Part 10

HYPERTENSIVE DISORDERS IN
PREGNANCY
Topic contents
• Introduction
• Objectives
• Definitions
• Cause or predisposing factors
• Diagnosis
• Management and Midwive’s responsibility
Introduction
HDP is the most common medical complication reported during
pregnancy.

A significant contributor to maternal and perinatal morbidity and

mortality.
One of the five major causes of direct maternal mortality in Ethiopia

Predispose the woman to potentially lethal complications

Blood pressure – regulation and measurement

• Blood pressure (BP) is the force exerted by blood volume on the blood
vessel walls, known as peripheral resistance.

• This force is generated by contraction of the ventricles of the heart, and

in the case of young, healthy adults blood enters the aorta at 120 mmHg
at systole (contraction) and falls to 80 mmHg at diastole (relaxation) .

• When cardiac output rises due to increased stroke volume or heart rate
the BP rises,
• providing peripheral resistance remains constant, and BP
lowers with a decrease in cardiac output.

• Haemorrhage lowers blood volume and cardiac output so the

blood pressure will fall; conversely

• it will rise due to fluid retention increasing blood volume

• Systolic pressure is relatively labile, and can be affected by

emotional mood and body posture.
Blood pressure adaptation in pregnancy

In pregnancy blood plasma volume increases from approximately 2600 ml

to 3800 ml by 32 weeks’ gestation and red cell mass from 1400 to 1800 ml;
consequently cardiac output increases by 40%, with the majority of the
extra output directed to the uterus and kidneys .

This should result in raised BP, however the increasing release of

progesterone throughout pregnancy causes vasodilatation, and systolic and
diastolic pressures actually fall in the first and second trimesters by about
10 mmHg which can predispose the pregnant woman to fainting due to
hypotension .

Systolic and diastolic measurements rise slowly to the pre-pregnancy levels

in the third trimester
 `
• Accurate measurement of BP is essential in order to confirm wellness
or to diagnose hypotension or hypertension at the earliest possibility

• BP in both arms and if the difference is >20 mmHg the measurements should be
repeated. If the >20 mmHg difference remains, all subsequent readings should
be measured in the arm with the higher reading and the midwife should bring
this difference to the attention of a doctor
Defining hypertension

• Hypertension is systolic or diastolic BP that is raised from normal

values.
• New guidelines recommend that a diagnosis of hypertension should be
confirmed using 24-hour ambulatory blood pressure monitoring
(ABPM) as goldstandard rather than be based solely on measurements
of BP taken in clinical situations .
• Mild hypertension
Diastolic blood pressure 90–99 mmHg, systolic blood pressure 140–149 mmHg.
• Moderate hypertension
• Diastolic blood pressure 100–109 mmHg, systolic blood pressure 150–159
mmHg.
• Severe hypertension
• Diastolic blood pressure 110 mmHg or greater, systolic blood pressure 160
mmHg or greater.
Note the lower measurements for this definition when compared with severe
hypertension in the general population.
CLASSIFICATIONS OF HDP

1. Gestational hypertension

• It is a development of hypertension after 20wks of gestation.

• Not characterized by proteinuria
• Resolve after 10 days of postpartum.
• Previously known as PIH
CLASSIFICATIONS OF HDP CONT’D…

2. Preeclampsia
It is a pregnancy specific syndrome which is characterized by the
development of hypertension with proteinuria after 20 weeks
of gestation.
3. Eclampsia
• This is the occurrence of seizure in a woman with
preeclampsia, with no history of preexisting pathology that can
result in seizure activity.
CLASSIFICATIONS OF HDP CONT’D…
Severe pre-eclampsia
• This is pre-eclampsia with severe hypertension and/or with symptoms
and/or biochemical and/or haematological impairment.
4. Chronic hypertension
• This is hypertension that is present at the initial visit (booking) or
before 20 weeks, or if the woman is already taking antihypertensive
medication when referred to maternity services. It can be primary or
secondary in aetiology.
• Or Chronic hypertension encompasses hypertension >140/90 mmHg
that existed before pregnancy
CLASSIFICATIONS OF HDP CONT’D…

Eclampsia
• This is the occurrence of seizure in a woman with
preeclampsia, with no history of preexisting pathology that
can result in seizure activity.
4. Chronic hypertension
• It is defined as hypertension that is present and observable in
pre pregnant state or prior to 20wks of gestation.
Complications

The complications of gestational hypertension and chronic hypertension

are the same:
• Intrauterine fetal growth restriction (IUGR)
• placental abruption
• Superimposed pre-eclampsia
• Worsening hypertension leading to severe
• Hypertension and risks of stroke (cerebral vascular
• Accident [CVA] and organ damage).
Management
• The woman with known chronic hypertension should be booked at a
consultant unit,or consult DR.

• And re-referred to any clinics treating he hypertension and co-existing

conditions.

• If she is taking ACE inhibitors or ARB these are discontinued and

alternative hypertensive therapy prescribed
Management con’t
• The physiological fall of BP in early pregnancy might entail reducing
or even ceasing antihypertensives in the first trimester, and then
increasing doses gradually towards term based on BP readings.

 The woman who has a raised BP without proteinuria presenting

during pregnancy is likely to have gestational hypertension and

 should be referred to a maternal medicine clinic and booked for

labour and birth in a consultant-led unit.
Management con’t

• There after management of both chronic and gestational hypertension

is the same and requires involvement of both doctor and midwife as
follows:
• Schedule antenatal appointments, as for nulliparae,
 to see a doctor and midwife at 16, 25, 28, 31, 34, 36, 38 weeks
• Additional appointments should be arranged for
 maternal medicine or hypertension clinics if indicated.
• At each appointment record BP, urinalysis with emphasis on
proteinuria,
Management con’t

• Assess fetal growth by symphysis–fundal height (SFH).

• Be alert for signs of pre-eclampsia.
• Review BP readings; adjust drug dosages accordingly, aiming to keep BP
<150/100 mmHg inuncomplicated cases (NICE 2010a).
• The doctor should prescribe low-dose aspirin (75 mg once daily).
• Arrange ultrasound fetal growth and amniotic fluid volume assessment
and umbilical artery Doppler
• velocimetry between 28 and 30 weeks and between 32 and 34 weeks.
• If results are normal, these are not repeated unless there is a clinical
indication.
Management con’t

• Labour should be induced at 37 weeks or earlier if BP is uncontrolled,

or fetal or antenatal complications develop.
• Labour will require hourly BP monitoring and administration of
hypertensive drugs with dosages adjusted if BP fluctuates.
• An epidural may be advantageous in labour as this lowers BP.
• Continuous fetal monitoring is required in lab.
• A normal birth by the midwife can be anticipated, and caesarean
section should be performed for obstetric reasons only.
 Management con’t

• The length of the second stage of labour should be shortened only if

severe hypertension develops.
• Ergometrine and syntometrine should be avoided for the third stage of
labour as these are acute vasoconstrictors.
• Use oxytocin .
.• Breastfeeding should be encouraged
.• The midwife should record BP daily in the postpartum period for the
first 3 days and then on the 5th day.
•
Management con’t

Postpartum BP should be maintained below 140/90 mmHg and, if

necessary, medication adjusted
• Prior to transfer home from hospital the woman should be seen by an
obstetrician who is likely to stop methyldopa within two days of birth
and restart the antihypertensive treatment the woman was taking
before she planned the pregnancy.
• If BP falls below 130/80 mmHg the obstetrician should reduce the
hypertensive treatment.
• The midwife should reinforce advice on lifestyle factors such as diet
and exercise.
Management con’t
• The combined oral contraceptive pill might be contraindicated, so
referral to a doctor or family planning clinic for specialist advice is
essential.
• The midwife should not discharge the woman from her care if BP
levels give concern and other members of the multidisciplinary team
may need to be involved.
• A 2-week postnatal review with the general practitioner (GP) should
be arranged where the continued use of antenatal hypertensive treatment
should be reviewed.
• A medical review in combination with the 6-week postnatal review
should also be arrange.
Superimposed pre-eclampsia
• Women with chronic hypertension may develop preeclampsia as well,
and the signs and symptoms are the same as for pre-eclampsia .

• In these women the blood pressure profile may be more difficult to

interpret

• Development of significant proteinuria is indicative of pre-eclampsia

and often accompanied by fetal growth restriction

• Management and treatment are as for pre-eclampsia.

PREECLAMPSIA

• It is a pregnancy specific syndrome in which hypertension develops

with proteinuria after 20 weeks in a previously normotensive woman.

• unique to human pregnancy

• Is a multisystem, vasospasmic disease process that reduce organ

perfusion characterized by the presence of HPN and Protein Urea.
Mild Pre-eclampsia

 Two readings of diastolic blood pressure 90-110 mm Hg 4 hours apart

after 20 weeks gestation
 Proteinuria up to 2+
 No other signs/symptoms of severe pre-eclampsia
 Severe Pre-eclampsia
 Diastolic blood pressure > 110 Other signs and symptoms
mm Hg sometimes present:
 Proteinuria > 3+  Epigastric tenderness
 Headache
 Visual changes
 Hyperreflexia
 Pulmonary edema
 Oliguria
Signs/symptoms due to vasospasm and/or leaky capillaries
End-organ changes:
•Central nervous system
•Pulmonary
•Renal
 Those women who developed gestational hypertension at an earlier
gestational age were more likely to progress to pre-eclampsia.
 Approximately 15–25% of women initially diagnosed with
gestational hypertension will develop pre-eclampsia
 It is difficult to predict who will develop pre-eclampsia
Etiology

• The ultimate cause remains unknown

• Several major concepts contribute to current theories regarding the
etiology of preeclampsia. These includes
- Endothelial cell dysfunction
- Abnormal prostaglandin activation
- Coagulation abnormalities
- Dietary deficiencies or excesses
 Risk factors for preeclampsia

• Extreme ages(<20 and >40 yrs )

• Multiple pregnancy
• Rh isoimmunization
• Diabetes
• Chronic renal disease
• Molar pregnancy
• Familiar inheritance
• New paternity, Black race & low socio economic
status
 Pathophysiology

• Vasoconstriction is the hallmark →marked increased in

peripheral resistance→ hypo perfusion to multi organs

• Hypo perfusion →endothelial dysfunction (resulted from the

imbalance of vasodilators (PGI2, NO) and vasoconstrictors
(angiotensin II, TXA2, endothilin-1).
 Pathophysiology cont’d…

• Reduced kidney perfusion → decreases GFR → degenerative

glomerular changes
• Increased oxidative stress→ endothelial injury→ increased
capillary permeability →accumulations of fluid in the
interstitial tissue→ edema is formed as a result of leaky
capillaries & decreased blood osmotic pressure.
• Decreased blood volume from reduced vascular space.
Pathophysiology cont’d…
• Spasm of the afferent glomerular arterioles→ anoxic change in the
endothelium of the glomerular tuft→ glomerular endotheliosis→ ↑ed
capillary permeability→↑ed protein leakage and reduced tubular
reabsorption → proteinuria.

• Capillary endothelial damage results in the formation of micro thrombi

in different organs mainly liver, kidney, and brain.
DIAGNOSIS OF PREECLAMPSIA

• The diagnosis of hypertensive disorders of pregnancy is usually

straight forward.

• But we must differentiate b/n different type of HDP (mild and severe
preeclampsia, chronic HTN, superimposed preeclampsia, Eclampsia &
transient HTN) and identify presence of complications
DIAGNOSIS OF PREECLAMPSIA cont’d…

The Dx is depends on
Hx
• Prim gravida
•Women with new paternity
•Past Hx of PIH
•Familiar Hx of PIH
•Hx of renal disease and vascular disease
•Hx of convulsion
Diagnosis cont’d…

P/E
• Blood pressure
•Weight
•Fundal height& fetal heart beat
•Dependent & nondependent edema
•Cardio vascular examination
•Motor and sensory function
Diagnosis cont’d…

• Lab investigations
-Urine protein
- CBC, hematocrit, platelet
count
-Blood chemistry(RFT &LFT)
• Ultra sound
-Gestational age
-Biophysical profile
 COMPLICATIONS OF PREECLAMPSIA
Early undiagnosed and untreated preeclampsia is usually associated with high
maternal and perinatal mortality &morbidity.
1. maternal
• Abruptio placenta
• Acute renal failure
• Hepatic failure
• HELLP syndrome & DIC
• Cerebral hemorrhage
• Pulmonary edema
• Heart failure
Complication cont’d…

2. fetal
• IUGR( due to chronic placental insufficiency)
• IUFD(due to spasm of utero-placental circulation→ accidental
hemorrhage)
• Asphyxia
• Prematurity (either due to spontaneous onset of labor or preterm
induction)
 
MANAGEMENT OF PREECLAMPSIA

Objectives of the management

• Prevention of Eclampsia
• Preserve the health of the mother and fetus
• Delivery of alive, healthy and mature fetus

 Management depends on the severity of the disease and

gestational age
 A. Management For Mild Preeclampsia
 

1. gestation less than 37 weeks/mild preeclampsia

 Conservative management
Follow up twice a week as an outpatient;
• Monitor BP, urine(for protein urea), and fetal condition
• Monitor uric acid, renal & liver function test, platelet and
hematocrit weekly
 Management cont’d…
• Counsel the woman and her family about danger signs for pre
eclampsia
 Sudden increase in weight, generalized edema involving the
upper extremities & face
Decreased in urine output
Persistence headache
Right upper quadrant or Epigastric pain
 Decreased fetal movement
Vaginal bleeding
Convulsion or loss of consciousness
Management cont’d…

 Encourage additional periods of rest

Encourage normal diet( salt restriction should be avoided)
Do not give anticonvulsants, antihypertensive, or sedatives.
 Start medium acting antihypertensive (methyl dopa) only if the
DBP is 100mmHg or more.
Management cont’d…

If follow up as an out pt is not possible, admit the woman to the

hospital and continue the same management until term.

If there are signs of growth restriction or exacerbation of the s/s

termination of pregnancy is considered.
Management cont’d…

II. GESTATION MORE THAN 37 COMPLETE WEEK

• termination of pregnancy is considered as method of choice

 
B. MGT FOR SEVERE PRE ECLAMPSIA

Severe pre-eclampsia encompasses high blood pressure of systole

>160 mmHg or diastole >110 mmHg on two occasions and significant
proteinuria.
• Modern definitions also include women with moderate hypertension who
have at least two of the features below:
• low blood platelet count <100 ×106/l
• Abnormal liver function
• liver tenderness
Haemolysis Elevated Liver enzymes and Low Platelet count (HELLP)
syndrome
• clonus (intermittent muscular contractions and relaxations)
• papilloedema
• epigastric pain
• vomiting
• severe headache
• visual disturbance (flashing light similar to migraine)
• All cases of severe preeclampsia should be managed
actively.
• Symptoms and signs of “impending eclampsia” are:-
 Blurred vision,
 Hyper rflexia,
 Severe frontal head ache
• Termination of pregnancy (after stabilization) is definitive and
curative treatment for preeclampsia →resolutions of
conditions within 48 hrs.
 Management cont’d…
Components of aggressive(active) mgt:
• Administration of short acting antihypertensive drug→ hydralazine
5mg IV slowly every 30 minutes if the DBP is 110 mmHg or more.

• If hydralazine is not available labetolol 10 mg iv or nifedipine 5mg

sublingual can be used.
• Start infusion of anticonvulsants→ magnesium sulphate or diazepam
can be used.
 Management cont’d…
• Delivery should take place as soon as the woman’s
condition has stabilized.
Mode of delivery is based on the prevailing conditions
(either by induction or C/S).
• Induction if;
The cervix is favorabl
Safe anesthesia is not available for c/s
The fetus is dead or too premature for survival
Management cont’d…

C/S if;
 Vaginal delivery is not anticipated within 24 hrs
There are FHR abnormalities
 The cervix is unfavorable and the fetus is alive
Management cont’d…

• During vaginal delivery, shorten the 2nd stage of labor by instrumental

delivery.
• In 3rd stage use oxytocin, don’t use ergometrine

• Continue monitoring after delivery

• Continue anticonvulsants for at least 24 hrs postpartum

 
 HELLP SYNDROME

• Is a laboratory diagnosis for a variant of severe preeclampsia that

involves hepatic dysfunction.
• Characterized by
Hemolysis (H)
• Elevated liver enzymes (EL)
• Low platelets (LP)
• appears in only 2-12% of severely preeclamptic women
• high maternal and perinatal mortality rates
HELLP SYNDROME cont’d..

Etiology
• Although the exact mechanism is unknown, HELLP syndrome is
thought to arise as a result of changes occurring with preeclampsia

• Arteriolar vaso spasm, endothelial damages, and platelets

aggregation with resultant tissue hypoxia are the underlying
mechanisms for the pathophysiology.
HELLP SYNDROME cont’d ..
S/S
• No apparent s/s in many women
-HX of malaise for several days
- Epigastric or right upper quadrant
abdominal pain
 HELLP SYNDROME cont’d..

Diagnosis
HELLP syndrome is a laboratory, not a clinical, diagnosis.
To have a diagnosis of HELLP syndrome,
 platelet count must be less than 100,000/mm3
 liver enzymes levels(AST & ALT) must be elevated
 there must be some evidence of intravascular hemolysis( burr
cells on peripheral smears or elevated bilirubin level)
A unique form of coagulopathy (not DIC) occurs with HELLP
syndrome. The platelets count is low, but coagulation factor assays,
PT, PTT and bleeding times remains normal.
HELLP SYNDROME cont’d..

Mgt
• Aggressive therapy has to be initiated to prevent maternal and
neonatal mortality.
Fulminant eclampsia

• This is the acute worsening of symptoms, especially

 Headache,
 Epigastric pain and
 Vomiting accompanied by high blood pressure,
indicating that severe eclampsia is developing into eclampsia
and that a convulsion is imminent.
• Consequently, emergency intervention is required
 ECLAMPSIA

The term Eclampsia is derived from Greek word, meaning”

like a flash of lightening”
• Occur quite abruptly, without warning manifestations.
• The disease is preceded by features of severe preeclampsia
• When preeclampsia is complicated with convulsion and/or
coma
• The pathophysiology is similar to preeclampsia
• Cause of convulsion still unknown but irritation may be
provoked by
 ECLAMPSIA cont’d…

• Anoxia → spasm of the cerebral vessels following

hypertension→ increased cerebral vascular resistance→ fall in
cerebral oxygen consumption
• Cerebral edema→ may contribute to irritation
Onsets of eclamptic fit
• Antepartum (50%)
• Intra partum (30%)
• Post partum (20%)
ECLAMPSIA cont’d…

Eclamptic convulsion/fit has four stages

• Premonitory stage→ the pt become unconscious→ lasts 30sec
• Tonic stage→ the whole body goes into a tonic spasm→30sec
• Clonic stage→ all the voluntary muscles undergo alternate contraction
and relaxation→ biting of tongue may occur→1-4min
• Coma stage→ rarely occur without convulsion→ fits recurring at
variable interval→ status eclampticus
ECLAMPSIA cont’d…

DDX
• Epilepsy
• Encephalitis
• Meningitis
• Puerperal cerebral thrombosis
• Cerebral malaria
• Intra cranial tumor
 
Mgt

The principles in the management of Eclampsia includes

• Control of convulsion
• Control of hypertension
• Termination of pregnancy regardless of the gestational age
ECLAMPSIA cont’d…

It is an acute obstetric emergency and managed as follow

• Start the ABC resuscitation (clear the air way by suction, maintain air
way, start IV fluid, position the women in lateral position to prevent
aspiration.
• Prevent tongue biting and fall accidents
• Catheterization
• Start short acting antihypertensive drugs
 Magnesium Sulfate protocol:
• Loading dose
• 4 gm magnesium sulfate( MgSo4) as 20% solution IV given
over 5 minutes (Mix 8 ml of 50% Mgso4 solution with 12ml
ofD5W or 09% Normal saline to make 20% solution)
• 10 g of 50% magnesium sulfate (MgSo4) solution, 5 g in each
buttock as deep IM injection with 1mL of 2% lignocaine in the
same syringe. Ensure that aseptic technique is practiced when
giving magnesium sulfate deep IM injection.
N.B. Warn the woman that a feeling of warmth will be felt
when magnesium sulfate is given

64
 Magnesium Sulfate…….Cont’d
• If convulsions recur after 15 minutes, give 2g magnesium
sulfate (20% solution) IV over 5 minutes (4ml magnisium
sulphate+6ml DW)

• Maintenance dose
• 5 g magnesium sulfate (50% solution) + 1 mL lignocaine 2%
IM every 4 hours into alternate buttocks.
• Continue treatment with magnesium sulfate for 24 hours after
delivery or the last convulsion, whichever occurs last.
Magnesium Sulfate protocol: contd…
Monitoring Hourly

Assess Normal Findings

Level of consciousness Sleepy but arousable

Should be maintained
Diastolic blood pressure
between 80–100 mmHg

16 breaths/minute or
Respiratory rate
more
Minimal but present
Deep tendon reflexes

Urine out put Minimum 30 ml /hr

66
 Magnesium Sulfate protocol: contd…

• Before repeat administration, ensure that:

• Respiratory rate is at least 16 per minute.
• Patellar reflexes are present.
• Urinary output is at least 30 mL per hour over 4 hours.
• WITHHOLD OR DELAY DRUG IF:
• Respiratory rate falls below 16 per minute.
• Patellar reflexes are absent.
• Urinary output falls below 30 mL/hour over preceding 4
hours.

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 Magnesium Sulfate protocol: cont’t

• Keep antidote ready

• In case of respiratory arrest:
• Assist ventilation (mask and bag, anaesthesia apparatus,
intubation).
• Give calcium gluconate 1 g (10 mL of 10% solution) IV to
antagonize the ffects of magnesium sulfate.

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