Hypertension Hypertensive disorders of pregnancy by :Ghassan Tariq

Classification of hypertension in pregnancy

1.gestational hypertension ( Non-proteinuric pregnancy-induced hypertension) .
2.Pre-eclampsia and eclampsia.
3.Chronic hypertension .
4.Preeclampsia syndrome superimposed on chronic hypertension.

Degrees of hypertension
Mild: diastolic blood pressure 90–99 mmHg, systolic blood pressure 140–149 mmHg .
Moderate: diastolic blood pressure 100–109 mmHg, systolic blood pressure 150–159 mmHg.
Severe: diastolic blood pressure ≥110 mmHg, systolic blood pressure ≥160 mmHg

Gestational hypertension : Defined as hypertension (>/=140/90 mmhg) in two separate

occasions at least four hours apart, for first time in the second half of pregnancy in the absence
of proteinuria or other markers of pre-eclampsia.
Blood Pressure usually returns to pre-pregnancy limits within 6wks of delivery.

Management of gestational hypertension:

for mild to moderate hypertension (blood pressure( BP) of 140/90–159/ 109 mmHg),do not
routinely admit to hospital
Offer pharmacological treatment (labetalol, nifedipine, methyldopa) if BP remains above
140/90 mmHg. Aim for BP of 135/85 mmHg or less
Blood pressure measurement once or twice a week (depending on BP) until BP is 135/85 mmHg
or less Dipstick proteinuria testing a once or twice a week (with BP measurement) Measure full
blood count, liver function and renal function at presentation and then weekly
Fetal assessment:
*Offer fetal heart auscultation at every antenatal appointment
*Carry out ultrasound assessment of the fetus at diagnosis and, if normal, repeat every 2 to 4
weeks, if clinically indicated
*Carry out a cardiotocography ( CTG )only if clinically indicated
for severe hypertension (blood pressure of 160/110 mmHg or more) admit to the hospital until
BP falls below 160/110 mmHg
Offer pharmacological treatment to all women. Aim for BP of 135/85 mmHg or less
Blood pressure measurement Every 15–30 minutes until BP is less than 160/110 mmHg dipstick
proteinuria testing Daily while admitted
Measure full blood count, liver function and renal function at presentation and then weekly
Fetal assessment
*Offer fetal heart auscultation at every antenatal appointment
*Carry out ultrasound assessment of the fetus at diagnosis and, if normal, repeat every 2 weeks,
if severe hypertension persists
*Carry out a CTG at diagnosis and then only if clinically indicated
Do not offer birth before 37 weeks to women with gestational hypertension whose blood
pressure is lower than 160/110 mmHg, unless there are other medical Indications
Pre-eclampsia
Pre-eclampsia is defined as hypertension of >/=140/90 mmHg recorded on two separate
occasions and at least 4 hours apart and in the presence of >/=300 mg protein in a 24-hour
collection of urine, arising after the 20th week of pregnancy in a previously normotensive woman
and resolving completely by the sixth postpartum week.

Pathophysiology :trophoblast invasion is patchy and the spiral arteries retain their muscular
walls. This is thought to prevent the development of a high-flow, low-Impedance uteroplacental
circulation and leads to uteroplacental ischemia.

HELLP syndrome
This is a serious complication regarded by most as a variant of severe pre-eclampsia which
manifests with hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). HELLP
syndrome is a particularly severe form of pre-eclampsia, occurring in just 2–4% of women with
the disease. It is associated with a high fetal loss rate (of up to 60%) with Maternal mortality is
estimated at 1%,
Women with HELLP syndrome typically present with epigastric or right upper quadrant pain,
nausea , vomiting and urine is tea colored due to hemolysis .
Hypertension may be mild or even absent in addition to other features of pre-eclampsia. HELLP
syndrome is associated with a range of serious complications including acute renal failure,
placental abruption,DIC ,maternal mortality and stillbirth. The management of HELLP syndrome
involves stabilizing the mother, correcting any coagulation deficits and assessing the fetus for
delivery.

Investigations
*To monitor maternal complications :
Full blood count (with particular emphasis on falling platelet count and rising hematocrit due to
hemoconcentration, Anemia if hemolysis ) .
Coagulation profile Mildly prolonged prothrombin time (PT) and activated partial
thromboplastin time (APTT). If platelet values are normal, additional clotting studies are not
indicated .
Serum renal profile (including serum uric acid levels). Increase Urate, Urea and creatinine.
Serum liver profile.( increase transaminases). 24-houre urine collection for protein.

Management
There is no cure for pre-eclampsia other than to end the pregnancy by delivering the baby (and
placenta) .
This can be a significant problem if pre-eclampsia occurs early in pregnancy, particularly at
gestations below 34 weeks, but this can sometimes be delayed with intensive monitoring if
<34wks . Therefore, management strategies are aimed at minimizing risk to the mother in order
to permit continued fetal growth .In severe cases this is often not possible.

Admission: a diagnosis of pre-eclampsia usually requires admission. Then either managed as :

1 .Outpatients
Patients with mild hypertension, minimal protein and normal hematological and biochemical
parameters may be monitored as outpatients, but will require frequent attendance for fetal and
maternal assessment. (1 –2/wk. review of BP and urine. Weekly review of blood biochemistry.)
2 .Inpatient
Women with moderate or severe hypertension, significant proteinuria (≥2+ protein) or
abnormal hematological or biochemical parameters require admission and inpatient
management. 4-hourly BP . daily urinalysis. Daily fetal assessment with CTG. Regular blood tests
(every 2–3 days unless symptoms or signs worsen) .
Regular ultrasound assessment (fortnightly growth and twice weekly Doppler/liquor volume
depending on severity of pre-eclampsia).
Treatment of hypertension. Methyldopa. Labetalol. Nifedipine is a calcium-channel blocker.
Vasodilators (Hydralazine)
Recommend delivery after 37 +0 week if preeclampsia of mild or controlled moderate
hypertension . If sever preeclampsia but controlled, delivery at 34 +0 weeks.

Eclampsia
Eclampsia is defined as the occurrence of one or more generalized tonic-
clonic seizure and/or coma in association with a diagnosis of pre-eclampsia
in the absence of other neurological conditions.
Eclampsia is an obstetric emergency associated with significant maternal
morbidity, in particular cerebrovascular events(2.3%) Cerebral
hemorrhage has been reported to be the most common cause of death in
patients with eclampsia.

Prevention: administration of magnesium sulphate in women with

preeclampsia who are thought to be unstable or suffering from severe
preeclampsia . However, remember all patients with preeclampsia
regardless of perceived severity are at risk of eclampsia.

Management
Admission
Call senior help and emergency alert team
Focus on airway, breathing and circulation plus IV access .
Perform full examination of patient,
Magnesium sulphate is indicated as the first-line anticonvulsant and should be dministered as
soon as possible either in women at risk of eclampsia or when eclampsia occurs .A loading dose
of 4 g is given followed by a maintenance infusion of 1 g/hour generally for 24 hours after
delivery .Magnesium sulphate has a narrow therapeutic range and overdose can cause
confusion, loss of reflexes, respiratory depression and ultimately cardiac arrest . The antidote is
10 ml 10% calcium gluconate given slowly intravenously. In repeated seizures use diazepam (if
still fitting the patient may need intubation and ventilation and imaging of the head to rule out
a cerebral hemorrhage)
Monitoring of the patient
•Pulse, BP, respiration rate, and oxygen saturations every 15min .
•hourly urine output .
• Assessment of reflexes every hour for Mg toxicity.
Deliver fetus once the mother is stable. Vaginal delivery is not contraindicated if cervix is
favorable .
Third stage should be managed with 5–10U oxytocin, rather than syntometrine or ergometrine
because of increase in BP.