Management Of

Hypertension in

pregnancy
 Hypertensive disorders of pregnancy (HDP) is
a global health problem with multisystem
affection that is distinct to human pregnancy.

 It is known to increase the risk of maternal

and perinatal morbidity and mortality
especially in middle and low income countries
 HTN disorders
complicates
8-10% of all
pregnancies

Pre-eclampsia
complicates
3-9% of
pregnancies in
developed
countries
 Approximately 1/3 of hypertensive disorders
in pregnancy (HDP) are due to chronic
hypertension and
 2/3 are due to

- gestational hypertension
– preeclampsia
 Thespectrum of the disease
ranges from mildly elevated blood
pressures with minimal clinical
significance to severe
hypertension and multi organ
dysfunction
 Classification of Pregnancy induced
hypertension
 Major changes of the new classification are as
follows:

 (1) HDP is defined as hypertension in pregnancy.

 (2) Eclampsia was removed from the major

classification.

 (3) Chronic hypertension was added to the major

classification.
 Cont…
 (4) If pregnant women with new onset of
hypertension have either maternal organ
dysfunction or uteroplacental dysfunction, they
should be diagnosed with preeclampsia, even in
the absence of proteinuria.

 (5) The severity classification should be ‘severe’

when hypertension is severe,
or when hypertension is mild but there is maternal
organ dysfunction or uterine placental dysfunction.
Cont…
 The term ‘mild’ was excluded from the
criteria of HDP because it can be
misinterpreted to mean ‘not at high risk’.

 (6) The definition of ‘early onset type’ is that

which appears earlier than 34 weeks
gestation, in accordance with international
standards
Classification of hypertensive
disorders in pregnancy (ACOG )
 Updated Classification of Hypertensive
disorders of pregnancy
 1. Preeclampsia (PE) (BP elevation after 20 weeks of gestation
with proteinuria OR any of the severe features of preeclampsia)

 2. Chronic hypertension (CHTN, of any cause that predates

pregnancy)

 3. Chronic hypertension with superimposed preeclampsia

(chronic hypertension in association with preeclampsia)

 4. Gestational hypertension (GH: BP elevation >20 weeks of
gestation in the absence of proteinuria or any of the severe
features of preeclampsia.
 As per National High Blood Pressure Education
Program (NHBPEP)

Normal or acceptable BP SBP ≤140 & DBP ≤ 90 mmHg

Mild hypertension SBP 140 - 159 or DBP 90 -109 mmHg

Severe hypertension SBP ≥ 160 or DBP ≥110 mmHg



Pre-eclampsia
 Pre-eclampsia
Nothing has changed…
 • The first description of Preeclampsia was given
by Hippocrates, a father of modern medicine (460-
377 BC),.

 • Even after more than two millennia since the first

descriptions, the syndrome of preeclampsia /
eclampsia (PE/E) has remained a multi-system
disorder of unknown etiology.
Cont….
 • The diagnosis is based on a clinical picture
and laboratory analysis; BUT, an efficient
prevention and screening are still missing,
 The New Vs. the Old classifications
• Pre-eclampsia does not require the
presence of proteinuria for Dx.
• Pre-eclampsia may be diagnosed if HTN +


1–Thrombocytopenia (PLTs x2 UNL)

2 – Renal dysfunction (SCr >1.1 or x2 from
baseline*)
3 – Pulmonary edema
4– New onset cerebral or visual disturbances
5.Rise alanine transaminase (over 70 IU/litre, or
twice upper limit of normal range
 Maternal personal risk factors for preeclampsia

 First pregnancy
 Age younger than 18 years or older than 35 years
 History of preeclampsia
 Family history of preeclampsia in a first-degree

relative
 Black race
 Obesity (BMI ≥30)
 Interpregnancy interval less than 2 years or longer

than 10 years
Maternal medical risk factors for preeclampsia

 Chronic hypertension, especially when secondary to such

disorders as hypercortisolism, hyperaldosteronism
, pheochromocytoma, or renal artery stenosis
 Preexisting diabetes (type 1 or type 2),

 Renal disease
 Systemic lupus erythematosus

 Obesity
 Thrombophilia
 History of migraine 

 Use of selective serotonin uptake inhibitor antidepressants

(SSRIs) beyond the first trimester 
Placental/fetal risk factors for preeclampsia

 Multiple gestations

 Hydrops fetalis

 Gestational trophoblastic disease

 Triploidy
Categories

 Non severe Preeclampsia

 Severe Preeclampsia
Severe Preeclampsia
 • Severe hypertension: Systolic ≥ 160 mm Hg and /or diastolic ≥
110 mm Hg

 • Severe proteinuria: >5 g/24 h

• Severity symptoms:
 Right upper quadrant or epigastric pain,

 headache,

 blurred vision

• Abnormal lab:
 Thrombocytopenia,

 Elevated liver enzymes,

 Raised creatinine
 Non severe
VS. Severe pre eclampsia

Nonsevere
Which Urine Test ?
Dipstick
Semi-quantitative, screening only
Affected by urine concentration, highly variable
Detection of urine albumin > 300 mg/day
1+ approximates albumin excretion of 30 mg/day)

Urine protein/creatinine ratio

All proteins, not just albumin (myeloma/CIN)
Urine albumin-to-creatinine ratio (UACR)
Quantifies urine albumin
Steps toward standardization currently in progress
24hr collection (or other timed)
Gold standard/cumbersome
 Algorithm :1 preeclampsia
Preeclampsia ( > 20 weeks + proteinuria \ severe
features )

Admit the patient

Non severe preeclmpsia: BP: 140/159/90-109 mm

hg + protienuria (1+)/severe features

maternal monitoring:
• Bed rest : no role
•Salt restriction :no role
•BP: 6 hourly
•Proteinuria: once daily (dipstick)
•CBC, LFT.RFT AT diagnosis and
•24 – Hour urine for protein  then twice a week
•PT/ INR (IF Platelet < 1 lac)
•Fundus : on admissoin
•ff
Fundus on Admission
Fetal assessment
 DFKC; Twice daily On admission and
 NST/CTG: then at 32 weeks and
then weekly
BPP
AFI
4 weeks
UA Doppler :
Fetal biometry :

 Start anti –HT at BP >_150/100 mm hg

 Labetalol : 100 mg TDS or methyldopa 250 mg TDS
 Give 4 dose or 2 dose of steroid
 Continue maternal and fetal monitoring
 Delivery at 37 weeks
 Mode of delivery : As per obstetric indication
 Severe preeclampsia
B P>-160/110 OR severe features
Maternal monitoring:
Bed rest no role
Salt restriction

 BP : 1 hourly
 Proteinuria : twice daily (dipstick)

 CBC, LFT,KFT Rpt After

 24 hour urine for protein 48 hrs
 PT /INR ( if platelet < 1 lac
 PT/PTTK

Fundus: on admission
Fetal assessment:
 DFKC : twice daily at admission
and
NST , then at
BPP, 32weeks and
AFI weekly

UA Doppler :
every 2 weeks
 Fetal biometry :
Start anti- HT

 Labetalol iv 20 mg 40mg , 80mg, (max 220

mg in 24 hours) or
 Nifedipine :10 mg TDS ( max 120 mg) or

injection hydralazine
 Give two doses of steroid
 Give Mgso4 loading dose
 BP controlled – continue maternal and fetal

monitoring and terminate at 34 weeks –

vaginal or LSCS ( according to Bishop’s
score)
 Continue
Persistent high BP and S/S of impending eclampsia – terminate
pregnancy

•In c/o pulmonary edema

• ARF,
•abruption,
• severe thrombocytopenia ,
•DIC,
• nonreassuring fetal testing ,
•fetal demise-

 irrespective of gestational age terminate pregnancy

During labor
 1 hourly BP monitoring

 watch for s/s of impending eclampsia

 No cutting short of second stage if BP controlled

 Amniotomy once in active labor

FHR monitoring : every 15 minutes (1st stage)

every 5 minutes (second stage)

 Active management of 3rd stage of labour.

After delivery
 : monitoring : 6 hourly

 Anti HT: restart if BP> 150 / 100 mm hg

 Methyldopa , if already in use should be

substituted

 No restriction of ACE inhibitors , B- blockers, and

dose should be readjusted

 Avoid diuretics during lactation

Cont…
 Discharge after 72 hours if BP controlled with /
without anti HT

 Follow up after 1 week and 6 weeks

 Contraception avoid ocps

PREDICTION OF HYPERTENSIVE
DISORDERS OF PREGNANCY
 Despite recent advances in the understanding
of pathophysiology of this heterogeneous
disorder, there is a lack of predictive markers
which would diagnose HDP with high
sensitivity and specificity.
 Preeclampsia can be subdivided into:

Early onset (<34 weeks)

Late onset (>34 weeks).
 As early onset preeclampsia is associated

with increased incidence of adverse outcome

Prediction Of PE
Methods
 I. Preconception factors
 II. Pregnancy-Related Factors
 1. Risk factors
 2. Markers
1. Preconception factors
 1 st step in the management of a woman with

a history of PE is to conduct a detailed

evaluation of potential risk factors

 II. Pregnancy-Related Factors

  Risk factors:
Magnitude of risk depends on the number of factors
 

Hydrops/hydropic degeneration of the placenta

Multifetal gestation
Unexplained FGR
Gestational hypertension
UTI
Periodontal infection

 Markers
Biophysical
Biochemical
 I. Biophysical
MAP is significantly better than
 Mean arterial pressure systolic or diastolic blood pressure in
predicting Preeclampsia
 •(2D BP+S BP)/3

•BP remains the cornerstone of early diagnosis

although it has limitations:
Measurement errors associated with
sphygmomanometer

 Effect of maternal posture on BP in pregnant women.

Repeated routine urinalysis
 •Throughout pregnancy NOT useful for
predicting PE :
Uterine artery Doppler ultrasound

 •impaired trophoblastic invasion of the spiral

arteries: reduction in uteroplacental blood
flow}
 •
High pulsatility index and/or
Notch in 1 st & 2 nd trimesters

: poor predictor of Pre eclampsia
 Uterine artery Doppler plus biochemical
markers •Promising results
 •BUT , Current data do not support this

combination for routine screening for PE

Uterine Artery Doppler

The most promising screening test for

preeclampsia is uterine artery Doppler
velocimetry
 Defective trophoblastic differentiation with

impaired invasion of the maternal spiral

arteries and failure of these vessels to
transform into low resistance vessels:
II. Biochemical Markers
 Angiogenic factors before & after the onset of PE

 Serum placental growth factor: Reduced

 Soluble fms-like tyrosine kinase: Elevated

 Pregnancy associted plasma protein A ( PAPP-A)

 Endoglin : Elevated
 Although there are innumerable number of

biochemical markers that have been

investigated for prediction of preeclampsia,

two novel markers have shown promising

results
 Two novel biomakers
Pregnancy associated plasma proteins Placenta growth factor (PIGF)
(PAPP-A)

• Syncytiotrophoblast derived •A glycosylated dimeric

metalloproteinase glycoprotein,

• Increases the mitogenic •Synthesized in villous and

function of the insulinlike extravillous cytotrophoblast
growth factors
• Contribute a change in
• Play important role in angiogenesis from branching
 FETAL MEDICINE FOUNDATION
A software has been developed by which allows
estimation of risks of
early preeclampsia (at <32 weeks’ gestation),

preterm-PE (<37 weeks),

term-preeclampsia (>37 weeks)

 by a combination of maternal factors and results of

various biophysical and biochemical measurements
made at different stages in pregnancies
 are MAP,
 Useful markers in the UAPI,
PIGF,
first trimester (11–14 weeks)
and PAPP-A

 Useful markers in the second trimester (19–

24 weeks) and third trimesters are

MAP,
Soluble fms-like tyrosine UAPI,
kinase: Elevated PIGF,
and sFLT-1
NICE GUIDELINES
 sFlt-1/PIGF ratio used with standard clinical

assesment and subsequent clinical follow up

rule out PE in women who suspected PE

between 20 weeks and 34 weeks gestation .

sFlt-1PIGF ratio Diagnosis Highly suggestive of PE
85 ( early onset PE) or another form of
>110 (late onset PE) placenta insufficiency

sFlt-1PIGF ratio short term prediction Pt. is likely to develop PE

> 38 -<85 (early onset Rule in PE in the next 4 with in 4 weeks
PE) weeks
>38 - < 110 ((late onset
PE)

sFlt-1PIGF ratio <38 short term prediction Pt will not develop PE for
Rule out PE for 1 weeks at least 1 week
But Remember…

BP remains the cornerstone of early

diagnosis

 •Markers Reliability is inconsistent Many

suffer from poor specificity & predictive
values.

 None provided a cutoff value that could be

clinically useful for the prediction of PE
But remember


In absence of effective
screening modalities
clinical risk factor help to
be more vigilant
PRIMARY PREVENTION
Lifestyle modifications
 Reduce obesity
 − Regular exercise
 − Thirty minutes of moderate exercise on

Encourage women to have children at younger

age (>18 years)

 Cessation of smoking
Nutritional supplements
 Do not recommend the following
supplements solely with the aim of
preventing hypertensive disorders during
pregnancy:
 magnesium
 folic acid
 antioxidants (vitamins C and E)
 fish oils or algal oils
 garlic.
Diet
normal diet without salt restriction is advised,
particularly close to delivery.
 Salt restriction may lead to small

intravascular volume.
 Calcium supplementation (>1 g/day)

Daily 1-1.5 gm Calcium reduce

incidence of HDP in areas with low
dietry calcium intake
SECONDARY PREVENTION
 Antiplatelet agents:
 x aspirin an anti-inflammatory agent blocks

production of thromboxanes
inhibits the alterations in systemic prostacyclins-
thromboxane balance, which is responsible for
preeclampsia
 Advice women with one high risk factor or
two or more moderate risk factors to take
150 mg aspirin daily from 12 weeks until the
baby is born (NICE).
CONT….
Do not use the :
 Nitric oxide donors
 Progesterone
 Diuretics
 Low molecular weight heparin
 Commonly oral antihypertensive agent in
pregnancy
drugs dosage comments
Labetalol 200 -2400 mg/day orally
in two to three divided Potential
doses bronhoconstrictiv effect
Initated at 100-200 mg Avoid in CCF,
bd ASTHMA,
DM
,BRADYCARDIA
Methyldopa 500-3000 mg/ day orally May not effective as other
in two to four divided medication esp. In
doses. control o severe htn
Commonly initiated at S/E sedation ,
250mg bd or tds depression, dizziness
Nifidipine 30 -120 mg/day orally Do not use S/L
Labetolol
 – 1 st Line Drug

 • Antihypertensive drug (oral as well as i.v.)

 • Combined both selective, competitive α1-

adrenergic blocking and nonselective,
competitive β-adrenergic blocking activity
 WHY NOT ALPHA-METHYLDOPA ?
 alpha-methyldopa takes 24 hours for complete action.

  Upon starting with a 250 mg dose, it needs to be taken three

times daily.( 250–500 mg QID—max 2 g)

  Patients commonly suffer from postural hypotension due to

alpha-receptor blockade. 

 Common side effects are constipation, galactorrhea,

postpartum depression and altered sleep pattern.

  It also causes headache, which can be confused with

impending eclampsia.
WHY NOT ALPHA-METHYLDOPA?
  Hematological manifestations include
hemolysis and thrombocytopenia on blood smear
and false positive Coomb’s test in 10% cases.

  It causes falsely non-assuring fetal heart

patterns on electronic fetal monitoring.

  Alpha-methyldopa accumulates in renal failure,

which can sometimes complicate pre-eclampsia
Why Labetalol?
Free of the side effects mentioned for methyl-
dopa

It results in good and sustained control of BP

. There is no tachycardia and BP is stabilized.

Labetalol has no effect on uteroplacental blood

flow

Injectable form is available for hypertensive crisis

ECLAMPSIA
 ADMIT THE PATIENT Take H/O
Gestation age
No. of fits
 AVOID MATERNAL INJURIES
H/O of epilepsy
H/O of HTN in previous
 MAINTAIN A,B,C pregnancy
Drug therapy

 EXAMINATION Conscious or
not,PR,BP,RR,Spo2,chest

 MAKE IV LINES
 ( CBC,LFT,KFT, Coagulation profileCROSS MATCH THE BLOOD

 Fluids not > 80 ml / hrs

 RL/NS prefer over colloids

 aBd.wall edema
,FH,liquor,contraction
 Do P/A exminations FHS

Foleys Catheterization the patient

Dilation
Do p/ v examination Cervical status,memb
B.score,

 Give inj magsulf loading dose f/b maintainance


Pritchard regime

4gm (20%) of mgsulf iv (10-15 min)

 10 gm im ( 5 gm im in each buttock)

 Maintenance
 5gm IM alternate buttock 4 hrly
 till 24 hrs delivery or last seizures
 zuspan regime iv

4-6 gm mgsulf diluted in 100ml

of Ns over 15 -20 min
Maintenance dose 1gm /hr till 24
hrs delivery or last seizures
If seizure recouurs give

2gm mgsulf bolus over 5 min or

increase the rate of infusion to 1.5
gm /hrs

If seizure recouurs

give phenobarbitone 300 mg iv over 5 min

monitor for magsulf toxicity

RR .> 12 min
Knee jerk + nt
Urine out > 30 ml/hrs
 If toxicity occur stop mgsulf

Inj calcium gluconate 1gm (10 ml) of

10% in 10 min.iv ( if resp. depresson
+nt)

 No diuretics if urine output decrease

Start inj phenytoin

loading dose 10-15 mg/kg at the rate of 50

mg/min
(600mg in 300 ml NS over in half hrs)

f/b 300 mg in 200 ml NS over in ½ hrs

Maintenance dose of 100 mg Iv 8 hrly

 Start antiHT labetlol 20 mg iv 40 mg

80 mg iv 80 mg iv every 20 min max dose

220mg /24 hrs

Once b.p controlled tab labetalol 200 mg tds

 Pt in labour not in lbour

Do ARM TERM PRETERM

DELIVER Induction according to B.S

bishop > 6 bishop < 6

ARM+ oxytocin miso/dino

reasscess score after 4 hrs 6 hrs

Favourble oxytocin not favourbale C.S

deliver
During delivery
 Cut short 2nd stage

 Active management of 3rd stage

 Be vigilant for pph

After delivery
 Cont.magsulf

 Bp monitoring hrly 24 hrs and then 6hrly

 I/O charting 6 hrly

 Restart anti htn after 24 hrs if bp >150/100 mm

hg readjust the dose

 Pt. dischrge after 1 week if no complication

 FU after 1 week
 Antihypertensie drugs in crisis
drugs dosages comments Onset of action
labetalol 10 -20 mg i/v Tachycrdia is less 1- 2 min
then 20-80 mg common A/E then
Every 10- 30 other agent
minutes to a max CCF,
dose 300mg or ASTHMA,
constant infusion DM
1- 2 mg / min i/v ,BRADYCARDIA

hydralaizine 5 mg iv or im then Hypotension, 10-20 min

5-10 mg iv every headache,
20-40 min to abnormal fetal
max dose 20 mg heart rate tracing
more common
then other drugs


GESTATIONAL HYPERTENSION
Gestational hypertension
 A sustained rise of blood pressure to 140/90
mm of Hg or more on at least two occasions
4 or more hours apart beyond the 20th week
of pregnancy or within the first 48 hours of
delivery in a previously normotensive women

 The blood pressure should come down to

normal within 12 weeks following pregnancy
 Risk factor
 nulliparity
 age 40 years or older
 pregnancy interval of more than 10 years
 family history of pre-eclampsia
 multi-fetal pregnancy
 BMI of 35 kg/m2 or more
 previous history of pre-eclampsia or gestational

hypertension
 pre-existing vascular disease
 pre-existing kidney disease.
BP<150/100 mm Hg

 Outpatient treatment
 Self- monitoring of BP at home
 DFKC by mother at home
 ANC visits

Every month (up to 32 weeks )

Once in 2 weeks (32 -36 week)
Every weeks after 36 weeks
 Ask for symptom of
headache ,
blurring of vision ,
epigastric discomfort –
each visit

 Proteinuria – every week

at diagnosis and
 CBC bld investigation then every 2
 ,LFT, weeks
 KFT,

 fundus – at time of diag.

Fetal monitoring:

NST, –( at 20 weeks
BPP 36 weeks
,AFI, earlier if
UA, Doppler, clinical suspicious
fetal biometry of FGR)

 Maternal and fetal assessment remains with

in normal limits

 Weekly ANC visits and delivery at 38 weeks

BP> 150/100 mmHg
 Admit the patient
 DFKC: daily
 Proteinuria:
 BP monitoring : 6 hourly
 Ask for symptoms- headache, blurring of
visions, epigastric discomfort

 CBC,LFT,KFT on admission
 24- hour urine for protein and then weekly
 fundus –
Fetal monitoring:
NST,
BPP on admission and
,AFI, then Every 2 weeks
UA Doppler
, Fetal biometry-

 Start anti hypertension

 Methydopa:250 mg TDS or Labetalol 100mg

TDS or Nifidipine: 10 mg TDS-
discharge from hospital if

 BP controlled on 1 anti-HT
 Local resident
 Preterm and with no superadded

complication
 weekly ANC visits-
 maternal and fetal assessment remains

normal- delivery at 38 weeks

If BP> 150/100 mm Hg OR develops
proteinuria OR FGR - Readmission
 Preterm- add another anti-HT (1or2)
– give steroid cover

 BP controlled – continue maternal

and fetal monitoring
and delivery at 37
weeks

 BP not controlled – delivery

 Term IOL/ LSCS ( as per obstetric
indication)
During labor
 1 hourly BP monitoring
 No cutting short of second stage if BP

controlled
 No early amniotomy

½ hourly (1st stage) FHS

15 minutes (2nd stage) MONITORING

 Active management of 3rd stage of labor

After delivery
 BP monitoring : once daily
 Anti-HT may not required
 Restart if BP> 150/100 mm Hg after 24 hrs
 No restriction of ACE inhibitors, B- blockers,

and dose should be readjust

 Avoid diuretics during lactation
 Discharged : after 72 hours if BP controlled or

patient is on anti- HT treatment

 FU after 1 week and 6 weeks

Recurrence risk:
Gestational HTN 16-47%
Preeclampsia 2 -7 %


CHRONIC
HYPERTENSION
Chronic hypertension in pregnancy
 The presence of hypertension of any cause
antedating or before the 20th week of pregnancy
beyond the 12 weeks after delivery

 Women with CH are low risk and have satisfactory

maternal and fetal outcome without any hypertensive
therapy by life-style modification

  With life-style modification, aerobic exercise

should be restricted based on theoretical concerns.
Risk factors CH
 : Age (>40 years

 Duration of hypertension (>15 years

 Level of BP (>160/110 mm of Hg)

 Presence of any medical disorder

 Presence of thrombophilias
 AIM for BP control target during
pregnancy:
Keep b.p < 150/100

If target organ damage b.p < 140/90

Start tab ecospirin 75-150 mg 12 weeks

onwards
 In case of chronic hypertension also advised usg
for B/L kidney and adrenal

 If patient already taking any antihypentensive

drugs before the pregnancy then during pregancy
switch to other safer antihypentensive drugs
( labetalol,nifidipine,methyldopa)

management of maternal and fetal monitoring

during pregnancy, labour is same like gestational
HTN managment
After delivery
 BP monitoring : once daily

 Anti-HT cont. methyldopa should not use

 No restriction of ACE inhibitors, B- blockers, and dose should be

readjust

 Avoid diuretics during lactation

 Discharged : after 72 hours if BP controlled or patient is on anti-

HT treatment

 FU after 1 week and 6 weeks

 Timing Of Delivery

 Gestational hypertension can be taken to term.

 Mild preeclampsia /chronic HTN should be

delivered at 37 weeks.

 Severe preeclampsia should be delivered after 34

weeks.

 Eclampsia should be delivered once stabilized

with MgSO4 at any weeks of gestation.
Cont..
 Corticosteroids are given for fetal lung
maturity where appropriate.

 Intramuscular Dexamethasone 6 mg 6
hourly 4 doses or Betamethasone 12 mg 12
hourly 2 doses.

 Cesarean section is done for Obstetric

indications only.
 K YO U
T H A N