HYPERTENSIVE DISORDERS OF

PREGNANCY.
LABOR WARD MMH
DEC 2022
 CONTENTS.
OVERVIEW
AETIOLOGY AND RISK FACTORS
PATHOPHYSIOLOGY
MANAGEMENT
HELLP SYNDROME
ECLAMPSIA
PREVENTION
REFERENCES
 OVERVIEW

Hypertensive disorders are among the member

that form a deadly triad along with
hemorrhage and infection—that contributes
greatly to maternal morbidity and mortality
Probably is the leading cause of maternal
morbidity and mortality
 Overview
Hypertension is blood pressures systolic≥140 and
diastolic≥90 mm Hg (measured twice interval of 6
hours apart).
 Four major hypertensive disorders related to
pregnancy
1.Gestational hypertension
2.Preeclampsia and eclampsia syndrome
3.Chronic hypertension of any etiology
4.Preeclampsia superimposed on chronic
hypertension.
 Overview.
Hypertensive disorders complicate 5 - 10%
Preeclampsia occurs in 3 – 14%
10% preeclampsia occurs in <34 weeks
Chronic hypertension complicates 3% of
pregnancies.
Gestational hypertension 6% of pregnancies
 Pregnant woman with BP> 140/90mmHg

GA < 20 weeks GA > 20weeks

No
No protein protein
proteinuria New uria
proteinuri uria

Chronic Preecl Gestational

preeclamps
HTN superimposed HTN
ia
on chronic HTN
 Risk factors.
Maternal specific factors
Age <20 and >35years
Past obstetrical hx of preeclampsia
Nulliparity
Family history of preeclampsia
Medical conditions eg DM, HTN, obesity
Antiphospholipid syndrome
Prolonged interval btn pregnancy
Pregnancy associated factors
Chromosomal abnormalities
Hydatidiform mole
Hydrops fetalis
Multiple pregnancy
Oocyte donation or donor insemination
Urinary tract infection
Paternal – specific factors

First time father

Previously fathered a preeclamptic pregnancy
in another woman
 Aetiology.
Aetiology is not well known, however there are some
theories
Abnormal trophoblastic invasion of uterine vessels.
Immunological intolerance between maternal and
fetoplacental tissues.
Maternal mal – adaptation to cardiovascular or
inflammatory changes of normal pregnancy.
Dietary deficiencies.
Genetic influence.
 PATHOPHYSIOLOGY.
Reduced uteroplacental perfusion

Prostaglandins Endothelial activation Cytokines

Nitric oxide Lipid
Endothelins. peroxidases
Capillary leak
Edema Hemoconcentration
Vasospasm Proteinuria Activation of
coagulation

HTN, fits, liver thrombocy

ischaemia, topenia
oliguria, abruption
 Management.
Investigations.
• Goals
Support the diagnosis
Know the severity of the disease.
 Tests to be done.
CBC
Peripheral blood smear
Platelets level
Protein excretion level
Serum creatinine level
ASAT and ALAT
Serum uric acid
Coagulation level
Fetal wellbeing assessment
Non stress test
Biophysical profile
Umbilical artery Doppler flow
 Treatment.
Definitive treatment is delivery.
Determinants
Gestation age
Maternal and fetal condition
Severity of the disease
Preeclampsia is classified as
 Severe
 None-severe/ mild
 Severe No Conservative/expectant management
˂34weeksGA-steroids for 48 hrs deliver,
≥34weeks GA-deliver immediately
MgSO4 is need to prevent eclampsia
 None severe/mild
 Conservative/expectant management<37weeks
 Delivery >37weeks→ No need of MgSO4
The preferred mode of delivery→vaginal
unless there is other obstetric indication for
caesarian delivery.
 Features of severity
Proteinuria 300 mg/24
Blood pressure 160 or > +2 in dipstick
mm Hg systolic or Impaired liver function
110 mm Hg diastolic Thrombocytopenia
Cerebral or visual Fetal growth restriction
disturbances
 Epigastric or right
Severe headache upper quadrant pain
Pulmonary edema or
cyanosis
Monitoring of the patient during labor
Vital signs urine output and patellar reflexes
Every hour
Lab test
Every 6-12hours
Fetal heart tone tracing is very important
during labor.
 Anticonvulsant therapy.
Can be initiated
During labor
While giving corticosteroids
Prior induction
Until 24 – 48hours after delivery
Previously
Lytic cocktail
Chloropromazine
Promethazine
Pethidine
Currently recommended
Magnesium sulphate.
• Magnesium sulphate Toxicity
Loss of deep tendon reflexes (9.6 - 12.0 mg/dL)
Respiratory paralysis (12.0 - 18.0 mg/dL)
Cardiac arrest at 24 - 30 mg/dL
• Antidote
Calcium gluconate 1 g iv (5 - 10 min)
NB; urethral catheter should be inserted in
patients who are using MgSO4
 Antihypertensives.
Commonly used in pregnancy
Methyldopa
Hydralazine
Nifedipine
Labetalol
 Antihypertensives

Lower blood pressure

DBP 90 – 105mmHg
SBP 140 – 155mmHg
 HELLP syndrome.
• Obstetric complication
Hemolysis
Elevated liver enzymes
Low platelets
• Occurs in 0.2 – 2.6% of all pregnancies
• But 5 – 7% in preeclamptic pts
• Presentation
– 90% generalized malaise
– 65% epigastric pain
– 30% nausea and vomiting
– 31% headache.
• DDx
Acute fatty liver of pregnancy
Thrombotic thrombocytopenic purpura
Hemolytic uremic syndrome.
 Treatment.
• Delivery ≥34 weeks
• Corticosteroids
High dose Dexamethasone 10mg iv 12
hourly should be given until
 platelet >100
Resolution of elevated Liver enzymes
• Platelet transfusion if platelet count < 50
 Complications of preeclampsia.
Eclampsia
Disseminated intravascular coagulopathy(DIC)
Placental abruption
Adult respiratory distress syndrome
Hepatorenal failure
Pulmonary edema
Subcapsular hematoma and
Hepatic rupture
 Eclampsia
 Grand mal seizures in woman with
preeclampsia, in the absence of other
neurologic conditions that could account for
the seizures.
 Generally manifests by tonic-clonic seizures
or coma.
In most cases seizures are self-limited, lasting
1–2 minutes
 Eclampsia
• Nearly all tonic–clonic seizures are
accompanied by a prolonged fetal heart rate
deceleration that resolves after the seizure has
ended
 Eclamplasia
Before convulsions women present with
Hypertension
Headache(persistent frontal or occipital headache.
Visual disturbances(stocomata, loss of vision,
blurred of vision
Right epigastric pain
Asymptomatic
 ankle clonus is also a co.mmon finding
 Management of eclamplasia
Call for help
Priorities
 airway is clear
prevent injury and aspiration of gastric
contents.
The definitive treatment is delivery
(preferably within 8-12 hours)
 Management of eclamplasia
Convulsions alone do not constitute an
indication for cesarean section.
However, if vaginal birth is not possible
within a reasonable period of time, cesarean
delivery is performed in most cases.
 Management of eclamplasia
Give Magnesium suphate to prevent further
convulsions
Diazepam or lorazepam should be used only if
seizures are sustained
Urethral catheter to monitor urine output.
Avoid excessive fluids
Lab tests should taken blood typing, RFTs
liver enzymes, CBC
 Prevention.
Preeclampsia
Not preventable (however its complications
can be prevented)
Calcium supplementation
Soluble aspirin therapy
antioxidants
 References.
• P. August, B. Sibai, Clinical features,
diagnosis, and long-term prognosis of
preeclampsia, UpToDate, Sept 2010.
• Current Diagnosis and treatment Obstetrics
and Gynecology
• Williams obstetrics 23rd edition
• Ten teachers obstetrics
• L. K. Wagner, Diagnosis and Management of
Preeclampsia, Am Fam Physician, Dec 2004,
70:12
• F. G. Cunningham, K. J. Leveno, S. L. Bloom, J.
C. Hauth, Larry Gilstrap III,
Katharine D. Wenstrom, William Obstetrics,
23rd Edition