HYPERTENSION IN

PREGNANCY

PRESENTER-DR.ARCHANA KUMARI
SENIOR RESIDENT AT VMMC AND SJH NEW DELHI
INTRODUCTION

Hypertensive disorders complicate 5-10% of all pregnancies

Preeclampsia 3.9% of all pregnancies

Eclampsia 0.05-0.5% of all pregnancies

50-100 NEAR MISS occurs every preeclampsia related death

16% of maternal deaths are due to hypertension

Risk for future metabolic disease

CLASSIFICATION OF HYPERTENSIVE DISORDERS OF PREGNANCY

Gestational hypertension
- evidence for
Preeclampsia
Chronic hypertension of Preeclampsia-eclampsia preeclampsia syndrome
superimposed on chronic
any etiology syndrome does not develop and
hypertension
hypertension resolves by
12 weeks postpartum
GESTATIONAL HYPERTENSION

BP ≥140/90 mmhg for first time after 20 weeks pog

No proteinuria

BP returns to normal<12 weeks postpartum

Confirm diagnosis can be made postpartum

Risk of future chronic hypertension is increased in these patients

PREECLAMSIA

 New onset hypertension plus new onset proteinuria.

 SBP ≥ 140 mmHg diastolic BP ≥90mmHg after 20 weeks pog, on 2 occasions 4 hours
apart in previously normotensive women.
 SBP ≥ 160 or DBP ≥ 110mmHg.
 Proteinuria ≥300mg/24hr
protein/ creatinine ≥ 0.3 or
Dipstick 1+ persistent only if quantitative methods are not available
CONT….

 In absence of proteinuria, preeclampsia is diagnosed as hypertension associated with

following-:
 Thrombocytopenia platelets <100,000/µ
 Renal insufficiency creatinine >1.1 mg/dl or
doubling of baseline
 Liver involvement serum transaminase levels twice normal
 Cerebral symptoms headache, visual disturbances, convulsions
 Pulmonary edema
 300mg/24 urine DIPSTICK PROTEIN PROTEIN
PROTEIN EXCRETION EXCRETION
collection READING gm/24 HOURS mg/dl
 Protein/creatinine negative <0.1 <10

ratio>/= 0.3 (measured trace 0.1-0.2 15

as mg/dl)
1+ 0.2-0.5 30
 Dipstick reading 1+
2+ 0.5-1.5 100

3+ 2.0-5.0 300

4+ >5.0 > 1000

SYMPTOMS OF PREECLAMPSIA

• Swelling of the face or hands

• Persitent headache that will not go away
• Seeing spots or changes in eyesight
• Pain in right upper quadrant or stomach
• Nausea or vomiting in second half of pregnancy
• Sudden weight gain
• Difficulty breathing
• Systolic bp >160 mmhg or diastolic bp >110 mmHg on 2 occasions atleast 4 hours apart while the
patient is on bedrest
• Platelet count <1,00,000/microlitre
• Severe right upper quadrant or epigastric pain unresponsive to medication
• Liver enzymes twice of normal concentration
• Serum creatinine 1.1mg/dl or doubling of serum creat in the absence of other renal disease
• Pulmonary edema
• New onset cerebral or visual disturbances
ECLAMPSIA

• Preeclampsia + new onset grand mal seizures

• Features of impending Eclampsia
• Persistent frontal or occipital headache
• Blurred vision
• Photophobia
• Epigastric pain or right upper quadrant pain or both
• Altered mental status
CHRONIC HYPERTENSION

• Documented BP ≥ 140/90 mmHg known to predate pregnancy or detected before 20

weeks gestation .
• Hypertension persistent after 12 weeks postpartum first diagnosed after 20 weeks
gestation.
SUPERIMPOSED PREECLAMPSIA

Sudden increase in BP that was previously well controlled or escalation of

antihypertensive medication to control BP
New onset of proteinuria
Sudden increase in proteinuria with known proteinuria before or early in pregnancy
Superimposed PE develops in 13-40% of women with chronic hypertension
SUPERIMPOSED PREECLAMPSIA WITH SEVERE
FEATURES
Any one of following must be present
Severe range BP despite escalation of antihypertensive therapy
Platelet count<1,00,000/µ
Elevated liver transaminases twice of normal
New onset and worsening renal insufficiency
Pulmonary edema
Persistent cerebral or visual disturbances
CASE 1

27 year old, Primigravida of 36 weeks 2 days period of gestation(b/d) admitted from opd
@amenorrhea for 8months with high BP records
No complain of leaking per vaginum, bleeding per vaginum,decrease fetal movement
No c/o headache/BOV/epigastric pain/decrease urine output.
No h/o yellowish discolouration of urine, skin, eyes.
HOPI

• The patient presented in ANC OPD with 8 months amenorrhea and was admitted for high
BP records and was kept for monitoring
• No h/o excessive hunger, thirst or frequency of urination,weight gain
• No h/o excessive nausea, vomiting
• No h/o severe pain abdomen, dizziness, fainting
• No h/o headache, blurring of vision, epigastric pain, pedal edema
• No h/o skin infection or discharge per vaginum
• T1
 UPT was done at home at 15 days overdue -positive
 She visited local dispensary at 3 month amenorrhoea
 No H/o folic acid intake present
 All routine investigations were done- and was normal
 No h/o bleeding or leaking per vaginum
 No h/o fever, rash/ radiation exposure/ drug intake
 No h/o excessive nausea or vomiting
 First scan was done at 3 month of amenorrhoea and was reported to be normal according to the patient
• T2
 Quickening was felt at 5 mA
 Received TT1 and 2
 She took iron, folic acid and calcium
 No h/o bleeding or leaking per vaginum
 No h/o excessive hunger/ thirst/ frequency of urination/ recurrent skin or urinary tract infections
 No h/o high BP records/ headache/ blurring of vision/ epigastric pain/ pedal edema
 No h/o breathlessness and easy fatiguability
 h/o 1 visit in second trimester
 Level 2 USG was done - normal according to the patient
• T3
 Perceiving adequate foetal movements
 She took iron and folic acid

 No h/o bleeding or leaking per vaginum
 No h/o excessive hunger/ thirst/ frequency of urination/ recurrent skin, vaginal or urinary tract infections
 h/o high BP records
 No c/o/ headache/ blurring of vision/ epigastric pain/ pedal edema

 h/o 2 visits in third trimester
MENSTRUAL HISTORY

• Past cycles – 4-5 days/ 2-2 ½ months, irregular delayed cycles, normal flow, associated
with mild dysmenorrhoea
• LMP – 19/02/2019
OBSTETRICS HIS

• Married for – 3 years

• Non- consanguineous
• No h/o contraceptive use
• Primigravida
PAST HISTORY

• No h/o tuberculosis, hypertension, diabetes or any prolonged medical or surgical illness

PERSONAL HISTORY

• Patient consumes mix diet

• Normal sleep pattern
• Normal bowel and bladder habits
• No addiction
DIETARY HISTORY
SOCIOECONOMIC HISTORY

• Lower middle class family by modified Kuppuswamy scale

GENERAL PHYSICAL EXAMINATION
• No thyromegaly no lymphadenopathy no sternal tenderness
• No pedal oedema
• JVP not raised
• Breast shows normal changes of pregnancy
• Cvs- S1, S2 normal, no murmur
• Respiratory system- NAD
ABDOMINAL EXAMINATION

• Inspection :
• Abdomen was uniformly distended
• All quadrants moving equal with respiration
• No dilated veins or scar marks
• Umbilicus central everted
• Stria gravidarum and linea nigra seen
• All hernial sites free on cough impulse
 Fundal height 36 wks
 Symphysio fundal height 35.5cm
 Abdominal girth 35 inches
 Longitudinal lie, cephalic presentation
 Uterus relaxed
 Liqour appears adequate
 FHS-135/min
 EFW-2.5 KG
PROVISIONAL DIAGNOSIS

• 27 year old ,Primigravida with 36 weeks 2 day with singleton pregnancy in cephalic
presentation with Gestational hypertention, not in labour