treatment and management

1. HYPERTENSIVE DISORDER
IN PREGNANCY

2. OUTLINE
• Definition
• Classification
• Management

3. DEFINITION OF HYPERTENSION
• Blood Pressure of 140/90mmHg and above, taken after a period of
rest on two occasions.
• Rise of systolic blood pressure (SBP) of 30mmHg and/or a rise in
diastolic blood pressure (DBP) of 15mmHg compared to pre
pregnancy levels.

4. PROTEINURIA
• Significant proteinuria in pregnancy is defined as
• 24 hour urine sample ≥300 mg protein
• spot urine protein-creatinine ratio (PCR) ≥30 mg/mmol
• urine dipstick :

5. CLASSIFICATION OF HYPERTENSION IN PREGNANCY
Pregnancy Induced Hypertension (PIH)
Chronic Hypertension
Chronic Hypertension with Superimposed PE
Isolated Office Hypertension
Gestational Hypertension (GH)
Pre – Eclampsia
Eclampsia
Essential Hypertension
Secondary Hypertension
Training Manual Hypertensive
Disorders in Pregnancy Revised
2018

6. PREGNANCY INDUCED HYPERTENSION
• hypertension detected for the first time after 20 weeks gestation, in
previously normotensive women
Gestational Hypertension (GH)—PIH without proteinuria
Pre-eclampsia (PE)—PIH with proteinuria
Eclampsia—PIH with convulsions
• HELLP syndrome is a severe form of PE manifested by Haemolysis, Elevated Liver Enzymes
and Low Platelets.
• The condition is expected to return to normal after pueperium.

7. CHRONIC HYPERTENSION
• Hypertension
• diagnosed prior to 20 weeks gestation or
• At least beyond 6 weeks post partum or
• de novo hypertension in late gestation that fails to resolve 3 months
postpartum
• Essential Hypertension and Secondary Hypertension

9. CHRONIC HYPERTENSION WITH SUPERIMPOSED PE
• Refers to the development of PE in women who have pre-existing
hypertension.
• Criteria used should include worsening hypertension, proteinuria and
non-dependent oedema.
• De novo proteinuria after 20 week gestation
• A sudden increase in the severity of hypertension
• A weight gain of 1kg within a week may point to increasing severity of
PIH especially in the presence of proteinuria.
• Appearance of features of preeclampsia-eclampsia

10. ISOLATED OFFICE HYPERTENSION
• Elevated BP of 140/90 mmHg only in the clinic with normal BP
demonstrated by ambulatory BP monitoring (ABPM) either awake or
during sleep.
• In the absence of ABPM device, HBPM can be used.
• Studies in non-pregnant population showed that they are comparable.
• Women in this group should not be considered low risk as they may
progress to gestational hypertension (50%) or PE (8%)

11. ABPM to Diagnose and Manage Isolated Office Hypertension in Pregnancy.*
ABPM = Ambulatory Blood Pressure Monitoring
HBPM = Home Blood Pressure Monitoring
* adapted from Brown MA 2014.

12. SEVERITY OF HDP
MILD
• SBP 140-149mmHg and or DBP 90-99 without albuminuria
OR
• rise in SBP 30mmHg or a DBP 15mmHg from pre pregnancy blood
pressure.
MODERATE • SBP 150-159mmHg and or DBP 100-109mmHg.
SEVERE
• characterised by progressive
deterioration in both maternal
and foetal condition
• SBP ≥160mmHg or DBP ≥110mmHg on two occasions 6 hours apart.
• Proteinuria of (3+) or >3g/L.
• Oliguria (<400ml/24 hours).
• Headache.
• Cerebral or visual disturbances.
• Epigastric pain.
• Hyper-reflexia.
• Pulmonary oedema.
• Impaired liver function tests.
• Increased serum creatinine
(>1.2mg/dl).
• Retinal haemorrhage, exudates or
papilloedema.
• Thrombocytopenia.
• IUGR.

13. Preconception counseling and adjustment of treatment
in women with chronic hypertension
• Women with chronic hypertension may require a change in the type of
antihypertensive agent used pre-pregnancy.
• The drugs of choice in pregnancy are methyldopa and labetalol .
• Atenolol has been shown to lead to fetal growth restriction.
• The use of ARBs, ACEIs and thiazide diuretics are associated with fetal anomaly
and are therefore contraindicated in pregnancy.

14. Preconception counseling and adjustment of treatment
in women with chronic hypertension
• Offer contraception to women in the reproductive age group with
chronic hypertension
• In the event of unplanned pregnancy, the teratogenic antiHPT must be
stopped – change to more suitable antiHPT
• It should be noted that the treatment of hypertension in pregnancy is solely for
maternal safety particularly for prevention of intracranial bleeding.
• It does not reduce the risk of development of preeclampsia or perinatal mortality,
nor improve fetal growth

15. Anti-hypertensive Drugs Commonly Used in Pregnancy
Drug Remark
Methydopa
(first line)
Oral 250 mg tds, doubling every 48 hours (up to 1 gm tds)
until BP well controlled. Oldest anti-hypertensive agent used in pregnancy,
with best safety profile.
Labetolol
(alternative first
line)
Oral 100 mg bd, doubling every 48 hours (up to 400mg bd) until BP well
controlled.
Nifedipine
(second line)
Oral 10 mg tds, up to 20 mg tds, usually as second line antihypertensive,
when BP poorly controlled despite maximum doses of methyldopa ―
labetalol.

16. EARLY IDENTIFICATION OF HYPERTENSIVE DISORDERS IN
PREGNANCY
History and complaints
• Family history of hypertension
• History of pregnancy induced hypertension
• Primigravida
• Associated conditions
• multiple pregnancy, diabetes mellitus, renal disease, systemic lupus erythematosus (SLE) /
anti-phospholipid syndrome (APS)
• obesity (>80kg; BMI >27)
• maternal age
• pre-existing chronic hypertension

17. EARLY IDENTIFICATION OF HYPERTENSIVE DISORDERS IN
PREGNANCY
Symptoms:
• headache
• visual disturbance
• nausea and vomiting
• epigastric pain

18. EARLY IDENTIFICATION OF HYPERTENSIVE DISORDERS IN
PREGNANCY
Physical examination
• Excessive weight gain (>1kg per week)
• Oedema in the face and abdomen and/or non-dependant oedema
• Proteinuria
• Obesity (Body Mass Index >27.5 or 80kg.)
• Abdominal examination:
• Polyhydramnios
• multiple pregnancy
Blood pressure:
• BP of 140/90 mmHg taken on 2 occasions 6 hours apart
• If baseline BP is known:
• Increase in systolic BP by 30mmHg
• Increase in diastolic BP by 15mmHg

19. Recognition of women at risk of preeclampsia for
commencement of prophylaxis
Risk Risk factors
Moderate
• Primigravida
• age >40 years
• pregnancy interval >10 years
• body mass index of >35 kg/m2 at first visit
• family history of PE
• multiple pregnancy
High
• Hypertensive disease during previous pregnancy
• Chronic kidney disease
• Autoimmune disease such as Systemic Lupus Erythematosus (SLE) or anti-
phospholipid syndrome (APS)
• Type 1 or type 2 diabetes mellitus, and
• Chronic hypertension

20. PROPHYLACTIC THERAPY
a. Aspirin
• Women with ≥2 moderate or one high risk factor should be started on low dose aspirin from 12 weeks up to
16 weeks of gestation until delivery.
• Recommended dosage 75mg OD and taken at bedtime in order to significantly reduce the incidence of PE.
b. Calcium
• A systematic review showed that low dose calcium supplement commenced before 20 weeks gestation reduces
the risk of PE. The WHO recommends calcium 1.5g to 2g daily for pregnant women with low dietary calcium
intake
c. Vitamin D
There is no proven role of vitamin D in reducing the risk of PE
d. Others
• Other supplements in pregnancy such as marine oil, garlic, and pyridoxine have no proven benefits.
• Combined vitamin C and E (i.e. tocopherol from soybean) should be avoided because they significantly
increase the incidence of low birth weight without any preventive effect against PE.

21. FETAL ANOMALY SCREENING
• Women with chronic hypertension have about
20-30% increased risk for fetal congenital cardiac
anomaly.
• These women are to be referred to the
Maternal-Fetal Medicine (MFM) specialist in the
tertiary centre to be recommended to undergo
nuchal translucency (NT) scan at 12-14 weeks
followed by a detailed ultrasound scan at 22-24
weeks of gestation.

22. MANAGEMENT OF MILD HDP
• Aim is to prolong the pregnancy to as near term as possible provided
there are no evidence of maternal complications or fetal compromise
(fetal distress, intrauterine growth restriction (IUGR) or
oligohydramnios).

23. Ambulatory Care (Out-Patient Management)
• Criteria for selection of patient for ambulatory care:
• BP ≥140/90mmHg but less than 160/100mmHg.
• No proteinuria.
• No signs/symptoms of impending eclampsia.
• No excessive weight gain.
• No signs of intrauterine growth retardation.
• Normal biochemical investigation.

24. Antenatal Care
• Mild HDP can be managed in health clinics.
• Aim of monitoring = to detect any deterioration in maternal and fetal condition.
• The frequency of each visit should be individualised.
• In patient who do not require medication and absence of maternal or fetal
complications, the patient should be attending the normal antenatal follow up.
• Patient should be counselled with regards to her condition, management option
and need for regular antenatal care.
• Maternal and fetal monitoring and surveillance is the mainstay of management of
HDP.

26. ANTIHYPERTENSIVE THERAPY
• Not all mild HDP require antihypertensive treatment.
• A majority of them may benefit from adequate rest.
• Patients with BP of 140/90mmHg, without any complications may not
require antihypertensive treatment.
• Antihypertensive therapy should be started when the diastolic BP is
≥100mmHg, and or systolic BP is ≥150mmHg.
• In all cases, care should be taken to avoid reducing the blood pressure
below the lower limits (110/80mmHg) which would lead to a risk of
placental underperfusion.

27. AIM OF TREATMENT
• The aim of treatment is to maintain a diastolic BP around 90-
100mmHg to:
• minimize the risk to the mother from events such as
cerebral vasculo-accident , cardiac failure and placental
abruption etc.
• avoid placental hypoperfusion which may lead to IUGR,
fetal hypoxia and intrauterine death.

28. INDICATION FOR HOSPITALIZATION
• Generally the indication for in-patient management is for those who
fail ambulatory care (out-patient) management. The reasons for
admission are:-
• symptomatic patients.
• maternal or fetal complications.
• persistent diastolic blood pressure >100mmHg or systolic >160mmHg for
stabilization.
• abnormal biochemical PE profile.
• presence of severe proteinuria >2+.

29. TIMING OF DELIVERY
• Do not offer birth to women with chronic hypertension whose blood pressure is
lower than 160/110mmHg, with or without antihypertensive treatment, before
37 weeks
• Chronic hypertension whose blood pressure is lower than 160/110mmHg after
37 weeks, with or without antihypertensive treatment,
• timing of birth and maternal and fetal indications for birth should be agreed
between the woman and the senior obstetrician
• In the absence of maternal and fetal complication,
• pregnancy should NOT be allowed beyond dates i.e 40 weeks POA
• If at anytime the maternal and fetal condition is compromised, early delivery
is mandatory and appropriate corticosteroid usage is necessary.

30. MANAGEMENT OF SEVERE HDP
• The aim of the management of severe HDP is
• to prevent a CVA to the mother whilst trying to achieve a clinically useful
prolongation of the pregnancy.
• This is because it is also aimed at delivering a live baby as mature as possible.
• PE when diagnosed at term, mandates delivery as there is no advantage to either
the fetus or mother in prolonging the pregnancy.
• MGSO4 should be considered to prevent seizure in women with pre-eclampsia
for whom there is concern about the risk of eclampsia.

31. SEVERE HDP
• SBP ≥160mmHg or DBP ≥110mmHg on two occasions 6 hours apart.
Sign and Symptoms Investigations
Headache. Proteinuria of 3+ or >3g/L.
Cerebral or visual disturbances Increased serum creatinine (>1.2mg/dl)
Epigastric pain. Impaired liver function tests.
Hyperreflexia. Thrombocytopenia.
Oliguria (<400ml/24 hours). Fetal growth compromise (IUGR).
Retinal haemorrhage, exudates or papilloedema.
Pulmonary oedema

32. Management at Home and Health Clinic
• CODE RED = Refer to the hospital immediately.
• Arrange for transport and accompany the patient to hospital. (by Doctor)
• Inform the receiving hospital (labour room) prior to referral.
• Set up an IV drip with normal saline
To lower blood pressure:
Oral nifedipine (10mg stat) OR
IV Labetolol 20 mg then 40 mg 10–20 mins later OR
Intramuscular IM hydralazine 6.25mg
[Preparation: 1 ampule contain 20mg hydralazine + 9ml distilled water = 2mg/ml.
Give 3.1 ml (equivalent to 6.2mg)]
Eclampsia prevention:
Intramuscular (IM) MgSO4 10g bolus (5g each buttock)

34. • During Transfer
• Monitor and record the maternal BP, pulse rate and fetal
heart rate every 15 minutes.
• If an acute situation arises, stop the vehicle to carry out
resuscitative measures or divert to the nearest health
facility.
Management at Home and Health Clinic

35. Anti-Hypertensive Drugs for Severe Preeclampsia with Acute
Hypertensive Crisis
Drug Administration Remarks
Labetolol In IV bolus:
• 20 mg then 40 mg 10–20 mins later
• 80 mg every10–15mins up to 200mg
Infusion:
continuous infusion of 1–2 mg/min until BP stabilises, then stop or reduce
to 0.5 mg/min.
May cause fetal bradycardia
May cause fetal
bradycardia.
Nifedipine Oral 5–10 mg stat (repeat in 30 minutes if necessary), especially prior to
transferring a patient from a peripheral clinic to hospital.
After the initial emergency dose, 10–20 mg can be given every 3–6 hours
until BP stabilizes.
Especially prior to
transferring a
patient
from a peripheral
clinic to hospital.

36. Anti-Hypertensive Drugs for Severe Preeclampsia with Acute
Hypertensive Crisis
Drug Administration Remarks
Hydralazine Initial: 5-10 mg via slow injection,
may repeat after 20-30 min.
Alternatively, as a continuous infusion, initial dose of 0.2- 0.3 mg/min.
Maintenance: 0.05-0.15 mg/min.
No longer
recommended as
first line treatment
for acute
hypertensive
crisis in pregnancy

37. • Is a variant of severe pre-eclampsia and is characterised by:
Haemolysis (H) + Elevated Liver enzymes (EL) +
Low Platelets (LP).
• serious complication in pregnancy occurring in 0.5 to 0.9% of all
pregnancies and in 10–20% of cases with severe pre-eclampsia
• The maternal mortality is high (24% in one series) and perinatal
mortality ranges from 30-40%.4
HELLP syndrome

38. Diagnostic criteria (Tennessee Classification System)
• Presence of signs and symptoms of pre-eclampsia
PLUS
• Microangiopathic haemolytic anemia.
• Thrombocytopenia ≤100 x 109/L.
• Hepatic dysfunction enzyme:
• AST or ASOT ≥70IU/L
• LDH ≥600IU/L
HELLP syndrome

39. Management include
• Pre hospital care early detection
and hospital referral
• Intensive hospital care
• Further investigation
• Treatment
• Labour and delivery
• Post partum care
HELLP syndrome – management

40. Eclampsia
• Pathophysiology of eclampsia = cerebral vasospasm leading to ischaemia,
disruption of the blood brain barrier and cerebral oedema.
• Neurological complications = coma, focal motor deficits, cortical blindness,
cerebrovascular haemorrhage may complicate about 2% of cases

42. Prevention of Eclampsia
Detect early (any risk factors) and treat early !
However, they can appear in any order or all together in less than 24 hours. The symptoms and signs of impending
eclampsia should always be looked for in patients with HDP:
The signs of HDP usually appear over a period of several days in the following order:

43. Management of Eclampsia at Home & Health Clinics
Immediate Measures
• Call for medical assistance.
• The patient should be placed in the lateral position.
• Maintain airway, oxygen given through nasal prong / ventimask.
• Give Intramuscular MgSO4 10gm 50% solution (20mls).
• One half is injected into upper outer quadrant of each buttock in zigzag manner
(proceeded by local anaesthesia if necessary) using a 21 gauge needle.
• Set up an IV drip with normal saline for emergency administration of
drugs for further resuscitation.
• Parenteral antihypertensive therapy to control hypertension e.g.
hydralazine / labetalol / nifedipine

44. • Insert a Foley’s catheter to record and monitor urine output.
• Suck out secretions / saliva.
• Monitor and record the maternal BP, pulse rate, respiration rate and the fetal
heart beat every 15 minutes using a Labour Progress Chart.
• Arrange for transport and accompany the patient to hospital
• To inform the labour room personnel of the receiving hospital prior referral.
Management of Eclampsia at Home & Health Clinics

45. During Transfer
• Continue the monitoring of the mother and fetus as above.
• Maintain patient in lateral position.
• Maintain airway with oxygen.
• Continue IV drip: normal saline (Be cautious not to cause overload)
• Prepare IV MgSO4 2g (or 5g for IM) in a syringe in case patient threw
recurrent seizure during transfer.
Max how mauch can give?
Management of Eclampsia at Home & Health Clinics

46. Anti-convulsant for Eclampsia
(and Severe Preeclampsia)
Drug Remark
Magnesuin Sulphate
2 preparation
1. 50% solution (contains 50g in
100ml solution i.e.5ml ampule
contains 2.5g MgSO4)
2. 20% solutions
Notes:
• 50% solution is suitable for
intramuscular use
• 20% solution is suitable for
intravenous route
Intramuscular:
10g IM loading dose,
then 5 g IM every 4 hours in alternate buttock.
Intravenous:
4g slow bolus over 10 minutes,
followed by 1-2 g/hour maintenance infusion given via a
controlled infusion pump.

47. Anti-convulsant for Eclampsia (and Severe Preeclampsia)
Drug Remark
Diazepam 10 mg IV bolus, followed by 40 mg in 5% dextrose slow infusion so that patient
remains sedated.
* Only when magnesium sulphate is contraindicated or not available

48. Monitoring During Magnesium Sulphate Therapy
• The next intra-muscular dose can only be given or the intravenous infusion can
only be continued if:
• Respiratory rate >6/minute - check every 15 minutes
• Urine output >25ml/hr - check every hour
• Patellar reflexes are present - check every 15 minutes
• Intravenous regime needs more frequent monitoring. In the first 2 hours
monitoring should be every 10 minutes.
Steps to be taken in Magnesium toxicity
Respiratory depression
• Give oxygen by mask
• Stop magnesium therapy
• Give 1g IV Calcium Gluconate
• Maintain the airway
• Nurse in the recovery position

49. Senarai peralatan di dalam “eclampsia KiT”

50. After Convulsions
• Continue maintain airway and oxygen administered at 6-8L/minute.
• Set up an IV line with normal saline.
• Insert Foley’s catheter to check urine output.
• Monitor maternal vital signs: BP, pulse rate, respiration rate and also tendon
reflexes.
• Continue MgSO4 infusion 1g/hour and to be continued till 24 hours after
delivery or convulsion whichever is later.
• If diastolic BP is more than 110mmHg, treat with IV hydralazine infusion titrate to
BP using syringe pump 50mg in 50mls normal saline (1mg /ml)
• start at 5mls/hr and titrate every 20 minutes by 1ml/hr and aim blood pressure diastolic BP
about 90mmHg. (maximum dose of 10mls/hr (10mg/ hr)

52. Postnatal Management at Primary Care Level
Discharge from Hospital
• Discharge Criteria
• Diastolic blood pressure has settled below 100mmHg
• NO end-organ dysfunction Patient:
• understand the disease and its complication
• compliant to medication
• accessible to a health center
• has good support from family

53. Care Plan on Discharge
Counselling
• Complication of HDP during puerperium
• Importance of contraception
• Notification of birth

54. Postpartum Care
• Women with hypertensive disorders in pregnancy are advised to have their BP
checked regularly at local clinics if there is a significant delay in their scheduled
hospital follow-up.
• In these patients, the dose of antihypertensive should be tailed down gradually and
not stopped suddenly.
• De novo onset of hypertension or aggravation of BP levels during the postpartum
period can occur.
• These patients should be promptly referred to hospital especially if there is
significant proteinuria.
• Eclampsia may occur in the postpartum period.
• Chronic hypertension is diagnosed when the hypertension and/or proteinuria persist
after three months postpartum.

55. Postnatal Management at Primary Care Level

56. Criteria for referral
Referral to hospital may be considered, if:-
• BP >150/100mmHg with proteinuria and/or with
• signs and symptoms of impending eclampsia
• If hypertension and proteinuria persist beyond six weeks postnatal
period

57. At Six Weeks Post Natal Follow-Up
• During this follow-up, counselling on the importance of contraception should
further be reinforced.
• Mothers whose blood pressure has returned to normal, should be advised to
have an early booking and regular antenatal care in the next pregnancy.
• If hypertension and proteinuria persists beyond six weeks postnatal period, the
mother should be referred to a physician with regular follow up.
• Counselling on the importance of effective contraception at least for 2 years.
• Pre-pregnancy counselling is necessary before next pregnancy.

58. Case Scenario
• 24 years old primigravida, noted BP high at 12 weeks POA (140/100 mmHg). BP was
poorly controlled requiring recurrent hospital admissions for BP stabilisation.
• She was also diagnosed to have GDM on diet control. She is continuously moving
between her home and her hometown in an adjacent state.
• She was last admitted at 29 weeks POA, and following discharge BP was still poorly
controlled with proteinuria. She was started on T.Labetolol 100 mg tds which was
later changed to T.Nifedipine 10 mg tds.
• Her last KK follow up at 29 weeks + BP taken 180/110 mmHg. T. Nifedipine 10 mg stat
dose was given, and repeated BP was 140/90 mmHg. Unfortunately she was not
referred to the hospital, and a TCA of 1 week was given instead. She defaulted follow
up.

59. Case Scenario
• 11 days later at POA 31 weeks, patient had complained of headache and
vomiting, but refused to go to the hospital.
• The next day at 4 am, patient developed GTC seizures 4 times at home and was
not responsive. Ambulance call was made.
• Arrived at the hospital nearly 2 hours later with GCS 3/15, BP 84/31 mmHg with
no pulse detected. CPR commenced. Fluid resuscitation and iv MgSO4 was given.
IUD was confirmed on scan. Managed to revive patient and was put on double
inotrope. Patient was also diagnosed to have abruptio placenta. Blood
investigation showed severe metabolic acidosis with renal and liver impairment,
complicated with DIVC. DIVC regime was transfused. ECHO done showed EF of
28% with poor biventricular function. That night (9:40 pm), patient became
asystole again, however fail to revive after 40 mins of CPR.

60. Thank you for your attention

61. REFERENCE