HYPERTENSION IN PREGNANCY

Preeclampsia and eclampsia

ph: Tahani Bahnasi

Classification of hypertensive disorder in pregnancy
1-Gestantional hypertension (pregnancy induced hypertension)
 Detected for the first time after 20 weeks’ gestation
 Absence of proteinuria ( no protein in urine)
 Blood pressure : >140 / >90mmHg
 Resolve within 3 months after birth

2- Chronic hypertension
Present before pregnancy or before 20 weeks’ of gestation
Could be essential (no under laying disease) or secondary

T. Bahnasi
3- Preeclampsia and eclampsia (toxemia of pregnancy)
 Detected for the first time: after 20 weeks of gestation
 Protein in urine ≥ 300 mg /day Or ≥ 1+ on dipstick
 Bp : >140/>90 mmHg
Eclampsia :convulsive condition associated with pre-eclampsia. occurrence of
seizures superimposed on the symptoms of preeclampsia, an acute and life-threatening
complication of pregnancy.

4- Superimposed preeclampsia
 Refer to women with chronic HTN (secondary or primary) who develop
preeclampsia ..new onset proteinuria ≥ 300 mg /day before 20 weeks’
gestation

T. Bahnasi
Although the exact pathophysiologic mechanism is not clearly understood,

preeclampsia is disorder of placental dysfunction (placental insufficiency with

diffuse placental thrombosis) narrower than normal blood vessels that react
differently to hormonal signaling.

a syndrome of endothelial dysfunction with associated vasospasm.

dysfunction of multiple organ systems, including the central nervous, hepatic,
renal, pulmonary and hematologic systems,

endothelial damage leads to pathologic capillary leak that can present in the mother
as rapid weight gain, nondependent edema (face or hands), pulmonary edema.
CASE (1)

40 years old lady was admitted to the labor clinic at 32 weeks' gestation
complaining of sever headache ,light sensitivity, flashing vision. On
examination she looked generally unwell, irritable, epigastric pain, nausea
& blood pressure was 170/110 pulse 90/m, wt 100 kg, with lower limb and
abdominal wall and face edema . Uterus was small for date with a viable
twins . Urine analysis showed protein urea.

PMH: DM.

T. Bahnasi
What is the diagnosis?
Preeclampsia
What are the symptoms for preeclampsia?
 Severe or rapid edema ( swelling of legs ,face and hands)
 Severe headache
 Sudden nausea and vomiting
 Upper right abdominal pain or stomach pain
 Rapid weight gain
 Sensations of flashing lights, auras, light sensitivity, or blurry vision or spots
 Difficulty breathing

T. Bahnasi
What are the risk factors for preeclampsia?
Pregnancy history:
 First pregnancy. Low risk
 Multiple gestation: twins, triplets, or a greater number of multiples
 Assisted reproduction (in vitro fertilization)
 Family or own history of pre-eclampsia (or intrauterine growth restriction, placental abruption)
Medical conditions
 Obesity (Body Mass Index ≥30)
 Chronic diseases (HTN, kidney diseases or diabetes)
 Autoimmune diseases (for example; systemic lupus erythematosus)
 Abnormal uterine artery Doppler scan.
Demographic factors:
 Age <18 years or >40 years. Ethnicity (black women)
How to reduce the risk of hypertensive disorders in pregnancy?
Preventative interventions may be best started before 16 weeks’ gestation
(when most of the physiologic transformation of uterine spiral arteries occurs), or even
before pregnancy.

WOMEN AT ‘LOW RISK’ WOMEN AT ‘HIGH RISK

Aspirin (81 mg/d at bedtime)
Oral calcium supplement of 1 g/d
Folate-containing multivitamins
Exercise regularly
Weight loss if overweight
Aspirin ((60–162 mg/d at bedtime) or
’
Low molecular weight heparin
Oral calcium supplement of 1 –2.5 g/d
Folate-containing multivitamins
Home rest
Reduction of workload or stress
What is the Management of preeclampsia?

Definitive treatment of preeclampsia is delivery.

Even after delivery, symptoms of preeclampsia can last 1 to 6 weeks or more.

Delivery is indicated if frank eclampsia is present. .

Otherwise, if no eclampsia: management consists of:
 If fetus is fully developed usually by 37 weeks or later:
 Induce labor or do a cesarean section to avoid further complications
 Antihypertensives are used prior to induction of labor if the DBP>105
mm Hg, with a target DBP of 95 -105 mm Hg.
 If fetus is not fully developed, less than 37 weeks:
 If the preeclampsia is not severe, it may be possible to wait to deliver.
To help prevent further complications:
 Bed rest
 Blood pressure lowering agent (e.g. methyldopa)
• Close monitoring of the woman and her fetus will be needed: Tests for woman
may include platelet counts, liver enzymes, kidney function, and urinary
protein levels,
• Tests for the fetus might include ultrasound, heart rate monitoring, assessment
of fetal growth, and amniotic fluid assessment.

T. Bahnasi
 If fetus is not fully developed, less than 37 weeks, severe preeclampsia:
 Admission to the hospital so she can be monitored closely and
continuously.
 Treatment in the hospital: IV medication to control Bp and prevent seizures
or other complications, as well as steroid injections to help speed up the
development of the fetus's lungs.

 If the pregnancy is at 34 weeks or later, severe preeclampsia:

Preterm delivery may be necessary, even if that means likely
complications for the infant, because of the risk of severe maternal
complications
T. Bahnasi
Preeclampsia management approaches

 Antihypertensive therapy
 Severe (blood pressure ≥160/110 mmHg)
Hydralazine IV/ Labetalol IV
 Non-severe hypertension
Methyldopa PO / Labetalol PO

 MgSO4: Eclampsia convulsions treatment and prevention, Fetal

neuroprotection

 Corticosteroids: Antenatal only, for fetal pulmonary maturity when delivery is

anticipated within the next 7 days and at <34 weeks, and for HELLP
syndrome

 Platelet transfusion for HELLP syndrome

T. Bahnasi
CASE (2)

A 36 year old obese lady at 38 weeks of gestation in her first pregnancy presents
to ER her blood pressure is found to be 170/110 mmHg with a pulse rate of
85/min, the patient complains of sever headache, dizziness, and vision
disturbances.

On examination the cardiovascular examination and chest examinations are

otherwise unremarkable, (+) edema was noticed, and urine analysis showed a
proteinurea ,while the pt was at ER she experienced two generalized seizures

T. Bahnasi
What is the difference between pre-eclampsia and eclampsia ?
Eclampsia with seizures, (emergency case)
What is the appropriate management for her eclampsia?
The definitive treatment is delivery of the fetus.
 Steroid Inj is given to help speed up development of fetus lungs.)
 Either intramuscular (IM) dexamethasone or IM betamethasone (total 24 mg in divided doses)
12 mg betamethasone X2 given IM (24 hours apart),
or 6 mg dexamethasone X 4 given IM (12 hours apart)

 Magnesium sulphate for seizures

 Diazepam, phenytoins are not effective as magnesium sulphate

 Manage high blood pressure:

 Hydralazine IV
 Labetalol IV
T. Bahnasi
 Intravenous hydralazine,
( repeat dose: 5-10 mg every 20 minutes -Duration: 3-8 hrs)
Continuos infusion 0.5–10 mg/h IV (max dosage 45 mg)
Side effects: headache, flushing, tachycardia, lupus like symptoms
 Intravenous Labetalol,
(20 mg IV over 2 min then if needed, 40 mg then 80 mg each over 2 min q 30 min- duration 4 hrs)
Continuos infusion1–2 mg/min (max dosage 300 mg)
parenteral labetalol may cause neonatal bradycardia

Labetalol should be avoided in women who have asthma heart failure /diabetes
Atenolol is not given will cause fetal growth restriction.
ACE↓,ARBs, are contraindicated in pregnancy
postpartum preeclampsia and eclampsia
In some women, preeclampsia develops between 48 hours and 6 weeks
after they deliver their baby (postpartum preeclampsia)

If a woman has seizures within 72 hours of delivery, she may have

postpartum eclampsia. It is important to recognize and treat postpartum
preeclampsia and eclampsia because the risk of complications may be
higher than if the conditions had occurred during pregnancy. Postpartum
preeclampsia and eclampsia can progress very quickly if not treated and
may lead to stroke or death.
T. Bahnasi
 Complications of preeclampsia
 Lack of blood flow to the placenta.
If the placenta doesn't get enough blood, the fetus may receive less O2
and fewer nutrients. lead to slow growth, low birth weight or preterm birth.
Prematurity can lead to breathing problems for the baby.

T. Bahnasi
 Complications of preeclampsia

 Placental abruption. the placenta

separates from the inner wall of the uterus
before delivery. This can lead to stillbirth

Severe abruption can cause heavy vaginal

bleeding and damage to the placenta, which
can be life-threatening for mother and her
baby.

T. Bahnasi
 Complications of preeclampsia may include:

 HELLP syndrome. HELLP — which stands for hemolysis (the destruction

of red blood cells), elevated liver enzymes and low platelet count —
syndrome can rapidly become life-threatening for both mother and her
fetus. Symptoms of HELLP syndrome include nausea and vomiting, headache, and
upper right abdominal pain

 Eclampsia. When preeclampsia isn't controlled, eclampsia — which is

essentially preeclampsia plus seizures — can develop

T. Bahnasi
CASE (3)

38-year-old lady, 19 wks gestation, was transferred to hospital/High Risk

Pregnancy for management of acute hypertension (systolic >200 mm Hg).
Her pressures were stabilized with hydralazine and labetolol. After approx. 48
hrs, severe fetal bradycardia occurred.

PMH – HTN, Anxiety, Depression

ROS –blurry vision, RUQ/epigastric pain, ankle swelling

Urine analysis showed proteinurea

What is the diagnosis?
………………………………………………..
Management of pregnancy with chronic hypertension
 Encourage women with chronic hypertension to keep their dietary sodium intake
low.
 In pregnant women with uncomplicated chronic hypertension aim to keep blood
pressure lower than 150/100 mmHg.
 In pregnant women with target-organ damage secondary to chronic
hypertension, the aim of keeping blood pressure lower than 140/90 mmHg.
 Methyldopa is still considered the drug of choice.
 B-Blockers, labetalol and CCBs are also reasonable alternatives.

 Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers

are contraindicated in pregnancy.

T. Bahnasi
CASE 4

26 years old lady was seen at clinic at 32 weeks gestation for routine check
up. On examination she looked generally well, blood pressure was 150/95
pulse 80/m with . Uterus was appropriate for date with a viable fetus. Urine
analysis showed (-) protien

What type of hypertension the pt has?

………………………………………………

T. Bahnasi
Management of pregnancy with gestational hypertension
Mention the monitoring parameters for hypertension in
pregnancy?
o Consider reducing antihypertensive treatment if their blood pressure falls
below 140/90 mmHg
o For women with gestational hypertension who did not take antihypertensive
treatment and have given birth, start antihypertensive treatment if their blood
pressure is higher than 149/99 mmHg.
o Women who have had gestational hypertension should have a medical
review at the postnatal review (6–8 weeks after the birth).

T. Bahnasi
 References
1-The FIGO Textbook of Pregnancy Hypertension An
evidence-based guide to monitoring, prevention
and management, 2016
2-Clinical pharmacy and therapeutics 6th edition ,
2019