Hypertension in

Pregnancy
 Hypertensive Disorders in
Pregnancy

 Pre-existing hypertension

 Gestational (pregnancy-induced) hypertension

 Preeclampsia

 Eclampsia
Definition

 DEFINITION: Pre-eclampsia is a multisystem disorder

of unknown etiology characterized by development
 of hypertension to the extent of 140/90 mm Hg or
more with proteinuria after the 20th week in a
previously normotensive and nonproteinuric woman
The term, ‘Pregnancy-induced hypertension (PIH)’ is defined as
the hypertension that develops as a direct
result of the gravid state. It includes—(i) gestational hypertension,
(ii) pre-eclampsia, and (iii) eclampsia.
 The underlying basic pathology is endothelial
dysfunction and intense vasospasm, affecting almost
all the vessels, particularly those of uterus, kidney,
placental bed and brain.
The basic underlying pathology remains as
endothelial dysfunction and vasospasm.
The responsible agent for endothelial
dysfunction and vasospasm, still has not been isolated
precisely, but it seems certain to be humoral in origin.
The following are the considerations:
• Increased circulating pressor substances
• Increased sensitivity of the vascular system to normally
circulating pressure substances
Criteria of Hypertension

 Hypertension
 Systolic blood pressure is >140 mmHg
AND/OR
 Diastolic blood pressure (Korotkoff V) is >90 mmHg.

 Severe hypertension
 Diastolic BP ≥ 110 mm Hg on two occasions
OR
 Systolic BP ≥ 160 mm Hg on two occasions

ASSHP Consensus Statement, 2000

RCOG, 2006
 Pre-existing Hypertension

 If alone – there is little risk for the mother or the foetus

 Treatment is aimed at preventing the development of severe

hypertensive disease

 Anti-hypertensive medication should be administered as dictated by

the blood pressure

 Outpatient treatment is preferable

Murray W. Enkin et al, 2000

 Gestational (Pregnancy-Induced)
Hypertension (1)
 Arises in pregnancy after 20 weeks gestation without any other
feature of the multisystem disorder preeclampsia resolves within 3
months postpartum.

ASSHP Consensus Statement, 2000

 Gestational (Pregnancy-Induced)
Hypertension (2)
 In mild pregnancy-induced hypertension there is:
 Little risk for the mother or the foetus
 Hospitalization and bed-rest – not recommended
 The use of diuretics has - no effect on the incidence of:
 Proteinuria
 Intra-uterine growth restriction
 Preterm birth
 Caesarean section
 If proteinuria develops admission to hospital for evaluation and
increased surveillance is recommended
 To detect any deterioration in maternal or foetal condition

Murray W. Enkin, 2000

RCOG, 2006
Antihypertensive Therapy of the Mild
Pregnancy-Induced Hypertension

 Prevents the development of severe hypertension

BUT

 No effect on the risk of preeclampsia

 No clear effect on the risk of perinatal morbidity and mortality,

preterm deliveries or small for gestational age babies

Murray W. Enkin et al, 2000

Abalos E et al, 2001
Preeclampsia: Problem

 Affects 3% of pregnancies
 Reason of death for 100.000 women yearly worldwide
 One of 3 main reasons for maternal deaths
 Leads to 25% of very low birth weight babies (<1500 g) and 15% of
preterm births
 Consequences for mother include – eclampsia, renal and liver
insufficiency, pulmonary oedema, intracerebral haemorrhages, etc.

Andrew H Shennan, 2003

RCOG, 2006
 Preeclampsia: Definition

 Preeclampsia
 Hypertension associated with proteinuria (> 0.3 g in 24 hours) ±
oedema. Virtually any organ system can be affected
 Severe preeclampsia
 Severe hypertension plus proteinuria, OR
 Any hypertension plus proteinuria, plus one of following symptoms:
 Severe headache
 Visual disturbance
 Epigastric pain and/or vomiting
 Signs of clonus
 Papilloedema
 Liver tenderness
 Platelet count falling to below 100 x 106/l
 Abnormal liver enzymes (ALT or AST rising to above 70 iu/l)
 HELLP syndrome

RCOG, 2006
 Preeclampsia: Diagnosis

 Strict criteria for diagnosis should be used

 Classification of severity is primarily based on the level of blood

pressure and the presence of proteinuria

 Over-diagnosis leads to
 Unjustified admissions to hospital
 Inappropriate interventions with unproved efficacy and even harm to
the mother and baby

WHO EURO, 2002

RCOG, 2006
 Criteria of Proteinuria

 Proteinuria
 ≥0.3 g/24 hours OR
 ≥ 0.3 g/l or ≥ 1+ in two specimens at least 4 hours apart

RCOG, 2006
 Oedema

 Oedema of hands and ankles is frequently a normal physiological

response (50-80%) to an increase in circulation and weight gain in
pregnancy

 Use of oedema as a criteria to diagnose preeclampsia often leads

to overrdiagnosis

 Only appearance of sudden and/or generalized oedema should be

considered when diagnose preeclampsia

Murray W. Enkin et al, 2000

 Prevention of Preeclampsia Effective
Methods
 Use of antiplatelet agents (low dose aspirin, 75 mg per day)
 Decreased risk of preeclampsia by 19% in high risk groups
 Can be useful in some high risk groups, such as chronic hypertension, anti-
phospholipids syndrome, etc.
 Calcium supplementation (1 g per day)
 Reduce the risk of preeclampsia
 By 50% in general population
 By 78% in high-risk women

Murray W. Enkin et al, 2000

Duley L et al, 2003
GJ Hofmeyr et al, 2006
 Prevention of Preeclampsia
Ineffective Methods
 Administering diuretics
 Administering antithrombotic agents (Heparin, Warfarin)
 Increasing protein and energy intake generally
 Restricting protein or energy intake for obese women
 Supplementing iron, folate, magnesium, zinc, or fish oil
 Restricting salt and fluid intake

Murray W. Enkin et al, 2000

Villar J et al, 2003
Monitoring of the Woman with Severe
Preeclampsia
 Check blood pressure
 Full blood count
 Liver function tests
 Renal function tests
 Pay close attention to fluid balance by charting of input and output
of urine
 A catheter with an hourly urometer is advisable in the acute situation

RCOG, 2006
Assessing the Foetus

 Initial assessment with cardiotocography

 Continuous electronic foetal monitoring in labour

 If conservative management is planned

 Ultrasound measurements of foetal size
 Umbilical artery Doppler and amniotic fluid volume
 Serial assessment will allow timing of delivery to be optimised

RCOG, 2006
 Management of Severe
Preeclampsia

 Control of blood pressure

 Prevention of seizures

 Delivery at optimal time for mother and foetus

RCOG, 2006
When to Start Antihypertensive
Therapy?
 In women with:
 Systolic blood pressure over 160 mm Hg
 Diastolic blood pressure over 110 mm Hg
 Other markers of potentially severe disease at lower degrees of
hypertension
 Heavy proteinuria
 Dysfunctioned liver
 Poor haematological test results

If the blood pressure is below 160/100 mmHg, there is no immediate

need for antihypertensive therapy

RCOG, 2006
 Blood Pressure Control
Rapid Acting Antihypertensive Drugs
 Hydralazine
 Intravenous injection, usually in a saline drip
 Unpleasant side effects in approximately 50% of cases, including severe
headache, palpitations, restlessness and anxiety
 May mask the symptoms of impending eclampsia
 Nifedipine
 Reduces blood pressure and can be taken orally
 Headaches are even more common than with hydralazine
 Labetolol
 IV infusion is an alternative to nifedipine
 Fewer side effects
 Sodium Nitroprusside
 Isoket

National High Blood Pressure Education Program, 2000

RCOG, 2006
 Blood Pressure Control
Slow Acting Antihypertensive Drugs
 Methyldopa
 Causes extreme sleepiness for the first 48 hours
 Is the only hypertensive drug known to have little long term effect on
the baby after initial sedation
 Clonidine
 More rapid onset of action than Methyldopa (about 30 min)
 Beta-blockers such as oxprenolol, labetalol
 Cause fewer side effects than Methyldopa

National High Blood Pressure Education Program, 2000

RCOG, 2006
Blood Pressure Control
Non Recommended Drugs

 The following should be avoided:

 Atenolol
 Angiotensin converting enzyme (ACE) inhibitors
 Angiotensin receptor-blocking drugs (ARB)
 Diuretics
 These drugs increased hypovolemia, and
 Side effects may be dangerous

RCOG, 2006
 Prevention of Seizures (1)
Magnesium Sulphate
 Should be administered routinely in women with severe preeclampsia
 If administered:
 Should be continued for 24 hours following delivery or 24 hours after the
last seizure
 The following should be regularly assessed:
 Urine output
 Maternal reflexes
 Respiratory rate
 Oxygen saturation
 Less effect in non-severe preeclampsia
 Each case requires individual assessment

RCOG, 2006
 Prevention of Seizures (2)

 Women allocated magnesium sulphate had:

 A 58% lower risk of eclampsia

 A tendency for lower maternal mortality

 A decreased incidence of placental abruption

Duley L, 2002
 Prevention of Seizures (3)
Intravenous Regimen for Magnesium Sulphate

 Start with 4-5 g intravenous loading dose within 20 minutes (16-20 ml of

a 25% solution)

 Then continuous infusion at a rate of 1-2g/hour

 Traditionally, therapy is continued 24 hours either after delivery or the

latest convulsion (in cases of eclampsia)

 Control: a patellar reflex is present, respiration rate exceeds 16 per

minute, and urine output during the preceding four hours has exceeded
100 ml

CREST, 2001
 Prevention of Seizures (4)
Intramuscular Regiment for Magnesium Sulphate

 Start with 5 g of a 50% solution of magnesium sulphate by deep

intramuscular injection to the upper outer quadrant of each buttock
(10 g totally)

 Thereafter, 5 g of a 50% solution magnesium sulphate 4-hourly

intramuscularly in the upper outer quadrant of alternate buttock

 Intramuscular injections are painful and complicated by local abscess

formation in 0.5% of cases. Therefore the intravenous route is
preferable

CREST, 2001
 Eclampsia

 The occurrence of one or more convulsions in woman with

preeclampsia

 5 out of 10 000 pregnant woman suffer from eclampsia

 Case fatality rate is 1.8%

 Further 35% of women experience a major complication

RCOG, 2006
 Control of Seizures

 Magnesium sulphate is the drug of choice for control of seizures

 Intravenous route is associated with fewer adverse effects
 Magnesium sulphate significantly reduces:
 The proportion of babies with Apgar scores less than 7 at 5 minute
 The number of babies with a length of stay in special care baby unit
more than 7 days
 Diazepam and phenytoin should no longer be used as first-line drugs

RCOG, 2006
 Management of Recurrent Seizures

 If recurrent seizures occur:

 IV bolus magnesium sulphate 2 g. OR
 Increase the rate of infusion of magnesium sulphate to 1.5 g or 2.0 g/hour
 If there are repeated seizures (despite magnesium sulphate)
 Diazepam (10mg IV) single dose, OR
 Thiopental (50mg IV) single dose
 If seizures persist:
 Intubation may become necessary to protect the airway and maintain
oxygenation
 Transfer to intensive care facilities with intermittent positive pressure
ventilation

RCOG, 2006
 Management of Fluid Balance

 No evidence of benefit in fluid expansion

 No evidence that maintenance of a specific urine output is

important to prevent renal failure

 Fluids should be limited to 80 ml/hour or 1 ml/kg/hour

 Risk of pulmonary and cerebral edema

RCOG, 2006
 Delivery at Optimal Time for
Mother and Foetus
 Decision to deliver should be made once the woman is stable and
with appropriate senior personnel present

 Prolongation of pregnancy is to increase chances of foetus’

survival only

RCOG, 2006
 When Should Pregnancy be
Prolonged?

 At gestation less than 34 weeks

 Corticosteroids help to reduce foetal respiratory mortality

 At very early gestations

 May improve the perinatal outcome, but
 Must be carefully balanced with maternal well-being

Careful monitoring of maternal and foetal well-being is

mandatory

RCOG, 2006
 Indications for Delivery in
Preeclampsia

 Term/near-term pregnancy

 Gestation is greater than 34 weeks

 Disorders in foetal well-being

 Complications of preeclampsia are threatening the life

of the mother

RCOG, 2006
Management of the Women after
Delivery
 Careful monitoring
 Anti-hypertensive therapy should be continued after delivery
 Blood pressure should not be allowed to exceed 160/110 mmHg
 A reduction in antihypertensive therapy should be made in a
stepwise fashion
 Most women will need inpatient care for 4 days or more following
delivery
 Refer for a specialist opinion and investigation if indicated

RCOG, 2006
 Conclusions (1)

 Women with mild pregnancy-induced hypertension should not be

hospitalized
 Preeclampsia cannot be prevented in the general population
 Strict criteria for diagnosing preeclampsia should be used
 If the blood pressure is below 160/100 mmHg, there is no immediate
need for antihypertensive therapy
 Antihypertensive therapy should be started when systolic blood
pressure over 160 mm Hg or diastolic blood pressure over 110 mm Hg
 General rule: use only drugs/interventions proven effective, avoid
combination of drugs that may harm
 Conclusions (2)

 Magnesium sulphate should be considered for women with

preeclampsia for whom there is concern about the risk of eclampsia
 Magnesium sulphate is the therapy of choice to control seizures
 Delivery is the only effective treatment for
pre-eclampsia/eclampsia
 The decision to deliver should be made once the woman is stable
 Prolongation of pregnancy should be considered to increase chances
of foetus’ survival only
 Anti-hypertensive medication should be continued after delivery as
dictated by the blood pressure
 Dangers/Difficulties of Caesarean
Section under General Anesthesia
 Difficult intubation (larynx oedema)

 Intra-cerebral haemorrhages
 Dramatic increase of medial arterial pressure (MAP) during intubation and
extubation / aspiration
 If MAP > 140 mm Hg – intracerebral blood vessels loose capacity to control
tone and may rupture

 Pulmonary oedema
 Very high pressure in pulmonary vessels

Hood D, 1997
 Is Immediate Caesarean Section
Delivery Beneficial?
 Immediate Caesarean section delivery confers no benefit to
patients with severe preeclampsia
 Pulmonary complications in the mother and newborn are more common
in Caesarean section delivery
 No complications are decreased by Caesarean section delivery

Coppage KH, Polzin WJ, 2002

 Caesarean Section for Eclampsia

 The definitive treatment of eclampsia is delivery. However, it is

inappropriate to deliver an unstable mother even if there is foetal
distress

 Once convulsions are controlled, severe hypertension treated, and

hypoxia corrected, delivery can be expedited

 Vaginal delivery should be considered, but Caesarean section is

likely to be required in situation with an uneffaced cervix

Hood D, 1997
RCOG, 2006
 Postoperative Complications

 Eclampsia (44% of all cases)

 Coagulation disturbances, hemorrhages

 Pulmonary edema (70-80% - after delivery) caused by

 Mobilization of interstitial fluids
 Increase in cardiac filing pressure (increased preload and excessive after-
load)
 Pulmonary capillary leak
 Reduction in colloid osmotic pressure

Douglas K A, Redman C W G, 1994

 Fluid Balance after Delivery (Caesarean
Section) in Women with Severe
Preeclapmsia
 Iatrogenic fluid overload is one of the main cause of
maternal death in preeclampsia/eclampsia

 Fluid intake:
 The standard intravenous fluid regime is 80 ml/hour

RCOG, 1999
RCOG, 2006
 Management of Postoperative
Period in Severe Preeclampsia
 Continuation of magnesium sulphate treatment (for decreasing of
the risk of eclampsia)

 Strict control of fluid intake (very limited)

 Strict control of blood pressure