Hypertensive emergencies are common in pregnancy. Severe hypertension, Preeclampsia, eclampsia, HELLP syndrome are some of these. Management includes control of blood pressure, monitoring, prevension of fits, safe delivery and postpartum care. Future prevention of preeclampsia is possible with Aspirin and calcium supplementation. Only practical way of early detection is currently with the use of uterine artery doppler measurements

1. Hypertensive Emergencies in
Pregnancy
Pre-congress sessions
Perinatal Society of Sri Lanka
Dr. Indunil Piyadigama

2. Hypertension in pregnancy
Systolic blood pressure >=140
Diastolic blood pressure >= 90
Should be confirmed by repeated readings over 4-6hrs apart

3. Measurement of blood pressure
Rested and seated at 45 degrees
23X12cm cuff
If mid arm circumference more than 33cm go for a large cuff
Systolic at Korotkoff 1, Diastolic at Korotkoff 5

4. What are the hypertensive emergencies
Severe hypertension
Preeclampsia
HELLP syndrome
Eclampsia

5. Severe
hypertension
• SBP >= 160
• DBP >= 110
• This represents the level above
which cerebral autoregulation is
overcome

6. Preeclampsia
• Pregnancy specific syndrome characterized
by variable degree of placental dysfunction
and a maternal response featuring systemic
inflammation.
• Hallmarks – hypertension and proteinuria

7. Diagnosis of proteinurea
24 hr urinary protein
> 300mg/24hrs
 Gold standard for proteinuria
95% CI – 260mg/24 hrs
UPCR
> 30mg/mmol
 Good for diagnosis
But not accurate in quantifying
Should not be used to track progression
Dipstick
≥1+ at least 2 random samples 4 hours apart
+1 – 0.3g/l
+2 – 1g/l
+3 – 3g/l
 High false positives and negatives
Automated can improve this (similar to UPCR)
Should only be used as the sole test in resource poor settings only.

8. HELLP
• Haemolysis elevated liver enzymes and low platelets
(HELLP) syndrome
Sign and symptom Percentage with the clinical feature
Malaise 90
Right upper quadrant tenderness 90
Proteinuria 87
Hypertension 85
Right upper quadrant/ epigastric pain 65
Headache 60
Nausea and vomiting 36

9. Eclampsia
• One or more generalized
convulsions or coma in the setting
of pre-eclampsia and in the
absence of other neurological
conditions.

10. Management
principles in
severe
preeclampsia
• Control blood pressure
• Prevention of convulsions
• Fluid management
• Monitoring
• Delivery
• Postpartum care
• Mother
• Newborn
• Prevention in future pregnancy
• Early detection

11. Blood pressure control
Methyldopa Nifedipine
Labetolol Hydralazine

12. Acute control of blood pressure
IV hydralazine
• Preload
• 5mg boluses
Labetalol
• Oral – 200mg followed by second dose after 30 minutes
• IV
• Bolus 50mg IV over 5 minutes. Can be repeated at every
10 minutes to a maximum of 200mg
• Then labetalol infusion of 20mg/hr. This can be doubled
every 30 minutes up to a maximum of 160mg/hr

13. Prevention of convulsions
• MgSO4
• 4g in 12ml of saline over 15 minutes
• 1g per hour infusion for 24 hours
• Monitor respiratory rate, neurology and UOP
hourly
• 10ml, 10% calcium gluconate slow IV in toxicity
• Intubation and ventilation – Recurrent seizures,
seizure lasting for more than 30 minutes

14. Fluid managment
• Plasma volume expansion can lead to
pulmonary or cerebral oedema
• Monitor daily fluid balance
• In severe preeclampsia
• Catheterize and hourly measurements
• Input - 1ml/kg/hour
• Twice daily kidney functions
• If oliguria not responding to fluid boluses
– invasive monitoring and guided fluid
therapy

15. Monitoring
• In severe hypertension
• Connect to monitor
• BP every 15 minutes
• In preeclampsia
• BP should be measured at least 4 times a day
• Blood investigations two to three times a week

16. Delivery
• Delivery after 37 weeks if BP < 160/110
with or without treatment
• If refractory severe hypertension (BP >
160/110) deliver with steroid cover
immediately
• Severe preeclampsia after 34 weeks –
delivery
• Severe preeclampsia between 24-34 –
expectant management

17. Postpartum care
• Disease can worsen in the 1st 48 hrs after delivery
• Therefore, initially monitoring about 4 times a day
• 3-5th day daily monitoring
• Risk of pulmonary oedema, ARF, HELLP, eclampsia, stroke
• Check biochemistry 2-3 days after birth
• <32 weeks onset of preeclampsia – APLS screening
• Review in 2 weeks
• Medical review at 6 weeks if still on antihypertensives. (Specialist
review for hypertension)

18. Prevention of preeclampsia
• Lengthier sexual relationship
• Weight control
• Folate and vit B12 supplementation
• Aggressive control of DM and HT several months before
conception
• DM – complete childbearing before vascular complications
develops
• If risk factors
• Aspirin from 12 weeks - 10% reduction in preeclampsia
and
• Calcium supplementation 1.5g-2g/ day from 20 weeks
– 52% reduction

19. Early detection
Only method in clinical practice is
uterine doppler measurements

20. Thank you