Hypertension in Pregnancy

Dr Richard Kiritta
Senior lecturer/ OBGYN
 learning objectives

• Overview
• risk factors and etiology
• Pathophysiology
• Classification
• Establishing diagnosis
• Management
• Prediction of pre-eclmpasia
• Prevention

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PREGNANCY INDUCED
HYPERTENSION
-pregnant
->=20weeks
-<= 42days after termination of pregnancy/delivery
-two readings, resting state, 4-6hrs apart

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PRE -ECLAMPSIA
• Non severe features
• Severe features

What to consider
-BP
-Protein in urine
-symptoms of end organ damage-brain, eyes, kidney, liver,blood, baby
-signs of end organ damage-laboratory work

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ECLAMPSIA
• -Convulsions, loss of conscoiusness.

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Whats the correct method?

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 overview

• WHO estimates globally 75000 women die due to hypertensive disorders during
pregnancy.

• For every maternal death, it has been estimated that an additional 20 or 30 women
suffer significant morbidity (Figo,2016)

• In Bugando, Incidence of eclamptic patients is 1.37. Maternal and perinatal case

fatality is 7.89 and 20 respectively(Ndaboine et al, 2012)

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risk factors

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 Etiopathogenesis
Will most likely occur in women whom are
• Exposed to chorionic villi for the first time.
• Exposed to a superabundance of chorionic villi
• Pre-existing vascular diseases.
• Genetically predisposed.

Williams 25th edition page 713 9

 Etiopathogenesis …
The causes may be due to

1. Abnormal placentation
2. Immunological maladaptive tolerance between maternal, paternal and
fetal tissues
3. Maternal maladaptation to cardiovascular or inflammatory changes of
normal pregnancy
4. Genetic factors

Williams 25th edition pg 714 10

 Classification
1. Preeclampsia and eclampsia syndrome
2. Chronic hypertension of any etiology
3. Preeclampsia superimposed on chronic hypertension
4. Gestational hypertension

ACOG TASK FORCE 2013 11

 pathophysiology

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 Pre-eclampsia
• Preeclampsia is diagnosed in the presence of hypertension with or without the
presence of proteinuria.
• Also now classified into either with severe features or without severe features
Systolic BP 160mmHg/DBP 110mmHg that are at-least on two occasions 4
hours apart
Thrombocytopenia(<100000 microliter)
Progressive renal insufficiency
Pulmonary edema
New onset cerebral or visual disturbances

ACOG Task force on HTN in pregnancy 2013 13

Diagnostic criteria for pre-eclampsia

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ACOG TASK FORCE 2013
 Presenting symptoms

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 Management goals
• Death that can be avoided.

• Termination of pregnancy with least possible trauma to the mother.

• Birth of a healthy new born that subsequently thrives.

• Complete restoration of health to the mother.

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 Management…
Definitive treatment is delivery.

Things to consider
• Gestation age

• Maternal and fetal condition

• Severity of the disease

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 Expectant management Vs Immediate
delivery
• While on expectant management, should be vigilante because there is
still risk of severe hypertension, HELLP syndrome, abruptio placenta,
IUGR and even IUFD.
• With immediate delivery, there’s an increase in NICU admissions and
perinatal mortality
In preterm < 28 weeks , not recommended to do expectant.(Sibai and
the Memphis et al, 1985) they tried to prolong pregnancy in 60 women
ranging GA from 17-28 weeks, results were catastrophic, 87%
perinatal mortality, all mothers experienced maternal near miss
situation.

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 Mode of delivery
• Maternal status should be stabilized first.

• Preferred mode of delivery is SVD but, fetal gestational age , fetal

presentation, cervical status will ultimately decide(obstetric
indications) or occurrence of complications.( Churchill, Duley,
Thornton, & Jones, 2013)

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 Management plan
Pre-eclampsia without severe features, consider GA, fetal
evaluation, presence of labor. deliver at 37/ 0/7, but increase
surveillance in postpartum.
Prior pre-eclampsia
• Counselling should start before the next pregnancy,
• Aspirin prophylaxis should be considered especially for those who
delivered preterm in prior pregnancy or more than one pregnancy with
pre-eclampsia

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 Management
Chronic hypertension with superimposed pre-eclampsia

• Are mostly affected with IUGR, most likely to develop eclampsia

• Should be initiated on Aspirin from late first trimester

• BP should be maintained at a range of systolic 160-120mmHg, and diastolic of

105-80mmHg

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 Management
Investigations to monitor maternal complications
• FBP
• Serum Urea and Creatinine
• Liver enzymes
• Uric acid( used to predict adverse outcomes and not as a diagnostic
tool)
• Urine for dipstick(recommended in areas where urine
protein/Creatinine ratio isn’t available)

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 Investigations to monitor fetal well being
Fetal wellbeing assessment
• Biophysical profile
• Fetal size
• Maternal and fetal doppler
• Antenatal cardiotocography

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 Antihypertensive therapy
• Has to be a balance between reducing cerebral vascular accident,
congestive heart failure, AKI Vs maintaining utero-placental blood
supply.
• Hydralazine
• Methyldopa
• Labetalol
• Nifedipine
Drug to drug interactions ,. MgS04 and nifedipine= neuromuscular
blockade.
Hypotension from spinal anesthesia with MgS04
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 Prevention of seizures
• MgSo4
1. reduced presynaptic release of the neurotransmitter glutamate,
2. blockade of glutamatergic N-methyl-D-aspartate (NMDA) receptors,
3. potentiation of adenosine action,
4. improved calcium buffering by mitochondria, and
5. blockage of calcium entry via voltage-gated channels (Eiland et al, 2012) .

Because labor and delivery is a more likely time for convulsions to develop,
women with preeclampsia-eclampsia usually are given magnesium sulfate during
labor and for 24 hours postpartum.

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 Eclampsia
The development of new onset
grandmal seizures in a woman with pre-
eclampsia
Vasospasm and cerebral oedema have
been implicated in the pathogenesis of
eclampsia
Headache, visual disturbances, or
epigastric pain are indicative that
convulsions may be imminent.

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 Management of eclampsia
• Start with ABCs

• MgS04, if still convulsing after loading dose, may repeat MgS04

loading dose of 2g IV or even higher if patient has a higher BMI

• Antihypertensive therapy with aim of maintaining Systolic blood

pressure at/< 160mmHg and diastolic at below 110mmHg.

• Delivery of the fetus should be within 12 hrs.

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 DDx
• AVM
• Ruptured aneurysms( Charcoat Bouchard)
• ?Tumour
• Cerebral malaria
• Idiopathic

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 Complications
• HELLP SYNDROME
• Placental abruption
• FGR
• Adult respiratory distress syndrome
• Hepatorenal failure
• Pulmonary edema
• Subcapsular hematoma and
• Hepatic rupture

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 prediction
Pre-eclampsia/eclampsia has a relatively low incidence, prediction test
should have high PPV and a low NPV.
Risk factors factors
• Demographic characteristics
• Prior pregnancy
• Amount of placental tissue

Biophysical findings
• Doppler Uterine/Umbilical/MCA velocimetry
• BPP
Biochemical analysis
• PlGF, VEGF, Soluble VEGF and soluble endoglin
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 Prevention
• ISSHP recommends that women with established strong clinical risk
factors for preeclampsia be treated, ideally before 16 weeks but
definitely before 20 weeks, with low-dose aspirin.

• Women considered at increased risk for preeclampsia should receive

supplemental calcium (1.2–2.5 g/d) if their intake is likely to be
lower than (<600 mg/d). When intake cannot be assessed or
predicted, it is reasonable to give calcium

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references
• Abalos E, Cuesta C, Carroli G, Qureshi Z, Widmer M, Vogel JP, Souza JP, WHO Multicountry Survey on Maternal and
Newborn Health Research Network. Pre‐eclampsia, eclampsia and adverse maternal and perinatal outcomes: a secondary
analysis of the W orld H ealth O rganization Multicountry S urvey on M aternaland N ewborn H ealth. BJOG: An
International Journal of Obstetrics & Gynaecology. 2014 Mar;121:14-24.
• Magee LA, von Dadelszen P, Stones W, Mathai M. The FIGO textbook of pregnancy hypertension: An evidence-based
guide to monitoring, prevention and management. 2016.
• Woelkers D, Barton J, von Dadelszen P, Sibai B. [71-OR]: the revised 2013 ACOG definitions of hypertensive disorders of
pregnancy significantly increase the diagnostic prevalence of preeclampsia. Pregnancy Hypertension: An International
Journal of Women's Cardiovascular Health. 2015 Jan 1;5(1):38.
• F. G. Cunningham, K. J. Leveno, S. L. Bloom, J. C. Hauth, Larry Gilstrap III, Katharine D. Wenstrom, William Obstetrics,
25th Edition
• Churchill, D., Duley, L., Thornton, J. G., & Jones, L. (2013), Interventionist versus expectant care for severe pre-eclampsia
between 24 and 34 weeks’ gestation. The Cochrane Database of Systematic Reviews, 7(7), CD003106.
https://doi.org/10.1002/14651858.CD003106.pub2
• Brown MA, Magee LA, Kenny LC, Karumanchi SA, McCarthy FP, Saito S, Hall DR, Warren CE, Adoyi G, Ishaku S.
Hypertensive disorders of pregnancy: ISSHP classification, diagnosis, and management recommendations for international
practice. Hypertension. 2018 Jul;72(1):24-43.
• Eiland E, Nzerue C, Faulkner M. Preeclampsia 2012. Journal of pregnancy. 2012 Oct;2012. 32