PREGNANCY INDUCED

HYPERTENSION
dr. I Gede Mega Putra, O&G (C)
Obstetrics and Gynecology Departement
Faculty of Medicine Udayana University
 Introduction

 Hypertensive disorders complicate 5 to 10 percent of all pregnancies, and

together they form deadly triad, along with hemorrhage and infection

 WHO systematically reviews maternal mortality : In developed countries,

16 % maternal deaths were due to hypertensive disorders. This percentage is
greater than three other leading causes: hemorrhage—13 percent, abortion
—8 percent, and sepsis—2 percent.

 Almost 16 percent of 3201 maternal deaths were from complications of

pregnancy-related hypertension. Over half of these hypertension-related
deaths were preventable.
 Terminology
and classification

Classification of hypertensive
disorders complicating pregnancy 1 Gestational hypertension
describes into four types:

2 Preeclampsia-eclampsia( mild and severe PE )

3 Superimposed Preeclampsia-eclampsia

4 Chronic(preexisting) hypertension.
Diagnosis Hypertension
in Pregnancy

Hypertension is diagnosed empirically when appropriately taken

blood pressure exceeds 140 mm Hg systolic or 90 mm Hg
diastolic. Korotkoff phase V is used to define diastolic pressure.
Diagnosis Hypertension
in Pregnancy
Gestational Hypertension

Systolic BP 140 or diastolic BP 90 mm Hg for first time during pregnancy, without

proteinuria and BP returns to normal before 12 weeks postpartum

Mild Preeclampsia

BP 140/90 mmHg or over, but less than 160/ll0 mm Hg, after 20 weeks gestation
Proteinuria 0,3 gr / L in 24 hours or +1-2 on dipstick
Diagnosis Hypertension
in Pregnancy
Severe Preeclampsia

• BP160/110 mmHg or over, after 20 weeks gestation

• Proteinuria 5 gr in 24 hours or +3-4 on dipstick
• Oligouria, urine production less than 500 cc in 24 hrs along with increasing level of creatinin
serum
• Subjective complain : visual disturbance, persistent headache, epigastric pain
• HELLP syndrome (Hemolysis, Elevated Liver enzyme, Low Platelet count)
• Cyanosis and Intrauterine fetal growth restriction

Eclampsia

Seizures that cannot be attributed to other causes in a woman with preeclampsia

 Diagnosis Hypertension
in Pregnancy

Superimposed Preeclampsia On Chronic Hypertension:

• New-onset proteinuria 300 mg/24 hours in hypertensive women but no
proteinuria before 20 weeks' gestation
• A sudden increase in proteinuria or blood pressure or platelet count < 100,000/L
in women with hypertension and proteinuria before 20 weeks' gestation

Chronic Hypertension
BP 140/90 mm Hg before pregnancy or diagnosed before 20 weeks' gestation not
attributable to gestational trophoblastic disease or Hypertension first diagnosed
before 20 weeks' gestation and persistent after 12 weeks postpartum
Break
question

?
What is the diagnose when 32 weeks of
pregnancy come to you with blood
pressuere 150/100 with proteinuria +2
with complained nausea and headache?
Pathofisiology
disease of theories

Abnormality Placenta ischemic,

vascularization of free radical, and
placenta theory endotel dysfunction

1 2 3
Imunology intolerance between
mother and fetus theory

Inflammation
theory 7 6 5 4 Cardiovascular
adaptation theory
Nutrition Genetic deficiency
deficiency theory theory
Abnormality vascularisation of
placenta theory
In pregnancy induced hypertension
In normal pregnancy

1 Remodeling the uterine spiral arterioles Incomplete trophoblastic invasion shallow

2 invasion uterine spiral arterioles
2 invaded by endovascular trophoblasts
muscularis lining uterine spiral arterioles

Replace the vascular endothelial and

3 muscular linings to enlarge the vessel
diameter & making the lining more firm
4 Easily distention and vasodilatation
reduced the blood pressure, vascular
5 resistance, and increasing blood flow in
utero-plasenta
3 become rigid, hard to distention and
vasodilatation  failed remmodeling
mean external diameter is only half vessels
4 in normal
impairs placental blood flow 
5 diminished perfusion and a hypoxic
environment
In Normal
Pregnancy

Pregnancy
Induced
Hypertension
Placenta ischemic, free radical,
and endotel dysfunction

1 2 3 4

Remmodeling Free Radical Damage Sel Dysfunction

damage membran sel
failure in remmodeling and produce free radical caused endothelial
cause ischemia and hypoxia And increased in lipid
“hidroxyl”
peroxide
dysfunction

Endothelial dysfunction further cause:

1.Prostaglandin metabolism impairment  tromboxane >>
2.Platelet agregation
3.Glomerular endotheliosis
4.Increased capillary permeability
5.Increased vasopressor production
6.Coagulation factor stimulation.
Imnonology intolerence between
mother and fetus theory

In normal pregnant
Immune response don’t reject
conception product because
of HLA-G.

Women with pregnancy induced hypertension

•Decreased in HLA-G make intolerance maternal to placenta.
•Early in a pregnancy, extravillous trophoblast express reduced amounts
of immunosuppressive human leukocyte antigen G (HLA-G) 
defective placental vascularization.
•Beginning in the early second trimester, in preeclampsia a significantly
lower proportion of helper T cells (Th1) compared with normotensive
women.
Cardiovascular
adaptation theory

Women with pregnancy

1 induced hypertension

Loss refracter capability againts

2 vasoconstrictor in blood

vassels  blood vassels become

3 very sensitive with

4 vasopressor product  high blood pressure

Genetic deficiency
theory

• Association between HLA-DR4 and proteinuric hypertension.

• Angiotensinogen gene variant T235 had a higher incidence preeclampsia and fetal growth restriction.
• Some of the inherited thrombophilias considerations in the development of hypertensive disorders due to
pregnancy predispose some women to preeclampsia.
• Polymorphisms of the genes for TNF, lymphotoxin-alpha, interleukin-1B have been studied with varying
results.
Nutrition deficiency
theory

Clinical trial from Ecuador with double

blind showed that women given calcium
suplementation 14% preeclampsia
compared with placebo 17%.

Fish Oil Calcium

Fish oil consumption Calcium deficiency
could reduce the risk of increase risk of getting
preeclampsia preeclampsia/eclampsia
Inflammation theory

In response to release antiangiogenic and provoke extreme activated

ischemic metabolic factors and other endothelial cell state of leukocytes in
changes inflammatory mediators dysfunction the maternal

production of the lipid- injure endothelial cells, modify their generate Tumor necrosis
laden macrophage nitric oxide production, and interfere highly toxic factor- (TNF-) &
foam cells with prostaglandin balance radicals interleukins (IL

Increased capillary permeability manifest by edema and proteinuria.

Management
Hypertension in Pregnancy
Management of mild
Preeclampsia
Base on NICE Guidlines
(Nasional Institute for Health and Care Exellence)
Improving health and social care through evidence-based guidance

Outpatient Inpatient Obstetrics/active

 A.Tidak mutlak harus tirah baring, dianjurkan ambulasi sesuai keinginannya.

Outpatient
Mild Preeclampsia
(NICE recommendation)

Tidak mutlak harus tirah baring, dianjurkan

ambulasi sesuai keinginannya 1
Do not recommend salt restriction during pregnancy solely to prevent
gestational hypertension or pre-eclampsia.
(NICE recommendation )
2
If conservative management of severe gestational hypertension or pre-
eclampsia is planned, carry out all the following tests at diagnosis:
3
ultrasound fetal growth and amniotic fluid volume assessment
umbilical artery doppler velocimetry
(NICE reccomendation )
 Outpatient
Mild Preeclampsia
(NICE recommendation)

Laboratory test : complete blood count, homocystein urinalysis, renal

function test, random blood sugar 4
Advise women with more than one moderate risk factor for pre-eclampsia to
take 75 mg of aspirin* daily from 12 weeks until the birth of the baby. Factors
indicating moderate risk are
5
1.first pregnancy
2.age 40 years or older
3.pregnancy interval of more than 10 years
4.body mass index (BMI) of 35 kg/m2 or more at first visit
5.family history of pre-eclampsia
6.multiple pregnancy.
 (NICE reccomendation )

Office visit every 1 week 6

 A.Tidak mutlak harus tirah baring, dianjurkan ambulasi sesuai keinginannya.

inpatient
Mild Preeclampsia
(NICE recommendation)

Indication Inpatient
Maternal Monitoring
If the result of fetal assesment are
doubtful or even poor, hospitalize for
termination
Fetal Monitoring
There are no improvement on patient
condition after 2 visit
Laboratory Monitoring
If there is one or more abnormal
laboratory finding

If there any tendency to become severe

preeclampsia ( one or two sign or
symptomps of severe PE )
 inpatient
Mild Preeclampsia
(NICE recommendation)
Maternal Monitoring
Maternal Blood Pressure Sign Impending Eclampsia
Monitoring maternal blood • Epigastrial Pain.
pressure Every 4 hours, • Mata berkunang-kunang
unless mother is sleeping • Irritable
• Headache .
Edema on extremity Monitoring maternal weight
And face Body every day
Clinical sign of fluid Acumulation of fluid should
accumulation in be monitored every day
preeclampsia shoild be
monitored every day
 inpatient
Mild Preeclampsia
(NICE recommendation)

Fetal Monitoring
BPP
Biophysical Profile

• Poor, deliver the baby

USG Doppler
Umbilical artery doppler
Uterine arteri doppler
• Doubtful, re-evaluate NST, fetal well
being, one day after
• Good, continue the treatment for at
least 4 days
 If the pregnancy are preterm :
NST Fetal Growth discharge from hospital
NST should be Fetal growth shoul be  If the pregnancy are term : deliver
twice a week monitored
with USG every 3-4 weeks
the baby
 If there are subjective complains :
treat as severe PE case
 inpatient
Mild Preeclampsia
(NICE recommendation)

Laboratory Monitoring
Gestosis Index
Gestos index should be monitored for the
prognostic value in preeclamsia case

Urine Laboratory Blood Test Urine Production

Urine labratory for Hematocrite, Platelet, Liver
monitor of Urine
proteinuria should be function test, Kidney
production every day
monitored when admission function test monitored
Normal production 0,5-
and followed for next 2 every 2 weeks
1cc/Kg/hours
days
Management of Severe
Preeclampsia
Base on Clinical Medicine Emergency LANGE

Medical decision making

In a pregnant patient with hypertension, the presence of
proteinuria is enough to make a diagnosis of preeclampsia

Before confirmation of proteinuria, other diagnoses should be

considered.
Management of Severe
Preeclampsia Pregnant Female (Usually > 20 weeks)

Base on Clinical Medicine Emergency LANGE

BP >140/90 And Proteinuria

Ask about symptoms of headache, abdominal

pain, visual disturbances, or edema
Initial Treatment
Initial treatment is focused on
seizures No seizures
stabilizing the patient. Place
the woman in the left lateral
decubitus position to improve Eclampsia Preeclampsia
circulation
Hemolysis (anemia), Abnormal Liver Enzimes,
Thrombocytopenia

HELLP Syndrome
 Severe preeclampsia

• Hospitalized
• Maternal and Fetal Evaluation 24 hours
• MgSO4 24 hours
• Anthyhipertensive if sistolik ≥ 160 mmHg dan
atau Diastolik ≥ 110 atau MAP > 125 mmHg
Algorithm of Severe
Maternal distress and (or)
Non reassuring Fetal status
Preeclampsia
Base on Clinical Medicine Emergency LANGE
No Tidak Yes And NICE Guidlines

< 24 wks 24-<34 wks 34-36+6 wks 37 wks

Conservatif

Failed Success

if required, a course of
corticosteroids has been
completed.

Termination Delivery
Management of Severe
Preeclampsia
Base on Clinical Medicine Emergency LANGE
ABC
Apply supplemental
oxygen, cardiac
monitoring, and establish
intravenous (IV) access.
Avoid over hydration, as it
may result in pulmonary
edema
Antihypertensive
Antihypertensive therapy is
indicated in the setting of
severe hypertension
(systolic blood pressure
>160 mmHg or diastolic
blood pressure >1 1 0
mmHg)
MgSO4
The definitive treatment of
Magnesium remains the
preeclampsia and
drug of choice for the
eclampsia is delivery of the
treatment of severe
fetus
preeclampsia and
eclampsia
ABC
Severe Preeclampsia
(NICE recommendation)

Airway and Cardiac Monitoring

Breathing Apply Cardiac monitor
Apply supplemental oxygen

Intravenous Line
Establish IV access
 Antihypertensive
Severe Preeclampsia
(NICE recommendation)

• Dangerous hypertension can cause

cerebrovascular hemorrhage, hypertensive
encephalopathy and can trigger eclamptic
convulsions, afterload congestive heart failure
and placental abruption.
• Recommended that treatment lowering
systolic pressures to 160 mm Hg.
• Most of these were hemorrhagic—93 percent
—and all women had systolic pressures > 160
mm Hg before suffering their stroke.
• The three most commonly are hydralazine,
labetalol, and nifedipine.
Orally administered nifedipine as first-line
treatment for severe gestational hypertension.
Antihypertensive
Severe Preeclampsia
(NICE recommendation)
The use of antihypertensive drugs in attempts to prolong
pregnancy or modify perinatal outcomes in pregnancies.
 Magnesium
Sulfat
Severe Preeclampsia
(NICE recommendation)

In more severe cases of preeclampsia, as well as in eclampsia, magnesium sulfate is an effective anticonvulsant
that avoids producing central nervous system depression in either the mother or the infant.
 Definitive therapy
Severe Preeclampsia
(NICE recommendation)

Conservative Therapy
• If gestational age less than 37 weeks, without subjective complain and fetal well being is good.
• Bed rest.
• IVFD Ringer lactate 60 cc/hour
• Magnesium sulfate: first dose MgSO4 40% 10 gram intramuscular, continue with MgSO4 40% 5 gram
every 6 hours until 24 hours.
• Give antihypertension Nifedipine 3x10 mg (orally) if BP systolic < 180 mmHg and diastolic < 110
mmHg or clonidin 1 amp diluted into 10 cc and give first dose 5 cc in 5 minute, the rest 5 cc given if
BP still high.
• Evaluation with complete blood count, LF, RF, UL, Gestosis Index, Proteinuria @ 24 hours.
 Definitive therapy
Severe Preeclampsia
(NICE recommendation)

Active Therapy

• If gestational age 37 weeks or more, fetus well beeing is not good, there are subjective complains, HELLP
Syndrome, failed for conservative treatment, or after 24 hours conservative treatment BP still 160/110 or higher
• Medication :
 Hospitalize the patient
 IVFD Ringer lactate 60 cc/hour
 Magnesium sulfate: first dose MgSO4 40% 10 gram intramuscular, continue with MgSO4 40% 5 gram every 6
hours until 24 hours after the baby has beeen delivered
 Give antihypertension Nifedipine 3x10 mg (orally) if BP systolic < 180 mmHg and diastolic < 110 mmHg or
clonidin 1 amp diluted into 10 cc and give first dose 5 cc in 5 minute, the rest 5 cc given if BP still high.
 Definitive therapy
Severe Preeclampsia
(NICE recommendation)

Active Therapy

Obstetric Treatment :

• Cesarean Section done if the fetal well being assessment result is poor, patient still not in labor

• with unfavorable pelvic score, or in case of induction failure

• Induction (by using oxytocin) is performed if PS are favorable with normal result of NST

• In severe PE cases the patient has to be in labor in 24 hours.

THANK YOU