HYPERTENSIVE DISORDERS OF

PREGNANCY
Introduction

HDP are an important cause of severe morbidity,

long-term disability and death among both mothers
and their babies.
HDP affect about 5-10% of all pregnant women around the
world
In Africa and Asia, nearly one tenth of all maternal
deaths are associated with HDP
The majority of deaths due to pre-eclampsia and
eclampsia are avoidable through the provision of
timely and effective care to the women presenting
with these complications
Introduction…..

However, the pathogenesis of pre-

eclampsia is only partially understood
and it is related to disturbances in
placentation at the beginning of
pregnancy, followed by generalized
inflammation and progressive
endothelial damage
ETIOPATHOGENESIS
Gestational hypertensive disorders are more
likely to develop in women with the following
characteristics:
 Are exposed to chorionic villi for the first time
 Are exposed to a superabundance of chorionic
villi, as with twins or hydatidiform mole
 Have preexisting conditions of endothelial cell
activation or inflammation such as diabetes or
renal or cardiovascular disease
 Are genetically predisposed to hypertension
developing during pregnancy.
Theories associated with etiology of
preeclampsia
  1. Abnormal trophoblast invasion  
2. Vascular endothelial damage
3. Genetic predisposition
4. Cardiovascular maladaptation   
5. Immunologic phenomena   
6. Coagulation abnormalities     
7. Dietary deficiencies or excesses

5
 Abnormal trophoblastic invasion
Development of uteroplacental vessels proceeds in two
waves or stages:
 The first wave occurs before 12 weeks postfertilization and
consists of invasion and modification of spiral arteries up to
the border between deciduas and myometrium.
 The second wave is b/n 12 and 16 weeks and involves
some invasion of the intramyometrial segments of spiral
arteries.

The remodeling by this two-phase invasion converts

narrow-lumen, muscular spiral arteries into dilated, low-
resistance, low-pressure,high-flow uteroplacental vessels.

6
In preeclampsia, trophoblastic invasion
is restricted to decidua segment of
uteroplacental arteries.

No myometrial spiral arterial invasion.

Definition
Hypertension

Pregnancy related HTN is defined as a SBP of

≥ 140mmhg or a DBP ≥ 90mmhg in 2
occasions at least 4hrs apart but not more
than 7days or a single BP recording of ≥
160/110mmhg, in a woman who was
normotensive prior to 20 wks of gestation.
Proteinuria

 Two urine dipstick measurements of at least

1+ (30 mg per dL) taken six hours apart;
at least 300 mg of protein in a 24-hour urine
sample; or
a urinary protein/creatinine ratio of 0.3 or
greater.
 Classification of HDP

1. Gestational hypertension: hypertension without

proteinuria (or other signs of preeclampsia)
developing after 20 weeks of gestation in a
previously normotensive woman.
(a) developing during pregnancy (prenatal)
(b) developing for the first time in labor
(c) developing for the first time in puerperium
Classification of HDP……..
2. Preeclampsia eclampsia syndrome
 Preeclampsia: new onset of hypertension and
proteinuria after 20 weeks of gestation in
previously normotensive woman.
 Eclampsia: grand mal seizure or coma in a
woman with preeclampsia.
Important causes of convulsion or coma like cerebral
malaria, meningitis, hypoglycemia, previous seizure
disorder, head injury or intracranial space
occupying lesions have to be ruled out.
Classification of HDP……..
3. Chronic hypertension: hypertension
that antedates pregnancy; is present before
20 weeks of gestation; or persists after 12
weeks postpartum.
4. Superimposed preeclampsia
 Superimposed pre-eclampsia without
severe features
 Superimposed pre-eclampsia with severe
features
Risk factors

Nulliparity(First pregnancy)
Age >40 or <18
Preeclampsia in previous pregnancy
Family history of preeclampsia
Medical comorbidities (renal disease, diabetes)
Multiple gestation
High body mass index(obesity)
IUGR, fetal demise or abruptio placentae in
previous pregnancy
Diagnosis
History
Age, parity, GA
ANC follow up
 Presence of cerebral symptoms
 Risk factors
 Medical history
 Socioeconomic status
Diagnosis cont…
 Physical examination: General appearance
 Blood pressure should be taken
appropriately!
 Look for pallor, jaundice, tongue bite
 Basal crepitation
 RUQ / epigastric tenderness
Diagnosis cont…
Hepatomegaly

Obstetric Examination
Pelvic Examination
Oedema
Diagnosis cont…
Investigations
Hematocrit
Platelet count
Urinalysis
Quantification of protein excretion
Serum Creatinine
Liver function test
Serum LDH level (135-214 U/L)
Serum uric acid (2.7-7.3 mg/dL)
Obstetric U/S
 Diagnosis and management of different
types of HDP
Gestational hypertension : hypertension is the
only sign at this stage.
Manage on an outpatient basis
Monitor blood pressure, urine (for proteinuria) and
fetal condition weekly.
If blood pressure worsens or the woman develops
features of pre-eclampsia, manage as pre-
eclampsia.
 Counsel the woman and her family about danger
signs indicating severe pre-eclampsia or eclampsia.
Management of Gestational
hypertension……
 If all observations remain stable, allow to
proceed with spontaneous labour and
childbirth.
If spontaneous labour has not occurred
before term, induce labour at term.
 No anti hypertensive should be given
 No anticonvulsants should be given
Pre-eclampsia

Diagnosis:
Hypertension and proteinuria are the
hallmark features of preeclampsia.
Classification
Pre-eclampsia without severe features
Pre-eclampsia with severe features
Severity features of preeclampsia are:
Headache, blurred vision, oliguria (<400 ml/24 hours), epigastric
pain or pain in right upper quadrant, difficulty breathing
(pulmonary edema)
 Low platelet count (<100,000/µl)
Elevated liver enzymes more than twice the upper limit of normal
 Serum creatinine higher than 1.1mg/dl
DBP >=110 and or SBP >=160mmHG
Hemolysis

IUGR
 Pre- eclampsia

Clinical Features
 The diastolic blood pressure remains on
two occasions 90 mm hg but less than 110
mmhg
 Proteinuria of 2+ (or 1 ~ with
specifications given in the definition).
 No other symptoms, signs or laboratory
findings of severe pre-eclampsia.
Management of pre-eclampsia without
severe features
Management may vary depending on the
gestational age
1) Gestational age less than 37 weeks
 Outpatient twice weekly follow up is
preferable as long as signs remain unchanged
or are normalized (if it is convenient for the
patient).
 Monitor blood pressure, urine protein, fetal
condition, CBC, liver and renal function tests
twice weekly.
Pre-eclampsia without severe
features……
 Counsel about the danger signs associated
with features of severe pre-eclampsia
 Encourage the woman to eat a normal diet
 Orient on fetal movement counting (kick
chart) daily
 No medications (do not give
anticonvulsants, anti hypertensives unless
clinically indicated)
 Delivery at 37 completed weeks
Pre-eclampsia without severe features……

If follow up as an outpatient is not possible or if

close observation is preferred, or pre-eclampsia
progress rapidly, admit to hospital and:
 Monitor blood pressure (twice daily) & urine
protein & weight (daily)
 Auscultation of FHB & kick chart daily
 Do not give medications
NB Weight gain should be : 0.45kg/wk (lesser
with placental dysfunction & excess with fluid
retention)
Pre-eclampsia without severe features……

If the Diastolic blood pressure decreases to

normal levels or her condition remains
stable send the woman home with the
following instruction:
 Watch out for signs of severity
 Continue follow up twice a week
 If diastolic blood pressure rises again,
readmit her
Pre-eclampsia without severe
features……
 If the signs remain unchanged, keep the
woman in the hospital and:
 Continue the same management & monitor fetal
growth & well-being (by symphysis fundal
height, kick chart)
 If there are signs of growth restriction consider
early delivery
 If not, continue hospitalization until term ( &
consider termination if cervix is favorable)
 If signs worsen manage as severe pre-eclampia
Pre-eclampsia without severe features……
2) Gestation ≥ 37 complete weeks
 If the woman's condition remains stable & there is no
signs of IUGR, Continue monitoring as above & plan
delivery when the cervix is favorable (but before going
post term, better not beyond 40wks )
 If there are signs of fetal compromise, assess the cervix &
expedite delivery :
 If the cervix favorable; rupture the membranes & induce labor.
 If the cervix is unfavorable, ripen the cervix using
prostaglandin or a folly catheter, or deliver by caesarian section.
Anticonvulsant during labor
Treatment of preeclampsia with severe
features
Includes any one or more of the severity features
The steps of management include:
 General measures - supporting the specific treatments
 Prevent convulsion
Control hypertension
 Delivery / expectant management in selected cases.
Preeclampsia with severe features…..

1) General Measures
 Admit the patient urgently, preferably to the labor ward
 Manage in left lateral position
 Setup IV line & infuse maintenance fluids
 Monitor urine output and maintain urine output at >30
ml/hr.
 Maintain a strict fluid balance chart (to avoid fluid
overload)
 Prepare equipment for convulsion management, at
bedside (airway, suction equipment, mask & bag,
oxygen)
Preeclampsia with severe features…..
Never leave the patient alone (if convulsion occurs,
aspiration may cause death)
Observe vital signs, FHB & reflexes
Auscultate the lung bases for crepitation indicating
pulmonary edema. If they occur, withhold fluids &
administer a diuretic (furosemide 40 mg Iv stat)
The immediate treatment should include managing
symptoms
Anti emetic - for nausea & vomiting to minimize maternal
discomfort
Anti pain - for RUQ pain, headache etc.
Preeclampsia with severe features…..

2) Anticonvulsant therapy (seizure

prophylaxis)
Seizure prophylaxis should be instituted :
 In all pre-eclamptics during labor &
continued for 24 hrs after delivery
 In all severe pre-eclamptics during
admission & continued during period of
evaluation & observation for 24 hrs.
 Magnesium sulfate: is the drug of choice
for preventing & treating convulsions in
severe pre-eclampsia & eclampsia

Diazepam: may be used as alternative, if

MgSO4 is not available
A greater risk for neonatal respiratory
depression because diazepam passes the
placenta freely
Severe pre-eclampsia cont…

3. Control hypertension( Anti -hypertensive therapy)

Administration of anti hypertensives should be started
if the systolic blood pressure is 160 mmHg or higher
and/or the diastolic blood pressure is 110 mmHg or
higher.
Hydralazine or labetalol is the drug of choice for acute
control.
 An important principle is to maintain blood pressures
above the lower limits of normal
Goal: To keep DBP B/N 90-100 and SBP b/n140-150
mmHg
Hydralazine
 Is the drug of choice for acute therapy
(arteriolar dilator with rapid onset )
Give 5 mg IV slowly every 20 minutes
until blood pressure is lowered (to diastolic
blood pressure <110 mmhg).
The maximum dose is 20 mg per 24 hours.
Labetalol
Oral treatment : Administer 200 mg; repeat dose
after one hour until the treatment goal is achieved.
The maximum dose is 1200 mg in 24 hours.
Intravenous treatment : Administer 10 mg IV.
If response is inadequate after 10 minutes, administer 20
mg IV.
The dose can be doubled to 40 mg and then 80 mg with
10-minute intervals until blood pressure is lowered
below threshold.
The maximum total dose is 300 mg; then switch to oral
treatment.
Severe pre-eclampsia cont…

Nifedipine
Calcium channel blocker, oral agent, with rapid onset of
action
 As alternative for acute therapy, administer 10 mg orally.
Repeat dose after 30 minutes if response is inadequate
until optimal blood pressure is reached.
The maximum total dose is 30 mg in the acute treatment
setting.
For maintenance therapy10-20 mg PO bid is given.
 Side effects: edema, flushing, headache, palpitation,
mgso4 toxicity, tocolytic effect
Severe pre-eclampsia cont…

Methyldopa
 Is the drug of choice for maintenance
therapy.
It has a minimal side effect & safe.
Methyldopa has a long history of safe use in
pregnancy, well tolerated .
Administer 250-750 mg PO every six to
eight hours.
The maximum dose is 3000 mg per 24 hrs.
Antihypertensive cont…
Safe and feasible options of
antihypertensives include

Calcium chanell blockers ( Nefidipine)

Labetalol (α & β blocker)
Hydralazine ( peripheral vasodilator )
Methyldopa ( central and peripheral
antiadrenergic)
4.Planning delivery
Gestational age < 28 weeks:

Termination
of pregnancy (expectant
management is not recommended)
Gestational age ≥ 28 weeks and <34 weeks:
Expectant management is recommended, provided that
there is no indication for delivery.
For expectant management:
Transfer to maternity ward
 Follow vital signs every 4 hours
 CBC, every other day
 Liver enzymes, and creatinine twice weekly
 Fetal kick count daily
 Fetal surveillance twice weekly
 Administer Dexamethasone 6 mg IM every 12 hours for 2
days or Betamethasone 12 mg daily for 2 days
Indications for delivery are:
 Failure to control hypertension with two antihypertensive
drugs with a maximum dose in 48 hrs
 Persistent maternal severity symptoms (severe headache,
visual changes and abdominal and/or epigastric pain with
elevated liver enzymes)
 HEELP Syndrome
Eclampsia
 Pulmonary edema or left ventricular failure
IUFD
 DIC
Severe renal dysfunction
Gestation 34 to 37 Weeks
In women with severe pre-eclampsia and a viable
fetus that is between 34 and 37 weeks of gestation,
expectant management may be recommended
provided that uncontrolled maternal hypertension,
worsening maternal status and fetal distress are absent
and can be closely monitored.
Gestation after 37 Completed Weeks
For women with pre-eclampsia at term (37 weeks),
regardless of severity features, giving birth is
recommended.
MODE OF DELIVERY
Depends on gestational age, fetal condition,
presentation, cervical condition & maternal condition.
Indication for Cesarean Section:
If the cervix is unfavorable (firm, thick, closed) esp.
in seriously ill patients
With poor progress of labor
If patient has not entered active labor within 8 hrs of
induction of labor
 If there is evidence of fetal distress, or other obstetric
indications,
INTRA PARTUM MANAGEMENT
Absolute bed rest in LLP, is essential
 Antihypertensive drugs should be given
as necessary to regulate diastolic blood
pressure between 90 &100mm Hg
 Careful monitoring of FHB, maternal
conditions & progress of labor
 Pain management as required
POSTPARTUM MANAGEMENT:
Watch closely for at least 2hrs after delivery for
complications such as shock, PPH & eclampsia
 Anticonvulsive therapy should be maintained
for 24-48 hrs after delivery or the last
convulsion, whichever occurs last
Continue anti-hypertensive therapy as long as
the BP is ≥ 110mmhg
Continue to monitor urine output & check for
coagulation failure, LFT, RFT
 Eclampsia
Treatment of eclampsia is symptomatic &
consists of six aspects:
1. General measures
2. Control of convulsions (to stop ongoing
convulsion & prevent repeated convulsion)
3. Correction of hypoxia & acidosis by clearing
airway & giving O2 by mask at 6L/min
4. Blood pressure control & stabilization of the
condition of the mother & fetus
5. Fluid balance & diuresis
6. Delivery & intra partum/post partum care
Treatement of eclampsia

i.) General Measures in the Mx of Eclampsia

 Set up IV line & maintain intravascular
volume & replace ongoing losses; avoid
overload
 Position the patient on her side (left lateral)
& in Trendelenburg (head down) position to
reduce risk of aspiration of secretions,
vomitus or blood.,
 Aspirate (suction) the mouth & throat as
necessary & ensure open airway
 Give oxygen by mask at 6 liters per minute

 Avoid tongue bite by placing an airway or

padded tongue blade between the teeth &
protect the Woman from injury but do not
actively restrain

 Place an indwelling catheter to monitor

urine output & urine test for protein
Treatement of eclampsia…

 Monitor vital signs, FHB & reflexes frequently &

auscultate the lung bases hourly for crepitation
indicating pulmonary edema or aspiration pneumonia
 If the pulmonary edema occurs, withhold fluids &
administer a diuretic such as furosemide 40mg IV stat
The patient has to be kept in the "eclampsia room" (a
specially designed quiet room (darkened room is no
more used), with intensive care ).
An attendant must be always beside the patient.
Administration of prophylactic IV antibiotics is
beneficial
Treatement of eclampsia…

ii) Anticonvulsant Therapy

 Administer anticonvulsant drugs to stop
the ongoing convulsion & prevent
repeated attacks
 Be aggressive & avoid under treatment, to
be successful
 Magnesium sulphate is the drug of choice
in eclampsia
 Treatement of eclampsia…

Before repeat administration, ensure that:

 Respiratory rate is at least 12 per minute.
 Patellar reflexes are present.
 Urinary output is at least at least 30 ml per hr or100 ml over
4 hours.
Withhold or delay drug if respiratory rate falls below 12 per
minute, patellar reflexes are absent or urinary output falls
below 30mL per hour over preceding 4 hours.
Keep antidote ready:
 In case of respiratory arrest:
 Assist ventilation (mask and bag, anesthesia apparatus,
intubation).
 Give calcium gluconate 1 g (10 mL of 10% solution) IV
slowly until respiration begins.
 Adverse effects/toxicity and
monitoring parameters
Side effects include:-
Facial flushing, feeling warm

Irritation at the site of injection

Nasal stuffiness

GI- upset (diarrhea, nausea and vomiting)

Urinary retention

56
 Clinical effects are related directly to plasma
levels
MgSO4 level (mg/dl) Effects
4.8- 8.4 Therapeutic level
8- 10 Loss of DTR
12 -17 Respiratory depression
13- 17 CNS depression, coma
19 -20 Cardiac arrest

19/04/2011 eclampsia 57
mgso4 toxicity…
Monitor
◦ Respiratory rate is at least 12 per minute

◦ Patellar reflexes are present

◦ Urinary output is at least 100 ml over 4 hours

19/04/2011 eclampsia 58
Drug interactions
Use with nifedipine may cause
hypotension and neuromuscular blockade

19/04/2011 eclampsia 59
Treatement of eclampsia

iii. Anti Hypertensive Therapy

 The therapeutic goal is to keep the
diastolic blood pressure < 110 mm Hg &
prevent cerebal hemorrhage.
Treatement of eclampsia

iV. Fluid balance & diuresis

 Keeping strict input & output record is
essential and determine serum electrolyte
 For unconscious patient, 5% DW
(1000ml) & ringer's Lactate (500ml) are
infused for maintenance of nutrition &
fluid balance during 24hrs.
 Replace extra fluid loss through vomiting,
diarrhea, sweating or blood loss
 Nothing by mouth is allowed (if
unconscious); when the patient becomes
conscious & can drink, oral feeding of
fluid is started.
 Lasix 20mg IM is given for diueresis
(especially after delivery)
V. DELIVERY
Delivery should take place within 12 hours of
onset of convulsions
Delivery should take place as soon as the
woman's condition has stabilized, regardless of
the gestational age
INTRA PARTUM AND POSTPARTUM
MANAGEMENT:
 As stated in the management of sever
preeclampsia with severe features
CHRONIC HYPERTENSION
Reading assignment
Prevention
Which women are at high risk for
developing preeclampsia???
Previous preeclampsia
Diabetes mellitus
Chronic hypertension
Multiple pregnancy
Renal diseases
Autoimmune diseases
Prevention cont…
 Suggested prevention strategies;
◦ Calcium supplementation during pregnancy
◦ Low dose Aspirin

No evidence and not recommended :

o Individual or combined vitamin C,D & E
supplementation
o Restriction in the dietary salt intake
o Resting from physical activities
Recommendation
 In areas where dietary calcium intake is
low, calcium supplementation during
pregnancy (at doses of 1.5–2.0 g
elemental calcium/day) is recommended
for the prevention of preeclampsia in all
women, but especially in those at high
risk of developing pre-eclampsia.
Antiplatelets for prevention of
pre-eclampsia…

Recommendations:
 Low-dose aspirin, 75 mg/day is
recommended for the prevention of pre-
eclampsia
References
 WHO recommendations for prevention and
treatment of preeclampsia and eclampsia,
 Management protocol on selected obstetrics
topics, FDRE, Ministry of health, January 2020
 Up To Date 21.2,
 Williams Obstetrics 24rd ed.
 Gabbe: Obstetrics: Normal and Problem
Pregnancies, 5th ed
Thank you!