Hypertensive

disorder in
Pregnancy
INTERN. RACHATA PIRIYAMANUN
ADVISOR. SUPATTA
Maternal mortality

• 500,000+ maternal deaths annually

• Thailand(2555):
pregnancy death 144 people
• From hypertensive disorder 25 people
(3.1 /100,000 people)
Why important?
●“Big Three” causes of maternal deaths
○“Hypertensive disorders”
○Hemorrhage
○Infection
○ Amniotic fluid embolism
○ Indirect cause : heart disease, …
Normal BP during pregnancy
1 trimester unchanged
st

(baseline)
2
nd
trimester decreasing
3rd trimester increasing to
baseline
“Lowest BP at 24-28 weeks”
 Definition of hypertension

“ Systolic BP ≥ 140 mmHg

OR Diastolic BP ≥ 90 mmHg 2time in 4
hour
Or Systolic BP ≥ 160 mmHg
OR Diastolic BP ≥ 110 mmHg 2time in min”
 Classification of hypertensive disorders
• Preeclampsia and Eclampsia
• Chronic hypertension
• Chronic hypertension with superimposed
preeclampsia
• Gestational hypertension
Chronic Hypertension

● Present prior to pregnancy

o
History
o
Evidence of chronic HT
● >140/90 mmHg, before 20 weeks GA
● Persist beyond12 weeks postpartum
Chronic hypertension with superimposed preeclampsia

● Increased BP and proteinuria in patients with

chronic HT
Gestational hypertension

● >140/90 mmHg, after 20 weeks GA

● No proteinuria
● Become normal blood pressure in 12 weeks
postpartum
Preeclampsia
● >140/90 mmHg, after 20 weeks GA in normal
blood pressure prior pregnancy
● In Proteinuria
○ Protein >= 300 mg in 24-hour urine collection
○ Or Protein: creatinine ratio in urine(UPCI) >= 0.3
○ Or Urine dipstick >= 1+
Preeclampsia(continue)
● In no proteinuria but new onset hypertension with
one of following
○ Thrombocytopenia: platelet<100,000 mm3

○ Renal insufficiency: serum creatinine >1.1 mg/dL or

increase 2 time to baseline

○ Impaired liver function:

liver transaminase increase 2 time to normal range

○ Pulmonary edema

○ Cerebral or visual symptoms

 Classification

Onset of HT Proteinuria absent Proteinuria present

Chronic HT Superimposed
< 20 weeks GA preeclampsia

> 20 weeks GA Gestational HT Preeclampsia

and Eclampsia
 Pregnancy-induced HT (PIH)

HT Proteinuria Seizure
(300mg/d or
UPCI>0.3)

Gestational HT ✔ ✖ ✖

Preeclampsia ✔ ✔ ✖

Eclampsia ✔ ✔ ✔
Preeclampsia with severe feature?
● Preeclampsia with one of following
○ SBP> 160 mmHg or DBP> 110 mmHg 2 time in 4 hour

○ Thrombocytopenia: platelet<100,000 mm3

○ Progressive Renal insufficiency: serum creatinine >1.1 mg/dL or

increase 2 time to baseline

○ Impaired liver function:

liver transaminase increase 2 time to normal range
or severe persistence at RUQ or epigastric pain

○ Pulmonary edema

○ Cerebral or visual symptoms(new onset)

Clinical signs & symptoms
● Edema
○ rapid weight gain, early but not diagnostic ring sign
●Hypertension
●Headache / Visual disturbance
○ impending eclampsia
●Retinal change
○ segmental spasm, decreased A:V ratio
●Epigastric pain
○ subcapsular hematoma
 Rapid weight
gain
Leg edema
1 Kg per week

Ring sign
Laboratory
● UA, UPCI for Proteinuria
● CBC for Thrombocytopenia
● BUN, Cr for Renal insufficiency
● LFT for Impaired liver function
● Uric for hyperuricemia
● Electrolyte
● Coagulation
● HELLP syndrome
○ Hemolysis Elevated Liver enzyme Low Platelets
What is HELLP syndrome ?
● A “severe form” of severe preeclampsia
● 0.5-0.9% of pregnancies
● 10-20% of severe preeclampsia
● HELLP syndrome
○ Hemolysis
○ Elevated Liver enzyme
○ Low Platelets
 Complications of HELLP
Maternal complications Maternal complications
Occurrence Occurrence

(%) (%)
Eclampsia 4-9 Eclampsia 4-9
Abruptio placentae 9-20 Abruptio placentae 9-20
DIC 5-56 DIC 5-56
Acute renal failure 7-36 Acute renal failure 7-36
Pulmonary edema 3-10 Pulmonary edema 3-10
7-14 7-14
Wound hematoma/infection (C/S) Wound hematoma/infection (C/S)
Subcapsular hematoma 0.9-2 Subcapsular hematoma 0.9-2

Cerebral hemorrhage 1.5-40 Cerebral hemorrhage 1.5-40

Death 1-25 Death 1-25
Management
hypertensive disorder in pregnancy
Preeclampsia
without
severe
feature
Severe
Preeclamp
sia
Severe
preeclampsia with
GA <= 24 week
Severe preeclampsia
with GA 24+1 to 33+6
week
Severe
preeclampsia with
GA >=34 week
Eclamps
 ACOG Recommendations based on good and
consistent scientific evidence (Level A):
Magnesium sulfate should be used for the
prevention and treatment of seizures in
women with severe preeclampsia or
eclampsia.
Serum Mg levels vs Effects

Serum Mg level Effects

4-7 mEq/L Anticonvulsant
(4.8-8.4 mg/dL) prophylaxis
(Therapeutic level)
10 mEq/L (8-10 mg/dL) Loss of DTR
12 mEq/L (12-25 mg/dL) Respiratory paralysis
15 mEq/L (25-30 mg/dL) Cardiac arrest
Low Therapeutic
Magnesium sulfate
 ACOG Resommendations based primarily
on consensus and expert opinion (Level C):
Antihypertensive therapy should be used
for treatment of diastolic blood pressure
levels of 105–110 mm Hg or higher
(with either hydralazine or labetalol)
First line
First line
First line
second line
Intrapartum management
● Close maternal and fetal monitoring
● Careful IV fluid administration, beware of pulmonary
edema
● Adequate sedation
● Shorten second stage of labor -> forceps extraction
Postpartum management
● Continuation of MgSO4 for 24 hours
● Careful observation of clinical S&S, and IV fluid
administration, observe urine output
● Beware of PPH
● Beware of postpartum preeclampsia
Prevention
● Low dose aspirin(81mg)
● Begin during 12-16 weeks
● Stops at 36 weeks
● Beneficial in high-risk cases only
○ Previous history of early-onset preelampsia with
labor before 34 weeks
○ Previous history of preeclampsia > 1 time
○ Chronic hypertension
○ Overt DM, SLE, autoimmune disease, chronic kidney
disease
How to reduce morbidity and mortality
● Early identification of preeclampsia
○ More frequent ANC visits in the third trimester
○ Blood pressure / Urine protein assessment
○ Prediction and prevention of preeclampsia
● Prevention of eclampsia
○ Access to medical care
○ Magnesium sulfate
● Proper management of severe cases
CPG-
CPG-
CPG-
CPG-
CPG-
Question
?
Thank
you