Hypertensive in pregnancy

 PRESENTER DR MOHD AFIF

 DATE : 16/8/22
 DEFINITION
 Defined as systolic blood pressure (SBP) ≥140 mmHg
and/or diastolic blood pressure (DBP) ≥90 mmHg.
 An increase of SBP of 30 mmHg and DBP of 15 mmHg
above baseline BP is no longer recognised as hypertension
if absolute values are below 140/90 mmHg.
 Nevertheless, this warrants close observation, especially if
proteinuria and hyperuricaemia are also present.
 The gold standard tool to measure blood pressure in
preeclampsia is still the mercury sphygmomanometer
 Proteinuria
 Significant proteinuria in pregnancy is defined as
≥300 mg protein in a 24H urine sample,
or
 a spot urine protein-creatinine ratio ≥30 mg/mmol

 If the dipstick is the only test available, 2+ is

approximated to ≥300 mg/day proteinuria.
 Incidence
 6%-8% of all the pregnancies
 Complicates about 10-20% of pregnancies
 Classification
 1. Preeclampsia (PE):
a. PE is clinically diagnosed in the presence of de novo
hypertension after 20 weeks gestation, with one or
more of the following:
i. Significant proteinuria
ii. Renal insufficiency: serum creatinine ≥90 micromol/l or oliguria
iii. Liver disease: raised transaminases and/or severe right upper quadrant or
epigastric pain
iv. Neurological problems: convulsions (eclampsia), hyperreflexia with clonus
or severe headaches, persistent visual disturbances (scotoma)
v. Haematological disturbances: thrombocytopenia, coagulopathy, haemolysis
vi. Fetal growth restriction
b. PE superimposed on chronic hypertension is
diagnosed in the presence of any of the following, in a
woman with chronic hypertension:
i. De novo proteinuria after 20 weeks gestation
ii. A sudden increase in the severity of hypertension
iii. Appearance of features of PE-eclampsia, and
iv. Worsening proteinuria in a woman with pre-
existing proteinuria early in gestation
 2. Gestational hypertension
 defined as hypertension detected for the first time
after 20 weeks gestation.

 Although it usually runs a benign course, it can

progress into PE in 25% of cases, more so if it
presents before 34 weeks of gestation.
 3.Isolated office hypertension
- white coat hypertension
 Defined as elevated BP of 140/90 mmHg only in the
clinic with normal BP demonstrated by ambulatory
BP monitoring (ABPM) either awake or during
sleep.
 In the absence of ABPM device, HBPM can be used.
 Women in this group should not be considered low
risk as they may progress to gestational
hypertension (50%) or PE (8%).
 4.Chronic hypertension
 Hypertension diagnosed prior to 20 weeks gestation
or presence of hypertension preconception, or de
novo hypertension in late gestation that fails to
resolve three months postpartum.
 Important role of primary care
 The primary care plays an important role in the prevention
and early detection of PE and its complications
 1. preconception counselling :
 Women with chronic hypertension may require a change in the
type of antihypertensive agent used pre-pregnancy.
 The drugs of choice in pregnancy are methyldopa and labetalol
 Atenolol has been shown to lead to fetal growth restriction.
 The use of ARBs, ACEIs and thiazide diuretics are associated with
fetal anomaly and are therefore contraindicated in pregnancy.
2. Recognition of women at risk of preeclampsia
for commencement of prophylaxis.
 3. Prophylactic therapy
 a. Aspirin:
- Women with ≥2 moderate or one high risk factor
should be started on low dose aspirin from 12 weeks up
to 16 weeks of gestation until delivery. The dosage
should be 100-150 mg and taken at bedtime in order to
significantly reduce the incidence of PE.
 b. Calcium :
- A systematic review showed that low dose calcium
supplement (generally 500-1000mg daily) commenced
before 20 weeks gestation reduces the risk of PE
 5. 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 Maternal-
Fetal Medicine (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.
 If a cardiac anomaly is detected, cardiology referral is
recommended
 Severe Preeclampsia
 Severe preeclampsia must be promptly identified so that the
patient can be urgently admitted to hospital for close observation
and timely delivery.
 The American College of Obstetricians and Gynecologists defines
severe preeclampsia based on the following features :
a. Systolic BP ≥160 mmHg or diastolic BP ≥110 mmHg on two
occasions at least 4 hours apart while the patient is resting
b.Thrombocytopenia – platelet count below 100,000/cm3
c. Abnormal liver enzymes (elevated AST/ALT), severe persistent right
upper quadrant or epigastric pain unresponsive to treatment
d.Pulmonary oedema
e. New onset of cerebral or visual disturbances
 HELLP syndrome
 A. Hemolysis (H)
 B. Elevated liver enzyme ( EL )
 C. Low platelet count ( LP )
 Acute hypertensive crisis
 In the event of an acute hypertensive crisis, IV
hydralazine, IV labetalol, or oral nifedipine, may be used
to lower the BP.
 Sublingual nifedipine is no longer recommended
 Diuretics are generally contraindicated as they reduce
plasma volume, may cause Intrauterine Growth
Restriction (IUGR) and may possibly increase perinatal
mortality. Their only use is in the treatment of acute
pulmonary oedema.
 In order to reduce the risk of maternal stroke, the blood
pressure should be reduced within 30-60 minutes.
 Eclampsia
 Definition :Pre eclampsia when complicated with
grandmal seizure ( generalized tonic clonic seizures)
and /or coma

 Pathogenesis : loss of normal cerebral auto

regulatory mechanisms cerebral hyperperfusion
leading to edema and reduce cerebral blood flow
 Clinical features
Eclamptic convulsions are epileptiform and consist of
four stages :
 Premonitory stage : twitching of muscles of face ,

tongue ,limbs and eye. Eyeballs rolled or turned to

one side
 Tonic stage : opisthotonus , limbs flexed , hand

clenched
 Clonic stage :1-4min, frothing , tongue bite ,

stertorous breathing
 Stage of coma :variable periods
 Different diagnosis
 1. Epilepsy
 2 Hysteria
 3 Encephalitis
 4 Meningitis
 5 Puerperal cerebral thrombosis
 6. Poisoning
 7.Cerebral Malaria
 8. Intracranial tumor
Management
Anticonvulsants in Preeclampsia-Eclampsia
 Parenteral MgS04 is currently the drug of choice for the
prevention of eclampsia and to abort an eclamptic fit
 The alternative is intravenous diazepam, but inferior in
efficacy compared to MgS04
 MgSO4 also provides fetal neuroprotection following
preterm birth with a significant reduction in the incidence of
cerebral palsy
 Postpartum Care
 Postpartum, women with hypertensive disorders in
pregnancy are advised to have their BP checked regularly at
local clinics and antihypertensive should be tailed down
gradually.
 anti-hypertensive agents are usually required for longer in
women with preeclampsia compared with those with
gestational hypertension
 De novo onset of hypertension or aggravation of BP levels
during the postpartum period can occur.
 Eclampsia may occur in the postpartum period.
 Chronic hypertension is diagnosed when the hypertension
and/or proteinuria persist after 3months postpartum.
Anti-Hypertensive Drugs Commonly Used in
Pregnancy
 Anti-Hypertensive Drugs for Severe
Preeclampsia with Acute Hypertensive Crisis
Anti-Convulsant for Eclampsia (and Severe
Preeclampsia)
Uptodate
 Thank you