2. INTRODUCTION
Hypertension (HTN) is the most commonly encountered disorder
during pregnancy.
It is defined as Bp of 140/90mm Hg on two separate occasions with
the patient supine or in sitting position
High blood pressure has a negative impact on the mother and the
foetus, which is why early diagnosis and proper control are mandatory
to avoid complications.
3. CLASSIFICATION OF HYPERTENSION IN
PREGNANCY
1. Pre-eclampsia & Eclampsia
2. Chronic Hypertension – HT since before 20 weeks
pregnancy
3. Chronic Hypertension with Superimposed Preeclampsia
4. Gestational Hypertension – HT after 20 weeks
4.
5. RISK FACTORS
﴿ Pre-existing medical diseases
– Diabetes, chronic hypertension, chronic kidney disease or autoimmune
disease, or the occurrence of hypertensive disease during a previous
pregnancy.
﴿ Other factors produce more modest increases in risk, such as
– Obesity, primiparity, age, a family history of hypertensive disorders of
pregnancy, or a blood pressure at the higher end of the normal range
for age.
6.
7. GESTATIONAL HYPERTENSION
Hypertension with onset >20 weeks’ gestation without any other features of
preeclampsia
Also called as pregnancy induced hypertension which gets
normalized postpartum
Of women with apparent gestational hypertension, about ⅓ develop
preeclampsia
BP > 140/90 mm Hg for the 1st time during pregnancy
No proteinuria
BP returns to normal < 12 wks postpartum
Final diagnosis made only postpartum
8. •Drug treatment- options are limited,
○ Methyldopa
○ Nifedipine
○ Hydralazine,
○ Labetalol are most commonly used
○ Corticosteroids for lung maturity
•Delivery : Timing of delivery: preeclampsia (no complication)= 37wks 0/7
9. Gestational Hypertension: Treatment
Degree of
hypertension
Mild
(140/90 to
149/99 mmHg)
Moderate
(150/100 to
159/109 mmHg)
Severe
(160/110 mmHg or higher)
Treat No
†
With oral labetalol as first-line treatment to keep: BP <150/100
Measure blood
pressure
Not more than once a
week
At least twice a week At least four times a day
Test for
proteinuria
At each visit using automated reagent-strip reading device or urinary
protein:creatinine ratio
Blood tests Only those for routine
antenatal care
Test kidney function, electrolytes, full blood count,
transaminases, bilirubin, Do not carry out further blood tests if
no proteinuria at subsequent visits
10. PREECLAMPSIA
Pre-eclampsia is gestational hypertension plus proteinuria.
BP > 140/90 mm Hg after 20 wks gestation
Proteinuria > 300 mg/24 hrs
bipedal edema.
Preeclampsia is more common in:
• Women 25-30 years old than in women > 40 years old
• Whites than in blacks
• Singletons than in multifetal pregnancies.
Woman with preexisting vascular disease
.
12. Preeclampsia – Diagnostic Criteria
Blood Pressure
1. ≥140/90 mmHg on two occasions at least 4 hours apart >20 week of gestation
in women with previously normal BP
2. ≥160/110 mmHg hypertension can be confirmed in short interval (Minutes) to
facilitate timely antihypertensive therapy
&
Proteinuria ≥300mg/24 hour urine collection or Protein/Creatinine ratio ≥0.3 mg/dl
Or in the absence of proteinuria, new onset hypertension with new onset of any of thefollowing:
Thrombocytopenia Platelet count <100,000/microlitre
Renal Insufficiency
Serum creatinine concentration >1.1mg/dl or a doubling of serum creatinine conc.
In the absence of other renal diseases
Impaired Renal Function Elevated concentration of liver transaminase to twice normal concentration
Pulmonary Edema & Cerebral or Visual Symptoms
14. HELLP SYNDROME
HELLP Syndrome is a type of preeclampsia.
HTN Patients with
HEMOLYSIS
ELEVATED LIVER ENZYMES
LOW PLATELETS
20% of women with severe preeclampsia and eclampsia develop HELP
Syndrome
SYMPTOMS:
• Nause
• Emesis
• Non specific virus like symptoms
15. Preeclampsia – Treatment
Degree of hypertension Mild
(140/90 to
149/99 mmHg)
Moderate
(150/100 to
159/109 mmHg)
Severe
(160/110 mmHg or
higher)
Treat No
†
With oral labetalol as first-line treatment to keep:
BP <150/100 mmHg
Measure blood
pressure
At least four times a
day
At least four times a
day
More than four times a
day, depending on
clinical circumstances
Test for proteinuria Do not repeat quantification of proteinuria
Blood tests Monitor using the following tests twice a week: kidney function, electrolytes,
full blood count, transaminases, bilirubin
16. Preeclampsia-Drug therapy
MAGNESIUM SULFATE
• to control convulsions
• Effective anticonvulsant
• No CNS depression
• Not given to treat hypertension
• Indications: Severe Preeclampsia
Eclampsia
Mild Preeclampsia
• ANTIHYPERTENSIVE THERAPY
GLUCOCORTICOIDS
to enhance fetal maturation in pregnancies between 24-34 wks
17. MAGNESIUM SULFATE
Dosage Schedule
CONTINUOUS IV INFUSION
• Loading Dose – 4-6 gms MgSO4 in 100 ml of IV fluid over 15 – 20 mins
• Maintenance Infusion – 2 g/hr in 100 ml IV fluid
INTERMITTENT IM INJECTIONS
• Loading Dose – 4g 20% sol MgSO4 IV at rate not > 1g/min
Or 5 g 50% MgSO4 deep IM to each buttock (+ 1 ml 2% LIDOCAINE)
• If convulsions persist after 15 min:2 g 20% IV at rate not > 1g/min
• Maintenance – 5 g 50% deep IM every 4 hrs
18. ECLAMPSIA
Eclamptic convulsions are life-threatening emergencies that require proper
treatment to decrease maternal morbidity and moratality.
Seizures that cannot be attributed to other causes in a woman with preeclampsia
(Epilepsy, Encephalitis, Meningitis, Cerebral tumor, Ruptured Cerebral
Aneurysm)
Grand mal type seizures
May be encountered up to 10 days postpartum.
Delivery is the only definitive treatment for eclampsia
Recent recommendation suggests that Magnesium sulphate may be utilized
for seizure prophylaxis in severe preeclampsia and eclampsia .
19. Pharmacological consideration for convulsions
and hypertension
Pharmacotherapy goals are to reduce morbidity, prevent complications,and correct
eclampsia.
The drug of choice to treat and prevent eclampsia is magnesium sulfate.
Secondline medications phenytoin and diazepam/lorazepam is required for cases
in which magnesium sulphate may be CI (Myasthenia gravis) or ineffective.
The most commonly used antihypertensive agents are hydralazine, labetalol, and
nifedipine.
IV magnesium sulfate is the initial drug administered to terminate seizures.
Seizures usually terminate after the loading dose of magnesium .
Loading dose 4-6g(15-20min)
Maintenance dose 1-2g per hour as a continuous IV solution should be
administered .
For recurrent seizures or when magnesium is contraindicated, one may use
lorazepam(Ativan;2-4 mgIVover2-5minutes) or
diazepam(Valium;5-10mgIVslowly) can be used to terminate the seizure.
20. Once the seizures terminate, 85% of patients note improved BP control.
Severe hypertension(>160mmHg systolic >110mmHg diastolic) must be
addressed after magnesium infusions.
Hydralazine or labetalol can be administered Iv for BP control.
The goal is to maintain systolic BP between 140 and 160mmHg and diastolic BP
between 90 and 110 mmHg.
An IV bolus of hydralazine (5-10mgover2minutes) or labetalol (initial dose
20mg) Is recommended. Alternatively, oral nifedipine capsules(10mg) may be
administered.
Other potent antihypertensive medications ,such as sodium nitroprusside or
nitroglycerin ,can be used but are rarely required.
Diuretics are used only in the setting of pulmonary edema prior to delivery.
Care must be taken not to decrease the BP too drastically ;an excessive decrease
can cause inadequate utero placental perfusion and fetal compromise.
A dose of ante natal steroids may be administered in anticipation of emergent
delivery when gestational age is less than 32 weeks.
Betamethasone (12mgIMq24h×2doses) or dexamethasone( 6mg IM q12h×
4doses) is recommended.
21. Prevention of Preeclampsia and
Eclampsia
Preventing the development of preeclampsia in high-risk patients could
theoretically decrease the risk of eclampsia and its complications later in pregnancy.
Aspirin blocks platelet aggregation and vasospasmin preeclampsia ,and it may be
effective in preventing preeclampsia.
Studies have shown that low-dose aspirin(80 mg) in women at high risk for
preeclampsia can contribute to a decreased risk of preeclampsia ,a reduction in
preterm delivery rates ,and a reduction in fetal death rates, without increasing the
risk of placental abruption.
If the patient has pre existing hypertension, she should have good control before
conception and throughout her pregnancy.
Supplementation during pregnancy with a special food(eg,bars) containingL-
arginine ,Calcium supplementation and antioxidants(Vitamin C Vitamin E) reduce
the risk of preeclampsia.
Notably,the beneficial effect was greatest when supplementation was started prior
to 24 weeks'gestation.
22. Eclampsia- Complications
Complications of eclampsia include the following :
Permanent neurologic damage from recurrent seizures or intracranial bleeding.
⁎Renal insufficiency and acute renal failure .
⁎ Fetal changes–IUGR, abruptio placentae, oligohydramnios .
⁎Hepatic damage and rarely hepatic rupture
⁎Hematologic compromise and DIC.
⁎Increased risk of recurrent preeclampsia / eclampsia with subsequent pregnancy.
⁎Maternal or fetal death: Eclampsia is associated with approximately 13% of
maternal deaths worldwide
23. CHRONIC HYPERTENSION
Chronic hypertension occurs in up to 22% of women of childbearing age
20-25% of women with chronic hypertension develop preeclampsia during
pregnancy
Preexisting Hypertension
• Systolic pressure ≥ 140 mmHg, diastolic pressure ≥90 mmHg, or both
• Presents before 20th week of pregnancy or persists longer then 12 weeks
postpartum
CAUSES
• Primary = “Essential Hypertension”
• Secondary = Result of other medical condition (e.g.: renal disease)
24. Chronic Hypertension – Complications
Preeclampsia (up to 40% Risk)
Cesarean delivery
Postpartum hemorrhage
Diagnosis
Hpn antecedent to pregnancy
Hpn detected before 20 weeks (unless there is gestational
trophoblastic disease)
Persistent Hpn long after delivery (> 12 wks postpartum)
25. Chronic Hypertension – Management
Usually do not require antihypertensive therapy because
blood pressure drops during normal pregnancy
If BP exceeds 160/100 mm Hg, drug treatment is
recommended
Patient should be closely monitored & laboratory investigations
for preeclampsia should be repeated if the patient‘s blood
pressure increases or if she develops signs or symptoms of
preeclampsia
26. CHRONIC HYPERTENSION WITH
SUPERIMPOSED PREECLAMPSIA (CHSP)
Develops in 13-40% of women with chronic hypertension
Associated with considerable maternal-fetal morbidity and
mortality
– CHSP without severe feature: only manifestation is elevation in BP to
levels <160/110mmHg & proteinuria
– CHSP with severe feature: Presence of organ dysfunction
27. CHSP: Diagnosis
Women with chronic hypertension before pregnancy but then
develop worsening of high BP and protein in urine or other
health complications during pregnancy .womens who
1. Experience a sudden exacerbation of hypertension (Need escalate the
dose of current meds)
2. Sudden increase in liver enzymes to abnormal levels
3. Reduction in platelet count <100,000/microlitre
4. Right upper quadrant pain & severe headaches
5. Pulmonary congestion or edema
6. Renal insufficiency (Creatinine level doubling or increasing ≥1.1
mg/dl)
7. Sudden increase in protein excretion
30. Antihypertensives for BP Control in Pregnancy
Atenolol Captopril Enalapril
Mechanism Beta Blocker ACE Inhibitor ACE Inhibitor
Pregnancy Avoid in first and second
trimester. Associated with
fetal growth restriction
and bradycardia, reduces
uteroplacental blood flow
No – associated with
severe fetal anomaly, fetal
nephropathy, and
intrauterine death
No – associated with severe
fetal anomaly, fetal
nephropathy, and
intrauterine death
Breast-feeding No known evidence of
harm (NICE). Second line
after labetalol
Recommended by Society
of Obstetricians and
Gynecologists of
Canada(SOGC). No
known evidence of
harm (NICE)
Not for preterm infants. No
known evidence of harm
(NICE)Particularly for
women needing
cardiac/renal protection
Postnatal Yes Yes Yes
Side-effects Risk of fetal growth
restriction and
bradycardia in
pregnancy
Cough Cough
31. Labetalol Methyldopa
Mechanism Beta blocker Alpha 2 agonist
Pregnancy Yes. Can be given intravenously
for rapid control of severe
resistant hypertension
Yes, including first trimester. Longest
post- marketing surveillance data
Breast-feeding Very small amounts in breast milk.
No known evidence of harm (NICE)
No known evidence of harm (NICE)
Postnatal Yes NICE says avoid
Side-effects Tachycardia Depression, headache, reduced variability on
CTG, hepatitis
32. Hydralazine Nifedipine
Mechanism Vasodilator Calcium channel blocker
Pregnancy Used intravenously for rapid blood
pressure control. May be associated
with neonatal thrombocytopenia. Long
history of use. Avoid rapid intravenous
bolus because of risk of hypotension
After 20 weeks. Available in short acting
forms for rapid blood pressure control
and long acting for long-term
maintenance therapy. May be used
simultaneously with magnesium sulfate.
May inhibit labor
Breast-feeding Excreted in breast milk, at levels too low
to be harmful
No known evidence of harm (NICE).
Amounts in breast milk too small to be
harmful.
Second line: Amlodipine
Postnatal Yes Yes
Side-effects Nausea, flushing Headache
33. LATEST GUIDELINE
RECOMMENDATIONS
Class of Recommendation (COR): CLASS I (Strong) Benefit >>> Risk
Class of Recommendation (COR): CLASS III (Strong) Risk > Benefit
Level of Evidence (LOE): Level C-LD)
34. FUTURE RISK & SCREENING
• All women who have had a hypertensive complication in
pregnancy should receive postnatal counseling regarding
the management of future pregnancies
•For women with
– Gestational hypertension, the risk of recurrence of hypertension in the
next pregnancy is 16%–47% and the risk of preeclampsia is 2%–7%
– Preeclampsia, the risk of recurrence is 16% if they delivered at term,
25% if they delivered before 34 weeks, and 55% if they delivered before
28 weeks
35. These women should be advised
– low-dose aspirin as prophylaxis against preeclampsia for
next pregnancy
– More frequent BP and urine dipstick monitoring in pregnancy
– In case of chronic hypertension, BP should be stabilized on medications
safe to use in first trimester, prior to attempting to conceive
– Women who have had preeclampsia and delivered before 34 weeks
should be screened for anti-phospholipid syndrome
Women with hypertensive disease in pregnancy or
puerperium have an increased risk of CVD in future
