HYPERTENSIVE DISEASE

IN PREGNANCY
Dr Mercy MOI
Definition
• BP ≥140/90 mm Hg measured two times with at least 6-hour interval.
• Gestational hypertension- BP ≥140/90 mm Hg for the first time in pregnancy
after 20 weeks, without proteinuria.
• Pre eclampsia- Gestational hypertension with proteinuria.
• Eclampsia- preeclampsia complicated with seizures or coma.
• HELLP Syndrome- Hemolysis, elevated liver enzymes and thrombocytopenia.
• Chronic hypertension- Known hypertension before pregnancy or
hypertension diagnosed first time before 20 weeks of pregnancy.
• Superimposed pre eclampsia/eclampsia- Occurrence of new onset of
proteinuria in women with chronic hypertension.
PRE ECLAMPSIA
• Incidence of 5-15%. 10% in primigravida and 5% in multigravida.
• Risk factors
• Primigravidity
• Family history of pre eclampsia
• Obesity
• Pre existing vascular disorders
• Pre gestational diabetes
• Essential hypertension
• Renal disease
• SLE
• Age more than 40 years or less than 20 years.
• Pre eclampsia in previous pregnancy
Pathogenesis
• Vasospasm accompanied by intra vascular volume depletion.
• Spiral arteries fail to dilate maximally.
• In normal placentation, trophoblast invades the myometrium and the
spiral arteries of the uterus, destroying the tunica muscularis media.
• This renders the spiral arteries dilated and unable to constrict
providing the pregnancy with a high flow low resistance circulation.
• In pre eclampsia the remodeling of spiral arteries is incomplete.
• A high resistance, low flow uteroplacental circulation develops as the
constrictive muscular walls of the spiral arterioles are maintained.
Pathogenesis
• Endothelial cell injury
• Generalized vasoconstriction.
• Placental under perfusion results into release of free radicals that
cause endothelial dysfunction
• Microangiopathy affects multiple organ systems – sometimes with life
threatening results ; as a result far more complicated than simple
hypertension
• Activation of coagulation system
Clinical features

• Edema
• Headache
• Confusion and apprehension
• Disturbed sleep
• Diminished urinary output
• Epigastric pain associated with vomiting
• Eye symptoms- blurring, scotomata, dimness of vision, or complete blindness.
• Lower abdominal pain secondary to placenta abruption.
Signs
• Abnormal weight gain
• Rise of blood pressure > 140 / 90
• Edema
• Pulmonary edema
• Right upper quadrant liver tenderness
• Epigastric tenderness.
• Small fundal height for gestation
• Hyperreflexia of deep tendons
Preeclampsia with severe features
• Blood pressure > 160 / 110 mmHg
• Proteinuria > 3gm 24 hour collection, or equivalent in the test strip of > +++
• Serum creatinine > 1.2mg / dl
• Thrombocytopenia < 150 000 cell / mm3
• Lactose Dehydrogenase > 600 IU
• Raised liver transaminases – ALT, AST
• Persistent headache and visual disturbance
• Epigastric pain
• Intrauterine fetal growth retardation
• Oligohydramnios
• Oliguria < 500 ml in 24 hours
• Upper quadrant pain
Complications
• Immediate vs remote
• Immediate - maternal vs fetal
• Maternal
• (a) During pregnancy
• Eclampsia
• Renal failure- Oliguria and anuria
• Blurred vision
• Preterm labor
• HELLP syndrome
• Cerebral hemorrhage/stroke
• Pulmonary edema- Acute respiratory distress syndrome
Complication - ctd
• b) During labor
• Postpartum hemorrhage

• c) puerperium
• Eclampsia
• Shock
• Sepsis
Fetal complications
• Intra uterine death
• Intra uterine growth restriction
• Asphyxia
• Prematurity
Remote complications
• Residual hypertension
• Recurrent pre eclampsia
• Chronic renal disease
• Risk of placenta abruptio
Investigations
• Urine - proteinuria [+++]
• Opthalmoscopic examination – Arteriovenous nicking
• Blood values - elevated LFTs, thrombocytopenia, serum uric acid more
than 4.5mg/dl, serum creatinine more than 1mg/dl.
• CT scan of the brain
• Fetal assessment:
i. Obstetric ultrasound –biophysical profile, resistive index greater than 0.7, daily
fetal movements counts and non stress testing
ii. Cardiotogogram – Fetal heart rate
iii. Assessment of fetal growth – sonographic estimation of fetal weight and
oligohydramnios
Prophylaxis
• Regular antenatal check up
• Anti thrombotic agents - low dose aspirin 60 mg. Inhibits
thromboxane a hormone that raises blood pressure and is known to
be elevated in women with pre eclampsia. Aspirin improves blood
flow across the placenta by dilating uterine arteries.
• Calcium supplementation
Management -
Goals
• Blood pressure control
• Prevent complications/ end organ damage
• Seizure prophylaxis
• Ensure fetal well being
• Delivery
BP control
• Commonly used oral drugs
• Methyldopa - 250 to 500 mg TDS
• Nifedipine - 10-20 mg BD
• Labetalol -100 mg TDS
• Hydralazine - 10-25 mg BD
• In case of hypertensive emergency (BP more than 160/110mmhg)
• Hydralazine 5mg IV every 30 minutes to a maximum of 30 mg IV
• Target BP –systolic of 140-150 and diastolic of 90-100 mmHg.
Seizure prophylaxis
 Magnesium sulphate loading dose of 4g IV as bolus in 500mls NS with
5g IM in each buttock afterwards.
 Then 5 g IM every 4 hourly for 24 hours.
 MGSO4 is a prophylactic anti seizure drug.
 Administered after ruling out renal failure by obtaining the UEC
results (85% renal excretion)
 Monitor for magnesium toxicity.
 Contra indicated in myasthenia gravis.
Magnesium Toxicity
• Antidote is calcium gluconate 1gm IV over 3 min
• Magnesium levels
• 2 – 4 mmol / l – Therapeutic
• 3.8 – 5 mmol / l – warmth, flushing, slurred speech
• >5 mmol / l - loss of patellar reflexes
• > 6 mmol / l – respiratory depression
• 6.3 – 7 mmol /l – respiratory arrest
• > 12 mmol/l – cardiac arrest, asystole
• Place foley catheter to monitor urine output.
• Confirm normal serum creatinine.
• Monitor respiratory rate and do serial evaluation of patellar deep tendon reflexes.
Delivery
• Definitive treatment is delivery
• At 34 weeks for pre eclampsia with severe features
• At 37 weeks for pre eclampsia without severe features
• Methods of delivery- induction of labor or cesarean section.
• Cesarean section delivery indications
i. Severe pre eclampsia with a tendency for prolonged induction- delivery
interval.
ii. Associated complicating factors like elderly primigravidae, contracted pelvis
iii. When an urgent termination is indicated and the cervix is unfavorable.
(Unripe and closed)
Puerperium
• Close monitoring for 48 hours
• Continue antihypertensives until target BP is achieved.
• Inpatient management until BP is brought down to a safe level and
proteinuria disappears.
• Diuresis >4L/day is believed to be the most accurate indicator of
resolution of pre eclampsia but not a guarantee against development of
seizures.
• Anticonvulsant medication are generally continued for 24-48 hours
postpartum.
• Avoid methyldopa due to risk of depression.
ECLAMPSIA
• Severe life threatening manifestation of pre eclampsia.
• Defined as convulsions during pregnancy and postpartum
• Causes of convulsions
• Anoxia- Spasms of cerebral vessels lead to increased vascular resistance and
fall in cerebral oxygen consumption
• Cerebral edema
• Cerebral dysrhythmia
• Onset of convulsions mostly in third trimester
• The fits consists of 4 stages: Premonitory, tonic, clonic, coma.
Differential diagnosis
• Epilepsy
• Hysteria
• Encephalitis
• Meningitis
• Puerperal cerebral thrombosis
• Cerebral malaria
• Intracranial tumors
• However convulsions in pregnancy is assumed to be eclampsia until
proven otherwise
Maternal complications
• Pulmonary; edema, pneumonia, adult respiratory distress syndrome,
embolism, aspiration pneumonitis
• Hepatic; necrosis, sub capsular hematoma, liver rupture
• CNS; Cerebral edema, hemorrhage. Neurological deficit.
• Hematologic; thrombocytopenia, Disseminated intravascular coagulopathy
• Disturbed vision.
• Renal failure.
• Postpartum; hemorrhage, shock, sepsis, psychosis.
• Cardiac; acute left ventricular failure, cardiomyopathy.
• Abruptio placentae
Fetal complications
• Prematurity
• Intrauterine asphyxia
• Effects of drugs used to control seizures
Management of eclampsia
• If a seizure is witnessed, first do maintenance of airway patency and
prevention of aspiration .
• Patient rolled onto her left side to reduce aspiration.
• Supplemental oxygen to treat hypoxemia due to hypoventilation during the
convulsive episode.
• Maintenance of maternal vital functions .
• Control of convulsions and blood pressure
• Prevention of recurrent seizures.
• Evaluation for prompt delivery.
• Close monitoring during labor and 24 hours postpartum.
 Gestational hypertension
• Diagnostic criteria
i. Absence of any evidences for the underlying cause of hypertension
ii. Generally unassociated with other evidences of preeclampsia (edema or
proteinuria).
iii. Generally not associated with hemoconcentration or thrombocytopenia,
raised serum uric acid level or deranged LFTs.
iv. The blood pressure should come down to normal within 12 weeks following
delivery.
It may however complicate to preeclampsia.
 Chronic hypertension
• Incidence is 2-4%
• 90% are secondary to essential hypertension.
• Risk factors:
i. Age > 40
ii. Duration of hypertension> 15 years
iii. Level of BP >160/110
iv. Presence of any medical disorder (renovascular)
v. Presence of thrombophilias.
Timing of delivery
• Chronic hypertension and no medications- <38 weeks not
recommended
• Chronic HTN on maintenance antihypertensives- <37 weeks not
recommended.
• Chronic HTN with superimposed pre eclampsia without severe
features- 37 weeks
• Chronic HTN with superimposed pre eclampsia with severe features-
34 weeks
 Essential hypertension in
pregnancy
• Incidence 1-3%.
• The diagnostic criteria are:
i. Rise of blood pressure to the extent of 140/90 mm Hg or more during
pregnancy prior to the 20th week (molar pregnancy excluded)
ii. Cardiac enlargement on chest radiograph and ECG
iii. Presence of medical disorders
iv. Prospective follow-up shows persistent rise of blood pressure even after 42
days following delivery
Essential HTN ctd
• There may be a mid pregnancy fall of blood pressure in about 50%.
However, the blood pressure tends to rise in the last trimester which may
or may not reach its previous level.
• In 50%, the blood pressure tends to rise progressively as pregnancy
advances
• In about 20%, it is superimposed by preeclampsia evidenced by rise of
blood pressure to the extent of 30 mm Hg systolic and 15 mm Hg diastolic
associated with edema and/or proteinuria
• Rarely, malignant hypertension supervenes
• In 30%, there is permanent deterioration of the hypertension following
delivery
Effects on pregnancy
• a)Fetal
i. Prematurity
ii. Abruptio placenta[0.5-1%]
iii. IUGR
iv. Perinatal loss which increases when complicated with eclampsia.

• b)maternal
Management
• Blood pressure control to below 160/100 mm Hg.
• To prevent superimposition of preeclampsia.
• To monitor the maternal and fetal well-being.
• To terminate the pregnancy at the optimal time.
• Preconceptional evaluation and counseling to assess the etiology,
severity of hypertension and possible outcome of pregnancy
• Adequate rest.
• Low salt diet.
Management - ctd
• Routine use of antihypertensive drug is not favored. It may lower the
blood pressure and thereby benefit the mother but the diminished
pressure may reduce the placental perfusion which may be detrimental
to the fetus.
• Antihypertensive drugs (methyldopa, labetalol, nifedipine or
hydralazine) should be used only when the pressure is raised beyond
160/100 mm Hg.
• Obstetric management; : In mild cases, spontaneous labor is awaited. In
severe or complicated cases, the aim is to try to continue the pregnancy
to at least 34 weeks otherwise up to the 37th week to attain fetal
maturity and then to terminate the pregnancy.
THANK YOU