Cardiovascular System

Unit II: Hypertensive Disorders in

Pregnancy
Jimmy M. Hangoma (Bpharm, MClinPharm, PhD Fellow)
HoD/Lecturer-Levy Mwanawasa Medical University/School of
Health Sciences/Department of Pharmacy
Clinical Pharmacist-University Teaching Hospitals, Women &
Newborn Hospital
Part-time Lecturer: UNZA, CUZ, LAMU

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 Classification of hypertensive
disorders of pregnancy

Preeclampsia

eclampsia

Chronic hypertension

Chronic hypertension with superimposed preeclampsia

Gestational or transient hypertension

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 I. Pre-eclampsia (PE)

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 Objectives

A unique disease (syndrome) of pregnant woman in the

second half of pregnancy

Carries significant maternal & fetal morbidity and mortality.

Two criteria for diagnosing preeclampsia

 hypertension & proteinuria, in eclampsia

 tonic and clonic convulsions

The definite cure of preeclamsia & eclampsia is delivery

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 Definition of preeclampsia

 The presence of hypertension of at least 140/90 mm Hg recorded

on two separate occasions at least 4 hours apart and in the
presence of at least 300 mg protein in a 24 hours collection of urine
arising de novo after the 20th week gestation in a previously
normotensive women and resolving completely by the sixth
postpartum week

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 Classification of Pre-eclampsia

Mild PE
 Diastolic blood pressure 90-
<110mmHg
Urine protein <3+
Normal heamatological and
biochemical parameters
Severe PE
BP>160/110mmHg
Urine protein > 5grams (3+)
Abnormal haematological and
biochemical parameters,
abnormal fetal findings

No fetal compromise

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 Aetiology of preeclampsia

(Genetic predisposition)

(Abnormal immunological response)

(Deficient trophoplast invasion)

(Hypoperfused placenta)

(Circulating factors)

(Vascular endothelial cell activation)

(Clinical manifestations of the disease)

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 Epidemiology of PE

Incidence- 3% of pregnancies.

More common in primigravid

There is 3-4 fold increase in first degree relatives of

affected women

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 Risk factors for PE
Condition in which the placenta is enlarged
 Diabetes
 hydrops

Pre-existing hyertension or renal diseases

Primagravid

Age (<18 years or > 35 years)

Pre-existing vascular disease

 Diabetes
 autoimmune vasculitis

Change of partners

Smoking
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 Pathophysiology of PE
Defective trophoblast invasion

hypoperfused placenta

release factors (growth factors, Cytokines)

vascular endothelial cell activation

Vasospasm Endothelial cell damage

Hypertension edema & hemoconcentration

Kidneys, glomeruloendotheliosis proteinuria, reduced uric excretion

and oliguria

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 Pathophysiology of PE Cont’d

Liver, subendothelial fibrin deposition leading to elevated liver,

hemorrhage, infarction, liver rupture and epigastric pain

On blood there is thrombocytopenia, DIC, HELLP syndrome

Placental vasospasm placental infarction, placental abruptio &

reduced uteroplacental perfusion leading to IUGR

CNS vasospasm & oedema leading to headache, visual symptoms

(blurred vision, spots, scotoma), hyperreflexia and convulsions

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 Symptoms & Signs of preeclampsia
Symptoms
1. Headache
2. May be symptomless
3. Visual symptoms
4. Epigastric and right abdominal pain

Signs
1. Hypertension
2. Non dependent oedema
3. Brisk reflexes
4. Ankle clonus (more than 3 beats)
5. Fundal height
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 Investigations

Maternal Foetal

Urinalysis by dipstick
 Uss (growth parameters, fetal
24hours urine collection
size, AF)
Full blood count(platelets & haematocrit)
 CTG
Renal function(uric acid, serum
creatinine, urea)  BPP

Liver function tests  Doppler

Coagulation profile

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 Management of preeclampsia

Principles
Early recognition of the syndrome
Awareness of the serious nature of the condition
Adherence to agreed guidelines(protocol)
Well timed delivery
Postnatal follow up and counselling for future pregnancy
Mild PE aim for term delivery
Severe PE aim for DBP of <100mmHg
NOTE: Delivery is the only cure for preeclampsia

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 Drugs to treat PE and other Hypertensive disorders in
pregnancy
agent action dose Side effect comment

Methyl dopa central 500-3000 Depression Late onset

mg/day PO Headache 24hours
Sedation

hydralazine Direct 5mg-10mg IV Headache, Drug of

vasodilator every 20-30min Flushing emergency
if DBP>/= palpitation
110mmHg

labetalol Beta & alpha 20mg-40mg IV Nausea Avoid in HF &

blocker every 10min Vomiting Asthma
50-2400mg/day h.block
PO

nifedipine Ca.channel 20-80mg/day Severe For quick

5/20/2020 blocker PO headache control of BP
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 Other drugs considered when managing PE & other
Hypertensive disorders in pregancy
Prophylaxis
aspirin 75mg PO OD from around started before PE onset in high risk individuals and stop
around 34-36 weeks GA
Prevention of seizures
Magnesium sulphate
LD: Give 4g (20mL) of 20% Magnesium sulphate IV over 5minutes, follow promptly with 10g 50%
Magnesium sulphate; give 5g (10mL) of 50% MgSO4 in each buttock as deep IM, add 2mls of 2% Lignocaine in
the same syringe
• If convulsions re-occur give 2g (10mL) of 20% Magnesium sulphate IV over 5minutes
MD: Give 5g 50% Magnesium sulphate with 1ml of 2% Lignocaine in the same syringe by deep IM injection
into alternate buttocks every 4hrs. Continue treatment for 24hrs after delivery or convulsion whichever comes
last.
NOTE: Calcium gluconate 1g intravenously is used for the management of magnesium
toxicity.

Fetal lung maturation if GA is less than 34 weeks & prevention of

transient tachypnea if scheduled for C-section GA less than 39 weeks
Dexamethasone 12mg IM 12hourly X 4 doses or betamethasone 12mg IM 12 or 24hrly X 2
doses

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 Complications of preeclampsia
ECLAMPSIA

Maternal

CVA

HEELP syndrome

Pulmonary oedema

Adult RDS

Renal failure

Fetal

IUGR

IUFD

Abruptio placenta
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 II. Eclampsia

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 Definition of eclampsia

Is a life threatening complications of pre-eclampsia, defined

as tonic-clonic convulsions in a pregnant woman in the
absence of any other neurological or metabolic causes

It is an obstetric emergency

It occurs during antenatal, intrapartum, postpartum (after

delivery 24-48hs)

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 Management of eclampsia

Turn the patient on her side

 Ensure clear airway(suction, mouth gag)
 Maintain iv access
 Stop fits(mgso4, diazepam)
 Control BP(hydralazine, labetalol)
 Intake & output chart
 Investigations(urine, FBC, RFT, LFT, clotting profile,
cross match)
 Monitor patient and her fetus
 After stabilization(BP controlled, no convulsions,
hypoxia controlled) deliver

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 Magnesium sulphate

Drug of choice in eclampsia

Given iv, im (depending on protocol for the hospital)

Acts as cerebral vasodilator and membrane stabilizer

Over dose lead to respiratory depression and cardiac arrest

Monitor patient
Tendon reflexes
Respiratory rate (should not be < 16bpm)
Pulse (should not be < 60bpm)
Urine out put (should not be < 100mL/4hrs)
Blood pressure

Antidote cal. gluconate 1g (10ml 10%) IV

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 III. Gestational (pregnancy
induced) hypertension

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 Definition of pregnancy induced hypertension
(PIH)

The presence of hypertension of at least 140/90 mm Hg

recorded on two separate occasions at least 4 hours apart
without protein in urine after the 20th week gestation in a
previously normotensive women and resolving
completely by the sixth postpartum week

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 Classification and management of PIH

Classification
Mild and severe based of DBP (see PE)

Management
Same drugs as PE with the exception of MgSo4

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 IV. Chronic Hypertension
(Chronic HTN)

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 Definition of Chronic HTN

The presence of hypertension of at least 140/90 mm Hg

recorded on two separate occasions at least 4 hours apart
without protein in urine, before conception or before the
20th week gestation in a previously normotensive women.

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 Classification and management of PIH

Classification
Mild and severe hypertension

Management
If patient was already on medication prior to conception other than the
medication safely used in pregnancy, change the medication to use those
safe in pregnancy
Same drugs as PE with the exception of MgSo4
Patient may be reverted back to their prior conception medication after
delivering

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V. Chronic hypertension with superimposed
preeclampsia

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 Definition & Management

Definition
Occurrence of PE in a known hypertensive pregnant woman (see definition of PE)

Management
Same as PE

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 References and Acknowledgments

HANGOMA, J. M., MUUNGO, L. T., MUNKOMBWE, D., KAMPAMBA, M., AHMED, Y.,
KAMPAMBA, D., MUBITA, M., KALUNGIA, C. A., HAKOOMA, L. S., SUTHAR, M. K. &
CHISEMBELE, M. 2018. A Guide to Pharmacotherapy in Obstetrics and Gynaecology:
31 Cases & Solutions, Lusaka, Zambia DNK General Consultancy Ltd.

Rodger Walker and Clive Edwards (2003), Clinical Pharmacy and Therapeutics, 3rd
edition, Edinburgh London New York Oxford Philadelphia St. Louis Sydney.

The Seventh Report of the Joint National Committee on Prevention, Detection,

Evaluation, and Treatment of High Blood Pressure, 2004: Pages 28, 49-52

Paul D. Chan-MD, Susan M. Johnson-MD, Gynaecology and Obstetrics 2004 edition,

New ACOG Treatment Guidelines. Current Clinical Strategies Publishing.
www.ccpublishing.com/ccs

Dr. Ghada Abed Almalki-Ob/Gyne demonstrator, KAU

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