JIMMA UNIVERSITY

INSTITUTE OF HEALTH

COLLEGE OF HEALTH SCIENCES

SCHOOL OF MIDWIFERY

3rd year midwifery/2023

Hypertensive Disorders of Pregnancy

10/07/2023 1
 Outlines of the presentation
• Objectives
• Introduction
• Pregnancy induced hypertension
• Summary
• Reference

10/07/2023 2
 Objectives
At the end of the session students 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

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 Introduction
• Hypertensive disorders of pregnancy are an important cause of
severe morbidity, long-term disability and death among both
mothers and their babies.
• Is the second common cause of maternal death.
• Hypertensive disorders represent the most common medical
complications of pregnancy.

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 Introduction cont..

Hypertension: A systolic blood pressure of ≥140 mmHg, or

diastolic blood pressure of ≥90 mmHg or both in two occasions
taken 4 hours or more apart; or a single blood pressure recording
of ≥160/110 mmHg.
Note:
 Measure the BP in the sitting position with cuff at the level
of the heart.
 Allow the mother to sit 5 – 10 minutes before measuring

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 Introduction cont..

• Proteinuria: Two urine dipstick measurements of at least 1+

(30 mg per dL) proteinuria taken six hours apart; or at least
300 mg of protein in a 24-hour urine collection; or a urinary
protein / creatinine ratio of ≥0.3.

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 Classification
• Chronic hypertension: Hypertension that antedates pregnancy
or is present before the 20th week of pregnancy or persists
after 12 weeks postpartum.
• Pregnancy Aggravated hypertension(PAH)/Preeclampsia
superimposed on chronic hypertension/ Superimposed pre-
eclampsia:
• If proteinuria or other features of pre-eclampsia develop in a
patient with chronic hypertension.
 Superimposed pre-eclampsia without severe features.
 Superimposed pre-eclampsia with severe features.
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 Classification cont.…
Gestational hypertension: Hypertension without proteinuria or
other features of preeclampsia developing after the 20th week of
pregnancy in a previously normotensive woman.
Gestational HTN is the development of an elevated BP during
pregnancy or in the first 24 hours postpartum without other signs
or symptoms of preeclampsia or preexisting HTN.

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 Classification cont.…

Preeclampsia: A new onset of hypertension and proteinuria after

20 weeks of gestation in a previously normotensive woman.
Preeclampsia is primarily defined as gestational HTN plus
proteinuria & it is a unique form of hypertension,
"preeclampsia," occurs only during pregnancy.
 Pre-eclampsia without severe features(mild Pre-eclampsia)
 Pre-eclampsia with severe features(sever pre-eclampsia).

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 Classification cont.…

• Eclampsia: Generalized convulsion and / or coma in a woman

with preeclampsia where the convulsion or coma is not
attributed to other causes.

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 Classification cont..

Pregnant woman with BP > 140/90mmHg

Before 20 Weeks > 20 weeks

No proteinuria Proteinuria No proteinuria Proteinuria

Chronic HTN Pre eclampsia Gestational HTN Preeclampsia

Superimposed on
Chronic HTN
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 Pre-eclampsia
Mild pre-eclampsia:
• BP of ≥ 140/90 mmHg but less than 160/110mmHg
• Proteinuria: 2+ on dipstick or ≥ 300 mg/24 hours urine
collection.
• Mild pre-eclampsia often has no symptoms.
• Sometimes generalized edema.

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 Severe preeclampsia:
• BP of ≥ 160/110 mm Hg and
• Proteinuria of ≥ 3+ dipstick or ≥ 5g /24 hours urine collection.
• Plus any one or more clinical manifestations from listed below
• Headache:-increasing frequency, unrelieved by regular
analgesics (frontal/occipital)
• Clouding of vision (blurred vision/photophobia)
• Oliguria (<400 ml urine in 24hrs) (followed by rapid weight
gain)
• Upper abdominal pain (epigastric or right upper quadrant pain)
• Pulmonary edema (rapid shallow breathing, cyanosis, rales).

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 Severe preeclampsia cont..
 Deranged Renal function test (RFT)(elevated creatinine
>1.2mg/dl).
 HELLP syndrome: characterized by Hemolysis, Elevated
Liver enzyme, Low Platelet (thrombocytopenia<
100,000/uL(microliter)).
• Edema in face, eyes or hands

Diagnosis of Pre eclampsia:

• The two essential feature of pre eclampsia are Hypertension &
Proteinuria.

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 Severe preeclampsia cont..
Proteinuria:
 In absence of UTI is indication of renal damage
 Is the most serious manifestation
 Usually the last manifestation of pre eclampsia
 Is an index of severity of pre eclampsia.
Other causes of proteinuria like:
 Contaminate urine
 Chronic nephritis
 Heart failure
 Pyelonephritis should be ruled out.

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 Eclampsia
 Eclampsia is defined as the occurrence of one or more
convulsions or coma in association with syndrome of pre-
eclampsia.
 Rise blood pressure(>140/90 MmHg.) and development of
grand mal seizures or coma in a woman with preeclampsia.
 Convulsion + preeclampsia

Note: 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.
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 Reading assignment

• Pathophysiology of pregnancy induced hypertension.

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 Strategies for Preventing Eclampsia
• Taking blood pressure during preconception care and early
pregnancy helps to know the changes in blood pressure latter.
• Antenatal care and recognition of hypertension
• Identification and treatment of pre-eclampsia by skilled
attendant
• Timely delivery
• 3.4% of women with severe pre-eclampsia will have a
convulsion.
• Eclampsia is abrupt in onset, without warning signs in about
20% of women.

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 Risk factors of PIH
 Null parity(most common)
 Small vessel disease (walls of
 Extreme age(<18year,> 35
the small arteries in the
year)
heart aren't working
 Chronic hypertension
properly)
 Multiple pregnancy
 Obesity
 Diabetes mellitus
 Family history
 Chronic renal disease
 Past history
 Black history/rice
 Antiphospholipid syndrome
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 Risk factors of PIH cont..

 Polyhydramnios  Poor outcome of previous

 RH-Isoimmunized pregnancy
pregnancy (IUGR, SB)
 Low socioeconomic status
 Family history of pregnancy
 Hydatidform mole
 Previous history of induced hypertension

preeclampsia  Pregnancy from new partner

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 Complication of pregnancy induced hypertension
A. On the mother:
 Eclampsia / convulsion and associated complication
 Placental abruption
 Damage to heart, kidneys, lungs and brain
 Damage to the capillary in the fundus of the eye leading
to blindness
 DIC
 Death
B. On the fetus:
 LBW
 Intrauterine hypoxia
 IUGR
 IUFD
 Pre term baby requiring resuscitation
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 Investigations
Hematocrit Serum uric acid
Coagulation profile
Platelet count
Serum electrolyte
Urinalysis
Obstetric U/S
Quantification of
Etc
protein excretion
Serum Creatinine
Liver function test
Serum LDH level

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 Management of chronic hypertension
• High risk(older age, not being physically active, over weight)
 Better advised not to become pregnant or grant abortion.

• Low risk
 Preconception advise (life style modification, wt. loss,
↓smoking, good control of HTN).
 Early in pregnancy change drugs that are contraindicated
 Frequent ANC, look for superimposed PE.
 Termination if there is superimposition, fetal jeopardy, at
term(40wks).
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 Management of pregnancy induced hypertension
A. Gestational hypertension (hypertension with out proteinuria)
• Manage on an outpatient basis: if GA is <36 weeks and blood
pressure is mild with out antihypertensive drugs.
• Monitor blood pressure, urine (for proteinuria) and fetal
condition weekly.
• If blood pressure worsens, proteinuria ensues or severity
features appear manage as mild pre-eclampsia.
• Counsel the woman and her family on danger signs indicating
severity features or eclampsia and provide advice on
preparedness for hospital delivery/refer at 36 weeks.
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Mild pre-eclampsia management:
Gestation less than 37 weeks
 If signs remain unchanged or normalize, follow up twice a
week as an outpatient:
 Monitor blood pressure, urine (for proteinuria), and fetal
condition.
 Counsel the woman and her family about danger signs of
severe pre-eclampsia or eclampsia.
 Encourage additional periods of rest.
 Encourage the woman to eat a normal diet (salt restriction
should be discouraged).
 Orient on fetal movement counting (kick chart) daily,
• No medications (do not give anticonvulsants, anti
hypertensives, sedatives)
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Mild pre-eclampsia management cont..
Follow up
 Random urine test protein twice/week
 BP measurement twice a week
 Orient on fetal movement counting (kick chart) daily, to be
reported at ANC visits.
 The patient should report immediately if, Sudden increase
weight, Generalized edema including the upper limb and face,
Decrease in urine output, Persistence headache, Right upper
quadrant pain, Decrease fetal movement, Blurred vision,
convulsion.
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Mild pre-eclampsia management cont..
Gestation more than 37 completed weeks:-
 If the woman's condition remains stable & there is no signs of
IUGR, Continue monitoring, expectant management.
 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 &
promptly delivery.

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Management of Severe pre-eclampsia and eclampsia
 Most of the time ,Severe pre-eclampsia and eclampsia are
managed similarly with the exception that plan of delivery.
 All cases of severe pre-eclampsia and eclampsia should be
managed actively.
Management principle
1. ABC
2. Control of Convulsion
3. Control of hypertension
4. Delivery
5. Prevent and Management of other complication

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 Initial Assessment and Management of sever pre-
eclampsia and 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(ABC)
 Use air way to open and prevent tongue bite; if available
 Give oxygen at 4–6 L per minute via nasal catheter;
 Position the patient on her side (left lateral) and in
Trendelenburg (head down) position to reduce risk of
aspiration of secretions, vomitus or blood.
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 Initial Assessment and Management of sever pre-eclampsia
and Eclampsia
• 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.
• Prepare equipment for convulsion management, at bedside
(mouthpiece, airway, suction equipment, mask & bag, oxygen)
• Avoid tongue bite by placing an airway or padded tongue
blade between the teeth.
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 Initial Assessment and Management of sever pre-eclampsia
and Eclampsia

 Never leave the patient alone (if convulsion occurs, aspiration

may cause death)

 Observe vital signs, FHB & reflexes hourly .

Active management of sever pre-eclampsia and Eclampsia

1. To prevent convolution initially/ further convulsions(using

Anticonvulsant drugs).

2. Control blood pressure(using Antihypertensive drugs) .

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 Anticonvulsive drugs
List of commonly used anticonvulsive drugs include:
 Magnesium sulfate(first line and safe))
 Diazepam
 Phenytoin
 Magnesium sulfate is the drug of choice for preventing and
treating convulsions in severe pre-eclampsia and eclampsia.

 MgSO4 was the most effective drug in reducing death and further
fits.

 MgSO4 is a CNS depressant and has vasodilator effects to lower

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BP.
 Magnesium Sulfate (Mgso4)

Use magnesium sulfate to convolution during:-

 Women with eclampsia

 First-line treatment of any seizure during pregnancy

 Women with severe pre-eclampsia necessitating delivery.

 Continue therapy until 24 hours after delivery or the last

convulsion, whichever occurs last.

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 Magnesium Sulfate cont..
Loading dose

 4 g magnesium sulfate( Mgso4) as 20% solution IV given over 5

minutes(Mix 8 ml of 50% Mgso4 solution with 12ml of D5W or

Normal saline to make 20% solution).

 10 g of 50% magnesium sulfate (Mgso4) solution, 5 g in each

buttock IM injection with 1 mL of 2% lidocaine in the same

syringe.

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 Magnesium Sulfate cont..

 Warn/inform the woman that a feeling of warmth will be felt

when magnesium sulfate is given.
 If convulsions recur after 15 minutes, give 2gm magnesium
sulfate (50% solution) IV over 5 minutes.

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 Magnesium Sulfate cont..

Maintenance dose

• 5gm magnesium sulfate (50% solution) + 1 mL lidocaine 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.

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 Magnesium Sulfate cont..
Before repeat administration, ensure that:
 Respiratory rate is at least 12 per minute.
 (Deep Tendon Reflex) Patellar reflexes are present.
 Urinary output is at least 30 mL per hour over 4 hours.

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 Magnesium Sulfate cont..
Withhold or delay drug if:
 Respiratory rate falls below 12 per minute.

 Patellar reflexes are absent.

 Urinary output falls below 30 mL/hour over preceding 4 hours.

 Keep antidote ready, In case of respiratory arrest/magnesium

sulfate toxicity :
 Assist ventilation (mask and bag, anesthesia apparatus, intubation).

 Give calcium gluconate 1gm (10 mL of 10% solution) IV slowly

until respiration begins to antagonize the effects of magnesium
sulfate.
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 Documentation while providing Magnesium Sulfate…
 Complete documentation before and after administration of
magnesium sulfate
 Name of provider
 Findings(including respiratory ,urine output, patellar reflex,
consciousness).
 Time of administration
 Route(right or left site).
 Dose
 All relevant findings of abnormality should be recorded and
communicated timely.
 Monitoring of catheter leakage, to monitor urine out put.
• Communication patients about the timing/ schedule to remained
the provider.
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 Diazepam
 If magnesium sulfate is not available, diazepam may be used
although there is a greater risk for neonatal respiratory
depression because diazepam passes the placenta freely.
 A single dose of diazepam to abort a convulsion seldom causes
neonatal respiratory depression.
 Long-term continuous IV administration increases the risk of
respiratory depression.

10/07/2023 40
 Diazepam cont..
Intravenous administration
Loading dose
• Diazepam 10 mg IV slowly over 2 minutes.
• If convulsions recur, repeat loading dose.

Maintenance dose :Diazepam 40 mg in 500 mL IV fluids (normal

saline or Ringer’s lactate) titrated to keep the woman sedated but
arousal.
• Maternal respiratory depression may occur when dose exceeds
30 mg in 1 hour.
• Do not give more than 100 mg/24hrs(risk of respiratory
depression).
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 Antihypertensive Drugs
 If the diastolic pressure is 110 mm Hg or more, give
antihypertensive drugs.
 The goal is
 To keep the diastolic pressure between 90 mm Hg and 100
mm Hg
 Prevent cerebral hemorrhage.

Safe and feasible options of antihypertensive include :

 Nefidipine(Calcium channel blockers)
 Labetalol (α & β blocker)
 Hydralazine ( peripheral vasodilator )
 Methyldopa ( central and peripheral antiadrenergic)

10/07/2023 42
 Hydralazine
• Hydralazine is the drug of choice to treat acute therapy.
• The onset of action is 10–20 minutes, and the dose can be
repeated in 20–30 minutes if necessary until diastolic BP is
around 90 mmHg. .
• Give hydralazine 5 mg IV slowly (3-4 minutes)
• If IV not possible give IM.
• Do not give more than 20 mg in total.

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 Labetalol
If hydralazine is not available,
give:
 labetalol 10 mg IV:
 If response is inadequate (diastolic blood pressure remains
above 110 mm Hg) after 10 minutes, give labetalol 20 mg IV;
 Increase the dose to 40 mg and then 80 mg if satisfactory
response is not obtained after 10 minutes of each dose.
 It works by relaxing blood vessels and slowing heart rate to
improve blood flow and decrease blood pressure.
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 Nifedipine

 Nifedipine 5 mg under the tongue:

 5-10 mg sublingually (under the tongue) as initial dose, followed

by 5-10mg if response is inadequate (in 30 minutes).

 Then continue as 10-20 mg PO every 6 hours.

 For maintenance therapy 10-40mg PO bid

 Side effects: edema, flushing, headache, palpitation, mgso4

toxicity, tocolysis (may stop labor).

10/07/2023 45
 4. Delivery
 Termination of pregnancy is the definitive and curative treatment.

Note: The ultimate aim is to prolong pregnancy until the fetus is

sufficiently mature enough to survive, while safeguarding the
mother’s life.
Factors that determine whether to follow aggressive(delivery) or
conservative management are:
 The gestational age/ Duration of the pregnancy
 The severity of disease
 Response to treatment
10/07/2023 46
 The fetal maturity or fetal condition
 Delivery cont..
 Delivery should take place as soon as the woman’s condition has
stabilized.
 Delivery should occur regardless of the gestational age(in case of
sever preeclampsia and eclampsia).
 In severe pre-eclampsia, delivery should occur within 24 hours of
the onset of symptoms.
 In eclampsia, delivery should occur within 12 hours of the onset

of convulsions.

10/07/2023 47
 Intrapartum care
 FHB monitoring every 15 min
 Maternal vital sign every 30 min-1 hr.
 Urine out put every 4 hrs.
 Shorten the second stage of labor
 Prevent PPH (mange third stage actively using oxytocin).

N.B-Ergometrine use is contraindicated.

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 Postpartum care
 Anticonvulsive therapy should be maintained for 24 hours after
delivery or the last convulsion, whichever occurs last.
 Continue antihypertensive therapy as long as the diastolic
pressure is 110 mm Hg or more.
 Continue to monitor urine output.
 Post natal care and counseling on hormonal contraception
danger signs of mother and newborn etc.

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 Postpartum care…
Consider referral of women who have:
 Oliguria that persists for 48 hours after delivery;
 Coagulation failure [e.g. coagulopathy or hemolysis, elevated
liver enzymes and low platelets (HELLP) syndrome
 Persistent coma lasting more than 24 hours after convulse

 If heart, kidney or liver failure is suspected

 If there is increasing drowsiness or coma

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 The role of Midwives in detection of PIH
 Pregnancy induced hypertension is unlikely to be prevented,
early detection and appropriate management can minimize the
severity of the condition.
 A midwife is in a unique position to identify those woman
with risk to pregnancy induced hypertension
History taking at booking visit will include:
 Adverse social circumstances or poverty
 Family tendency towards hypertension
 Mothers age and parity
 A new partnership
 A past history of pre-eclampsia.

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 References
 Basic Emergency Obstetric & Newborn care (BEmONC)
Training Manual Federal Democratic Republic of Ethiopia
Ministry of Health, 2013
 Management protocol on selected obstetrics topics,Federal
Democratic Republic of Ethiopia Ministry of Health January,
2010.

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 Summary
• Pregnancy induced hyperextension

• Classification of induced hyperextension

• Diagnosis and management of induced hyperextension

• Role of midwives

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 Thank you for your attention!
Questions?
Comments ?

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