Hypertensive disorders of pregnancy

1. DEPARTMENT OF OBSTETRICS AND
GYNAECOLOCY, FTH KATSINA
TOPIC: PRINCIPLES OF MANAGEMENT OF
HYPERTENSIVE DISORDERS OF PREGNANCY
PRESENTER: DR. KABIR IBRAHIM JAEN (HO)
MODERATOR: DR. MIYASSARATU I. LADAN (S.Reg)
DATE: 08th June, 2023
1

2. OUTLINE
• Introduction/Epidemiology
• Classification of HDP
• Risk factors
• Clinical presentation
• Management
• Complications
• Prevention
• Conclusion
2

3. INTRODUCTION
• Hypertension is one of the common medical
complications of pregnancy and contributes
significantly to maternal and perinatal morbidity
and mortality.
• Affects about 8-10% of pregnancies
3

4. • PE/Eclampsia are the most important
hypertensive disorders in pregnancy in terms
of incidence, morbidity and mortality.
• The incidence of Eclampsia is higher in
developing countries,
• It varies btw 10 to 50 /1000 deliveries (1-5%)
4

5. • It is one of the leading causes of MM
worldwide
• 97% of these are in developing countries,
particularly in sub-Saharan Africa
• In Northern Nigeria, Eclampsia account >40%
of MM.
5

6. Definition of HBP
• BP measurements (≥140/90 mmHg), made at
least 4-6 hours apart while the patient is at
rest.
• Single diastolic BP ≥ 110 mmHg on any one
occasion
• Rise in systolic BP by 30mmHg and diastolic
BP by 15mmHg above pre-pregnancy values
• Rise in MAP by 20mmHg or MAP of 105mmHg
6

7. Classification of HDP
NHBPEP
• Chronic hypertension
• Preeclampsia
• Eclampsia
• Superimposed preeclampsia-eclampsia
• Gestational hypertension
• Transient hypertension of pregnancy
7

8. Classification of HDP
ISSHP 2018
• Hypertension known before pregnancy or
present in the first 20weeks
– Chronic Hypertension
• Essential
• Secondary
– White coat hypertension
– Masked Hypertension
• Hypertension arising de novo at or after
20weeks
– Transient gestational hypertension
– Gestational hypertension
– Preeclampsia de novo or superimposed on chronic
hypertension
8

9. • Chronic hypertension is BP (≥140/90 mm Hg),
predating pregnancy or diagnosed before 20
weeks of pregnancy and persist beyond 12
weeks postpartum.
• White-coat hypertension refers to office/clinic
BP (≥140/90 mm Hg), but normal BP
measured at home or work.
• Masked hypertension is BP that is normal at a
clinic or office visit but elevated at other
times.
9

10. • Transient gestational hypertension is de novo
hypertension that develops at any gestation
that resolves without treatment during the
pregnancy.
• Gestational hypertension is BP (≥140/90mm
Hg), arising de novo after 20 weeks’ gestation
in the absence of proteinuria and without
biochemical or hematological abnormalities.
10

11. PRE-ECLAMPSIA
• Pre-eclampsia = BP of ≥140 mmHg systolic
and/or ≥90 mmHg diastolic on at least two
occasions measured 4 hours apart in previously
normotensive women
• Accompanied by ≥1 of the following new-onset
conditions at or after 20 weeks of gestation:
– Proteinuria: 24-hour urine protein ≥300 mg/day;
spot urine P/Cr ≥30 mg/mmol or ≥0.3 mg/mg, or
urine dipstick testing ≥2+
– Other maternal organ dysfunction
11

12. Other maternal organ dysfunction
• Acute kidney injury (creatinine ≥90 µmol/L; >1.1 mg/dL)
• Liver involvement (such as elevated liver transaminases >40
IU/L) with or without right upper quadrant or epigastric pain
• Neurological complications (including eclampsia, etc)
• Haematological complications (thrombocytopenia–platelet
count <150000/µL, DIC, haemolysis)
• Uteroplacental dysfunction (such as FGR, abnormal umbilical
artery Doppler wave form or stillbirth).
12

13. ECLAMPSIA
• Eclampsia is new-onset grand mal
seizures appearing before, during labour
or within 48 hours from delivery and/or
coma unrelated to other cerebral
conditions in a pregnant woman with
symptoms and signs of PE
13

14. • Complicates PE but can occur without prior PE
• It may occur suddenly and can occur in the
presence of only proteinuria
• Preeclampsia superimposed on chronic
hypertension is when a pregnant woman with
chronic hypertension develops proteinuria or
any of the maternal organ dysfunction
consistent with preeclampsia.
14

15. Risk factors
High
• Previous hx of PE
• Chronic HTN
• Diabetes mellitus
• Renal disease
• SLE
• APS
Moderate
• Nulliparity
• Obesity BMI>30kg/m2
• Family hx of PE
• Black race,
• Age >35 yrs
• >10yrs pregnancy interval
15

16. Clinical presentation
• Hypertension
• Proteinuria
• Severe headaches
• Blurred or loss of vision, scotomata
• Shortness of breath, cyanosis
• Epigastric or right upper abdominal pain
• Nausea or vomiting
• Reduced urine output
• Convulsion, coma, stroke
16

17. Classification of PE
Feature Mild Severe
Systolic BP 140-159 160 and above
Diastolic BP 90-109 110 and above
Proteinuria 1+, 2+ 2+, 3+
Symptoms Nil May be present: Headache,
blurring of vision, epigastric
pain
17

18. Investigations
• Urinalysis,
• FBC,
• E/U/Cr,
• Uric acid level,
• LFTs,
• Bedside clotting time
• Clotting profile
18

19. Management
• Regardless of the hypertensive disorder of
pregnancy, BP requires urgent treatment in a
monitored setting when ≥160/110 mmHg
• BPs consistently at or >140/90 mmHg be
treated aiming for a target diastolic BP of 85
mmHg (and systolic BP at least <160 mmHg)
19

20. Management of CHT
• Preconception care
• Review and change of medications
• Prophylactic strategies
• Assessment of comorbidities
• BP control
• Regular ANC visits
• Delivery of fetus
20

21. Management of GH
• Control BP to target level
• Monitor for development of preeclampsia.
• Monitoring of fetal growth
• Delivery can be delayed until 39+6 weeks
provided BP can be controlled, fetal
monitoring is reassuring, and preeclampsia
has not developed.
21

22. Management of PE
• Control of hypertension
• Prevention of convulsions
• Delivery of the foetus
22

23. Control of hypertension
• Aim is to achieve or maintain the target BP
Drugs use
• IV Labetalol
• IV Hydralazine
• Nifedipine
• Alpha methyl dopa
23

24. Prevention of convulsions
• Magnesium sulphate is the best drug
• In severe PE, 14g loading dose of MgSO4, 4g
IV followed by 10g IM.
• Followed by 5g IM 4 hourly for at least 24hrs
after delivery
24

25. Delivery of the fetus
• Delivery should be effected depending on
gestational age, maternal and fetal status, as
follows:
• Women with onset of preeclampsia at ≥37 weeks’
gestation should be delivered.
• Those between 34 and 37 weeks’ gestation should
be managed with an expectant conservative
approach, as below.
25

26. • Those at <34 weeks’ gestation should be
managed with a conservative (expectant)
approach.
• Those <28 weeks gestation should be
counseled that termination of pregnancy may
be required.
26

27. Conservative management
• Bed rest
• Fetomaternal monitoring: maternal BP
monitoring, FKC, CTG, twice weekly
biophysical profile.
• Regular investigations: daily urinalysis, twice
weekly U&E, creatinine, uric acid and LFT
27

28. Indications for delivery
• 37 weeks + 0 days
• Inability to control maternal BP despite using ≥3
classes of antihypertensives in appropriate doses
• Maternal pulse oximetry <90%
• Progressive deterioration in liver function,
creatinine, hemolysis, or platelet count
• Pulmonary oedema;
• Abnormal neurological features such as severe
intractable headache, repeated visual scotomata, or
convulsions;
• Placental abruption
• Non-reassuring fetal status.
28

29. 29

30. Management of Eclampsia
• Resuscitation
• Control and prevention of eclamptic fits
• Control of blood pressure
• Fluid and Electroloyte management
• Delivery of the fetus
• Nursing care
• Post-delivery care
30

31. Resuscitation
• Position patient in left lateral position
• Abort convulsions with loading dose of
magnesium sulphate
• Clear and maintain airway
• Oxygen by face mask
• NG tube and indwelling Foley’s catheter
• IVF and take blood sample
• History and measure BP
• If DBP is equal to or more than 110mmHg,
give Hydrallazine
• If in a primary health facility, refer 31

32. Control and prevention of fits
• MGSO4 the best agent.
• Two main regimens available:
• Pritchard and Zuspan regimen
32

33. Control of BP
• Boluses of IV Labetalol or Hydralazine
Aim is to reduce and maintain the DBP
<110mmHg
33

34. After stabilization:
• General physical examination
• Vital signs: pulse rate, blood pressure,
respiratory rate, temperature and urine
output
• Examine the cardiovascular, respiratory,
central nervous system and the abdomen
• Do a pelvic examination to determine if the
patient is in labour
34

35. Fluid and electrolyte balance
• Eclamptics have contracted blood volume
• 1ml/kg or 80mls per hour
• Best recommended IVF is Ringers Lactate (1L
every 12 hours)
• Correction of electrolytes derangement
35

36. Delivery of the fetus
• Vaginal delivery is the route of choice
• Labour could be augmented
• Shortening of the second stage
• AMTSL
• However, if the delivery is not feasible within
6-9 hours, C/S is recommended
36

37. Nursing care
• Intensive care unit.
• Nurse in a cool quiet environment
• For patients in coma, manage as unconscious
patient
37

38. Post delivery care
• Nursing care, IVF, MgSO4 and
antihypertensive drugs
• Discharge after full recovery of consciousness
and stabilization of the blood pressure.
38

39. Follow up
• One or two weeks after discharge.
• Measure vital signs.
• Continue oral antihypertensive drugs if blood
pressure still remains high.
• Education on the cause and prevention in
subsequent pregnancy.
39

40. • Emphasize importance of ANC and risk of
recurrence of the condition.
• Contraception should be offered.
• At the six-week post natal visit, the patient
should be referred to the physician if the
blood pressure remains high.
40

41. 41

42. Complications
Maternal:
• Eclampsia, Amaurosis, Cerebral hemorrhage,
Psychosis
• Cardiac failure, Cardiomyopathy
• Pulmonary oedema, ARDs, Aspiration
pneumonitis
• AKI, CKI
• Abruptio placentae, HELLP, DIC, PPH, Shock,
VTE, Sepsis,
42

43. Complications
• Hepatic necrosis, subcapsular hematoma
• Tongue bite, bed sores, injuries due to fall
Fetal:
• Prematurity, Oligohydramnios, IUGR, Perinatal
asphyxia, IUFD
43

44. Prevention
• CLASP Trial: low dose Aspirin
• Calcium supplement
• LMWH
• Vitamin C or E
• Magnesium
• Statins
• Folate
• Metformin
44

45. Conclusion
• Hypertensive disorders are associated with
high morbidity and mortality
• Close monitoring, early detection and
appropriate management are essential to
ensure the best outcomes
• Antenatal care is key to its initial discovery
45

46. References
• Edmonds K. (2018). Dewhurst ’ s Textbook of Obstetrics & Gynaecology.
John Wiley & Sons Ltd. Pg.73-84
• Brown MA, Magee LA, Kenny LC, Karumanchi SA, McCarthy FP, Saito S, et al.
Hypertensive disorders of pregnancy: ISSHP classification, diagnosis, and
management recommendations for international practice. Hypertension.
2018;72(1):24–43.
• Agboola, A. (2005). Textbook of Obstetrics and Gynaecology for Medical
Students. Heinemann educational books Nigeria PLC. Pg.346-369
• Dutta DC. (2015). Textbook of obstetrics. Jaypee Brothers Medical Publishers
(P) Ltd. Pg.255-281
46

47. Thanks for listening
47