TRAINING MANUAL

HYPERTENSIVE DR AIMI NAHDIAH

KK SG SEKAMAT
DISORDER IN 2021

PREGNANCY
 DEFINITION OF
HYPERTENSION
• Blood Pressure of 140/90mmHg taken
after a period of rest on two occasions.
OR
Rise of systolic blood pressure (SBP) of
30mmHg and/or a rise in diastolic blood
pressure (DBP) of 15mmHg
compared to pre pregnancy levels.

CPG HPT 2018

 CLASSIFICATION OF HDP
used in this manual is:
i. Pregnancy Induced Hypertension (PIH)
 Hypertension after the 20th week of pregnancy in a previously normotensive woman. It may be associated
with proteinuria.
• Gestational Hypertension (GH)—PIH without proteinuria
• Pre-eclampsia (PE)—PIH with proteinuria
• Eclampsia—PIH with convulsions

 HELLP syndrome is a severe form of PE manifested by Haemolysis, Elevated Liver Enzymes and Low
Platelets.

ii. Chronic Hypertension (includes essential and secondary hypertension)

iii. Chronic Hypertension with Superimposed Pre-eclampsia
 Chronic Hypertension
 BP of at least 140/90
 before 20 weeks of pregnancy OR > 6 weeks postpartum.
 Chronic Hypertension with Superimposed PE
 PE in women who have pre-existing hypertension.
 Criteria used should include worsening hypertension, proteinuria and non-dependent oedema.
 Essential Hypertension and Secondary Hypertension
 best categorised under chronic HPT
 pregnancy outcomes in all these categories are similar.
 Proteinuria
 UTI must be excluded.
 defined as 300mg/24 hours urine collection or 1g/L (2+ dipstick) or more in two randomly collected urine
samples 6 hours apart.
 Oedema
 commonly seen , may not be a usual sign for early detection of PIH.
 In severe PIH, there is generalised accumulation of fluid largely due to endothelial damage resulting in
accumulation of fluid >> pitting oedema following 12 hours of recumbant bedrest.
 A weight gain of 1kg within a week may point to increasing severity of PIH especially in the presence of
proteinuria.
.
CPG HPT 2018
CLASSIFICATION OF HDP

CPG HPT 2018

 SEVERITY OF HDP
a. Mild – Proteinuria of (3+) or >3g/L.
SBP 140-149mmHg and or DBP 90-99 without – Oliguria (<400ml/24 hours).
albuminuria
– Headache.
OR a rise in SBP 30mmHg or a DBP 15mmHg
from prepregnancy BP – Cerebral or visual disturbances.

b. Moderate – Epigastric pain.

SBP 150-159mmHg and or DBP 100-109mmHg – Hyper-reflexia.

– Pulmonary oedema.

c. Severe – Impaired liver function tests.

characterised by progressive deterioration in both – Increased serum creatinine (>1.2mg/dl).

maternal and foetal condition. – Retinal haemorrhage, exudates or
It is characterised by: papilloedema.

– SBP ≥160mmHg or DBP ≥110mmHg on 2 – Thrombocytopenia.

occasions 6 hours apart. – IUGR.
 IDENTIFYING THE MOTHER AT
RISK
•HDP cannot be prevented. – Non-immune foetal hydrops
•Identifying this group early, prenatally and – Underlying renal disease
during early booking
– Chronic hypertension
•keep these patients under surveillance. The
– Diabetes mellitus
risk factors include:
– Gestational trophoblastic disease (molar
– Maternal age <20 years and >35 years
pregnancy)
– Primigravida
– Low socio-economic group
– Previous history of HDP
– Pregnancies with different partners
– Multiple gestation
– Excessive weight gain
– Polyhydramnios
– Rh incompatibility
CPG HPT 2018
ANTIHYPERTENSIVE DRUGS

CPG HPT 2018

CPG HPT 2018

CPG HPT 2018

ANTICONVULSANT DRUG
 MANAGEMENT OF MILD
HYPERTENSIVE DISORDERS
IN must
• A decision PREGNANCY
be made at the time of diagnosis whether to manage mild HDP as an
out-patient or as an in-patient.
•Goal of Management of Mild HDP
to prolong the pregnancy to as near term as possible
provided there are no evidence of maternal complications or fetal compromise
(fetal distress, intrauterine growth restriction (IUGR) or oligohydramnios).
MANAGEMENT OF MILD
HYPERTENSIVE DISORDERS
IN PREGNANCY
Ambulatory Care (Out-Patient Management)
a. Criteria for selection of patient for ambulatory care:
• BP ≥140/90mmHg but less than 160/100mmHg.
• No proteinuria.
• No signs/symptoms of impending eclampsia.
• No excessive weight gain.
• No signs of intrauterine growth retardation.
• Normal biochemical investigation.
MANAGEMENT OF MILD
HYPERTENSIVE DISORDERS
IN PREGNANCY
b. Antenatal Care
• Mild HDP can be managed in health clinics.
• Every patient should be monitored to detect any deterioration in maternal and fetal
condition.
• The frequency of each visit should be individualised
• Maternal and fetal monitoring and surveillance is the mainstay of management
MANAGEMENT OF MILD
HYPERTENSIVE DISORDERS
IN PREGNANCY
c. Antihypertensive Therapy
 Not all mild HDP require antihypertensive Rx.
 A majority may benefit from adequate rest.
 treatment may be considered when DBP is persistently >100mmHg.
 In all cases, to avoid reducing the BP below the lower limits ( 110/80mmHg)
  lead to a risk of placental underperfusion

d. Referral to Hospital with Specialist

 At any time, when there is any deviation from the above criteria.
 MANAGEMENT OF MILD
HYPERTENSIVE DISORDERS
IN PREGNANCY
In-Patient Management
a. Indications for Hospitalization
for those who fail ambulatory care (out-patient) management. The reasons for admission
are:-
• symptomatic patients.
• maternal or fetal complications.
• persistent DBP>100mmHg or systolic >160mmHg for stabilization.
• abnormal biochemical PE profile.
• presence of severe proteinuria >2+.
MANAGEMENT OF MILD
HYPERTENSIVE DISORDERS
IN PREGNANCY
Timing of Delivery
• Do not offer birth to women with chronic HPT whose BP is <160/110mmHg, with or
without antihypertensive treatment, before 37 weeks.
• For women with chronic hypertension whose BP is <160/110mmHg after 37 weeks,
with or without antihypertensive treatment, timing of birth and maternal and fetal
indications for birth should be agreed between the woman and the senior obstetrician.
•In the absence of maternal and fetal complication, pregnancy should not be allowed
beyond dates.
• If at anytime the maternal and fetal condition is compromised, early delivery is
mandatory and appropriate corticosteroid usage is necessary.
 MANAGEMENT OF SEVERE
HYPERTENSIVE DISORDERS
INpromptly,
• lowered PREGNANCY
albeit carefully, to prevent cerebral hemorrhage and hypertensive
encephalopathy.
• systolic as well as diastolic hypertension increases risk of cerebral hemorrhage.
MANAGEMENT OF SEVERE HYPERTENSIVE
DISORDERS IN PREGNANCY

Definition • Cerebral or visual disturbances.

= progressive deterioration in both maternal and • Epigastric pain.

fetal conditions. • Hyperreflexia.
The characteristics are: • Pulmonary oedema.
• SBP ≥160mmHg or DBP ≥110mmHg on 2 • Impaired liver function tests.
occasions 6 hours apart.
• Increased serum creatinine (>1.2mg/dl).
• Proteinuria of 3+ or >3g/L.
• Retinal haemorrhage, exudates or •
• Oliguria (<400ml/24 hours). Thrombocytopenia.
• Headache. • Fetal growth compromise (IUGR).
MANAGEMENT OF SEVERE
HYPERTENSIVE DISORDERS IN
PREGNANCY
Management
• The aim : prevent a CVA to the mother whilst achieve a clinically useful
prolongation of the pregnancy.
: delivering a live baby as mature as possible.
• Pre-eclampsia when diagnosed at term, mandates delivery
 no advantage to either the fetus or mother in prolonging the pregnancy.
• MgSO4 should be considered to prevent seizure in women with PE for whom there
is concern about the risk of eclampsia.
 MANAGEMENT OF SEVERE HYPERTENSIVE
DISORDERS IN PREGNANCY
Management at Home and Health Clinic
• refer to hospital immediately with Code Red.
• Arrange for transport and accompany the patient to hospital. Inform the receiving hospital (labour room)
prior to referral.
• Set up an IV drip with normal saline for emergency administration of drugs for resuscitation if the need
arises.
Give deep intramuscular (IM) MgSO4 10g bolus (5g each buttock) to prevent eclampsia.

• To lower BP, give oral nifedipine (10mg stat) or IM hydralazine 6.25mg.

During Transfer
• Monitor and record the maternal BP, HR and FHR every 15minutes.

Role of Steroid Dexamethasone reduces neonatal morbidity and mortality. initiate between 24-36 weeks
gestation
MANAGEMENT OF
ECLAMPSIA
• convulsions in a patient with HDP.
• may occur even in a modest hypertension
without proteinuria
• The goals of treatment are:
• To treat convulsions and prevent
recurrence.
• To control the blood pressure.
• To stabilise the mother.
• To deliver the fetus.
 MANAGEMENT OF ECLAMPSIA
MANAGEMENT OF ECLAMPSIA AT HOME & HEALTH CLINICS
Immediate Measures
• Call for medical assistance.
• The patient should be placed in the lateral position. Maintain airway, oxygen given through nasal prong/ventimask.
• Give IM MgSO4 10gm 50% solution (20mls). One half is injected into upper outer quadrant of each buttock in zigzag manner
(proceeded by LA if necessary) using a 21G needle.
• IV antihypertensive therapy e.g. hydralazine or labetalol if available
or nifedipine, to control hypertension.
• Set up an IV drip with NS for emergency administration of drugs for further resuscitation.
• Suck out secretions/saliva.
• Insert a Foley’s catheter to record and monitor urine output.
• Monitor and record the maternal BP, HR, RR and FHR every 15 minutes using a Labour Progress Chart.
• Arrange for transport and accompany the patient to hospital (Refer Section 4). To inform the labour room personnel of the receiving
hospital prior referral.

During Transfer: IV MgSO4 2g (or 5g for IM) in a syringe in case patient threw recurrent seizure during transfer.
 FETAL SURVEILLANCE IN HYPERTENSIVE
DISORDERS IN PREGNANCY
In HDP, the fetus monitored for: • Growth • Well-being
Fetal growth
•1 SFH performed routinely from 22-24 weeks onwards in all pregnancies.
- important in patients who are going to develop HDP.
•2 Maternal weight gain may not be useful now with the availability of ultrasound.
- Static weight gain or weight loss might be indicating IUGR and subsequent increased risk to the fetus.
•3 Ultrasound scanning: Measurement of CRL in the 1ST trimester or the BPD before 24 weeks are
accurate measures of POG.
- For HDP patients, BPD, FL, HC, AC and AFI measured monthly to ensure satisfactory growth of the fetus.
- Commonly associated with IUGR. Plotting of the fetal growth chart is encourage to identify early onset
of IUGR
Fetal Well-Being
•1Cardiotocography (CTG): It is more useful than Doppler studies because of the wide normal
variability seen with the latter particularly in the second trimester2
. The frequency test based on the severity and stability of HPT. Normally, if HDP is not severe,
twice weekly CTG should be sufficient. In severe HDP, this may have to be done more
frequently.
•2 Fetal Movement Chart (FMC)
• 3 Fetal heart rate monitoring with the Pinard’s fetal stethoscope
• 4 Ultrasound scanning can also assess fetal well being i.e by doing the Biophysical Profile.
This includes: – FHR, fetal movements and tone, breathing movements, AFI and also the CTG.
•5 Doppler velocimetry studies: This is available in tertiary centres.
- reverse end diastolic flow in the umbilical artery is associated with poor fetal perfusion and
hypoxia  immediate delivery
- increase Doppler signals  for closer fetal surveillance and anticipate early delivery.
DISCHARGE AND FOLLOW-UP
STRATEGIES
Care Plan on Discharge
• Counselling
i. Complication of HDP during puerperium
ii. Importance of contraception
iii. Notification of birth
DISCHARGE AND FOLLOW-UP
STRATEGIES
DISCHARGE AND FOLLOW-UP
STRATEGIES
DISCHARGE AND FOLLOW-UP
STRATEGIES
REFERRAL PROCEDURES
REFERENCES
1. TRAINING MANUAL HYPERTENSIVE DISORDER IN PREGNANCY 3RD ED
2018
2. CPG MANAGEMENT OF HYPERTENSION 5TH EDITION 2018