This document provides guidance on the management of hypertensive disorders in pregnancy. It begins with collecting patient history and conducting examinations. Key examinations include measuring blood pressure and checking for signs of preeclampsia. Investigations help assess maternal and fetal wellbeing. Treatment involves controlling blood pressure, monitoring for complications, and timely delivery planning. Magnesium sulfate prevents seizures in preeclampsia and eclampsia. Postpartum care includes monitoring for recurrence of hypertension and advising on prevention in future pregnancies. The overall aim is to stabilize the mother's condition and deliver the baby safely.

1. Dr.J.Rajeevan
Hypertensive disorders in pregnancy
History
General information
 Name
 Age
 Occupation
 Address
 Gravidity and parity
 LMP and POA
 Calculate the EDD
P/C
1. Chronic hypertensive patient(can have supper added pre-eclampsia)(high risk)
2. Gestational hypertension
3. Pre-eclampsia
H/P/C
Any presenting feature assess further
 Onset
 duration,
 progression
 associated features wise
 symptoms of pre eclampsic toxemia
History of current pregnancy
Trimester
1
o Is it a planned pregnancy
o Pre-pregnancy folic acid
o Rubella vaccination
o Pre pregnancy hormonal contraception and last dose.
o Date of confirmation of preg. & how
o Booking visit ( At what POA) – in SL <8wks
o Tests done : Urine – Sugar, Albumin
Blood – Group/DT, Hb, VDRL, PPBS
BP (They are at risk of PIH)
o Complications :
 Hyperemesis gravidarum
 Bleeding PV
 Drugs taken
o Ultra sound scans done ( Dating scan 11 -13wks)
 To confirm EDD (Calculated date taken if within one week
of scan date)
 Detect congenital anomalies(Anencephaly, Spina-bifida)

2. Dr.J.Rajeevan
 Chorionicity if twin pregnancy
Trimester
2
o Regular antenatal visits, Quickening, Tetanus, Complications
o BP record
o OGTT (after 28 wks)
o Anomaly scan (18-22wks)
 Identify congenital abnormality.
 To identify placentation (Low lying placenta : <28wks 
Should undergo repeat USS at 28 weeks  If still low
lying  Placenta preavia
o FeSO4, Vit C
o Calcium lactate and Folic acid
o Detection of GDM/PIH
Trimester
3
o PV bleeding, GDM, HT, Antepartum hemorrhage, Growth
retardation
o Weight gain
o SFH measurement
o Fetal movements
o Growth scan (after 28 wks…. In case of growth problem 2weekly
repeat scans done)
Detail
diagnosis
and
treatment.
o How did diagnosed and where?
o Any hospital admission?
o What drugs she is on?
o Developed any complication?
o What about her blood pressure control?
o Where did she monitor BP?
o Whether regular clinic follow up?
Symptoms and sign of pre eclampsia
complication features
Maternal
CNS
eclampsia
Cerebral hemorrhage/edema
Cortical blindness
Fits, persistent headache, visual
blurring, visual halos, scotomas
Renal Renal cortical necrosis
Renal tubular necrosis
Reduced UOP
Respiratory Pulmonary oedema Chest pain, cough, hemoptysis
Liver Periportal necrosis
Subcapsular haematoma
HELLP syndrome
RHC pain, jaundice,

3. Dr.J.Rajeevan
Coagulation
system
DIC
Microangiopathic haemolysis
Bleeding
placenta Abruptio placentae
Retroplacental bleeding
Abdominal pain,Vaginal bleeding
fetal
complications
IUGR
Fetal hypoxaemia
IUD
SFH measurement in clinics and
Hx, Fetal movements
Risk factors
Maternal Fetal/placental factors
Primigravidity
Age < 20; >35
H/O pre eclampsia
Obesity
Medical disorders
 Chronic renal disease
 Chronic hypertension
 G.D.M.
 Antiphospholipid syndrome
F/H of pre eclampsia
multiple pregnancy-large pregnancy
Multiple pregnancy
H.mole
triploidy
Past Obstetric History –
 Detail history of previous pregnancy- MOD, TOD, any fetal and maternal complication,
hypertensive disorders in past pregnancies
Menstrual and gyn History
Past Medical History
 chronic HT
 DM
 Chronic renal disease
 Connective tissue disorder
Past surgical history
Family history
o pre eclampsia
o HT
o DM
Social history
 Family support
 Economic support

4. Dr.J.Rajeevan
 Distance from hospital
 Transport facility
Examination
General
 Wt/ht-BMI
 Jaundice(fulminant hepatic failure)
 Pale
 Facial edema
 Patichiae,bruising, bleeding gum
 Fluid retension(non dependant)-face and finger tips
 Oral cavity examination
 Ankle edema
CVS
 PR
 BP-
 Position- left lateral or seated(avoid aortic, caval compression)
 Appropriate size cup
 Patient should be resting
 Muffling sound should be taken as diastolic
 More important value is DBP-more related to maternal and fetal morbidities and
mortality
 Systolic is related to cerebral perfusion
RS
 Lung bases for crepts.
CNS
 GCS
 vision
 Knee jerk
 Clonus >1
 Fundi-papilloedema,haemorrage
Abdomen
 inspection
 abdomen is distended with evidence of pregnancy like Linea nigra, striae, flat
umbilicus
 surgical scar - pfanensteil / supra pubic transeverse incision, laparoscopic scar
 visible FM
 SFH – from variable point to fixed point , compatible with dates [ +/- 3] cm after 36 week ,
before 36 week +/- 2 cm

5. Dr.J.Rajeevan
 Palpation - start from lower pole
 Lie
 Presentation
 Engagement
 Position
 Back on which side(Smooth curved mass on left - Back is in the left side, Soft boggy
mass on right – limbs are on the right side
 EFW
 LQ amount( less/ average/high)
 FHR
Investigations
Investigations-maternal
1. liver enzymes(SGOT/SGPT)
2. FBC(Hb/PLT)
3. S.creatinine, SE/BU
4. UFR
5. PT/INR
6. Urine ward test
HELLP/periportal necrosis
Renal function
If oliguric
Protenuria(differentiate from a UTI)
If plt are low
Investigations-fetal (affects growth and wellbeing)
USS
 Growth-HC/AC
 Wellbeing-
 AFI, fetal movements, fetal tone
 Doppler studies(umbilical artery/middle cerebral artery)
CTG-
Assessment of protein-urea
Methods available to assess protein-urea
1. Heat coagulation test
2. Sulphur-salysilic acid( SSA) test
3. Urine dipstick test/ automated reagent strip
4. Urine protein:creatinine ratio in a spot sample
5. 24 hour urinary collection
Heat coagulation test
Steps of the standardized heat coagulation test
 Apply 5 mL of the urine sample into a test tube.
 Add a few drops of dilute acetic acid to the tube to make the sample acidic.
 Heat the urine column in the tube over a burner without boiling over.

6. Dr.J.Rajeevan
 Compare the tube against the diagrammatic result interpretation chart and record the
result.
Management
Principles of management
 Maternal assessment- BP, Proteinurea, heamatological assessment, RFT,LFT
 Blood pressure control- antihypertensives
 Early detection of complications severe pre-eclampsia, abruption, HELLP, Eclampsia
 Fetal surveillance IUGR
 Timely delivery/ intrapartum care
 Post-partum monitoring and follow up to detect chronic hypertension
Treatment of hypertension
Mild HT DBP- 90-99 Hgmm
SBP- 140-19 Hgmm
No treatment
Moderate HT DBP-100-109 Hgmm
SBP-150-159 Hgmm
Oral drugs
Severe HT DBP-≥110 Hgmm
SBB-≥ 160 Hgmm
IV drugs
General measures
1. Diet
2. Exercise
3. Relaxation
Oral drugs
 Nifedipine(SR)-
 20 mg bd (max- 80mg/120mg daily)
 Safe during pregnancy, quick action, only bd dose
 SE- palpitation and headache
 Methyl dopa-
 loading dose 500-750 mg
 Continue with 250/8h(3g/day)
 Take 3 days to act
 Change every third day
 Psychosis risk
 Oral labitalol-100mg/bd(max 800mg daily)
Contraindication in BA
IV drugs
 IV hydralzine-
 Bolus- 5mg(can rpt every 15-20 mins upto 4 doses)

7. Dr.J.Rajeevan
 Infusion(if not settled)-20 mg in 100ml of N/S or RL(not Dextrose)- 1-
5mg/hr
 Action-vasodilator(cause reflex tachycardia so stop if HR > 140)
 IV labitalol-(alpha and beta effects)
 if not controlled with above or HR > 140
 Bolus-20mg slowly(rpt in every 10-20 mis upto 200mg)
 Infusion-200mg in 100ml of N/S- 20mg/hr can go upto 160mg/hr
Follow up and monitoring
 Every 2 week review with BP chart
 Monitor fetal wellbeing- SFH from 24 week, EFW and umbilical artery Doppler from 28
week- every 2 weeks.
 According to BP adjust dose.
Delivery plan
1. Place – hospital where VOG, Anesthetics, neonatologist
2. TIME- from 37-38 weeks
3. Mode- HT per say not an indication for LSCS. Consider all clinical picture.
Pre- eclampsia.
 Complication of hypertension
 Can progress to eclampsia
 Aim- BP control, prevention of fits, delivery of baby.
 If pregnancy is pre-term, if delivery can postponed to 24 hours consider dexamethasone.
Eclampsia
 Eclampsia may be defined as a tonic–clonic seizure occurring in association with features
of pre-eclampsia.
 Convulsions may occur antepartum -45%, intrapartum (18%–19%) or postpartum (36%).
 Teenagers are three times more likely to suffer eclampsia than older women.
 Eclamptic fits are self limiting and short lasting. If prolonged fit occurs need CT to rule
out other pathologies
Complications of eclampsia
 Respiratory arrest during a fit
 Eclampsia may be associated with ischaemic or haemorrhagic stroke, with cerebral
oedema.
 Cortical blindness (usually reversible).
 Visual impairment may also result from retinal detachment

8. Dr.J.Rajeevan
Emergency management
1. Call for assistance— senior obstetrician and anaesthetist.
2. Protect the patient— avoid maternal trauma by placing the patient in a safe environment.
4. left lateral position
3. ABC— assess Airway, Breathing, and Circulation. (Measurement of BP and testing for
proteinuria should confirm eclampsia) no BP measurement during fit
4. Respiratory support— high flow 15L/min give oxygen.
5. IV access.
6. Bloods— draw blood for FBC, U&Es, liver function, glucose, clotting,
7. Assess fetal heart rate- bradycardia can occur during seizure which resolve spontaneously.
If it is lasting>10 min suspect abruption
8. Loading dose magnesium sulfate 4 g/ 40 mL IV (over 10 minutes).
• Maintenance dose magnesium sulfate 1 g/ 10 mL/ hr maintained for 24 hours.
• Recurrent seizures should be treated with further boluses of magnesium sulfate 2– 4g IV given
over 5 minutes.
• Or increase maintenance to 1.5– 2 g/ hr
9. Drugs such as diazepam, phenytoin, or lytic cocktail should not be used as an alternative to
magnesium sulfate in women with eclampsia.
10. However, if magnesium is contraindicated, diazepam 10 mg IV bolus should be given.
Delivery
 Eclampsia dictates delivery (or induction) once the maternal condition is stabilized,
irrespective of the foetal condition or maturity. A decision regarding the mode and time
of delivery will require to be made early.
 Eclampsia is not an indication for caesarean section.
 Consider caesarean section in women who are not in labour with a Bishop score below 7
Prevention and treatment of preeclampsia
Indications for MgSO4
1. Severe PIH or severe pre eclamosia has or previously had eclamptic fit
2. Eclampsia
3. Birth planned within 24 h with severe pre eclampsia
Method of administration
 Loading dose-4g diluted in 200ml N/S over 10-15 mins - IV
 Maintenance-1g/hr as an infusion for 24 hrs
 Continue 24 hrs following last fit or 24 hrs postpartum whichever is longer
Monitor for toxicity
 Patellar reflex
 Respiratory rate > 14
 UOP > 0.5ml/kg/hr

9. Dr.J.Rajeevan
 Saturation
 Heart rate
Management of toxicity
 Stop the drug (reduce or stop)
 Hydration with fluids(furosemide should be avoided-slow excretion)
 Calcium gluconate(if severe bradycardia or cardiac arrest)- 10% calcium gluconate over
10 mins
Early delivery of the baby
 Multidisciplinary approach(obstetrician, anesthetist, pediatrician)
 Hysterotomy , NVD, LSCS can be performed
 Once had a fit baby should be delivered ASAP
 If patient favorouble- NVD
 If not- LSCS
Close monitoring of fluid balance is neede if pre eclampsia is present
Avoid ergometrine during third stage-exacerbate the HT
Irrespective of fetal condition indications for delivery
 HELLP syndrome(within 24h)
 Eclampsia, severe preeclampsia
 Liver necrosis
 Severe water lodgining /oedeme(facial/hands)
 Albuminuria (increasing)
At least monitor postpartum for 48h
But can get a fit even after 2-3 wks after the delivary
Usually resolves after delivery can recure in subsequent pregnancies
Postpartum care
 Continue BP monitoring
 Monitor for signs of pre eclampsia mainly during first 48h
 Discharge after 3rd day if no complications and BP stable
 Continue antenatal anti HT treatment
 In PIH
 Start antihypertensive treatment ≥150/100
 If <130/80-can stop the drugs
 If , 140/90 – consider reducing treatment
 Chronic HT
 Aim to keep <140/90
 If anti-hypertensive to be continued offer medical review after 2 wks
 Offer medical review for all at 6-8 wk postnatal visit
 If anti HT treatment is to be continued after 12 week postnatal review offer specialist
assessment
 Advice to achieve and keep BMI 18.8-24.9 before next pregnancy

10. Dr.J.Rajeevan
 Use anti HT which are safe during breast feeding
 Labetalol
 Nifedipine
 Enalapril
 Captropil
 Atenalol
 metoprolol
(ARB ,amlodipine ACEI(other than enalapril and captopril) not have sufficient evidence to
comment on safty)
Prevention of pre-eclapsia
1. calcium supplementation
2. fish oil supplementation
3. Antiplatelet agents
 Advise women at high risk of pre-eclampsia to take 75 mg of aspirin daily from 12
weeks until the birth of the baby.
Women at high risk are those with any of the following:
 hypertensive disease during a previous pregnancy
 chronic kidney disease
 autoimmune disease such as systemic lupus erythematosis or antiphospholipid
syndrome
 type 1 or type 2 diabetes
 chronic hypertension.
 Advise women with 2 or more moderate risk factor for pre-eclampsia to take 75 mg of
aspirin* daily from 12 weeks until the birth of the baby.
Factors indicating moderate risk are:
 first pregnancy
 age 40 years or older
 pregnancy interval of more than 10 years
 body mass index (BMI) of 35 kg/m2 or more at first visit
 family history of pre-eclampsia
 Multiple pregnancy.
Classification
 Chronic hypertension
 Pregnancy induced hypertension (PIH)
Chronic hypertension
 The presence of hypertension before 20 weeks’ gestation (in the absence of a hydatiform
mole)
OR

11. Dr.J.Rajeevan
 Persistent hypertension beyond 6 weeks postpartum
Aetiology can be essential/primary hypertension or secondary hypertension
Pregnancy induced hypertension (PIH)
 Hypertension caused by, but unrelated to, other pathology associated with the pregnancy
which occurs after 2nd
half of the pregnancy.
Two entities
 Non-proteinuric PIH
 Pre-eclampsia PIH+ Proteiurea
NICE (2010) definitions
1. Chronic hypertension is hypertension that is present at the booking visit or before 20
weeks or if the woman is already taking antihypertensive medication when referred to
maternity services. It can be primary or secondary in aetiology.
2. Gestational hypertension is new hypertension presenting after 20 weeks without
significant proteinuria.

12. Dr.J.Rajeevan
3. Pre-eclampsia is new hypertension presenting after 20 weeks with significant
proteinuria.
4. Signifificant proteinuria is defined as the urinary protein:creatinine ratio is greater than
30 mg/mmol or a validated 24-hour urine collection result shows greater than 300 mg
protein.
5. Eclampsia -is a convulsive condition associated with pre-eclampsia.
6. HELLP syndrome is haemolysis, elevated liver enzymes and low platelet count.
7. Severe pre-eclampsia is pre-eclampsia with severe hypertension and/or with symptoms,
and/or biochemical and/or haematological impairment.
8. Mild hypertension diastolic blood pressure 90–99mmHg, systolic blood pressure 140–
149 mmHg.
9. Moderate hypertension diastolic blood pressure 100–109mmHg, systolic blood pressure
150–159 mmHg.
10. Severe hypertension diastolic blood pressure 110mmHg or greater, systolic blood
pressure 160 mmHg or greater.
Pathophysiology
Risk Factors
 Primigravida
 Family history -in a first-degree relative increases the risk of pre-eclampsia 4- to 8-fold.
 Women with a history of pre-eclampsia, particularly those requiring delivery before 37
weeks, all have about a 20 % of developing pre-eclampsia again

13. Dr.J.Rajeevan
 Booking visit diastolic BP> 80mm Hg
 New partner
 Pregnant by a partner who had previously fathered an affected pregnancy
 Teenage mothers and age>40 years
 pregnancy interval of more than 10 years
 Pregnancies conceived by donor insemination
 Chronic hypertension – increase the risk of pre-eclampsia -to over 20%
 All forms of glucose intolerance, including GDM
 Obesity ( BMI>35) is an independ¬ent risk factor
 Pre-existing kidney disease.
 Women with antiphospholipid syndrome/ SLE
 Multiple pregnancies
 Molar pregnancies have been associated with pre-eclampsia
COMMON COMPLICATIONS ASSOCIATED WITH HYPERTENSIVE DISORDERS
OF PREGNANCY
Maternal
 Increased risk of:
 Hemorrhagic stroke
 pulmonary edema
 Acute renal failure or accelerated end-organ damage
 Gestational diabetes
 Heart failure/cardiopulmonary decompensation
 Hypertensive encephalopathy
 Retinopathy
 Cesarean delivery
 Postpartum hemorrhage
 maternal mortality-
Fetal
 Increased risk of:
• Abruptio placenta
• FGR
• Preterm delivery
Intrauterine fetal demise
• Perinatal mortality
• Potential teratogen exposure from hypertensive medications