HYPERTENSION

IN PREGNANCY
Professor Dr Zaleha Abdullah Mahdy

PATHOPHYSIOLOGY
Placental
Origin

Failure of Second Wave

of Trophoblastic Invasion

Failure of Dilatation of
Maternal Spiral Arteries

Uteroplacental Insufficiency
Hypoxia,
Death

IUGR

Placental Bed Ischaemia

Release of Factor X
Maternal Endothelial Dysfunction
Maternal Syndrome of Preeclampsia

Trophoblast need
progesterone to
invade the maternal
spiral arteries. Failure
of invasion is because
of there is reduce in
progesterone level.
Maternal
Disease

The Pathology of PE-Eclampsia

Microangiopathic
haemolysis

Maternal Endothelial Dysfunction

Coagulopathy

TXA2 > PGI2

Thrombocytopenia

Sensitive to Vasoconstrictors
Renal Glomerular
Endotheliosis

Vasospasm
TPR

Subcapsular liver haemorrhage

RBF
GFR

Proteinuria
Liver enzymes

BP

Oliguria

Haemoconcentration
Plasma expansion
COP

Periportal haemorrhagic
liver necrosis

TBV

Hypoalbuminaemia
Oncotic pressure

Intraperitoneal
bleeding
Leaky vessel

Fluid extravasation
Oedema

Cerebral Pathology in Severe PE-Eclampsia

Maternal Endothelial Dysfunction
Systemic hypertension
Cerebral Blood Flow
Distal Cerebral Vasospasm

Cerebral Perfusion Pressure

Cerebral Oedema*
Reversible
(Vasogenic)
* Petechial haemorrhages, haematoma

Irreversible
(Ischaemic / Cytotoxic)
Cerebral Infarct

SYMPTOMS & SIGNS

Symptoms
Headache / nausea /
vomiting
Blurring of vision
Epigastric pain
Excessive weight gain
Breathlessness

Signs

Raised BP, proteinuria

Puffiness, oedema
Cerebral irritation
(Jitteriness, brisk
reflexes)
Papilloedema, retinal
haemorrhage
Pulmonary oedema
Epigastric tenderness
Oliguria

Complications
Maternal

Eclampsia
HELLP Syndrome
Nephrotic Syndrome
Acute Pulmonary
Oedema
Acute Renal Failure
Intracranial
Haemorrhage
Subcapsular Liver
Haemorrhage
Maternal Death

Fetal
Intrauterine Growth
Restriction (IUGR)
Fetal Distress
Fetal Death
Iatrogenic Prematurity

Definition of Hypertension
SBP 140 mmHg, AND / OR
DBP 90 mmHg (Korotkoff V)
Both the NHBPEP and the ASSHP no longer recognize an
increase of 15 mmHg and 30 mmHg DBP and SBP levels, with
absolute values below 140/90 mmHg, as hypertension.
However, the NHBPEP states that, Nonetheless a rise of
30 systolic or 15 diastolic warrants close observation,
especially if proteinuria and hyperuricemia are also present.

Measurement of BP

The ISSHP endorsed the Australasian suggestions:

The pregnant woman should be seated (45 angle RCOG), with feet supported,
for 2-3 min.
An appropriately sized cuff should be used; the standard if arm has a
circumference of 33 cm or less; large cuff (15 x 33 cm bladder) for larger arms.
The cuff bladder should encircle at least 80% of the arm.
SBP should be palpated at the brachial artery and the cuff inflated to 20 mmHg
above this level.
The cuff should be deflated slowly, at approximately 2 mmHg per second.
BP should be recorded with a mercury manometer.
SBP and DBP should be recorded, the latter as Korotkoff 5 (disappearance), and
K4 (muffling) only utilized when a phase 5 is absent.
BP is ideally recorded using both arms at the first antenatal visit, and if there is
little difference, the right arm should be utilized thereafter. Detection of
significant differences requires referral to an expert.
Brown et al, Hypertension in Pregnancy 2001, 20(1):ix-xiv

Caution regarding inaccuracy of automated methods, e.g. Dinamap

RCOG 2006

Definition of Proteinuria
The ISSHP endorsed the following:
Abnormal proteinuria is most certain when measured in a timed
collection, 300 mg/day considered abnormal for pregnancy.
Urinalysis should be a guide for further testing, as it has a high rate of
both false positives and negatives; if the dipstick is the only test
available, 1+ (30 mg/dl) is often, but not always, associated with 300
mg/day proteinuria.
Spot urine protein/creatinine ratio 30 mg protein/mmol creatinine
is another alternative, superior to qualitative (dipstick) evaluation
alone and equivalent to 24-h urine collection.
Significant proteinuria reflects advanced disease, associated with
poorer prognosis.

CLASSIFICATION
HYPERTENSION IN PREGNANCY

PREECLAMPSIA - ECLAMPSIA

CHRONIC HYPERTENSION (PRIMARY OR SECONDARY)

PREECLAMPSIA SUPERIMPOSED ON CHRONIC HYPERTENSION

GESTATIONAL HYPERTENSION

Brown MA et al (2001). The classification and diagnosis of the hypertensive disorders of pregnancy:
statement from the International Society for the Study of Hypertension in Pregnancy (ISSHP).
Hypertension in Pregnancy 20 (1), ix-xiv.

PREECLAMPSIA
Research Definition

De novo hypertension after 20 weeks

gestation, returning to normal postpartum,
AND
Properly documented proteinuria

Brown MA et al (2001). The classification and diagnosis of the hypertensive disorders of pregnancy:
statement from the International Society for the Study of Hypertension in Pregnancy (ISSHP).
Hypertension in Pregnancy 20 (1), ix-xiv.

PREECLAMPSIA
Clinical Diagnosis
De novo hypertension after gestational week 20, AND
One or more of the following:
Proteinuria (ISSHP definition)
Renal insufficiency (serum creatinine 90 mol/l or oliguria)
Liver disease (raised transaminases and/or severe right upper quadrant or
epigastric pain)
Neurological problems: convulsions (eclampsia), hyperreflexia with clonus,
severe headaches with hyperreflexia, persistent visual disturbances (scotoma)
Haematological disturbances: thrombocytopenia, DIVC, haemolysis
Fetal growth restriction

BP normalizes within 3 months postpartum

Oedema is no longer part of the definition of preeclampsia
Brown MA et al (2000). The detection, investigation and management of hypertension in pregnancy.
ANZ JOG 40, 133-155.
Brown MA et al (2001). The classification and diagnosis of the hypertensive disorders of pregnancy:
statement from the International Society for the Study of Hypertension in Pregnancy (ISSHP).
Hypertension in Pregnancy 20 (1), ix-xiv.

 Chronic hypertension

Hypertension diagnosed prior to gestational week 20, or

Presence or history of hypertension preconception, and
De novo hypertension in late gestation that fails to resolve postpartum.
Considered essential if there is no underlying cause or secondary if associated
with definitive aetiology.

Preeclampsia superimposed on chronic hypertension

The appearance of de novo proteinuria starting at 20 weeks gestation, or

A sudden increase in the magnitude of hypertension, or
Appearance of thrombocytopenia, and/or abnormal levels of transaminases, etc, or
In women who have proteinuria early in gestation, a sudden increase in proteinuria.

Gestational hypertension
Hypertension alone, detected for the first time at 20 weeks, a definition that is
changed to transient when pressure normalizes postpartum.

SEVERE Preeclampsia
DBP 110 OR SBP 170 on two occasions, AND proteinuria 1g/l
DBP 100 on two occasions AND proteinuria AND 2 signs or symptoms
of imminent eclampsia
Other features of severe PE:

Severe headache
Visual disturbance
Epigastric pain and/or vomiting
Clonus / hyperreflexia
Papilloedema
Liver tenderness
Platelet count < 100,000/cmm
Abnormal liver enzymes (ALT or AST > 70 IU/l)
HELLP Syndrome
Intrauterine growth restriction (IUGR)
Pulmonary oedema and/or CCF

Caution on reliance on overly precise criteria

RCOG Guideline No. 10A, March 2006. The management of severe pre-eclampsia/eclampsia. Valid until
March 2009.
Lain & Roberts JM (2002). JAMA 287, 3183-5.

Management in Brief
Anti-hypertensive Rx
Initiate if DBP persistently 100 mmHg
Methyldopa, labetalol, nifedipine

Acute hypertensive crisis

IV hydralazine or IV labetalol or oral nifedipine

Diuretics
Generally contraindicated
Reduce plasma volume
Cause IUGR
Possibly increase perinatal mortality

Only used in Rx of acute pulmonary oedema

Anticonvulsants
MgSO4 (IV or IM)

Drug of choice for:

Prevention of eclampsia
Aborting eclamptic fits
Prevention of recurrent eclamptic fits

Diazepam (IV) as an alternative

Management of Cold Cases

Outpatient / Inpatient
PE Chart (Inpatient)
BP, Pulse 4 hourly
Daily urine protein, I/O chart
Weekly maternal weight

Day Care (Outpatient)

BP Monitoring

Management of Severe PE
Severe PE / Impending or imminent eclampsia
Nurse in HDU
Consider MgSO4 (drug of choice) or Diazepam
Treat acute hypertensive crisis
BP, pulse hourly
RR, reflexes hourly (if on anticonvulsant)

CBD with strict I/O chart

For delivery within 6 hours

Management of Eclampsia
ABC of resuscitation
Nurse in ICU ventilatory support
Anticonvulsant
MgSO4 (drug of choice) or Diazepam

Treat acute hypertensive crisis

BP, pulse, RR, reflexes hourly, O2 sat
CBD with strict I/O chart
For delivery within 6 hours

General Aspects of Management

Investigations

FBC
Renal Profile
Uric Acid
Liver Function Test
Coagulation Profile
CXR
ABG
CT Brain

Fluid Balance
IV fluids limited to
85ml/hour, or
Urine output/hour + 30ml

CVP line

Delivery
In the absence of maternal or fetal compromise, pregnancy is
terminated at 38 - 40 weeks gestation
Earlier delivery is often indicated based on unacceptable
maternal or fetal risk with continuation of pregnancy
Vaginal delivery is aimed for, except if
obstetric contraindications exist
vaginal delivery not likely to be achieved within 6 hours of diagnosis of
eclampsia or imminent eclampsia

Intrapartum
Epidural is the labour pain relief of choice
Shorten second stage
Ergometrine (and syntometrine) is contraindicated in third stage

POSTPARTUM CARE
Regular BP checks at local clinic
Tail down dose of antihypertensive Rx gradually
Do not stop Rx suddenly

Postpartum onset or aggravation of hypertension can

occur
Eclampsia can occur postpartum

Chronic hypertension if hypertension fails to

resolve within 3 months postpartum
Up to 13% of preeclampsia have underlying essential
hypertension

High risk of CVS disease in later life

Long-term follow-up is advisable

Prevention of PE-Eclampsia
Timely intervention
Screening and prevention of preeclampsia
Preconceptional counseling and early antenatal
booking and screening for high risk groups
Prophylaxis against preeclampsia should commence
before 16 weeks gestation, in order to be beneficial
Hermida et al, Hypertension 1999; 34:1016-1023

Prevention of eclampsia
Timely termination of pregnancies affected by
preeclampsia
Timely administration of anticonvulsant

CONCLUSIONS
RECOMMENDATIONS

Pregnant women at high risk of PE should be referred

to obstetrician for screening and commencement of
prophylaxis with aspirin
Prophylactic Ca2+ supplement is beneficial
Diagnosis & Rx is based on K5 as DBP
Pregnant women with hypertension should be
referred to obstetrician
Antihypertensives of choice are methyldopa &
labetalol
Oral nifedipine 10 mg stat can be used in acute
hypertensive crisis prior to transfer to hospital
MgSO4 is the anticonvulsant of choice