HYPERTENSIVE DISORDERS DURING PREGNANCY

1. PROFESSOR SHABNAM NAZ SHAIKH
MBBS (GOLD MEDALIST) ,MCPS,FCPS.
DEPTT: OF OBSTETRICS AND GYNECOLOGY
CMC,SMBB MEDICAL UNIVERISITY LARKANA

2. INTRODUCTION
•Hypertensive disorders are the most common and yet
serious conditions seen in obstetrics
•Leading cause of maternal deaths globally
Complicates about 2-10% of pregnancies.
•with an estimated 50,000-60.000 preeclampsia
•related deaths worldwide
Incidence is 7x higher in developing countries
• (2.8% of live births) than in developed countries (0.4%)
•The most frequent cause of iatrogenicprematurity.
•Preterm delivery
•Intrauterine growth restriction(IUGR)
•Perinatal death
•Maternal cerebrovascular accidents (CVA).
•Placental abruption

3. Maternal causes
○ Obesity
o Primiparity
○ Mothers under 20 or over 40 years old
○ Past history of DM, HTN, RD.
○ Adolescent pregnancy.
○ Chronic hypertension
○ New paternity.
○ Thrombophilia
○ Having a renal graft
Who Is Most at the Risk of Getting
Gestational htn, p.E ,eclampsia?
Pregnancy
○ Previous Preeclampsia
○ Multiple gestation (twins or
triplets, etc.)
○ Placental abnormalities: Molar
preg .
Family history of preeclampsia.

4. Classification
Pre-
eclampsia
Eclampsia
CHRONIC
HYPERTENSION
WITH REGN
Preeclampsia
superimposed on
chronic hypertension
Gestational
hypertension
• New-onset proteinuria > 300
mg/24 hrs in hypertensive
women but no proteinuria
before20 wks gestation
New diagnosed HTN
after 20/wks without
significant proteinuria
New HTN diagnosed >20/40,
with significant proteinuria
P.E WITH FITS
Types /classification
• Hypertension present
at the booking visit,
• or at less than 20/40,
• or already taking anti
Hypertension

5. Hypertension in pregnancy
Diastolic Systolic
mild >90 –109
mmHg
>140–159
mmHg
Severe ≥ 110 mmHg ≥ 160 mmHg

6. Auscultatory technique:
• Inflate cuff 20 to 30 mm Hg above
palpatory B.P.
• Lower mercury column by 2 mm/sec.
• Diastolic B.P (DBP) measured at
Korotkoff `s sound 5.
• Regular cuff size is appropriate for 32
cm arm circumference.
• Larger cuff is required for > 33 cm.
MEASUREMENT OF B.P:

7. use automated reagent strip
• If 1+ or more then do quantify proteinuria in
preg by
• Urine protein creatinine ratio PCR >
30mg/Mmol.
• Or albumin creatinine ratio ACR 8 mmol
• Do not use first morning urine void to quantify
proteinuria in pregnant women.
• Do not routinely use 24-hour urine collection to
quantify proteinuria in pregnant women.
Grades of proteinuria (in g/L):
• Trace=0.1,
• 1+=0.3,
• 2+=1,
• 3+=3,
• 4+=10
MEASUREMENT OF PROEINURIA

8. cytotrophoblasts fail to adoptan
invasive endothelialphenotype
invasion of the spiral arteries is
shallow and they remain smallcaliber,
resistance vessels
placental ischemia
Preeclampsia

10. • –Sudden weight gain 1 KG/WEEK
• –Blurred vision or sensitivity to light
• –Nausea and vomiting
• –Persistent headaches
• –Epigastric pains
Presentaion
• High blood pressure is the major
sign.
• EDEMA
• Other signs specific to relevant
organ damage

11. New HTN diagnosed >20wks ,
without significant proteinuria
a full assessment in a secondary
setting
Inquire risk factors that require
additional assessment and follow-
up: (medical disorders )
Management

12. TREATMENT Mild severe
Hypertension: Blood pressure of
140/90-159/109mmHg
Severe hypertension:
Blood pressure of 160/110mmHg
or more
Admission to
hospital
Do not routinely admit hospital Admit, but if BP falls below
160/110 mmHg then manage as
for hypertension.
Antihypertensive
treatment
• Offer ---if BP remains above 140/90
mmHg
• Consider labetalol
• consider nifedipine if labetalol is
c/I
• methyldopa if both labetalol and
nifedipine are c/I
Offer treatment to all women
Target blood
pressure
Aim for BP of 135/85 mmHg or less Aim for BP of 135/85 mmHg or less

13. Fetal assessment
• fetal heart auscultation at every antenatal
appointment
• ultrasound -- at diagnosis and, if normal, repeat
every 2 to 4 weeks, if clinically indicated.
• CTG if clinically indicated
• fetal heart auscultation at every
antenatal appointment
• ultrasound at diagnosis if normal, repeat
every 2 weeks,
• CTG at diagnosis then only if clinically
indicated.
B.P monitoring Once or twice a week (depending on BP) until
BP is 135/85 mmHg or less
Every 15-30 minutes until Bp is less than
160/110 mmHg
Dipstick proteinuria
testing
Once or twice a week (with Bp
measurement)
Daily while admitted
Blood test Measure FBC, LFT, RFT--- at presentation then
weekly.
Measure FBC.LFT,RFT at presentation
then weekly
PIGF-based testing
ANC VISITS
on 1 occasion) if there is suspicion of pre-
eclampsia
Well controlled. every 2 to 4 weeks
on 1 occasion if there is suspicion of
pre-eclampsia
Poorly controlled weekly visit

14. TOB
• IF BP <160/ 110 mmHg with or without antihypertensive treatment. ----- after 37 weeks,,
• If planned early birth is necessary---offer a course of antenatal corticosteroids and
magnesium sulfate if indicated,
• Postnatal investigation, monitoring and
treatment
• BP CHECK daily for the first 2 days after birth
• • at least once between day 3 and day 5 after birth
• • as clinically indicated if antihypertensive treatment
is changed after birth.
• aim to keep blood pressure lower than 140/90 mmHg
• • continue antihypertensive treatment, if required
• review of antihypertensive treatment 2 weeks after
the birth,
•
• stop methyldopa within 2 days after the birth and
change to an alternative
• medical review 6–8 weeks after the birth with their
GP or specialist as appropriate

15. Preeclamsia
Gestational
Hypertension
Proteinuria

16. TREATMENT Degree of SEVERITY
Monitor to
prevent
• Eclampsia
• hellp syndrome
• pulmonary
edema,
mild Hyperte:
Blood pressure
of 140/90-159/
109mmHg
Severe hypertension:
Blood pressure of 160/110mmHg or more
• features of severe pre-eclamsia
• ongoing or recurring severe headaches
• visual scotomata
• nausea or vomiting
• epigastric pain
• oliguria and severe hypertension
• progressive deterioration in laboratory
blood tests (such as rising creatinine or liver
transaminases, or falling platelet count).

17. Admission to hospital Admit
• if any fetomaternal concerns
1. sustained systolic blood pressure of 160
mmHg or higher
2 Any lab concerns
 new and persistent: rise in creatinine (90
micromol/litre or more, 1 mg/100 ml or more)
 Or. rise in alanine transaminase (over 70
IU/litre, or twice upper limit of normal range)
 Or fall in platelet count (under
150,000/microlitre)
3 signs of impending eclampsia
4. signs of impending pulmonary oedema
5. other signs of severe pre-eclampsia
6. suspected fetal compromise
7. any other clinical signs that cause concern.
Admit, but if BP falls
below 160/110
mmHg then manage
as for hypertension.
MDT
• Involve a senior
obstetrician
• Discuss with the
anaesthetic team
• neonatal team
MANAEMENT Mild HTN. sever HTN

18. Antihypertensive
treatment
Offer treatment if BP remains above
140/90 mmHg
Offer treatment to all women
Target blood pressure
once
Aim for BP of 135/85 mmHg or less Aim for Bp of 135/85 mmHg or less
Blood pressure
measurement
At least every 48 hours, and more
frequently if the woman is admitted to
hospital
Every 15-30 minutes until BP is less than
160/110 mmHg, then at least 4 times
daily while the woman is an inpatient,
depending on clinical circumstances
Dipstick proteinuria
testing
Only repeat if clinically indicated, for
example. If new symptoms and signs
develop or if there is uncertainty over
diagnosis
Only repeat if clinically indicated, for
example. If new symptoms and sings
develop or if there is uncertainty over
diagnosis
Blood status Measure full blood count, liver function
and renal function twice week.
Measure full blood liver function renal
function 3 times a week
Mild HTN. sever HTN

19. Fetal assessment fetal heart auscultation at
every antenatal
appointment
ultrasound a at diagnosis
and, if normal, repeat every
2 weeks,
CTG if clinically indicated
fetal heart auscultation at every antenatal appointment
ultrasound and doppler studies at diagnosis and, if
normal, repeat every 2 weeks,
Carry out a CTG at diagnosis and then only if
• Reduced fetal movement
• vaginal bleeding
• abdominal pain
• deterioration in maternal condition.
TOD
• < 34 weeks. --- mg sulphate plus steroids and continue survillience unless
indications of delivery
• 34 to 36 weeks --- steroids (up to 35 weeks) continue surveillance unless
indication for delivery
• 37 weeks and onward – delver with in 24 to 48 hrs
• MOD --- C- sec / induction. according to the clinical circumstances and the
woman's preference

20. Intrapartum care
• Contnue anti htn tx
• bp monitor 1 hrly.
• if sever htn. Than every 15–30 minutes until blood
pressure is less than 160/110 mmHg
• haematological and biochemical tests during labour
in women with hypertension using the same criteria
as in the antenatal period
• Do not preload women who have severe pre-
eclampsia with intravenous fluids before establishing
low-dose epidural analgesia or combined spinal
epidural analgesia
• Sec stage --- Consider operative or assisted birth in
severe hypertension
• 3RD STAGE –Avoid ergometrine
• Choice of anaesthesia----General
anaesthesia is preferred
• Postpartum care
• Continuous nursing
care inHDU for at least
24 hours post delivery
• Breast feeding
• Vte prophylaxis
• Contraception
• Continue anti htn
• Bp monitoring
• medical review
• Risk of recurrence

21. • inability to control maternal blood pressure despite using 3
or more classes of antihypertensives in appropriate doses
• maternal pulse oximetry less than 90%
• progressive deterioration in liver function, renal function,
haemolysis, or platelet count
• ongoing neurological features, such as severe intractable
headache, repeated visual scotomata, or eclampsia
• placental abruption
• reversed end-diastolic flow in the umbilical artery doppler
velocimetry, a non- reassuring cardiotocograph, or stillbirth.
indications of birth < 37 weeks

22. Women without anti htn ---
ask for severe headache and epigastric pain each time bp chek
measure blood pressure:
 at least 4 times a day while the woman is an inpatient
 at least once between day 3 and day 5
 if blood pressure was abnormal on days 3–5. than on alternate days until normal,
 start antihypertensive treatment if blood pressure is 150/ 100 mmHg or higher.
POSTNATAL INVESTIGATION, MONITORING AND TREATMENT
Women on anti htn tx Check blood pressure: and
 4 times a day in inpt
 every 1–2 days for up to 2 weeks after transfer to community care until the woman is off treatment
and has no hypertension.
Continue anti htn tx
if bp below 140/ 90 consider reducing antihypertensive treatment
reduce antihypertensive treatment if bp below 130/80

23. discharge criteria
• there are no symptoms of pre-eclampsia
• blood pressure, with or without treatment, is 150/100 mmHg or less
• blood test results are stable or improving.
Write clear care plane
• who will provide follow-up care, including medical review if needed
• frequency of blood pressure monitoring
• thresholds for reducing or stopping treatment
• indications for referral to primary care for blood pressure review
• self-monitoring for symptoms

24. medical review with their GP or specialist
2 weeks after transfer to community care.
6–8 weeks after the birth
investigations.
platelet count, transaminases and serum creatinine 48–72 hours after birth
• if normal than do not repeat
• If abnormal repeat as clinically indicated until results return to normal
urinary reagent- strip test 6–8 weeks after the birth
.if 1+ or more. review with their GP or specialist at
3 months after the birth to assess kidney function. If abnormal than refer to nephrologist
women with a history of pre-eclampsia who have no proteinuria and no
hypertension at the postnatal review (6–8 weeks after the birth)
the relative risk of end-stage kidney disease is increased,
but the absolute risk is low and no further follow-up is necessary

25. • convulsions in a woman with
preeclampsia
• occurs in 0.5-4% of deliveries
• 25% have eclamptic seizures before
labour, 50%during labour, and 25%
after delivery.
Eclampsia Preeclampsia
Seizure/
Convulsion/
Coma

26. ECLAMPTIC FIT
• Premonitary Stage
• Tonic Stage
• Clonic Stage
• Coma Stage

27.  meningitis
 encephalitis
 space occupying lesion
 electrolyte disturbance
 vasculitis
 amniotic fluid embolism
 Medications
 organ failure
 stroke

28. MANAGEMENT
1. Stop convulsions withMgSO4
2. Prompt delivery at anygestational age
3. Lower diastolic BP 90-100mm/Hg
ECLAMPSIA
IV MgSO4 – Toprevent convulsions
( continue 24 hrs post-partum)
LOWER B.P ( hydralazine orlabetalol)
INDUCE LABOR (IV oxytocin and amniotomy )

29. Preparation of mgso4

32. 90
• Not used to lowerbp
• Produce intravascular volume
depletion
• Worsenmaternal
hemoconcentration
• Use is limited to presence of
pulmonary edema (FUROSEMIDE)
• May be used in persistent severe
postpartum hypertension

33. Unless contraindicated:--------Eclamptic women
should undergo normal vaginal delivery
Indications for caesarean section - Fetal
distress
Placental abruption
Unfavourable cervix
Failed induction of labour Recurrent
seizures
POST PARTUM CARE IN ICU

34. ECLAMPSIA AT PRIMARY OR SECONDARY HEALTH CARE LEVEL
Pre Transfer
• Patient must be stabilised and optimised Before
transfer
• control BP with antihypertensive
• consider giving MgSO4
• consult and inform staff of referral hospital
about patient
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35. • Patient should be monitored and
managed in the high dependency area
while awaiting transfer
• Patient should be accompanied by skilled
medical and nursing staff who are trained
and competent in resuscitation
• Husband or next of kin should be
informed and should accompany the
patient
• Ensure essential equipment available
during transfer
• Use the safest and quickest means of
transport
• A fully equipped ambulance is preferable
• Consider the services of an obstetric
retrieval team
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36. Maternal Complications of Eclampsia
• Stroke (Rare)
• Pulmonary Edema.
• Aspiration Pneumonia(2%-5%)
• Long Term Cardiovascular Morbidity
• Abruptio- Placentae (1%-4%)
• Disseminated Coagulopathy.
• HELLP Syndrome (10%-20%)
• Acute Renal Failure (1%-5%)
• Liver Failure OR Haemorrhage
(<1%)
• Death (Rare)

37. • Fetal Growth Restriction (10%-25%)
• Pre-Term Delivery (15%-67%)
• Hypoxia- Neurologic Injury (<1%)
• Perinatal Death (1%-2%)
• Long Term Cardiovascular Morbidity
Associated with Low Birth Weight
NEONATAL COMPLICATIONS OF P.E AND ECLAMPSIA

38. Primary Prevention
Secondary Prevention
A – Primary Prevention by control of
• Obesity
• Chronic Hypertension
• Diabetes Mellitus
• Connective Tissue Disorder
PREVENTION

39. B- Secondary Prevention
A) Awareness: patients should be aware of
warning signs and when to report to the
hospital.
• (i.e: headache, blurring of vision, pain below
ribs, vomiting, edema over hands and feet)
B) Anti-platelet agents: Start tablet,
asprine 75-150 mg OD from 12 weeks of
pregnancy till delevery for the following:

40. If 1 high risk factor is
present (major)
more than 1. Moderate risk
factors
1. Previous history of
gestational hypertension
2. chronic kidney disease
3. auto immune diseases
(SLE, APLA)
4. type I or II diabetes
mellitus
5. chronic hypertension.
1) Primigravida.
2) Age > 40 years
3) Pregnancy interval of >10 years.
4) BMI . 35 Kg/m2
5) Family history of pre-eclampsia.
6) Multiple pregnancy.
Reduce risk of cvs disease and
htn in future
• avoiding smoking,
• maintaining a healthy lifestyle,
• maintaining a healthy weight,
• keep a BMI within the healthy
range before their next
pregnancy (18.5–24.9 kg/m2)
• Recurrence increases with an
inter-pregnancy interval
greater than 10 years.
ASPIRINE

41. DO NOT USE:------ for prevent
hypertensive disorders during
pregnancy:
MEDICATIONS
• nitric oxide donors
• progesterone
• diuretics
• low molecular weight heparin
NUTRITIONAL SUPPLEMENTS
• Magnisium ,folic acid
• antioxidants (vitamins C and E)
• fish oils or algal oils
• garlic.
Diet ---- Do not recommend
salt restriction during pregnancy
.
Life style – do not offer rest in
hospital
Do not routinely perform
screening for thrombophilia in
women who have had pre-
eclampsia

42. PREVETION AT COMMUNITY LEVEL
• Increase awareness of HTN- Educate the
patient, family and community
• Health talks, pamphlets, posters, media
• Counselling, group discussions about HTN and
the importance of antenatal care
• Address transportation problems
• Address adverse traditional beliefs and taboos
• Consider the influence of TBAs
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43. PREVENTION AT HEALTH CARE LEVEL
• At health care provider level
• Problems
• Failure to recognise severity
• Delay in referral
• Problems of transfer
• Educate all categories of staff
• in-service training, telemedicine, refresher
courses
• Effective supervision
• Provide education material - check list
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44. • Recent Multicentre Randomized
Controlled Trial –the Magnesium
Sulphate for Prevention of Eclampsia
(MAGPIE) Lancet July 2002
• Magnesium Sulphate reduced
Eclampsia by 58%.
• Severe PE or with impending
eclampsia

45. RECURRENCE RISK

46. RISK OF CVS DISEASES IN PTS WITH HTN

47. TO KNOW MORE
REFRENCES
• NICE GUIDLINE ON HYPERTENSIVE DIRSORDER OF PREGNANCY 2019.
• DEWHAURTS TEXT BOOK OF OBS GYNAE 2018
• ADVANCE LIFE SUPPORT IN OBSTETRICS
• STRAT OG
• DC DUTTA TEXT BOOK OF OBSTETRICS.

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