 mmHg
▪ BP ≥140/90 mmHg after ▪ Proteinuria 2.0g/24 hours or ≥ 2+ Dipstick
20 weeks Gestation ▪ Serum Creatinine > 1.2 mg/dL unless
known to be previously elevated
▪ Proteinuria ≥ 300 mg/24 ▪ Platelets < 100,000/mm3
hours or ≥ 1+ Dipstick ▪ Microangiopathic Hemolysis (Increased
Other symptoms: LDH)
▪ Vomiting ▪ Elevated ALT or AST
▪ Dizziness ▪ Persistent Headache or other Cerebral or
▪ Oliguria Visual Disturbance
▪ Persistent Epigastric Pain
PRE ECLAMPSIA: MILD VS. SEVERE
NON SEVERE

Note: Dreaded Outcome of HELLP SYNDROME

▪ Hemolysis
▪ Elevated Liver Enzymes
▪ Low Platelet Count
QUESTION #4: WHAT LABORATORY EXAMS/MANAGEMENT SHOULD YOU REQUEST?
LABORATORY/ WORK UPS

▪ CBC with Platelet Count

▪ Serum Creatinine
▪ BUN
▪ Na, K, Mg
▪ Total bilirubin
▪ ALT, AST,
▪ LDH
▪ Peripheral Blood Smear
PLAN/MANAGEMENT
▪ Admit Monitor during labor:
▪ Secure Consent for admission & mgt ▪ Vital signs
▪ I & O every shift ▪ Fetal Heart tone/
▪ TPR every shift ▪ EFM (electronic fetal
▪ DIET: NPO Temporarily monitoring)
▪ IVF: d5LR x 8 hours ▪ Uterine contractions
▪ BASELINE CTG
QUESTION #5: ARE THERE ADDITIONAL MEDICATIONS YOU WILL GIVE?
PLAN/MANAGEMENT
Medications:
▪ MgSO4
Loading dose: 4g Slow IV in 250ml D5W
5g Deep IM each buttocks
▪ Hydralazine
Initial dose: 5mg amp slow IV
20mg drip if diastolic BP does not improve
▪ Watch out for:
• Magnesium toxicity: hyporeflexia
• RR less than 12 cpm
• Urine Output less than 30cc/hr
• Level of Consciousness
QUESTION #6: HOW WILL YOU DELIVER THE BABY?
PLAN/MANAGEMENT
Manner of Delivery:
Five factors govern the decision in timing and mode of
delivery in pre-eclampsia:
▪ Age of gestation
▪ Severity of disease
▪ Fetal status
▪ Maternal condition
▪ Nursery capabilities
QUESTION #6: HOW WILL YOU DELIVER THE BABY?
PLAN/MANAGEMENT: MANNER OF DELIVERY
Labor induction
=>Prostaglandins, misoprostol, cervical Foley catheters, amniotomy, oxytocin

Vaginal Spontaneous Delivery

▪ Controlled BP
Assisted Vaginal Delivery (forceps)
▪ Uncontrolled BP
▪ Completely dilated cervix
▪ Engaged fetal head
CS
▪ Failed induction of labor
PLAN/MANAGEMENT
Post partum Medication:
▪ Methyldopa 250 mg q4

May Go Home:
▪ If Controlled BP
▪ Asymptomatic for 24 hours
▪ Follow up after 1-2 weeks
QUESTION #7:
FAMILY PLANNING METHOD

Contraception
▪ progestin only pill, progestin injectables or implants
IUD
▪ copper or hormonal
Barrier method
▪ condoms, diaphragm
Fertility Awareness based method
▪ calendar method, basal body temperature, ovulation
method
FAMILY PLANNING METHOD
Counselling
▪ Informed Consent should be done. Any minor availing of FP services must have
written consent of their parents or guardians.
▪ She must be informed about all the methods of contraception.
▪ They must also be informed about contraceptive and safe sex practice options to
reduce risks for STIs and HIV AIDS.
▪ As the contraceptive needs of adolescents frequently change, counseling should
prepare them for their use of a variety of methods that are effective and appropriate
for their needs.
▪ She must be assured that the counseling sessions and follow up visits are
confidential
JOURNAL APPRAISAL
◼ Keywords: Pre eclampsia, Management, Delivery, Hypertension
◼Filter: 5 years
◼Filter: full text
◼Filter: systematic review
ELECTIVE DELIVERY VERSUS EXPECTANT MANAGEMENT
FOR PRE-ECLAMPSIA A META-ANALYSIS OF RCTS
YONGHONG WANG · MIN HAO1 · STEPHANIE SAMPSON · JUN XIA
INTRODUCTION

● Pre-eclampsia (PE): Hypertension and consequent damage to other organs.

● 2–8% of pregnancies
○ 2nd or 3rd trimester
○ One of the most common, dangerous, and unpredictable complications of
pregnancy
● Women with PE are at 4x risk of death
● Neonates born to mothers with PE
○ Increased odds of death and severe complications
○ Small for gestational age
○ Fetal growth restriction
INTRODUCTION
● Pre-eclampsia Management
○ Gestational age
○ Severity of the disease
● Timing of delivery is critical for clinical outcomes
○ ACOG: delivery at 37 weeks of gestation for women with PE
○ NICE guidelines do not recommend elective delivery for PE management before
34 weeks AOG
● Objectives of the Meta-analysis
○ Maternal and fetal outcomes of elective delivery vs. expectant management
○ Optimal timing of delivery (<34 weeks AOG vs >34 weeks AOG) for preventing
PE-associated complications
METHOD

● Sources: Various databases were searched from establishment dates to June 29,2014
● Criteria for Study Selection: Severity of PE determined by clinical features and
laboratory abnormalities based on ACOG guideline
○ Included
■ RCTs
■ Evaluated any methods of elective delivery vs. expectant management
■ Treatment of women with PE or gestational hypertension who are either at before or at term delivery
○ Excluded
■ Cluster-randomised studies
■ Studies with quasi-random design
■ Studies with cross-over design
● Outcomes
○ Maternal and neonatal outcomes
RESULTS AND DISCUSSION

● Study Selection: Seven studies were included in the analysis. Total of 1,501
participants
○ 481 Severe PE
○ 264 PE and severe hypertensive disorders
○ 756 PE and gestational hypertension
● Study Characteristics
○ Maternal and gestational ages as well as the length of pregnancies were fairly uniform
○ Elective delivery (induction of labor or CS)
● No maternal deaths were reported in the studies and some reports of eclampsia were
noted but were not significant.
● The meta analysis evaluated the effectiveness of elective delivery vs. expectant
management performed either before or after 34 weeks of gestation in women with
PE in general or severe PE
RESULTS AND DISCUSSION

● Maternal Outcomes
○ Incidence of eclampsia similar for elective delivery and expectant management across all patient
groups
● Maternal Complications (elective delivery)
○ Reduced all maternal complications after 34 weeks AOG in women with PE
○ Decreased incidence of placental abruption before 34 weeks AOG in women with severe PE
● Hypertension (elective delivery)
○ Associated with less increase in diastolic and systolic blood pressures
○ Lower rates of antihypertensive therapy
RESULTS AND DISCUSSION

● Neonatal Outcomes
○ No significant difference between elective delivery and expectant management
in fetal and neonatal mortality.
● Neonatal Complication
○ Elective delivery was associated with higher rate of ventilation use and
interventricular hemorrhage/hypoxic ischemic encephalopathy.
○ Expectant management was associated with increased incidence of small
neonates for their gestation age
CONCLUSION

● Elective delivery is generally more beneficial than expectant management for women with PE or
gestational hypertension beyond 34 weeks of gestation and women with severe PE.
○ Reduce the risk of PE related complications and lower the incidence of severe hypertension and
the need for antihypertensive medication in women with PE beyond 34 weeks of gestation
○ Reduce the risk of placental abruption in women with severe PE before 34 weeks of gestation
○ May increase the rate of ventilation use and the risk of interventricular hemorrhage/hypoxic
ischemic encephalopathy in neonates
● More data from RCTs with larger sample sizes will be required to further evaluate the benefits and
harm of elective delivery versus expectant management for women and neonatal outcomes
RESEARCH QUESTION

In women with Pre-Eclampsia or gestational

hypertension beyond 34 weeks AOG, what is the
effect of elective delivery compared to expectant
management?
ELECTIVE DELIVERY VERSUS EXPECTANT
MANAGEMENT FOR PRE-ECLAMPSIA: A META-ANALYSIS
OF RCTS
OBJECTIVE
▪ To evaluate the effectiveness and safety of elective delivery versus
expectant management for women with pre-eclampsia (PE)
▪ To assess neonatal outcomes before and after 34 weeks gestation

RESEARCH DESIGN
▪ Meta analysis of RCTs
 APPRAISING DIRECTNESS
Does the study provide a direct enough answer to your clinical question in terms of type of
patients, exposure/intervention, and outcome?
RESEARCH CLINICAL
POPULATION Women with pre eclampsia Patient diagnosed with Pre
beyond 34 weeks AOG eclampsia, 37-38weeks AOG
INTERVENTION Plan of delivery/Management Immediate Delivery
COMPARISON elective delivery vs expectant elective delivery vs expectant
management management

OUTCOME successful neonatal delivery Less maternal/neonatal

without complications complications

Yes, type of patients included in the study coincides with the patient.
 APPRAISING VALIDITY
Study population
Inclusion criteria: Exclusion criterion:
◼ Randomized controlled trials, ◼ Pregnant women with AOG
◼ Evaluated any methods of elective delivery less than 34 weeks
(induction of labor or caesarean section) ◼ Unspecified/ undiagnosed
versus expectant management (policy of pregnant went with Pre
delayed delivery) eclampsia
◼ Included treatment of women with pre-
eclampsia (however defined) or gestational
hypertension, who either before or at-term
delivery (up to and greater than 34 weeks).
APPRAISING THE RESULTS

◼ A total of 1,501 participants were included (range 30–756), 481were diagnosed with severe
PE, 264 with pre-eclampsia and severe hypertensive disorders, and 756 with PE and
gestational hypertension

◼ With respect to maternal outcomes, the incidence of eclampsia was similar for elective
delivery and expectant management across all patient groups. The evidence for this finding is
graded as moderate.

◼ high quality evidence has suggested that elective delivery also significantly decreased the
incidence of placental abruption before 34 weeks of gestation in women with severe PE.
APPRAISING THE RESULTS

◼ Regarding the management of hypertension, elective delivery was associated with

significantly less increase in diastolic and systolic blood pressure and lower rates of
antihypertensive drug therapy than expectant delivery after34 weeks of gestation in
women with PE

◼ With respect to neonatal outcomes, evidence was only available for before 34 weeks
of gestation in women with severe PE. No difference existed between elective
delivery and expectant management in fetal and neonatal mortality
 ASSESSING APPLICABILITY
Are the results applicable to the patients you see?

◼ As termination of pregnancy is recommended in women with severe PE beyond 34 weeks

of gestation by the Federation of Gynecology and Obstetrics, expectant management is
rarely used in this population.

◼ Since evidence suggests that elective delivery is generally more beneficial than expectant
management in women with severe PE below 34 weeks of gestation, it is reasonable to
speculate that elective delivery should also be recommended in severe PE patients beyond
34 weeks of gestation.
INDIVIDUALIZING THE RESULTS

◼ This intervention can reduce the risk of PE related complications and lower the
incidence of severe hypertension and the need for antihypertensive medication in
women with PE beyond 34 weeks of gestation; it can also reduce the risk of placental
abruption in women with severe PE before 34 weeks of gestation.

◼ Given that the risk of placental abruption may outweigh that of neonatal
complications, elective delivery could be more beneficial than expectant management
to high risk women with severe PE before 34 weeks’ gestation.
TAKE HOME POINTS:
▪ Hypertensive Disease in pregnancy continue to be a leading cause of maternal and
perinatal mortality and morbidity worldwide.
▪ Early and Prenatal Check-ups is still the most effective means of decreasing the
incidence/severity of HPN in pregnancy.
▪ Three main general aims of management are to prevent Convulsion, Control of
Hypertension and Optimum Time and Manner of delivery.
▪ The critical time of delivery is mainly governed by Age of Gestation, Severity of
the disease, Maternal Evaluation, fetal status and nursery capability.
▪ The main objective in the management of HPN in pregnancy must always be the
safety of the mother and the baby.
TAKE HOME POINTS:
JOURNAL
◼ Elective delivery is generally more beneficial than expectant
management for women with PE or gestational hypertension beyond 34
weeks of gestation and women with severe PE.
◼ However, elective delivery may increase the rate of ventilation use and the
risk of inter ventricular hemorrhage/hypoxic ischemic encephalopathy in
neonates.