This document discusses the evaluation and management of hypertension in pregnancy. It defines the various hypertensive disorders that can occur during pregnancy, including preeclampsia, chronic hypertension, chronic hypertension with superimposed preeclampsia, and gestational hypertension. It provides details on the signs, symptoms, diagnostic criteria, risk factors, prevention, and treatment approaches for each condition. The management of hypertension during pregnancy aims to prevent complications through careful monitoring, timely delivery when indicated, and antihypertensive treatment as needed.

1. Evaluation and
Management of
Hypertension in
Pregnancy
Dr Imran Hassan
PGY2, FCPS II Family Medicine
The Aga Khan University Hospital, Karachi

2. Objectives
• To define the various hypertensive disorders occurring in
pregnancy
• To recognize the signs associated with disease progression and
worsening severity
• To be familiar with the principles of management

3. Terminology
• ACOG guidelines on “Hypertension in Pregnancy” 2013 classify
these disorders into 4 categories
1. Preeclampsia-eclampsia
2. Chronic hypertension
3. Chronic hypertension with superimposed preeclampsia
4. Gestational hypertension

4. Preeclampsia
Clinically evident edema or
rapid weight gain may raise
suspicion for preeclampsia
but are not sensitive or
specific, neither are they
included in diagnostic
criteria.

5. Clinical features
• Severe headache
• Problems with vision, such as blurring or flashing before the
eyes
• Severe pain in RUQ or epigastrium
• Nausea, vomiting (in 2nd half of pregnancy)
• Dyspnea
• Sudden weight gain or edema of the face, hands or feet

6. • Based on the presence or absence of severe features,
preeclampsia is classified as
• Preeclampsia without severe features
• Severe preeclampsia

7. Severe features
Removed from severe features
list:
• Massive proteinuria as it
does not correlate with
disease severity
• IUGR as it is managed
similarly in patients with or
without preeclampsia

8. Initial investigations
• CBC
• LFTs
• Serum creatinine
• Urinary protein (dipstick, spot urinary protein to creatinine
ratio or 24 hour urinary protein)
• LDH

9. Pathophysiology of
preeclampsia
• Abnormal trophoblastic invasion of spiral arteries leading to
hypoperfusion of uteroplacental circulation
• Ischemic placenta produces factors that alter maternal
endothelial cell function and cause microangiopathy of target
organs
• Other factors that contribute are immunologic dysfunction,
genetic predisposition (maternal, paternal, thrombophilias),
oxidative stress

10. Prevention of preeclampsia
Decreased salt intake
Strict bedrest
Moderate exercise
Low dose aspirin started in late 1st trimester
Calcium supplementation
Antioxidants (vitamins C & E)
Vitamin D supplementation
Low calorie diet
Lying in left
lateral decubitus
position
recommended

11. Low dose aspirin (NICE
recommendations)
• Primary prevention in pregnant women at risk of preeclampsia
• Started at 12 weeks (before 16 weeks) as 75mg/day upto
delivery* in women with:
• One or more risk factor(s) constituting high risk
• Two or more risk factors constituting moderate risk
• Outcome is reduction in risk of
• preeclampsia
• preterm birth
• IUGR
* Usual practice is to stop 2 weeks before delivery (no consensus
in literature)

12. Risk factors for preeclampsia
High risk
1. Hypertensive disease
during a previous
pregnancy
2. Chronic kidney
disease
3. Autoimmune disease
such as SLE or APLA
4. Type 1 or type 2
diabetes
5. Chronic
hypertension
Moderate risk
1. Nulliparity
2. Age 40 years or older
3. Pregnancy interval of
more than 10 years
4. BMI of 35 kg/m2 or
more at first visit
5. Family history of pre-
eclampsia (mother
or sister)
6. Multiple pregnancy

13. Management of preeclampsia
• Is based on severity status therefore ongoing severity
assessment is key
• Key features are:
• Admission
• Expectant management
• Seizure prophylaxis
• Blood pressure control
• Steroids for fetal lung maturation
• Timely delivery

14. Antenatal care
• Lab workup and clinical assessment to ascertain level of
severity
• Monitoring of maternal and fetal condition
• Antihypertensive drugs if indicated
• Corticosteroids to accelerate lung maturation between 24 and
34 weeks
• Delivery timing involves balancing the risks of prematurity
against worsening preeclampsia
• Attempted vaginal delivery recommended unless otherwise
contraindicated
• No proven benefit of starting aspirin once preeclampsia
established in current pregnancy

15. Preeclampsia without severe
features
• Twice-weekly BP monitoring
• Weekly labs (CBC, creatinine, SGPT, SGOT)
• Twice weekly fetal CTG, daily kick count
• Weekly amniotic fluid indices
• Fetal growth ultrasonography every 3 weeks (umbilical artery
doppler every 2 weeks if any growth restriction suspected)
• Antihypertensive therapy controversial* (may reduce progression to
severe preeclampsia but may also cause IUGR)
• Corticosteroids if <34 weeks gestation
• Seizure prophylaxis not required until severe features present
• Delivery at 37 weeks gestation
* Usual practice is to keep BP between 120/80 and 140/90mmHg

16. Severe preeclampsia
• Hospitalization for monitoring (daily labs, 8 hourly vital signs,
fluid balance, symptoms of severe preeclampsia)
• Monitor contractions, rupture of membranes and vaginal
bleeding every 8 hours
• Fluid management (maintain UOP>30ml/hr)
• Antihypertensives with target BP between 120/80 and
160/110mmHg
• Corticosteroid administration if <34 weeks
• Seizure prevention with MgSO4
• Delivery recommended at 34 weeks

17. Antihypertensive therapy
• Objective is to prevent cardiovascular, renal and cerebrovascular
complications of uncontrolled BP
• Recommended threshold for using antihypertensives is
BP160/110mmHg
• Excessive lowering of BP can lead to uteroplacental insufficiency
and IUGR
• IV labetalol (avoided in asthmatics), hydralazine commonly used
• Oral (not sublingual) nifedipine is an alternative if IV access is not
available
• Diuretics only have a role in pulmonary edema
• Atenolol (IUGR risk), ACEIs and ARBs (teratogenic) should be
avoided

18. Corticosteroid administration
• Objective is to accelerate fetal lung maturation by inducing
surfactant production
• Greatest benefit between gestational age 24 to 34 weeks
• Betamethasone (two 12-mg intramuscular doses given 24
hours apart) OR dexamethasone (four 6-mg intramuscular
doses given 12 hours apart)

19. Seizure prevention
• MgSO4 prevents eclamptic seizures and placental abruption
• Most effective agent for this indication
• Should be used only when severe features develop.
• Magnesium toxicity: Loss of DTRs, respiratory paralysis, CNS
depression, cardiac arrest
• Check Mg levels immediately if DTRs lost, R/R<12/min,
UOP<30ml/hr (Therapeutic range of 4-8mg/dl)
• Antidote is 1g of Calcium gluconate IV over 2 minutes

20. Timing of delivery
• Gestational hypertension and preeclampsia without severe
features
• <37 weeks: expectant management
• 37 weeks: delivery
• Severe preeclampsia
• Before viability (24 weeks): delivery
• <34 weeks: expectant management only if
• stable maternal-fetal condition
• adequate maternal and neonatal ICU resources at facility
• 34 weeks: delivery

21. • Indications for immediate delivery soon after maternal
stabilization (without waiting 48 hours for completing
corticosteroids course):
• Resistant severe hypertension
• Eclampsia
• Pulmonary edema
• Placental abruption
• DIC
• Fetal demise
• Non reassuring fetal status

22. • Indications for delivery after completion of 48 hours
corticosteroid course:
• Labor
• PPROM
• Thrombocytopenia (<100)
• HELLP or partial HELLP
• Liver transaminases > 2 times upper limit of normal
• IUGR (<5th percentile)
• Severe oligohydramnios
• Reversed umbilical artery end-diastolic flow
• New or worsening renal dysfunction
if maternal-fetal condition allows

23. Intrapartum management
• Regional anesthesia is preferred over general anesthesia
• Continuous maternal-fetal monitoring to identify worsening or
progression to eclampsia (can worsen rapidly). Monitor for
premonitory signs (headache, altered mental state, blurred
vision, scotomata, clonus, RUQ pain)
• Seizure prophylaxis with MgSO4 if severe preeclampsia
present or signs of impending eclampsia
• Fluid balance (prone to pulmonary edema and 3rd spacing)
• Monitor and treat for severe hypertension (>160/110) to
prevent stroke

24. Postpartum management
• BP normalizes within 48 hours of delivery after preeclampsia but
increases again at 3-6 days
• Preeclampsia and eclampsia can develop upto 4 weeks postpartum
• The greatest risk of postpartum eclampsia is in the first 48 hours
following delivery
• For all women in postpartum period (not just those with
preeclampsia) education about signs and symptoms of
preeclampsia and importance of prompt reporting on discharge
• BP monitoring for the first 72 hours and again at 7-10 days
postpartum

25. • Avoid NSAIDs if hypertension persists beyond 24 hours
postpartum
• Antihypertensives if BP150/100 on 2 occasions 4-6 hours
apart but within 1 hour if BP160/110
• MgSO4 should be continued for 12 to 24 hours postpartum
• Administer MgSO4 for at least 24 hours if:
• New-onset hypertension with headache/blurred vision
• Preeclampsia with severe hypertension

26. Long-term effects of
preeclampsia
• Preeclampsia predisposes to long term development of
hypertension and cardiovascular disease(MI, stroke, CHF)
• The risk is greater with
• recurrent preeclampsia
• preterm delivery
• pregnancy with IUGR
• The risk for future renal disease is not clear however some
studies suggest an association
• ACOG recommends yearly assessment of blood pressure, lipid
profile, fasting blood glucose and BMI in women with a history
of preeclampsia with preterm birth or recurrent preeclampsia

27. These individuals should be advised to:
• Maintain ideal body weight
• Engage in aerobic exercise regularly
• Eat a diet high in fiber, vegetables, fruit and low in fat
• Avoid tobacco

28. Eclampsia
• Eclampsia is the presence of new onset grand mal seizures in a
woman with preeclampsia
• Can occur antepartum, intrapartum or postpartum
• May be preceded by CNS symptoms such as headaches and
visual changes
• Usually generalized 60-90 second seizures with postictal
confusion
• During the seizure, fetal bradycardia often occurs but usually
recovers

29. Management
• Protect the airway: Place patient in left lateral position and
suction mouth
• Keep intubation on standby
• Prevent injury from fall/trauma
• MgSO4 is the drug of choice for initial and recurrent eclamptic
seizures
• Prevent stroke , if severe hypertension with IV labetalol or
hydralazine
• Timely delivery
Dosage: loading dose of 4-6g
over 15 minutes followed by
maintenance dose of 2g/hr.
Continue for 12 to 24 hours
postpartum. Bolus repeated
for recurrence of seizure

30. Chronic hypertension
• BP140/90mmHg on two occasions at least 4 hours apart
before 20 weeks gestation or persisting longer than 12 weeks
after delivery
• Associated with increased risk of superimposed preeclampsia,
IUGR, GDM and placental abruption
• If newly diagnosed, secondary hypertension and target organ
damage should be ruled out
• Stop use of ACEIs/ARBs, mineralocorticoid antagonists and
statins
• Educate about signs and symptoms of preeclampsia
• Home BP monitoring
• Baseline labs (creatinine, electrolytes, uric acid, liver
transaminases, platelet count, urine protein) to use as
comparators if superimposed preeclampsia is suspected later

31. • Medication recommended for BP persistently over
160/105mmHg. Target BP between 120/80 and
160/105mmHg
• Serial ultrasounds to screen for fetal growth restriction.
Umbilical artery doppler if IUGR suspected
• Delivery not recommended before 38 weeks if no added
maternal-fetal complications

32. Gestational hypertension
• Hypertension after 20 weeks gestation without proteinuria or
other criteria for preeclampsia
• May develop preeclampsia, unrecognized chronic
hypertension (will persist beyond 12 weeks postpartum),
transient gestational hypertension
• Expectant monitoring (similar to preeclampsia without severe
features except weekly CTG and testing for proteinuria and
twice weekly BP measurement) and labor induction at 37
weeks gestation
• Antihypertensive therapy does not reduce risk of developing
preeclampsia
Uric acid shows promise as a marker of progression to preeclampsia or adverse
outcomes in patients with gestational hypertension. Recommendations are not
yet clear but it may be beneficial in the triage setting to select patients at
potentially higher risk. (PPV 91.4% for a cutoff of 5.2mg/dl)
PS: Elevated serum uric acid is not a part of diagnostic criteria for preeclampsia

33. Antihypertensive drugs in
pregnancy
• First line
• Methyldopa (not as effective for severe hypertension)
• Labetalol (contraindicated in asthma, heart disease, CHF)
• Hydralazine (higher doses associated with fetal distress)
• Nifedipine (may cause reflex tachycardia and headaches, not to
be used sublingual)
• Second line
• Thiazides (primarily used for pulmonary edema)
• Clonidine

34. Scenario 1
• A 21 year old primigravida comes for her routine antenatal
visit at 10 weeks gestation. Her blood pressure is
145/92mmHg today. She has no significant past medical
history. She denies any headache, blurry vision, abdominal
pain, nausea or vomiting but reports that her blood pressure
was 142/90 when checked yesterday at home. Urine dipstick is
negative for proteinuria. Fetal heart rate is 150/min.
• What is the likely diagnosis?
• What other signs and symptoms should be sought?
• What investigations are needed at this stage?

35. • Contraindicated
• ACE inhibitors/ARBs (teratogenic in pregnancy and
preconception)
• Spironolactone (endocrine problems)
• Direct renin inhibitors (increased fetal mortality)
• Furosemide (associated with macrosomia)

36. HELLP Syndrome
• A severe complication of preeclampsia characterized by
hemolysis, elevated liver enzymes and thrombocytopenia
• More commonly (20%) occurs in pregnancies complicated
with severe preeclampsia
• May present at term (18%), preterm (53%), or postpartum
(30%)
• 12% to 18% of women with the condition are normotensive
and 13% do not have proteinuria
• Complications are DIC, hepatic infarction or hemorrhage, renal
failure, pulmonary edema and fetal demise

37. Investigations
• CBC with peripheral smear (platelets<100x103, evidence of
hemolysis on smear eg: helmet cells, burr cells, schistocytes)
• Serum bilirubin(>1.2mg/dl)
• LDH (>600mg/dl)
• SGPT, SGOT (>2 times UNL)(helps differentiate HELLP from
HUS and TTP)
• DIC workup (fibrinogen, PT, aPTT) in women with abnormal
bleeding or platelets<50x103

38. Management
• Emergent admission to a tertiary care facility
• MgSO4 from admission to 24-48 hours postpartum
• Platelet transfusion if platelet count <20x 103 for vaginal delivery
and <50x103 for C-section or if abnormal bleeding occurs
• Corticosteroids indicated for lung maturation if required by
gestational age. Also improve platelet count however no clear
evidence of benefit in maternal-fetal outcomes
• Prompt delivery is recommended
• Before fetal viability: Delivery after maternal stabilization
• After age of viability but <34 weeks: Delivery after 48 hour
corticosteroid course if maternal-fetal condition stable. Conservative
management may be considered if maternal-fetal condition allows
(needs adequate ICU facilities)
• 34 weeks: Delivery after maternal stabilization

39. Scenario 2
• A 28 year old woman in her first pregnancy is seen in clinic at
38 weeks of gestation. She has no significant past medical
history. Her blood pressure when pregnancy was first
confirmed at 8 weeks was 120/70. Today she presents with a
mild frontal headache and increasing swelling of her ankles.
Blood pressure is 170/120, urine dip stick testing shows 3+ of
protein and there is edema of both ankles to the mid-calf.
• What is the most likely diagnosis?
• How would you approach management of this patient?

40. References
• Leeman L, Dresang LT, Fontaine P. Hypertensive Disorders of
Pregnancy. American family physician. 2016;93(2):121-7.
• Hypertension in pregnancy. Report of the American College of
Obstetricians and Gynecologists' Task Force on Hypertension in
Pregnancy. Obstetrics and gynecology. 2013;122(5):1122-31.
• Bellomo G, Venanzi S, Saronio P, Verdura C, Narducci PL. Prognostic
significance of serum uric acid in women with gestational
hypertension. Hypertension. 2011 Oct 1;58(4):704-8.
• National Collaborating Centre for Women's and Children's Health.
Hypertension in pregnancy. The management of hypertensive
disorders during pregnancy. London (UK): National Institute for
Health and Clinical Excellence (NICE); 2010 Aug. 46 p. (Clinical
guideline; no. 107).
http://www.guideline.gov/content.aspx?id=24122.

41. Thankyou!