Hypertensive disorder in

pregnancy
Dr melat asrat
Objective:

 Define hypertension in pregnancy

 Classification of hypertension in pregnancy

 Define each type of hypertension in

pregnancy

 Possible etiologies for hypertension in

pregnancy
 List the principles of management in brief.
Outline of presentation

 Case scenario

 Terminologies

 Introduction to hypertension in pregnancy

 Classification

 Summary of the types of hypertension in pregnancy

 Possible risk factors for hypertension in

pregnancy
 Management principle
Case scenario:

 A 20 years old primigravid lady at a

gestational age of 32 weeks from reliable
date come to OPD with complaint of
blurring of vision, headache, and
epigastric pain.

How do you approach her?

Terminologies

1. Hypertension: Bp measurement of 140

and/or 90 mmhg and above two times 4-6
hours apart but, with in 7 days.
2. Proteinuria: could be measured
quantitatively or qualitatively.
1. Quantitative: 0.3gm/L in 24 hours
collection or greater than 1gm/L in
two random samples obtained at least 6
hours apart.
2. Qualitative: urine dipstick plus 1 and
above.( specific gravity should be
specified)
3. Edema:
 Pathological edema is characterized by
a) If edema doesn’t relief after 12 hours of
rest
b) If it involves non-dependent areas like
face and upper extremity
c) It there is weight increment greater than
2.2 kg per week or 11 kg per month

NB: Edema is no more criteria for diagnosis

of PIH.
Correct BP Measurement:

1. Patient should sit quietly for 3-5 minutes before

measurement.
2. Use correct size cuff and bladder (12 cm width and 35
cm long).
1. The bladder width should be approximately 40% of
the circumference of the arm (12 cm for a normal
arm, or 15 cm for an arm with mid upper
circumference >33 cm)
2. The bladder length should be long enough to wrap
80% to 100% around the arm.

3. Measure BP while patient is sitting on a chair with

back support and with the arm supported at the level
of the heart. The patient’s arm must be relaxed.
4. BP in both arms should be measured at the first visit
and the arm with the highest BP should be used for
future measurements.
5. Elderly patients, diabetics and other
patients complaining of symptoms
suggestive of postural hypotension (e.g.
dizziness, unsteadiness or fainting when
changing posture) should also have their
BP measured while standing, so that
standing BP can be compared to sitting
BP.
6. The patient should not smoke or consume
any caffeine-containing beverage (e.g.,
coffee, tea, cool drink) in the 30 minutes
before BP measurement.
7. The lower edge of the cuff should be placed 3 cm
above the inner crease of the elbow.
8. The arm should be free of clothing and supported
by a table or bed, so that the cuff is at the level
of the heart.
9. Patients should not talk while the BP is being
measured. Legs should not be crossed
10. BP should be measured twice with at least 1-2
minutes in between. Unless they are very different,
the higher of the two readings should be recorded.
If the two readings are very different the higher
of the two readings should be recorded. And
different readings should be taken.
11. The patient lies comfortably on the
left side that her back makes an angle of
about 30˚ with the bed. The right arm is
supported to be with the sphygmomanometer
at the same level with the patient’s
sternum i.e. her heart. Each cm above or
below the level of the heart induces a
difference of 0.7mmHg in blood pressure
reading. She should lie undisturbed in
this position for 2-3 min. before blood
pressure is measured.
12. Let air out slowly so that mercury
falls steadily by 2-3 mm/sec.
Introduction:

 Hypertension is a common medical disorder

that affects 20–30% of adults in the
United States and complicates as many as
5–8% of all pregnancies.
 Hypertensive disorders of pregnancy rank
among the leading causes of maternal
morbidity and mortality.
 Approximately 15% of maternal deaths are
attributable to hypertension, making it
the second leading cause of maternal
mortality in the United States.
 Severe hypertension increases the mother's risk of
heart attack
cardiac failure
cerebral vascular accidents
renal failure.
 The fetus and neonate also are at increased risk
from complications such as
poor placental transfer of oxygen
fetal growth restriction
preterm birth
placental abruption
Stillbirth
neonatal death.
 Classification:
According to the system prepared by the National Institutes of
Health (NIH) Working Group on Hypertension in Pregnancy the
classification is:-

Preeclampsia
Chronic Gestational Preeclampsia- superimposed
hypertension hypertension eclampsia on chronic
hypertension
Chronic hypertension

Definition:
 Hypertension is present before pregnancy
 detected in early pregnancy ( before 20 weeks
in absence of vesicular mole )
 Persisted beyond six weeks of postpartum.
Classification:
A. Primary (essential) hypertension
B. Secondary Hypertension
i. chronic renal disorders e.g. pyelonephritis
and renal artery stenosis
ii. coarctation of the aorta
iii.systemic lupus erythematosus
iv. pheochromocytoma.
 Gestational (transient)
Hypertension
 Defined as new-onset blood pressure
elevations in the absence of proteinuria
after 20 weeks of gestation.

 Pre-eclampsia
 Defined as new-onset blood pressure
elevations accompanied by proteinuria
after 20 weeks of gestation.
Classification of pre-eclampsia
I. Pre-eclampsia with out severe
feature
II.Pre-eclampsia with severe
feature- Severe preeclampsia is made
for any of the following criteria:
o Blood pressure of 160 mmHg systolic or higher or
110 mmHg diastolic or higher on two occasions at
least 6 hours apart while the patient is on bed
rest
o Proteinuria level of 5g or higher in a 24-hour
urine specimen or a 3+ or greater value on two
random urine samples collected at least 4 hours
apart
o Oliguria of less than 500 mL in 24 hours
o Cerebral or visual disturbances
o Pulmonary edema or cyanosis
o Epigastric or right upper quadrant pain
o Impaired liver function………2x elevation
o Impaired renal function test……………>1.2 mg/dl
o Thrombocytopenia…………………<100,000
o Fetal growth restriction
 Etiology of pre-eclampsia

Not exactly known, but there

are theories
o The uteroplacental bed:
o Immunological factor:
o Genetic factor:
o Renin- angiotensin system:
o Atrial natriuretic peptide (ANP):
o Prostaglandins
o Neutrophils:
 Pathological changes in
preeclampsia
I. Vasospasm :
II.Coagulation status
III.Sodium and water retention:
Eclampsia

 Occurrence of seizures that cannot be

attributed to other causes in a woman with
preeclampsia.
 Possible differentials that should be
ruled out
 Reversible posterior leukoencephalopathy syndrome
 Idiopathic epilepsy
 Stroke
 Space-occupying lesions
 Metabolic disorders
 Infection
 Use of illicit drugs
 Cerebral vasculitis
 Timing of Elampsia:

Timing Percentage(%)

Antepatum 38 to 55

Intrapartum 13 to 36

Postpartum

<48 hours 5 to 39

>48 hours 5 to 17
 Preeclampsia superimposed on
chronic hypertension
 The diagnosis of superimposed preeclampsia is made
when:
 There is new onset of proteinuria after 20 weeks’
gestation.
 Women with preexisting proteinuria who display a
sudden increase in blood pressure or proteinuria.
 When a women presented with severity symptoms
 When a women display objective evidence of
involvement of other organ systems, including
o thrombocytopenia (platelet count
<100,000/mm3)
o elevated levels of liver transaminases
o worsening renal function.
NB:-
It is associated with much worse
maternal and fetal prognoses
than either condition alone.
Possible risk factors associated
with hypertension in pregnancy
Nulliparity
Preeclampsia in a previous pregnancy
Age >40 years or <18 years
Family history of preeclampsia
Chronic hypertension
Chronic renal disease
Antiphospholipid antibody syndrome or
inherited thrombophilia
Vascular or connective tissue disease
Diabetes mellitus (pregestational and
gestational)
 Multifetal gestation
 High body mass index  
 Black race
 Male partner whose mother or previous
partner had preeclampsia
 Hydrops fetalis
 Unexplained fetal growth restriction
 Woman herself was small for gestational
age
 Fetal growth restriction, abruptio
placentae, or fetal demise in a previous
pregnancy
 Prolonged interpregnancy interval
 Partner related factors (new partner,
limted sperm exposure [eg, previous use of
barrier contraception])
 Hydatidiform mole 
 Susceptibility genes 
Approach to the patient
A. History
 Exhaust for possible risk factors
B. Physical examination
o General appearance……edema, puffy face
o V/S…….Bp
o HEENT……sclera, conjunctiva
o Chest……..chest creptation for
pulmonary edema
o Abdomen……small for date uterus
o Integumentary system……signs of DIC
 C. Investigations
 Complete blood cell count
 U/A
 VDRL
 HIV TEST
 B/F
 Twenty-four–hour urine for protein
 OFT
 Electrolytes
 Uric acid
 Serum glucose
 PT, aPTT
 Non stress test or biophysical profile
 Ultrasound for fetal growth and
amniotic fluid volume
Imaging Studies
 CT scan of the head
 Magnetic resonance imaging
Other tests
 EEG
 Cerebral spinal fluid studies
Management
o Prevention:
o use of aspirin
o Preconceptional care
o To optimize chronic hypertension
o Use of anti-hypertensive if necessary
o Pre-eclampsia with severity feature
o Eclampsia
o Preeclampsia superimposed on
chronic hypertension
o Use of anticonvulsant
o Pre-eclampsia with severity feature
o Eclampsia
o Preeclampsia superimposed on
chronic hypertension
o Use of steroids
o For gestational age 24-37 weeks
o Use of broad spectrum antibiotics
o Timing of delivery
o At 37 weeks unless indicated.
 Indications for termination of
pregnancy
 Term
 Remote from term
 Congenital anomaly incompatible with life
 Eclampsia
 Organ function derangement
 Acute pulmonary edema
 Abruptio placenta
 IUFD
 Severe IUGR
 Severe oligohydraminous
 Fetal jeopardy
References
 Crezy and resnik’s maternal
fetal medicine
 Current obstetrics 2007
 Simplified obstetrics
 Williams obstetric 24 edition
 Management of selected
obstetric cases , FMoH 2010
Thank you!