Hypertensive

Disorders in
Pregnancy
By Ira Marlina Handajani &
Daaniyal Reesha bin Rosman
Definition

• Blood pressure of ≥140/90mmHg on at least two occasions, at least

4 hours apart
Classification
CLASSIFICATION CHARACTERISTIC

Gestational hypertension New onset of hypertension after 20 weeks of gestation without signification
proteinuria

Pre-eclampsia New onset of hypertension after 20 weeks with significant proteinuria

- 24H urine protein ≥300mg/day (urine dipstick 2+)
- Protein creatinine ratio ≥30mg/mmol
or other new onset of symptoms (as listed in next slide)

Chronic hypertension Hypertension which exists before 20 weeks of gestation

Unclassified hypertension Diagnosed after 20 weeks without prior documented normal blood pressure
Maternal organ dysfunction/fetal involvement

Organ dysfunction Characteristics

Renal impairment Creatinine >90umol/L

Liver involvement Transaminitis

Severe RUQ or epigastric pain

Neurological manifestation Eclampsia, altered mental status, blindness, stroke,

hyperreflexia, clonus, severe headache, persistent visua
scotomata

Haematological abnormalities Thrombocytopenia (<100,000/μL), coagulopathy, haemolysia

Fetal growth restriction

• 25% of women with chronic hypertension can develop preeclampsia during
pregnancy.

• Chronic hypertension occurs in up to 22% of women of childbearing age, with

the prevalence varying according to age, race, and body mass index (BMI).

• Approximately 1% of pregnancies are complicated by chronic hypertension, 5-

6% by gestational hypertension (without proteinuria), and 3-6% by preeclampsia. 
Severe pre-eclampsia

• Systolic BP ≥160 mmHg or diastolic BP ≥110 mmHg on two

occasions at least 4 hours apart while the patient is resting
• Thrombocytopenia – platelet count below 100,000/cm3
• Abnormal liver enzymes (elevated AST/ALT), severe persistent right
upper quadrant or epigastric pain unresponsive to treatment
• Pulmonary oedema
• New onset of cerebral or visual disturbances
 • Mechanisms:
• Abnormal placenta implantation
• Maternal immunologic intolerance
Pathophysiology • Genetic, nutritional, environmental
factors
• Cardiovascular and inflammatory
changes
Evaluation of a woman with high BP

• Gestational age
• Signs and symptoms of pre-eclampsia
• End organ damage/involvement – CVS, eyes, renal, liver, CNS
• Secondary causes of hypertension – hyperthyroidism, renal artery
stenosis
Signs & symptoms

Headache, altered
Visual disturbance Shortness of breath
mental status

Epigastric/RUQ
Oedema PV bleeding
pain
Investigations
INVESTIGATIONS JUSTIFICATION

24-H urine protein - >300mg/day (urine dipstick 2+) Proteinuria

Protein creatinine ratio - >30mg/mmol

Creatinine - increased Renal function

Uric acid - increased

FBC – low platelets, low Hb HELLP syndrome

LFT – elevated AST, ALT
LDH - increased due to haemolysis
Coagulation profile – increased PT/APTT

CXR Pulmonary oedema

ECG LVH
Investigations
(Fetal)

Investigation Justification
Ultrasound TAS – evaluate for growth
restriction
Umbilical artery Doppler - to
assess blood flow

CTG Fetal distress

Preconception counseling

• Chronic hypertension – may require change of antihypertensive

drugs (methyldopa, labetolol)
• Atenolol – fetal growth restriction
• ARBs, ACEIs, thiazide – fetal anomaly
• Treatment of hypertension for maternal safety – does not reduce risk
of pre-eclampsia, perinatal mortality, improve fetal growth
Screening

• BP monitoring and proteinuria during antenatal visits

• Isolated raised BP should be taken seriously
• Weight and oedema should be noted – associated with PE
• High risk women need close monitoring and early referral to
secondary or tertiary centre early in the pregnancy.
Management: Antenatal

Prophylactic therapy
a. Aspirin 100-150 mg ON
- Women with ≥2 moderate or one high risk factor should be started
from 12 weeks up to 16 weeks of gestation

b. Calcium 500-1000mg OD
- Should commenced before 20 weeks
Fetal anomaly screening
- Women with chronic hypertension have about 20-30% increased risk for fetal
congenital cardiac anomaly.

- These women are to be referred to the MFM specialist in the tertiary centre to
be recommended to undergo nuchal translucency (NT) scan at 12-14 weeks
followed by a detailed ultrasound scan at 22-24 weeks of gestation.
Management: Mode of Delivery
Anticonvulsants
Management: Postpartum

• Regular BP check ups at local clinics

• On average, anti-hypertensive agents are required for longer in women with preeclampsia
(approximately two weeks) compared with those with gestational hypertension (approximately one
week)
• De novo onset of hypertension or aggravation of BP levels during the postpartum period can
occur. These patients should be promptly referred to hospital especially if there is significant
proteinuria.
• Eclampsia may occur in the postpartum period.
• Chronic hypertension is diagnosed when the hypertension and/or proteinuria persist after three
months postpartum
Complications

Maternal Fetal
 Eclampsia  Preterm labour
 Stroke  LBW baby
 HELLP Syndrome  IUGR
 Abruptio placenta  IUD
 Caesarean section
 Pulmonary Edema (d/t oliguria, LVF,
fluid overload)
References

• CPG Management of Hypertension 5th edition

• NICE guidelines, https://www.nice.org.uk/guidance/ng133
• https://emedicine.medscape.com/article/261435-overview#a1
• http://www.myhealth.gov.my/en/hypertension-in-pregnancy/
Thank You