Hypertension Disorder

in pregnancy
 Introduction
• HDP remains a common cause of direct maternal deaths worldwide.
• It is associated with significant maternal and fetal mortality and morbidity
• In Malaysia, it is the third most common cause of maternal deadth
(Confidential Enquiry into Maternal Deadths,CEMD 2009-2011)
• In Uk however, due to the effective management strategies, its been
reduce to eighth main cause of direct maternal deadth.
Pathophysiology of HDP
Hemodynamic Changes in Normal Pregnancy and Preeclampsia
• Systemic vascular resistance

• plasma volume & cardiac output

• There is a physiological in BP, due to Vasodilation

• Renal blood flow & glomerular filtration rate by 50% in normal pregnancy

• but are ≈30% in women with preeclampsia

• as a result of both in renal blood flow & ultrafiltration

• d/t to endotheliosis in the glomerular capillary bed.

• Plasma volume in normal pregnancy, in pre-clampsia

• Hypercoagulability in normal pregnancy, however in pre-eclampsia

AHA Journals published 15/12/21

Abnormal Placentation and the Pathogenesis of the Maternal Preeclampsia Syndrome

• The diameter of the uterine spiral arteries greatly during normal pregnancy as a result of remodeling of
the endothelium and vascular smooth muscle.

• Failure of spiral artery remodeling (ie, retention of smooth muscle) is a feature of preeclampsia

• and leads to utero-placental perfusion, demonstrated by noninvasive blood flow and perfusion studies
using Doppler ultrasound

AHA Journals published

 DEFINITIONS

Mild Hypertension : SBP 140-149, DBP 90-99mmHg

Moderate Hypertension: SBP 150-159mmHg, DBP 100-109mmHg

Severe Hypertension: SBP≥160mmHg, DBP ≥110mmHg

Proteinuria :
is when urine protein creatinine ratio is greater than 30mg/mmol or 24 hour urine collection is
greater than 300mg of protein

Handbook of obstetric emergency

(OGSM)
 BP Measurement
1) Device :
Aneroid Sphygmomanometer , Automated

2) Position
a) Ambulatory –sitting
Blood pressured measured with a women rested and seated at 45 degree angle with the arm at the level of
the heart

b) Hospitalization- women rest on coach or bed on her right side with 15-30◦ tilt and the right arm well
supported at same level as the heart.

SOSCG 4th
Edition
Chronic hypertension in pregnancy ( ACOG)
https://www.ahajournals.org/doi/10.1161/circulationaha.113.003904
- blood pressure ≥140 mm Hg systolic and/or 90 mm Hg diastolic before pregnancy or,
- in recognition that many women seek medical care only once pregnant,
- before 20 weeks of gestation,
- use of antihypertensive medications before pregnancy, or persistence of hypertension for >12 weeks
after delivery.

CHRONIC HYPERTENSION ( NICE Guideline)

Hypertension that is present at the booking visit, or before 20 weeks, or if the woman is already taking
antihypertensive medication when referred to maternity services. It can be primary or secondary in aetiology

GESTATIONAL HYPERTENSION ( Nice Guideline)

New hypertension presenting after 20 weeks of pregnancy without significant proteinuria.
PRE-ECLAMPSIA
-New onset of hypertension (over 140 mmHg systolic or over 90 mmHg diastolic)
-after 20 weeks of pregnancy and the
-coexistence of 1 or more of the following new-onset conditions:

• proteinuria

• other maternal organ dysfunction:

 renal insufficiency
 liver involvement
 neurological complications
 hematological complications

• uteroplacental dysfunction

NICE guideline [NG133]Published: 25 June 2019

SEVERE HYPERTENSION
BP:≥ 160/110 mmHg

SEVERE PRE-ECLAMPSIA
-BP ≥160/110 with proteinuria≥2+
-or end-organ involvement

ECLAMPSIA
HPT + seizure

CHRONIC HPT with SUPERIMPOSED PRE-ECLAMPSIA

New onset of proteinuria in the setting of hypertension before 20weeks of gestation
An increase in proteinuria ( if present earlier)
An Increase in blood pressure
Onset of HELLP syndrome
Classification of hypertensive disorder in pregnancy

Classification Characteristics
Gestational Hypertension New Hypertension after 20weeks without significant proteinuria
Preeclampsia (PET) Hypertension after 20weeks with significant proteinuria
Severe preeclampsia PET(Preeclampsia) with severe hypertension, symptoms or
biochemical derangement
Eclampsia PET with convulsion
Chronic Hypertension Hypertension detected before 20weeks or before pregnancy
Chronic hypertension with superimposed preeclampsia
New onset of proteinuria in the setting of hypertension before 20 week of gestation
An increase in proteinuria (if present earlier)
An increase in blood pressure .Onset of HELLP syndrome (AHA journal)

Handbook of obstetric emergency

(OGSM)
 Complication of Preeclampsia
Maternal complication
Central nervous system Eclampsia, Encephalopathy, Ischemia, Infarction , Hemorrhage,
Oedema, Cortical blindness, Retinal detachment
Respiratory system Adult Respiratory distress syndrome, Pulmonary Oedema
Cardiovascular system Hypertension, Cardiac failure
Liver Elevated liver enzymes, subcapsular hematoma, HELLP syndrome
Renal system Oliguria, Acute tubular necrosis, Cortical necrosis
Hematological Disseminated intravascular coagulopathy

Fetal Complication
Prematurity, intrauterine growth restriction, Intrauterine death, Fetal distress

Handbook of obstetric emergency

(OGSM)
Pre-eclampsia Prophylaxis ( Aspirin and calcium supplementation)

High Risk: If she has 1 major or more than 1 Moderate risk factor
Major Risk Factor Moderate Risk Factor
1. Hypertensive Disease during previous pregnancy 1. Primiparity
2.Chronic Kidney disease 2. Age >40years old
3. Auto-immune disease (SLE/APS) 3. Pregnancy interval > 10 years
4. T1DM/T2DM 4. BMI ≥ 35kg/m2 at booking
5. Chronic HPT 5. Family h/o pre-eclampsia
6. Multi-Fetal pregnancy
If high risk PE
-Start calcium carbonate 1g BD at booking ( start latest by 20weeks)
-start cardiprin 100mg ON if available or Aspirin 150mg ON (btwn 12-20 weeks and continue until delivery)
- If › 20weeks, to consult O&G sp, if patient requires aspirin initiation
SOSCG 4th Edition
Pre-pregnancy Secondary causes of Chronic HPT in pregnancy
- Anti-HPT contraindicated in pregnancy CKD e.g. Glomerulonephritis, reflux nephropathy
Eg: ACEI,ARB,Thiazides
- Stabilize BP Adult PCOS
- Find out cause if not sought Renal artery stenosis
Systemic disease with renal involvement e.g DM,
Chronic HPT in pregnancy SLE
- Important secondary causes of Chronic HPT in
- May deferred ix postdelivery Endocrine disorder e.g Pheochromocytoma, Cushing’s
- Investigation for causes secondary hypertension syndrome
That have little value in pregnancy include: Coarctation of aorta
a) Urinary/serum cortisol
b) Urinary VMA
@Booking/Diangnosis
Gestation (weeks) 24 32 36 38
• Change ACEI, ARB, Thiazides UA (mmol/L) 280 320 340 380
• Dating scan Creatinine level ≥ 90 (abnormal in pregnancy)
• PE prophylaxis
• Use anti-HPT in pregnancy: To do clotting studies if PLT <100
• ≤ 20 weeks: T. Methyldopa
• 20weeks≥: Either T.Methyldopa or Labetolol 24-hour urinary protein >300mg/24hour
• SBP-120-135mmhg, DBP 80-85mmhg (abnormal)
• Do the following:
- BP, weight, Urine Protein Spot urine protein :creatinine ratio≥ 30mg/mmol
- Baseline PE profile ( FBC,RP,SUA, LFT) (0.3mg/mg) abnormal
-Educate mother to return immediately if symptom of
pre-eclampsia

• Fetal anomaly screening

SOSCG 4th
Edition
Subsequent Antenatal Follow-up

• PE symptom
• Maternal surveillance
• Refer O&G team if: Severe HPT & Moderate HPT
• Assess maternal and fetal
• PE profile every trimester
• Fetal surveillance
• Return Immediately PE symptom
• Delivery plan
• Refer Hospital-PE

SOSCG 4th Edition

Delivery:
 Outline by O&G Specialist at 36weeks
 Hospital Delivery

Postpartum: (Chronic HPT)

 Continue antenatal anti-HPT
 BP <140/90 mmHg
 Continue to monitor BP
 contraception

Postpartum: (Gestational HPT & Pre-eclampsia)

 Continue to monitor BP – 3 months postpartum
 anti-HPT - it should not be stopped abruptly
 Stop methyldopa
 consider anti-HPT , 3m postpartum, Bp remained high

SOSCG 4th Edition

Upon discharge from hospital
 Notification of high-risk cases
 Follow-up care
 Home visit:
 At 2 weeks: review by MO
 PPC 3months

SOSCG 4th Edition

Anti- Hypertensive Drugs For Treatment in Pregnancy

Drugs:
• Methyldopa
• Prolonged beta blocker
• Diuretics
• ACE inhibitors
• ARB ( Angiontensin receptor blocker)
Drugs Action Contraindication Adverse effect
PO Methyldopa Central Pheochromocytoma Hepatic necrosis
250mg-1g TDS Hepatitis Hemolytic anaemia
Liver cirrhosis Increased risk of postnatal
H/o Depression depression
Depression
Current use of monoamide
oxidase inhibitor

PO Labetolol Beta adrenergic Obstructive airway disease Hepatic injury

Initial: 100mg BD blocker with mild Bronchial asthma Bronchospasm
Maintainance: 200- alpha vasodilation Heart block Bradycardia
400mg TDS effect Severe bradycardia
PO Nifedipine Peak blood level Cardiogenic shock Peripheral Oedema
10-20mg TDS occurs Unstable angina Increase risk or heart failure in
approximately 30 Myocardial infarction event in patient with aortic stenosis
mins the past 1 month

SOSCG 4th Edition

Degree of hypertension and management
Degree of Mild Hypertension Moderate Hypertension (150/100 to Severe Hypertension
hypertension (140/90 TO 149/99) 159/109) (≥160/110)
Management No antihypertensive • First Line • First line:
 Oral Labetolol  Oral labetolol
 Oral nifedipine
• Second line
 IV labetolol
 IV hydralazine
• Consider
eclampsia
prophylaxis
Regular monitoring Aim for SBP ≤ 150mmHg and DBP Aim for
80-110mmHg. If there is target organ SBP≤150mmHg and
damage, aim for BP ‹140/90mmHg DBP 80-110mmHg

* Labetalol is contraindicated in mothers with asthma and heart

block
Handbook of obstetric emergency
(OGSM)
Antihypertensive for severe hypertension
Drug Initia Onset of Peak Repeat Comment
l action Effect dose
dose (min) (min) (mg)
(mg)
IV 20 2-5 5-15 20 • Repeat doses every 10mins up to maximum 300mg
Labetalol 40 • Avoid in bradycardic mothers, heart block or severe asthma
40

Nifedipine 10 20 30- 10 to 20 • Maximum of 3 doses

oral 120 • Mother should not bite the capsule
• Sublingual is not recommended
• Associated with headache and tachycardia
IV 5 to 5 to 20 10-80 10 • Repeat every 20mins up to maximum of 30mg
hydralazin 10 • Avoid in mothers with headache or tachycardia
e

Handbook of obstetric emergency

(OGSM)
ECLAMPSIA PROPHYLAXIS
1) Start Magnesium Sulphate (MgSO4) and continue for 24H following delivery or initiation
(Which ever comes later)
2) Consider delivery once decision for Magnesium Sulphate has been made
Magnesium Sulphate Regime
Regime Route Regime
Loading dose IV 4g(8ml) MgSo4 with 12ml saline (NS) given over 15mins
OR
10g to be given as 5g(10ml) MgSo4, at each buttock (add
IM 1ml of lignocaine 2%)
Maintenance dose IV 24.7g (10 ampoules) MgS04 with 500ml NS to run at
1g/hour (21ml/hour)
OR
IM 5g(10ml) MgSO4, deep IM in alternate buttock every 4 hours
Recurrent seizure 2g (4ml)+ 8ml NS given over 15minutes and continue with
maintenance dose of 1g/hour

Handbook of obstetric emergency

(OGSM)
MgSO4 preparation: 1vial= 2.47g/5ml ( 50% concentration)
4g( 8ml) MgSo4

8ml of MgSO4 + 12ml of NS = 20mls of MgSo4 ( given over 15minutes)

 GCS AVPU Criteria
Magnesium sulphate
15 A Pt aware of examiner and can
1) Monitoring toxicity (hourly):
Alert respond to environment around
• ECG independently, follows
• Reflex command, open eye
• Urine output spontaneously
• Respiratory rate
• Oxygen saturation 12-13 V Pt’s eyes does not open
• Assess AVPU Verbally spontaneously. The patient eyes
responsiv response to a verbal stimulus
e directed toward them, react to
verbal stimulus directly and in
meaningful way

5-6 P Pt’s eyes does not open

Painfully spontaneously, response to
responsiv application of painful stimuli, or
e may move, cry out directly in
response to stimuli
3 U Does not respond spontaneously,
Unrespon not respond to verbal or painful
sive stimuli
Handbook of obstetric emergency
Magnesium level and toxicity
Magnesium level Clinical feature Management
(mmol/L)
2.0-4.0 Therapeutic range
3.5-5.0 ECG changes Stop infusion
• Prolong PR interval
• Widened QRS complex
5.5-6.5 Loss of deep tendon reflex Initiate resuscitation and
administer calcium gluconate
>12.5 Maternal collapse Initiate Resuscitation + Calcium
gluconate

2. Antidote
1g calcium gluconate (10ml of 10% solution) given slow IV bolus over 3 minutes

Handbook of obstetric emergency

(OGSM
The 7 principles of managing eclampsia
Prevent Hypoxia • Call for help and trigger “Emergency Alert System” Involve senior multi-
professional team
• Initiate Resuscitation
• Oxygen delivery of 15L/min via facemask
Prevent Maternal Injury • Do not leave the mother unattended
• Padded tongue blade
• When seizure resolves, insert oral airway until mother regain
consciousness
• Prevent aspiration by turning head to 1 side, Mother in left lateral or
recovery position and use oral suction to clear airway
• Raise bed railing to prevent fall
No Urgency to arrest the Most Seizure are self limiting
first seizure
Prevent recurrent seizure Administer MgSO4 as per protocol
Prevent intracranial Control severe Hypertension
hemorrhage
Manage complication Manage HELLP or acute pulmonary oedema in a tertiary center
Ensure fetal well being Plan for delivery by optimal mode and time

Handbook of obstetric emergency

Step by step management of Severe PE/ eclampsia in primary care setting

1) Ask help
2) Patient position
3) Airway
4) Breathing
5) Circulation
6) Loading dose MgSo4
7) Set up IV line
8) Reassessment
9) Recurrrent PE
10) Medication
11) Food/drinks
12) Refer patient
 Case Base Discussion
A 28 year old woman in her first pregnancy is admitted to the labor ward at 38
weeks of gestation. She has no past medical history of significance. Her blood
pressure when pregnancy was first confirmed at 8 weeks was 120/70. Today she
presents with a mild frontal headache and increasing swelling of her ankles.
Blood pressure is 170/120, urine dip stick testing shows 3+ of protein and there
is oedema of both ankles to the mid-calf.
What can be the most likely diagnosis?

- Primigravida
- 38weeks of gestation
- Bp booking@8weeks 120/70
- No past medical history
- Symptom: headache, increasing swelling of angkles
- BP: 170/120
- Urine Dipstic :3+ protein

Pre-Eclampsia
What are the sign and symptom should be looked for?
Symptom that should be looked for to diagnose pre-eclampsia include:
• Headache
• Visual disturbance
• Epigastric pain/ right upper quadrant pain
• Nausea/vomiting
• Increasing swelling of legs, fingers, face

Sign to identify include:

• CVS: Hypertension, vasoconstriction leading to cool peripheries, peripheral oedema
• Respiratory system: Pulmonary Oedema, facial and laryngeal oedema, acute respiratory distress syndrome
(ARDS)
• Renal system: Proteinuria, Oligouria, acute renal failure
• CNS: Hyperreflexia,clonus, cerebral haemorrhage,convulsion (Eclampsia), papilloedema,coma
• Others: HELLP (Haemolysis,Elevated liver enzymes, low platelet), Thrombocytopenia, DIC
• Fetal sign include: CTG abnormalities, pre-term labor, and IUGR
Investigation include?

Blood investigation:
FBC, RP, COAG, UA, LFT

Urine
Urine protein : creatinine ratio (PCR) >30 is significant
Assessment of urine output is important

Regular assessment of fetal well being using CTG, ultrasound scan to assess fetal growth and uterine artery
doppler blood flow to assess placental blood flow

The aims of management at this stage are: confirmation of diagnosis, control of BP, Prevention of
convulsions and decision regarding timely delivery
 Then,

She C/o worsening of headache, seeing flashing light

She is found to be hyper-reflexic
Bp remined high at 170/120 given T. Labetolol 200mg
At this stage her BP is being monitored every 15mins and despite the oral antihypertensive her BP
remains high two hours later.

This woman has severe pre-eclampsia which is a serious threat to the lives of
both mother and fetus

What IV antihypertensive drugs are suitable in this case?

IV Labetolol

*Labetalol should be avoided in women with asthma

What to do if patient BP remained high at maximum rate of IV labetolol?

IV Hydralazine

Hydralazine
Causes headache, tremor, nausea, and
tachycardia and may be less well
tolerated than labetolol

Fluid Bolus of 250ml

Should be considered before commencing
IV antihypertensive therapy as there is
some evidence that this may avoid the
hypotension observed with initiation of
vasodilator therapy
Then, BP starts to stabilize.

Observations of BP, O2, HR, RR every 15 mins

grand mal fit.

What is the most likely reason for the fit?

eclamptic seizure.

Other causes of a fit in this situation include:

• Epilepsy
• Intracranial event
• Vaso-vagal
• Hypoglycaemia
Management of an eclamptic seizure:

 The patient should be turned to the left lateral position

 Call for help
 Assess and support Airway, Breathing and Circulation
 High flow oxygen by face mask
 Obtain IV access
 Treat with IV magnesium sulphate
 Monitor ECG, BP, respiratory rate and oxygen saturations
 Check blood sugar
Would earlier administration of magnesium have reduced the risk of fitting in this particular
case?

The drug of choice : MgSo4

 Guidelines, RCOG, MgSo4 to be consider for severe PE

 This is based on the Magpie Trial.
-This study showed that magnesium sulphate given to
women with pre-eclampsia
-reduced the risk of an eclamptic seizure by around 58%.
-not all women with pre-eclampsia will progress to eclampsia; only 1–2% progress
The Magpie trial :
-pre-eclamptic women needed to be treated with magnesium to prevent 1 of them from fitting is 91
Loading dose for MgSo4 given. Monitored frequently for magnesium toxicity.
The CTG now demonstrates repetitive and severe fetal heart rate decelerations.

Next, Caesarean section.

Regional anaesthesia
Women with severe pre-eclampsia should be encouraged to have regional anaesthesia
for caesarean section

The benefits of spinal anaesthesia include :

rapid, dense and predictable block suitable for surgery while avoiding general anaesthesia which has the
risk of BP surges due to the pressor response of laryngoscopy, intubation and extubation.

General anaesthesia
Caesarean section under general anaesthesia in severe pre-eclampsia is a high risk
procedure
Then, Patient have thrombocytopenia, proceeded with GA.

At the end of the caesarean section she is slow to wake up

There are several reasons why she is slow to wake up and these include:
 Effect of excess anesthetic agents
 Effect of excess opiates
 Inadequate reversal of neuromuscular block
 Respiratory depression
 Hypoglycemia

Most concerning possibility

she has experienced an intracranial event due to
excessive
hypertension during intubation. This should be
diagnosed by pupil examination and response and
emergency CT scan.
Then, after 15mins patient wake up?

What on-going management of her pre-eclampsia should be continued?

After her caesarean section this lady should go to a high dependency area for close observation and
blood tests. It is important she also has:
• Effective postoperative analgesia.

• Ongoing anti-hypertensive therapy.

• Close monitoring must continue as she is at risk of further eclamptic seizures. Magnesium therapy
should be continued until 24hrs after her delivery (or the last convulsion, whichever is the later).

• Cautious fluid intake.

Take Home message

1) Management should ideally be in tertiary center with multi-professional team involvement

2) There should be clear guidelines in place recognition, stabilization of BP, arrest of seizure and close
monitoring of multi-organ dysfunction

3) MgSO4 is the recommended drug of choice for seizure prophylaxis and treatment

4) Use appropriate antihypertensive to prevent cerebral vascular injury

5) Strict fluid management is essential to prevent pulmonary oedema

6) Definitive management of preeclampsia is delivery of fetus