Hypertension in Pregnancy by Dr Naila Adil

1. HYPERTENSIVE
DISORDERS IN
PREGNANCY
Dr Naila Adil
Assistant Professor – Gynae &
Obs

2. Hypertensive disorders are
the most common and yet
serious conditions seen in
obstetrics

3. INTRODUCTION
Incidence is 5-10%.
The most frequent cause of iatrogenic
prematurity.
Preterm delivery
Intrauterine growth restriction (IUGR)
Perinatal death
Maternal cerebrovascular accidents (
CVA).
Placental abruption.

4. NORMAL BLOOD PRESSURE CHANGES
IN PREGNANCY
Decreases during the first
trimester,
Reaching its lowest point at 20
weeks,
Returns to pre-pregnancy levels
during the third trimester.

5. Classification
Pre-eclampsia
Eclampsia
Preeclampsia
superimposed on
chronic hypertension
Chronic hypertension
with pregnancy
Gestational
hypertension

6. Pregnancy induced
Hypertension
Gestational
HTN
● BP ≥ 140/90mmHg
●No evidence of underlying
cause of HTN
●No associated symptoms
●Comes to normal within 6
wks of delivery
Pre-
eclampsia
Non Severe Severe
Eclampsia
PreEclamsia
+
Convulsion
±
Coma
N.B: Grades of proteinuria (in g/L): Trace=0.1, 1+=0.3, 2+=1, 3+=3, 4+=10

7. GESTATIONAL
HYPERTENSION
Blood Pressure ≥ 140/90mmHg on two
or more occasions
- in a previously normotensive patient
- after 20 weeks gestation
- without proteinuria
- returning to normal 6 weeks after
delivery
• Almost half of these develop preeclampsia
syndrome

8. GESTATIONAL HYPERTENSION
GESTATION ≥ 20 WEEKS
SUSTAINED HYPERTENSION ( ≥ 140/90)
NO PROTEINURIA

9. CRITERIA FOR GESTATIONAL HYPERTENSION
Blood Pressure > 140 to < 160 mm Hg, systolic
> 90 to < 110 mm Hg, diastolic
Proteinuria < 300 mg per 24-hr collection
Platelet count > 100,000/mm3
Liver enzymes Normal
Maternal symptoms Absent
IUGR / Oligohydramnios Absent

10. PREECLAMPSI
A
• It is defined as hypertension of at
least 140/90mm Hg recorded on
two separate occasions at least 4
hours apart and in the presence
of at least 300mg protein in a 24
hour collection of urine, arising
after the 20th week of gestation in
a previously normotensive
woman and resolving completely
by the 6th postpartum week.

11. DEFINATION OF
PRE ECLAMPSIA
Blood pressure >140/90 mm of Hg with
proteinuria
- >30 mm of Hg or more in SBP.
- >15 mm of Hg or more in DBP.
This rise of BP is observed at interval of 4
hrs.

12. DEGREE OF HYPERTENSION
Systolic BP Diastolic BP
Mild Hypertension 140-149 90-99
Moderate
Hypertension
150-159 100-109
Severe Hypertension ≥ 160 ≥ 110

13. RISK FACTORS FOR PREECLAMPSIA
DEMOGRAPHIC
OBSTETRICS
MEDICAL
NULLIPARA
(Age extremes <20yrs ,
>35yrs )
1. Multiple gestation
2. Molar pregnancy
3. Non-immune
hydrops
1. Diabetes mellitus
2. Chronic HTN
3. Renal disease
4. SLE

14. Genetic
Genetic
Predisposition
Family History
Race & Ethnicity
More Common in
black & Asians
Pregnancy by
ovum donation
Age
&Parity
Teenage
pregnancy <18 yrs
Age>35 yrs
Long interval
between
pregnancy >10
years
Nulliparity
Partner
Factors
Change of partner
Limited sperm
exposure
Pregnancy by
donor
insemination
Partner fathered
an eclamptic
pregnancy

15. Pregnancy Factors
• Multiple pregnancy
• Hydatiform mole
• Hydrops fetalis
• Fetal chromosomal
anomaly
(trisomy 13)
Underlying Medical
Diseae
• Chronic
hypertension
• Diabetes mellitus
• Renal Disease
• Cardiovascular
disease
• Hyperthyroidism
• Metabolic Syndrome
Others
• Obesity BMI> 35
kg/m2
• Psychological stress
& strain
Smoking
• Previous history of
preeclamsia

16. PREECLAMPSIA
GESTATION ≥ 20 WEEKS
SUSTAINED HYPERTENSION ( ≥
140/90)
Proteinuria ( ≥ 300mg /24 hr)
GESTATIONAL HYPERTENSION
GESTATION ≥ 20 WEEKS
SUSTAINED HYPERTENSION (≥
140/90)
NO PROTEINURIA

17. PATHOPHYSIOLOGY
Complex disease triggered by the
placenta

18. MECHANISMS
Stage 0
3-8 weeks
Stage 1
8-18 weeks
Stage 2
20 weeks to
birth
Poor Immunoregulation
Inadequate tolerance to feto-paternal
antigens during conception and implantation
Poor Placentation
Deficient trophoblast invasion and
spiral artery remodeling
Clinical manifestation
Over activation of maternal
endothelium and systemic
inflammatory network
Oxidative
Stress
Endoplasmic reticulum
Stress
Inflammatory
Stress

19. MECHANISMS
Invasive cytotrophoblasts of
fetal origin invade the
maternal spiral arteries
Transforms them from small-
caliber resistance vessels to
high-caliber capacitance
vessels
Capable of providing placental
perfusion adequate to sustain
the growing fetus
Normal
Pregnancy

20. PREECLAMPSIA
cytotrophoblasts fail to adopt an
invasive endothelial phenotype
invasion of the spiral arteries is shallow
and they remain small caliber, resistance
vessels
placental ischemia

21. NORMAL
PREGNANC
Y
PREECLAMPSIA

23. TWO – STAGE
MODEL FOR
PREECLAMPSI
A
Stage 1:
reduced placental
perfusion
Abnormal
implantation
Stage 2:
maternal syndrome
-hypertension
-proteinuria
-endothelial
dysfunction

24. Cardiovascular
• Generalized vasospasm
• Increased peripheral
resistance
• Reduced central venous/
pulmonary pressure
Hematological
• Platelet activation and depletion
• Coagulopathy
• Decreased plasma volume
• Increased blood viscosity
• Proteinuria
• Decreased glomerular filtration
rate
• Decreased urate excretion
Renal
Hepatic
• Periportal necrosis
• Subscapular
hematoma
• Cerebral oedema
• Cerebral haemorrhages
Central Nervous System
Organ Specific Changes associated with
Pre-eclampsia

25. Organ Damage
utero-placenta IUGR
Hematological Low platelet count hemoconcentration
CNS Cerebral edema, cerebral hge seizures
Heart Subendothelial hge , focal necrosis & hge,
cardiomyopathy, heart failure
Lungs Pulmonary edema, hemorrhagic brochopneumonia
Kidneys glomerular endotheliosis, oliguria
Liver Subcapsular hge, ischaemiaperiportal necrosis,
HELLP

26. INDICATORS
OF
SEVERITY
OF PRE-
ECLAMPSIA
ABNORMALITIES NONSEVERE SEVERE
Blood pressure ≥140/90mmHg but
<160/110mmHg
≥160/110mmHg
Proteinuria ≤2+ ≥3+
Oliguria Absent <400ml/day
Headache Absent Present
Visual disturbances Absent Present
Platelet count Normal Thrombocytopenia
(<100,000/mm3)
HELLP syndrome Absent May be present
ALT,AST >70 IU/L
LDH>600 IU/L
Bilirubin >1.2g/L
Serum transaminases(AST,ALT) Normal (<40 IU/L) Elevated
Serum Creatinine Normal Elevated
Epigastric pain Absent Present
Fetal growth restriction Absent Obvious
Pulmonary oedema Absent present

27. PRE-
ECLAMPSIA IS
TWO STAGE
DISEASE
Maternal Syndrome Fetal Syndrome

28. C O M P L I C AT I O N S
- M AT E R N A L :
Convulsions and coma (eclampsia).
Cerebral haemorrhage.
Renal failure.
Heart failure.
Liver failure.
Disseminated intravascular coagulation.
Abruptio placentae.
Residual chronic hypertension in about 1/3 of cases.
Recurrent pre-eclampsia in next pregnancies.

29. COMPLICATIONS – FOETAL:
a. Intrauterine
growth
retardation
(IUGR).
b. Intrauterine
foetal death.
c. Prematurity
and its
complications.

30. PREDICTION OF PRE ECLAMPSIA
• Prediction of pre-eclampsia depends on variety of biochemical and
biophysical markers based on rationale implicated in the pathology
and pathophysiology

31. ANTI-ANGIOGENIC
FACTORS
ANGIOGENIC
FACTORS
Vascular endothelial
growth (VEGF)
including placental
growth factor
Transforming growth
factor- beta (TGF-B)
Look after maternal
endothelium
Soluble endoglin (sEng)
Soluble FMS-like tyrosine
kinase-1 (sFlt-1)
Released from diseased
placenta

32. UTERINE ARTERY DOPPLER
In Normal Mother
In preeclamptic mother:
Showing early diastolic NOTCH
Decreased EDF
(due to high resistance)

33. Antenatal Investigation
•Hb
•ABO RH
•Urine Routine Microscopy
•Screening blood sugar
•VDRL
•HbsAg
•HIV
•Obst USG
Specific Investigation
•Complete Haemogram
•General blood picture
•Pletelet Count
•24 hrs urinary protein
•Liver function test
•Kidney function test
•Serum Uric Acid
•Coagulation profile
•Fundus Examination
•Doppler USG

34. INVESTIGATIONS
• Urine: 24 hour urine, Proteinuria
• Kidney functions: serum creatinine, urea, creatinine
clearance and uric acid.
• Liver functions: bilirubin, Enzymes
• Blood: CBC, HCt , Hemolysis and Platelet count
(Thrombocytopenia)
• Coagulation Profile: Bleeding and clotting time

35. PREVENTIO
N
Regular Antenatal checkup:
• rapid gain in weight
• rising blood pressure
• edema
• proteinuria/deranged liver or renal profile
Low dose Aspirin in High risk group: ↑PGs
and↓TXA2
Calcium supplementation: no effects unless
women are calcium deficient
Antioxidants- Vitamin C and E
Nutritional supplementation: zinc, magnesium,
fish oil, low salt diet

36. PRINCIPLES
OF
MANAGEMENT
Control of blood
pressure
Delivery
Post natal care

37. ANTI HYPERTENSIVE DRUGS
Drug Starting dose Maximum dose
Methyldopa 250 mg TDS/QID 4 g / day
Labetalol 100 mg BD 2400 mg/ day
Nifedipine 10 mg BD 120 mg / day

39. • Blood pressure ≥
140/90 before 20
weeks of gestation.
OR
• persistence of
hypertension beyond
6 weeks after
delivery.
CHRONIC HYPERTENSION

40. CHRONIC
HYPERTENSIO
N
GESTATION < 20 WEEKS OR Pre
pregnancy
SUSTAINED HYPERTENSION (≥140/90)
+/- PROTEINURIA

41. CHRONIC HTN
PREGNANCY
PROGNOSIS
GOOD
PROGNOSIS
POOR
PROGNOSIS
WORST
PROGNOSIS
B.P 140/90 to 179/109
No end organ damage
KIDNEYS: Renal disease
EYES : Retinopathy
HEART : Left Ventricular
Hypertrophy (B.P
>180/110)
Uncontrolled HTN
Chronic HTN
+Superimposed PIH

42. M AN A G E M E N T
O F C H R O N I C
H Y P E R T E N S I O N
Antihypertensive meds
(if B.P >100 mm Hg diastolic)
Labetalol is drug of choice
Serial ultrasounds (increase risk of
IUGR >30 weeks )
Serial B.P and urine protein
(watch for superimposed preeclampsia)
Induce labour at term

43. SU PER IMPOSED
PR EEC LA MPSIA
( ON C H R ON IC
HYPERTENSION
)
New-onset proteinuria > 300
mg/24 hrs in hypertensive women
but no proteinuria before 20 wks
gestation.
A sudden increase in proteinuria
or blood pressure or platelet count
< 100,000/ cu mm in women with
hypertension and proteinuria
before 20 wks gestation.

44. CHRONIC HTN
SUPERIMPOSE
D PIH
CHRONIC HYPERTENSION
Worsening BLOOD PRESSURE
Worsening proteinuria

45. MANAGEMENT
IV MgSO4 – To prevent convulsions
( continue 24 hrs post-partum )
LOWER B.P ( hydralazine or
labetalol)
INDUCE LABOR (IV oxytocin and
amniotomy )

46. HELLP SYNDROME
• HTN patients with hemolysis (H),
elevated liver enzymes (EL), low
platelet count (LP)
• 5-20% of pt. with severe
preeclampsia and eclampsia develop
HELLP syndrome

47. HELLP SYNDROME
• Cardiovascular stabilization, correction of
coagulation abnormalities, and delivery
• PLT transfusion before or after delivery if PLT
count is <20,000/mm3 (advised at
<50,000/mm3 before cesarean)
• <32 weeks gestation; steroid therapy may
help stabilize maternal PLT count

48. TREATMENT OF HYPERTENSION:
• Antihypertensive drugs used in pregnancy are
• Hydralazine
• labetalol

49. ECLAMPSIA
• New onset of seizures or unexplained coma during
pregnancy in patients with pre-existing preeclampsia and
without pre-existing neurological disorder.

50. ECLAMPSIA
• Addition of convulsions in a woman with preeclampsia
• Occurs in 0.5-4% of deliveries
• 38% antenatlly 18% intrapartum, and 44% post partum.
Eclampsia Preeclampsia
Seizure/
Convulsion/
Coma

51. SEIZURE PROPHYLAXIS
• Routinely used in severe PE.
• Magnesium sulphate: most commonly used

52. RECOMMENDED REGIME FOR MGSO4
• Loading dose for IV is 4g. i.e. 8 ml diluted in 12ml
normal saline. This 20 ml is given in 20 minutes.
• Maintenance dose is 20 g i.e. 40ml diluted in 60ml
normal saline and given at rate of 1g/hr.

53. DELIVERY IN ECLAMPSIA
• 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