PRESENTATION 4.

HYPERTENSIVE DISORDERS OF
PREGNANCY

Federal Democratic Republic of Ethiopia

Ministry of Health

BEmONC – LRP
ETHIOPIA Best Practices in Maternal and Newborn Care
 Session Objectives

By the end of this session, participants will be able to

Discuss best practices for diagnosing and managing



hypertension, pre-eclampsia and eclampsia

Describe strategies for controlling hypertension



Describe strategies for preventing and treating convulsions in



eclampsia

Describe measures for the prevention of preeclampsia/



eclampsia
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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Introduction

 Hypertensive disorders complicate 5% to 10% of pregnancies

 Preeclampsia is the cause of 9%–26% of global maternal
mortality and a significant proportion of preterm delivery, and
maternal and neonatal morbidity
 3rd leading cause of maternal mortality in Ethiopia

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Intro…

 No effective screening for the detection of

preeclampsia
 Eclampsia can be prevented by early diagnosis & Mx
of preeclampsia

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Diagnosis HDP…..

i) Symptom/signs
Pregnant or recently delivered woman who:


 Has elevated blood pressure

 Complains of headache or blurred vision
 Is found unconscious or convulsing
 Has upper abdominal (epigastric pain), with or without
nausea/vomiting
 Has difficulty of breathing

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Diagnosis HDP…..

ii) Elevated blood pressure (Hypertension)

* Systolic blood pressure (SBP) greater than or equal to 140 mmHg

and/or

* diastolic blood pressure (DBP) greater than or equal to 90 mmHg

(two consecutive readings four hours or more apart).

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Diagnosis HDP…….

iii) Proteinuria

0.3 g protein in a 24-hour urine specimen or



1+ on dipstick (specific gravity < 1030) or



2+ protein on dipstick (twice taken 6hrs apart)



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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Revised classification of HDP

 Chronic hypertension (elevation of blood pressure noted before 20

weeks of gestation or persisting more than 12 weeks postpartum)
 Gestational hypertension
 Mild pre-eclampsia
 Severe pre-eclampsia
 Eclampsia
 Chronic hypertension with superimposed pre-eclampsia

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Gestational Hypertension (GH)
 Two readings of
* SBP 140 mmHg to 160 mmHg and/or
* DBP 90 mmHg to 110 mmHg measured 4 hours apart after
20 weeks of gestation
 No proteinuria

 No features of preeclampsia (see next slides)

N:B If a woman with GH develops SBP>160mhg and/or DBP >

110, she should be managed as a case of sever preeclampsia
even if there are no other signs of preeclampsia.

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 QUESTIONS ???

 What is pre-eclampsia?

 When can it occur?

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Pre-Eclampsia
 Woman over 20 weeks gestation with:
 Diastolic blood pressure ≥ 90 mm Hg and/or

Systolic blood pressure ≥ 140 mmhg

Plus
 Proteinuria (2+)
 Predisposes woman to develop eclampsia

NB: Edema is not necessary for the diagnosis of preeclampsia

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Mild Preeclampsia

 New onset hypertension & proteinuria after 20wks of

Gestation
 Diastolic blood pressure ≥ 90 mm Hg and/or
 Systolic blood pressure ≥ 140 mmhg
Plus
 Proteinuria (2+)
 No sever features present

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Severe Preeclampsia

 New onset hypertension & proteinuria after 20wks of gestation

with a hypertension in the severe range
* SBP >160 mmHg and/or DBP >110 mmHg after 20 weeks
 any of the following features present

 Headache (increasing frequency, unrelieved by regular

analgesics)
 Vision changes (e.g. blurred vision)
 Oliguria (passing less than 400 mL urine in 24 hours)
 Upper abdominal pain (epigastric pain or pain in right
upper quadrant)

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Predicting Pre-eclampsia :

 Despite numerous clinical and biochemical tests studied for prediction of

pre-eclampsa, to date there are no reliable tests. But

 women who develop gestational hypertension at an earlier gestational age

are more likely to progress to pre-eclampsia.

 Approximately 15–25% of women initially diagnosed with gestational

hypertension will develop pre-eclampsia

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Management of Preeclampsia
 Considerations In management
* GA
* Severity of hypertension
* presence of end organ damage (liver, kidneys, lungs……)
* Fetal status and facility capacity (efficiency of NICU to manage
complications of prematurity)

N.B in lower level health facilities referral of patients after pre-referral care
including administration of1st dose of Mg sulfate for sever preeclampsia/
eclampsia is recommended

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Management of Mild Preeclampsia

GA greater than 37wks

* In women with mild pre-eclampsia at term (37 + 0/7 weeks or more),

induction of labour is recommended.

GA less than 37 wks

* the goal is to achieve a GA of 37wks if there is stable maternal & fetal

condition
* monitor maternal & fetal condition
* advise on danger signs
* Delivery at 37 complete weeks

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Guidance on monitoring and timing of delivery
for sever preeclampsia

 GA less than 28wks (termination)

* administer Mgso4, antihypertensive

* Terminate Pregnancy(induction) after thorough counseling

 GA b/n 26/28wks to 34wks (conservative management)
* MGso4, antihypertensive, steroids for lung maturity
* close maternal/fetal monitoring
* termination at GA of 34wks or fetal & maternal status deteriorates
 GA above 34wks: (termination)
* induction or CS after stabilization

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 QUESTION ???

 What is “eclampsia”?

 When can it occur?

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Eclampsia: Typical signs

 Generalized tonic clonic convulsions occurring after 20 weeks of gestation

in a woman without a previously known seizure disorder. (Can also occur
intrapartum and in first few days postpartum.)
 Proteinuria (negative in 15% - 20%)
 Elevated Blood pressure
 A small proportion of women with eclampsia have normal blood
pressure (20%)

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 QUESTION ???

What should be your initial response when you

find a woman in late pregnancy , labor or
postpartum convulsing?

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Initial Assessment and Management of
Eclampsia
 Shout for help - mobilize personnel
 Rapidly evaluate breathing and state of consciousness
 If not breathing, assist ventilation using Ambu bag and mask
 Check airway, blood pressure and pulse
 Use air way to open and prevent tongue bite; if available
 Give oxygen at 4–6 L per minute via nasal cathetor;

 Position on left side

DO NOT LEAVE THE WOMAN UNATTENDED

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Initial Assessment and Management of
Eclampsia; contd…

 Protect from injury but do not restrain

 Start IV infusion with large bore needle (16-gauge)
 If eclampsia is diagnosed, initiate magnesium sulfate
 If the cause of convulsions has not been determined, manage as eclampsia
and continue to investigate other causes.
 Administer prophylactic antibiotics (e.g Ampiciline or ceftriaxone; if
unconscious add Metronidazole)

DO NOT LEAVE THE WOMAN UNATTENDED

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Post-convulsion Management

 Prevent further convulsions

 Control blood pressure
 Prepare for delivery (if undelivered)
 After emergency management and initiating
magnesium sulfate refer urgently to a higher facility.

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Antihypertensive Drugs for sever
hypertension
Drugs Principles:

 Hydralazine
 Initiate anti-hypertensives if diastolic
blood pressure ≥110 mm Hg and/or
 Labetolol
Systolic BP ≥ 160mmhg
 Nifedipine
 Maintain diastolic blood pressure
 Aldomet (in areas where above
between 90-105 mm Hg to prevent
drugs are not available 750mg PO
cerebral hemorrhage
every 3hrs)

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Antihypertensive Drugs

Hydralazine
 Administer 5 mg IV, slowly (risk of maternal hypotension;
closely monitor blood pressure).
 Repeat every 20 minutes until BP goal is achieved (DBP 90-
105mmhg and SBP 140-155mmhg).
 If BP is not controlled after administering a total of 20mg,
another agent should be used (Nifedipine)

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Antihypertensive Drugs

Nifedipine

Administer 5–10 mg orally or sublingual.



Repeat dose after 30 minutes until optimal blood



pressure is reached (see above).

The maximum total dose is 30 mg



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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Anticonvulsive Drugs

 Magnesium sulfate
 Diazepam
 Phenytoin

* Numerous well designed studies have confirmed

that Magnesium sulfate is the drug of choice for
preventing and treating convulsions in pre-
eclampsia and eclampsia

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Magnesium Sulfate; contd…

 Use magnesium sulfate in

 Women with eclampsia
 Women with severe pre-eclampsia
 Women with mild pre-eclampsia intrapartum and postpartum for the
first 24 hrs

(Start magnesium sulfate when decision for delivery is made)

 Continue therapy until 24 hours after delivery or the last convulsion,
whichever occurs last

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Magnesium Sulfate protocol:
 Loading dose
 4 gm magnesium sulfate( MgSo4) as 20% solution IV given over 5
minutes (Mix 8 ml of 50% Mgso4 solution with 12ml of D5W or 09%
Normal saline to make 20% solution)
 10 g of 50% magnesium sulfate (MgSo4) solution, 5 g in each buttock as
deep IM injection with 1mL of 2% lignocaine in the same syringe. Ensure
that aseptic technique is practiced when giving magnesium sulfate deep IM
injection.

NB. Warn the woman that a feeling of warmth will be felt when magnesium
sulfate is given

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Magnesium Sulfate…….Cont’d

 If convulsions recur after 15 minutes, give 2 g magnesium

sulfate (50% solution) IV over 5 minutes.
 Maintenance dose
 5 g magnesium sulfate (50% solution) + 1 mL lignocaine
2% IM every 4 hours into alternate buttocks.
 Continue treatment with magnesium sulfate for 24 hours
after delivery or the last convulsion, whichever occurs last.

BEmONC – LRP: Ethiopia Management of Headache, Convulsions,

Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Magnesium Sulfate protocol: contd…
Monitoring Hourly
Assess Normal Findings
Level of Sleepy but
consciousness arousable
16 breaths/minute
Respiratory rate
or more
Deep tendon reflexes Minimal but present
NB: Administer Magnesium cautiously in women with
hypotension, pulmonary edema, atonic PPH
: recent evidences suggest concomitant
administration of Mg sulphate with Nifedipine is NOT
contraindicated
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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Magnesium Sulfate protocol: contd…

 Before repeat administration, ensure that:

 Respiratory rate is at least 16 per minute.
 Patellar reflexes are present.
 Urinary output is at least 30 mL per hour over 4 hours.
 WITHHOLD OR DELAY DRUG IF:
 Respiratory rate falls below 16 per minute.
 Patellar reflexes are absent.
 Urinary output falls below 30 mL/hour over preceding
4 hours.

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Magnesium Sulfate protocol: contd…
 Keep antidote ready
 In case of respiratory arrest:
Assist ventilation (mask and bag, anaesthesia


apparatus, intubation).
 Give calcium gluconate 1 g (10 mL of 10% solution)

IV to antagonize the effects of magnesium sulfate

* Once patients condition has been stabilized, restart with
half the dose of magnesium with close monitoring

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Referral to a higher (Tertiary care) center

Consider referral of women who have:

 HELLP-syndrome (haemolysis,  severe pre-eclampsia and

elevated liver enzymes and low maternal and fetal well-being
platelets) coagulopathy cannot be adequately monitored

 persistent coma lasting more than  uncontrolled hypertension despite

24 hours after convulsion treatment with anti-hypertensives

 oliguria that persists for 48 hours

after giving birth

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Prevention of Preeclampsia (WHO 2016)
 Low-dose acetylsalicylic acid (aspirin, 75 mg) from before 20 weeks
of gestation (as early as 12 weeks) until 34wks of GA for women at
high risk of developing pre-eclampsia
* previous severe pre-eclampsia,
* diabetes,
* chronic hypertension,
* obesity,
* renal disease,
* autoimmune disease and
* multiple pregnancies.

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Strategies for Preventing Eclampsia

 Antenatal care and  3.4% of women with

early recognition of severe pre-eclampsia will
hypertension have a convulsion
 Timely & effective
treatment of pre-  Eclampsia is abrupt in
eclampsia by skilled onset, without warning
attendant signs in about 20% of
 Timely delivery women

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Summary

 Show SDA video on hypertension in Pregnancy

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Case Study

 Divide participants into groups of 4-5

 Each group should read Case Study: Pregnancy-
Induced Hypertension and answer the questions
 Reassemble the larger group and discuss case
study and questions

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 Summary

 There are many manifestations of increased blood pressure in

pregnancy
 Vigilant care is needed to make the diagnosis
 Once the diagnosis is made, appropriate treatment can reduce
morbidity and mortality
 Anticonvulsants should be used, with magnesium sulfate being
the first line
 Anti-hypertensives should be employed if DBP is >110 and or
SBP > 160mmhg.
 Close monitoring is needed for side effects

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Best Practices in Maternal and Newborn Loss of Consciousness or Elevated Blood
 References
 WHO. Managing Complications of Pregnancy and Childbirth. WHO. Geneva. 2017.
 Gabbes Text book of Obstetrics (2013)
 WHO (2016) ANC For Positive Pregnancy Experience
 American College of Obstetricians an Gynecologists. 1996. Technical Bulletin Hypertension in
Pregnancy. #219.
 Moutquin J et al. 1985. A prospective study of blood pressure in pregnancy: Prediction of pre-
eclampsia. Am J Obstet Gynecol 151: 191–196.
 Saudan P et al. 1998. Does gestational hypertension become pre-eclampsia? Br J Obstet
Gynaecol 105: 1177-1184.
 Szal SE, MS Croughan-Minihane and SJ Kilpatrick. 1999. Effect of magnesium prophylaxis
and pre-eclampsia on the duration of labor. Am J Obstet Gynecol 180: 1475–1479.
 Villar MA and BM Sibai. 1989. Clinical significance of elevated mean arterial blood pressure
in second trimester and threshold increase in systolic and diastolic blood pressure during third
trimester. Am J Obstet Gynecol 160: 419–423.
 Witlin AG, SA Friedman and BM Sibai. 1997. The effect of magnesium sulfate on the duration
of labor in women with mild pre-eclampsia at term: a randomized, double-blind, placebo-
controlled trial. Am J Obstet Gynecol 176(3): 623–627 .

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