This is to share a ppt for gestational hypertensive disorders

1. HYPERTENSIVE DISODERS
OF PREGNANCY
By Dr. Antoine
Under Supervision of
Dr. Philbert consultant obstetrician and Gynaecologist

2. INTRODUCTION
• The four major hypertensive disorders that occur in pregnant
women are :
• Preeclampsia (and related disorders: eclampsia and HELLP
[hemolysis, elevated liver enzymes, low platelets] syndrome)
• Gestational hypertension
• Chronic hypertension
• Preeclampsia superimposed on chronic hypertension

3. EPIDEMIOLOGY
• Chronic hypertension leads to superimposed preeclampsia in one-third
of patients.
• Preeclampsia occurs in 5% to 6% of all live births and can develop
anytime after the 20th week.
• It causes 50000 to 60000 death per year worldwide
• It is most commonly seen in the third trimester near term.
• HELLP syndrome is more likely to be less than 36 weeks’ gestation at
the time of presentation.
• Although 80% of patients develop HELLP syndrome after being diagnosed
with preeclampsia (30% with preeclampsia without severe features and 50%
with preeclampsia with severe features).

4. EPIDEMIOLOGY
• 20% with HELLP syndrome have no previous HX of HTN before their diagnosis
and will present merely with the symptom of right upper quadrant (RUQ) pain.
• Thus, any patient who presents with RUQ pain, epigastric pain, or nausea and
vomiting in the third trimester should be seen immediately to rule out HELLP
syndrome.
• Despite careful management, HELLP syndrome results in a high rate of stillbirth
(10% to 15%) and neonatal death (20% to 25%).
• Eclampsia occurs in 2% to 3% of women with severe features of preeclampsia but
can also occur in women with preeclampsia without severe features. The overall
incidence of eclampsia is roughly 2 to 10 per 10,000.

5. RISK FACTORS
• Nulliparity
• Multiple gestation
• Diabetes
• Previous history
• Family history
• Chronic Hypertension
• Vascular Disease
• Connective Tissue
Disease
• Renal Disease
• Antiphospholipid
Antibody Syndrome
• Advanced Maternal Age

6. ETIOLOGY
•Remains unclear, but probably endovascular
disorder
•Manifests early in pregnancy, but symptoms
produced much later

7. PATHOGENESIS
• The pathogenesis of preeclampsia likely involves both maternal and
fetal/placental factors.
• Abnormal development of the placental vasculature early in pregnancy is a
key event that results in relative placental under
perfusion/hypoxia/ischemia, leading to release of antiangiogenic factors into
the maternal circulation.
• These factors alter maternal systemic endothelial function and cause the
clinical manifestations of the disease (hypertension and hematologic,
neurologic, cardiac, pulmonary, renal, and hepatic dysfunction).

9. DIAGNOSIS
• Gestational Hypertension
• Elevated systolic BP of above 140 and/or diastolic BP above 90
mm Hg on two occasions at least 4 to 6 hours apart.
• BP should be evaluated while the patient is in a seated position
because when patients lie in the supine position on their side, this
lowers their BP; therefore, BP should always be taken in the seated
position to obtain the most accurate reading.
• In all women with elevated BP, it is important to rule out
preeclampsia

10. DIAGNOSIS
• Preeclampsia without severe features
• BP SBP ≥ 140 mm Hg and/or DBP ≥ 90 mm Hg on two occasions
at least 4 h apart after 20 wks’ gestation in women with previously
normal BP and
• Proteinuria ≥300 mg/24 h or protein/creatinine ratio ≥0.3 or
dipstick reading of +1 (used only if other quantitative methods are
unavailable)

11. DIAGNOSIS Cont’’
• Preeclampsia with severe features
• SBP ≥ 160 mm Hg and/or DBP ≥ 110 mmHg confirmed
within a short interval (minutes) to facilitate antihypertensive,
• Proteinuria > 5g in 24-hour collection
• Proteinuria 3+ or greater on 2 random samples at least 4 hours
apart
• Oliguria: < 500 mL in24 hours
• Cerebral or visual disturbances

12. DIAGNOSIS Cont’’
• Preeclampsia with severe features
• Epigastric or RUQ pain
• Pulmonary edema or cyanosis
• Impaired liver function
• Thrombocytopenia
• Fetal growth restriction

13. DIAGNOSIS OF HELLP SYNDROME
• Hemolytic anemia
• Schistocytes on peripheral blood smear
• Elevated lactate dehydrogenase
• Elevated total bilirubin
• Elevated liver enzymes
• Increase in aspartate aminotransferase
• Increase in alanine aminotransferase
• Low platelets Thrombocytopenia
HELLP, hemolysis, elevated liver enzymes, and low platelet count.

14. DIAGNOSIS Cont’’
• Chronic hypertension
• hypertension present before conception, before 20 weeks’ gestation, or
persisting more than 6 weeks postpartum.
• For women who present without prenatal care prior to 20 weeks of gestation,
this can be difficult to differentiate from GH.
• Superimposed preeclampsia
• Approximately one-third of patients with chronic hypertension in pregnancy
will develop superimposed preeclampsia.
• Because of poor vascular development, the fetus may suffer from IUGR, and
the mother is at increased risk for superimposed preeclampsia, premature
delivery, and abruptio placentae.

15. Note that
• If systolic blood pressure is ≥160 mmHg and/or diastolic blood pressure is
≥110 mmHg, confirmation within minutes is sufficient.
• Response to analgesia does not exclude the possibility of preeclampsia.
• Adapted from: American College of Obstetricians and Gynecologists
(ACOG) Practice Bulletin No. 222: Gestational Hypertension and
Preeclampsia. Obstet Gynecol 2020; 135:e237.

16. ECLAMPSIA
• Eclampsia is the occurrence of grand mal seizures in the preeclamptic
patient that cannot be attributed to other causes.
• A seizure in a pregnant woman should be assumed to be eclampsia until
proven otherwise.
• Tonic–clonic in nature which may or may not be preceded by an aura.
• These seizures may develop before labor (59%), during labor (20%), or after delivery
(21%). Most postpartum seizures occur within the first 48 hours after delivery, but
will occasionally occur as late as several weeks after delivery.
• Fetal bradycardia can also occur during and after an eclamptic seizure.

17. INVESTIGATIONS
• FBC
• Liver function tests(ALAT AND ASAT)
• Kidney function tests(Urea and Creatinine)
• Electrolyte( sodium, potassium, magnesium, calcium, and chloride)
• Coagulation status PLT count, Elevated PT or Partial thromboplastin time (PTT). This is a
measure of the time it takes blood to clot. decreased fibrinogen as DIC develop,
• Eyes fundus examination
• US
• Test for fetal well being BPP
• Urine test(proteinuria, urine dipstick)

18. MANAGEMENT
• Preeclampsia without severe features: Expectant management ≤34+0/7
• If the mother and fetus are stable, the goal is for the woman to reach 37 + 0/7 weeks of gestation while
monitoring of maternal and fetal status continues.
• Close monitoring and a high suspicion for worsening disease are important.
• If blood pressure and signs of pre-eclampsia remain unchanged or normalized, follow up with the
woman as an outpatient twice a week:
• Monitor blood pressure, reflexes and fetal condition (Biophysical profile and Doppler whenever
possible).
• Monitor for danger signs associated with features of severe pre-eclampsia (see signs of severity).
• Counsel the woman and her family about danger signs associated with severe preeclampsia or eclampsia.
• Do not give anticonvulsants or antihypertensives unless clinically indicated.

19. MANAGEMENT
• Preeclampsia with severe features
• Assess maternal condition
• Assess fetus
• Control blood pressure
• Prevent seizures
• Manage fluid and electrolytes
• Manage labor and delivery
• Optimize neonatal care
• Postpartum care

20. Assess Maternal Condition
• Bed rest
• Blood pressure monitoring
• Neurologic assessment
• Renal- watch urine output
• Respiratory
• Serial CBC, serum chemistries, UA (24hr urine collection)

21. Assess Fetal condition
• Continuous fetal monitoring
• Ultrasound for EFW, AFI
• Steroids for Fetal Lung Maturity?
• YES!!!!

22. Maternal BP Control
• Labetalol slow IV (ampoule of 100 mg in 20 ml, 5 mg/ml
• One dose of 20 mg (4 ml) over at least one minute.
• Check BP 5 and 10 minutes after injection.
• If hypertension remains uncontrolled, administer another dose of 20 mg and
check BP. Administer additional doses, of 40 mg then 80 mg with 10 minutes
between each dose as long as hypertension is not controlled. Do not exceed a
cumulative dose of 300 mg
• Nifedipine Immediate release Oral Treatment
• Administer 5–10 mg orally
• Repeat dose after 30 minutes if response is inadequate until optimal blood
pressure is reached,maximum dose is 30 mg in the acute treatment.

23. Maternal BP Control
• Hydralazine slow IV (20 mg/1 ml vial)
• Dilute 20 mg (1 vial of hydralazine reconstituted in 1 ml of water for injection) in 9 ml of
0.9% sodium chloride to obtain 10 ml of solution containing 2 mg hydralazine/ml.
• Administer 5 mg (2.5 ml of the diluted solution) over 2 to 4 minutes.
• Monitor BP for 20 minutes.
• If hypertension remains uncontrolled, repeat injection.
• Continue repeating if necessary, waiting 20 minutes between each injection.
• Do not exceed a cumulative dose of 20 mg.

24. Maternal BP Control
• Nifedipine tabs 20mg Long acting 20mg twice daily.
• Titrate the dose accordingly. Max: 120mg in 24hr
• Methyldopa Administer 250 mg every six to eight hours.
• The maximum dose is 2000 mg per 24 hours.
• NB: Angiotensin converting enzyme inhibitors, angiotensin II receptor
blockers, and direct renin inhibitors are contraindicated at all stages of
pregnancy
• RWANDA STANDARD TREATMENT GUIDELINES | OBSTETRICS
AND GYNECOLOGY - | 2022

25. Anticonvulsant Therapy– Magnesium
Sulfate
• Intramuscular route
• Give 4 g of 20% magnesium sulphate solution IV over five minutes
• Follow promptly with 10 g of 50% magnesium sulphate solution:
Give 5 g in each buttock as a deep IM injection with 1 mL of 2%
lidocaine in the same syringe.
• Ensure aseptic technique when giving magnesium sulphate deep IM
injection.
• Warn the woman that she will have a feeling of warmth when the
magnesium sulphate is given.
• Maintenance dose (IM): Give 5 g of 50% magnesium sulphate
solution with 1 mL of 2% lidocaine in the same syringe by deep IM
injection into alternate buttocks every four hours.
• Continue treatment for 24 hours after birth or the last convulsion,
whichever occurs last

26. Anticonvulsant Therapy– Magnesium
Sulfate
• Intravenous administration Can be considered, preferably using an infusion
pump, if available:
• Loading dose:
• Give 4g of 50% magnesium sulphate solution IV.
• If convulsions recur after 15 minutes, give 2 g of 50% magnesium sulphate solution IV over
five minutes.
• Maintenance dose (IV):
• Give intravenous infusion 1g/ hour. Continue treatment for 24 hours after childbirth or the last
convulsion, whichever occurs last.
• Assessing for signs of magnesium toxicity.
• RWANDA STANDARD TREATMENT GUIDELINES | OBSTETRICS
AND GYNECOLOGY - | 2022

27. Magnesium Toxicity
Effect
Seizure prophylaxis
EKG changes
Loss of DTRs
Respiratory Paralysis
Cardiac Arrest
Serum Level (mEq/L)
4-6
5-10
10
12-15
15-20

28. Magnesium Toxicity
• Stop IV MgSO4 infusion
• Rx with Calcium Gluconate
• 1g IV slow push

29. Fluid Management
• Maternal blood volume is constricted
• Need controlled, conservative fluid administration
• Limit fluid intake to 2400-3000 cc/ 24 hrs
• Keep strict I & O’s
• Oliguria (<30cc/ hr) for 2 consecutive hours associated
with Acute Tubular Necrosis

30. TIMING FOR DELIVERY
• Gestational hypertension
• In women with gestational hypertension, if spontaneous labour has
not occurred before term, induce labour at 37+0 to 38+6 weeks for
all women with any degree of gestational hypertension because of
the risk of progression to preeclampsia.

31. TIMING FOR DELIVERY
PREECLAMPSIA
• Gestation Less than 24 Weeks (Pre-Viable Fetus)
• Termination of pregnancy is recommended for women with severe pre-
eclampsia if the fetus is not viable (or if unlikely to achieve viability within
one to two weeks)
• Assess the cervix and induce as per medical management of abortion
• If medical management is unsuccessful or expedited delivery required, offer
dilatation and evacuation for expedited birth

32. Timing for delivery con’t
• Between 24-34 weeks of gestation
• In case of severe pre-eclampsia and a viable fetus that is between 24 and 33 +
6/7 weeks of gestation, expectant management is recommended, provided that:
• Maternal hypertension is controlled, maternal status not worsening and there is no fetal
distress
• The mother needs close monitoring
• Admit the patient and do clinical assessment
• Give antenatal corticosteroids to accelerate fetal lung maturation.
• Betamethasone 12 mg IM, 24 hours apart, or
• Dexamethasone 6 mg IM, 12 hours apart for four doses
• If the maternal or fetal condition is rapidly deteriorating, expedite birth after the first dose
of antenatal corticosteroids. Do not wait to complete the course of antenatal
corticosteroids before the woman gives birth.
• Monitor fetal growth by symphysis-fundal height (weekly) or ultrasound and fetal well-
being by doing at least twice weekly biophysical profile and Doppler or growth scan
every 2 weeks.

33. Timing for delivery con’t
• Gestation after 34 + 0/7 Completed Weeks
• For women with pre-eclampsia above (34 + 0/7 weeks), regardless of
preeclampsia severity, delivery is recommended.
• Vaginal birth is preferred unless there are indications for caesarean section
• Assess the cervix by using Bishop Score and induce/augment labour.
• If vaginal birth is not anticipated within 12 hours (eclampsia) or 24 hours
(severe pre-eclampsia), perform a caesarean delivery.
• If the fetus is dead:
• Aim for vaginal birth.

34. Chronic HTN timing for Delivery
• If there are no complications, the following approach for timing of
delivery is used
• ≥38+0 to 39+0 weeks of gestation for women not requiring medication
• ≥37+0 to 39+0 weeks for women with hypertension controlled with
medication
• Late preterm delivery (34+0 to 36+6 weeks) for women with severe
hypertension difficult to control

35. Maternal Complications of Preeclampsia
• Medical manifestations
• Seizure Cerebral hemorrhage
• DIC and thrombocytopenia
• Renal failure
• Hepatic rupture or failure
• Pulmonary edema Obstetric complications
• Uteroplacental insufficiency
• Placental abruption
• Increased premature deliveries
• DIC, disseminated intravascular coagulation.

36. Take home message
• 4 categories :chronic hypertension, gestational hypertension (GH).
preeclampsia, and eclampsia
• Preeclampsia is ultimately treated with delivery, but seizures can be
prevented with magnesium sulfate, and BPs can be controlled with
antihypertensive medications.
• Eclampsia is the occurrence of grand mal seizures in the preeclamptic
patient that cannot be attributed to other causes.
• Paramedical test includes CBC, AST, ALT, and Cr, Proteinuria and US

37. REFERANCES
• https://www.uptodate.com/contents/hypertensive-disorders-in-
pregnancy-approach-to-differential-diagnosis
• https://www.uptodate.com/contents/preeclampsia-clinical-
features-and-diagnosis
• RWANDA STANDARD TREATMENT GUIDELINES |
OBSTETRICS AND GYNECOLOGY - | 2022
• Blue prints obstetrics and Gynecology

38. THANK YOU FOR YOUR KIND
ATTENTION!!!