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 .

oedema Cerebral irritation (Jitteriness.SYMPTOMS & SIGNS • Symptoms – Headache / nausea / vomiting – Blurring of vision – Epigastric pain – Excessive weight gain – Breathlessness • Signs – – – – – – – – Raised BP. proteinuria Puffiness. 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 .

the NHBPEP states that.” . especially if proteinuria and hyperuricemia are also present. However.Definition of Hypertension • SBP ≥ 140 mmHg. with absolute values below 140/90 mmHg. as hypertension. 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. “Nonetheless … a rise of 30 systolic or 15 diastolic warrants close observation.

Hypertension in Pregnancy 2001. – BP should be recorded with a mercury manometer. – SBP and DBP should be recorded. Detection of significant differences requires referral to an expert. for 2-3 min. at approximately 2 mmHg per second. – The cuff should be deflated slowly. e.Measurement of BP • The ISSHP endorsed the Australasian suggestions: – The pregnant woman should be seated (45° angle – RCOG). with feet supported. 20(1):ix-xiv Caution regarding inaccuracy of automated methods. Brown et al. – SBP should be palpated at the brachial artery and the cuff inflated to 20 mmHg above this level.g. The cuff bladder should encircle at least 80% of the arm. the standard if arm has a circumference of 33 cm or less. the right arm should be utilized thereafter. the latter as Korotkoff 5 (disappearance). and if there is little difference. and K4 (muffling) only utilized when a phase 5 is absent. – An appropriately sized cuff should be used. Dinamap RCOG 2006 . – BP is ideally recorded using both arms at the first antenatal visit. “large cuff” (15 x 33 cm bladder) for larger arms.

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

. Hypertension in Pregnancy 20 (1).CLASSIFICATION HYPERTENSION IN PREGNANCY PREECLAMPSIA . The classification and diagnosis of the hypertensive disorders of pregnancy: statement from the International Society for the Study of Hypertension in Pregnancy (ISSHP).ECLAMPSIA CHRONIC HYPERTENSION (PRIMARY OR SECONDARY) PREECLAMPSIA SUPERIMPOSED ON CHRONIC HYPERTENSION GESTATIONAL HYPERTENSION Brown MA et al (2001). ix-xiv.

AND • Properly documented proteinuria Brown MA et al (2001). Hypertension in Pregnancy 20 (1). returning to normal postpartum. The classification and diagnosis of the hypertensive disorders of pregnancy: statement from the International Society for the Study of Hypertension in Pregnancy (ISSHP). . ix-xiv.PREECLAMPSIA Research Definition • De novo hypertension after 20 weeks gestation.

DIVC.PREECLAMPSIA Clinical Diagnosis • De novo hypertension after gestational week 20. . 133-155. ix-xiv. The classification and diagnosis of the hypertensive disorders of pregnancy: statement from the International Society for the Study of Hypertension in Pregnancy (ISSHP). Brown MA et al (2001). investigation and management of hypertension in pregnancy. AND • One or more of the following: – Proteinuria (ISSHP definition) – Renal insufficiency (serum creatinine ≥ 90 μmol/l or oliguria) – Liver disease (raised transaminases and/or severe right upper quadrant or epigastric pain) – Neurological problems: convulsions (eclampsia). persistent visual disturbances (scotoma) – Haematological disturbances: thrombocytopenia. severe headaches with hyperreflexia. The detection. 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). Hypertension in Pregnancy 20 (1). ANZ JOG 40. hyperreflexia with clonus.

detected for the first time at ≥ 20 weeks. • Gestational hypertension – Hypertension alone. a sudden increase in proteinuria. and De novo hypertension in late gestation that fails to resolve postpartum. or Appearance of thrombocytopenia. • Preeclampsia superimposed on chronic hypertension – – – – The appearance of de novo proteinuria starting at ≥20 weeks gestation. or In women who have proteinuria early in gestation. and/or abnormal levels of transaminases. . a definition that is changed to “transient” when pressure normalizes postpartum. etc. or A sudden increase in the magnitude of hypertension. Considered “essential” if there is no underlying cause or “secondary” if associated with definitive aetiology.• Chronic hypertension – – – – Hypertension diagnosed prior to gestational week 20. or Presence or history of hypertension preconception.

JAMA 287. Valid until March 2009. 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. March 2006. 3183-5. 10A.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. .SEVERE Preeclampsia • DBP  110 OR SBP  170 on two occasions. The management of severe pre-eclampsia/eclampsia. Lain & Roberts JM (2002).

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 .

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Pulse 4 hourly – Daily urine protein.Management of “Cold” Cases • Outpatient / Inpatient • PE Chart (Inpatient) – BP. 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. reflexes ¼ hourly (if on anticonvulsant) – CBD with strict I/O chart – For delivery within 6 hours . pulse ¼ hourly • RR.

pulse. O2 sat CBD with strict I/O chart For delivery within 6 hours . reflexes ¼ hourly.Management of Eclampsia • ABC of resuscitation • Nurse in ICU ± ventilatory support • Anticonvulsant – MgSO4 (drug of choice) or Diazepam • • • • Treat acute hypertensive crisis BP. RR.

or • Urine output/hour + 30ml – ± CVP line .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.

40 weeks gestation • Earlier delivery is often indicated based on unacceptable maternal or fetal risk with continuation of pregnancy • Vaginal delivery is aimed for. pregnancy is terminated at 38 . 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 .Delivery • In the absence of maternal or fetal compromise.

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 .

34:1016-1023 – Prevention of eclampsia • Timely termination of pregnancies affected by preeclampsia • Timely administration of anticonvulsant . in order to be beneficial Hermida et al.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. Hypertension 1999.

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 .