Hypertensive in pregnancy

1. HYPERTENSIVE DISORDERS
By:- Michiale H. (BSc Mw, MSc Mw)
Lecturer, Department of Midwifery
Dire Dawa Universty CMHS

2. DEFINITION
Hypertension:
A SBP ≥140 mmHg, DBP ≥90 mmHg or both in two occasions taken 4
hours or more apart; or
 a single blood pressure recording of ≥160/110 mmHg.
Proteinuria:
Two urine dipstick measurements of at least 1+ (30 mg per dL) taken
six hours apart; at least 300 mg of protein in a 24-hour urine sample;
or
a urinary protein/creatinine ratio of 0.3 or greater

3. CLASSIFICATION:
Gestational hypertension:
 hypertension without proteinuria (or other signs of preeclampsia)
developing after 20 weeks of gestation in a previously normotensive
woman.
Preeclampsia eclampsia syndrome
Pre eclampsia:new onset of hypertension and proteinuria after 20
weeks of gestation in a previously normotensive woman.
Eclampsia: grand mal seizure or coma in a woman with preeclampsia.
Important causes of convulsion or coma like cerebral malaria,
meningitis, hypoglycemia, previous seizure disorder, head injury or
intracranial space occupying lesions have to be ruled out

4. Superimposed preeclampsia
chronic hypertension develops new onset proteinuria after 20 weeks
Women with chronic hypertension and preexisting proteinuria (before 20
weeks) are considered preeclamptic (SBP 160 mmHg orDBP 110 mm Hg)
Chronic hypertension:
 is defined as hypertension that antedates pregnancy; is present before
the 20th week of pregnancy; or persists after 12 weeks postpartum.

5. GESTATIONAL HYPERTENSION
Manage on an outpatient basis:
Monitor BP, urine (for proteinuria) and fetal condition weekly.
If blood pressure worsens or the woman develops features of pre-
eclampsia, manage as pre-eclampsia
Counsel the woman and her family about danger signs indicating severe
pre-eclampsia or eclampsia.
 If all observations remain stable, allow to proceed with spontaneous
labour and childbirth.
 If spontaneous labour has not occurred before term, induce labour at
term

6. PRE-ECLAMPSIA
RISK FACTORS:
First pregnancy,
young or old age,
Multiple gestation,
History of hypertension,
Renal disease,
Diabetes, obesity,
Family history of pre-eclampsia

7. DIAGNOSIS:
• Hypertension and proteinuria are the hallmark features of preeclampsia.
Severity features of preeclampsia are:
 Headache, blurred vision, oliguria (<400 ml/24 hours), epigastric pain or
pain in right upper quadrant, difficulty breathing , edema
 Low platelet count (<100,000/µl)
 Elevated liver enzymes more than twice the upper limit of normal
Serum creatinine higher than 1.1mg/dl (baseline 0.48 mg/dL)

8. CLASSIFICATION
Pre-eclampsia without severe features
 Pre-eclampsia with severe features

9. TREATMENT OF PRE-ECLAMPSIA WITHOUT SEVERE FEATURES
Gestational age less than 37weeks
Twice weekly outpatient follow-up
 Monitor BP, fetal condition, CBC, liver and renal function tests 2 weekly.
Counsel about the danger signs
 Encourage the woman to eat a normal diet.
 Orient on fetal movement counting (kick chart) daily.
Do not give anticonvulsants or antihypertensives
Delivery at 37 completed weeks
 If follow up as an outpatient is not possible or if close observation is
preferred, or preeclampsia progress rapidly, admit to hospital

10. Gestational age ≥37complete weeks
Delivery is recommended.
Anticonvulsant during labor

11. TREATMENT OF PREECLAMPSIA WITH SEVERE FEATURES
• Includes any one or more of the severity features.
• The steps of management include:
 General measures:
 Prevent convulsion
Control hypertension.
 Delivery / expectant management in selected cases.

12. General measures
Admit the patient urgently, preferably to the labor ward
 Manage in left lateral position
Setup IV line & infuse maintenance fluids
Monitor urine output and maintain urine output at >30 ml/hr.
 Maintain a strict fluid balance chart
Prepare equipment for convulsion management at bed side (airway,
suction equipment, mask & bag, oxygen)
 Never leave the patient alone
 Monitor vital signs, FHB & reflexes

13. Anticonvulsant therapy (seizure prophylaxis)
 Give Magnesium sulfate.
 In all severe preeclamptic mothers during admission & continued during
period of evaluation & observation for 24 hours.
 Diazepam: may be used as alternative, if MgSO4 is not available

14. Control hypertension
Administration of antihypertensives should be started if the SBP is 160
mmHg or higher and/or the DBP is 110 mmHg or higher.
Hydralazine or labetalol is the drug of choice for acute control.
Note: An important principle is to maintain blood pressures above the
lower limits of normal.
Hydralazine
 Give 5 mg IV slowly every 20 minutes until blood pressure is lowered (to
DBP <110 mmhg). The maximum dose is 20 mg per 24 hours

15. Labetalol
 Oral treatment: Administer 200 mg; repeat dose after one hour
until the treatment goal is achieved. The maximum dose is 1200 mg in
24hr
 IV treatment:Administer 10 mg IV.If response is inadequate after 10
minutes, administer 20 mg IV.
The dose can be doubled to 40 mg and then 80 mg with 10-minute
intervals until blood pressure is lowered below threshold. The
maximum total dose is 300 mg; then switch to oral treatment.
Nifedipine
As alternative for acute therapy, administer 10 mg orally. Repeat dose
after 30 minutes if response is inadequate until optimal blood
pressure is reached.
The maximum total dose is 30 mg in the acute treatment setting. For
maintenance therapy10-20 mg PO bid is given.

16. PLANNING DELIVERY:
Gestational age < 28 weeks:
Termination of pregnancy (expectant management is not
recommended)

17. Gestational age ≥ 28 weeks and <34 weeks:
Expectant management is recommended,
Transfer to maternity ward
Follow vital signs every 4 hours
CBC, every other day
Liver enzymes, and creatinine twice weekly
Fetal kick count daily
 Fetal surveillance twice weekly
Administer Dexamethasone 6 mg IM every 12 hours for 2 days or
Betamethasone 12 mg daily for 2 days

18. Indications for delivery are:
Failure to control hypertension with two antihypertensive drugs with
a maximum dose in 48 hours
 Persistent maternal severity symptoms
 HEELP Syndrome
 Eclampsia
 Pulmonary edema or left ventricular failure
IUFD
 DIC
Severe renal dysfunction

19. Gestation 34 to 37 Weeks
In women with severe pre-eclampsia and a viable fetus that is
between 34 and 37 weeks of gestation, expectant management may
be recommended, provided that uncontrolled maternal hypertension,
worsening maternal status and fetal distress are absent and can be
closely monitored.
Gestation after 37 Completed Weeks
For women with pre-eclampsia at term (37 weeks), regardless of
severity features, giving birth is recommended

20. MODE OF DELIVERY
Depends on gestational age, fetal condition, presentation, cervical
condition & maternal condition.
Indication for Cesarean Section:
 If the cervix is unfavorable (firm, thick, closed) esp. in seriously ill
patients
With poor progress of labor
If patient has not entered active labor within 8 hrs of induction of
labor
If there is evidence of fetal distress, or other obstetric indications,

21. INTRA PARTUM MANAGEMENT
Absolute bed rest in LLP, is essential
Antihypertensive drugs should be given as necessary to regulate
diastolic blood pressure between 90 &110mm Hg
 Careful monitoring of FHB, maternal conditions & progress of labor
Pain management as required

22. POSTPARTUM MANAGEMENT
Watch closely for at least 2hrs after delivery for complications
Anticonvulsive therapy should be maintained for 24hrs to 48 hrs after
delivery or the last convulsion, whichever occurs last
 Continue anti-hypertensive therapy as long as the BP is ≥ 110mmhg
 Continue to monitor urine output & check for coagulation failure,
LFT, RFT
 Postnatal follow-up of these cases is very important for the
treatment of hypertension & possible complications such as DIC,
acute renal failure and pulmonary edema.

23. ECLAMPSIA
Treatment of eclampsia consists of
 General measures
 Control of convulsions
BP control, stabilization of the condition of the mother & fetus
 Fluid balance
 Delivery & intrapartum/postpartum care

24. GENERAL MEASURES IN THE MANAGEMENT OF ECLAMPSIA
Set up IV line & maintain intravascular volume
Position the patient on her side (left lateral) position to reduce risk of
aspiration of secretions, vomitus or blood.
Aspirate suction the mouth & throat to ensure open airway.
 Give oxygen by mask at 6 liters per minute.
 Avoid tongue bite by placing an airway or padded tongue blade

25. Place an indwelling catheter to monitor urine output.
 Observe vital signs, FHB & reflexes frequently & auscultate the lung
bases hourly for crepitation indicating pulmonary edema. If the
pulmonary edema occurs, withhold fluids & administer a diuretic
such as furosemide 40 mg IV stat.
The patient has to be kept in a quiet room.
An attendant must be always present beside the patient.
 Administration of broad-spectrum IV antibiotics is recommended

26. ANTICONVULSANT THERAPY
To stop the ongoing convulsion & prevent subsequent attack.
 MgSO4 is the drug of choice in the management of eclampsia
Despite the compelling evidence for the effectiveness of magnesium
sulfate, it has potential for toxicity.
Before repeat administration, ensure that
 respiratory rate is at least 12 per minute,
 patellar reflexes are present and
urinary output is at least 30 ml per hour or 100 ml per 4 hours.

27. Withhold or delay drug if
respiratory rate falls below 12 per minute,
patellar reflexes are absent or
urinary output falls below 30mL per hour over preceding 4 hours.
Keep antidote ready in case of respiratory arrest.
If there is respiratory arrest, assist ventilation (mask and bag,
anesthesia apparatus, intubation) and
Administer calcium gluconate 1g (10mL of 10% solution) IV slowly

28. MgSO4 SCHEDULES FOR SEVERE PRE-ECLAMPSIA AND ECLAMPSIA
Loading dose
Magnesium sulfate 20% solution, 4g IV over 5 minutes.
 Follow promptly with 10g of 50% magnesium sulfate solution, 5g in
each buttock as deep IM injection with 1mL of 2% lidocaine in the
same syringe.
Ensure that aseptic technique is practiced when giving magnesium
sulfate deep IM injection.
Warn the woman that a feeling of warmth will be felt when
magnesium sulfate is given.
 If convulsion recurs after 15 minutes, give 2g magnesium sulfate (20%
solution) IV over 5 minutes

29. Maintenance dose
5g magnesium sulfate (50% solution) + 1 mL lidocaine 2% IM every 4
hours into alternate buttocks.
 Continue treatment with magnesium sulfate for 24 hours after delivery
or the last convulsion, whichever occurs last

30. ANTI-HYPERTENSIVE THERAPY
 The therapeutic goal is to keep the diastolic blood pressure <110 mmHg
(between 90 and 100mmHg & prevent cerebral hemorrhage).
For drugs used as antihypertensive medication refer to management of
severe pre-eclampsia above (use same drugs & doses).

31. FLUID BALANCE
 Keeping strict input & output record is essential and determine
serum electrolyte, if possible
For unconscious patient, 5% DW & ringer's Lactate are infused for
maintenance of nutrition & fluid balance during 24 hrs.
 Replace extra fluid loss through vomiting, diarrhea, sweating or
blood loss
 Nothing by mouth is allowed (if unconscious); when the patient
becomes conscious & can drink, oral feeding of fluid is started

32. DELIVERY
 Delivery should take place within 12 hours of onset of convulsions
 Delivery should take place as soon as the woman's condition has
stabilized, regardless of the gestational age
INTRA PARTUM AND POSTPARTUM MANAGEMENT
 As stated in the management of sever preeclampsia with severe
features

33. Quiz 2
• List cause of Primary PPH ?
• Define PP ?
• List type of PA?
• Drug of choice for convulsion?
• Maximum dose of hydralazine?