Mrs. A is 28 weeks pregnant with gestational hypertension and proteinuria. Her fetus has normal growth but high umbilical artery resistance on Doppler. The document discusses expectant management vs expedited delivery. For Mrs. A, expectant management is recommended up to 34 weeks given her fetus' normal growth. This involves strict maternal monitoring and interventions like corticosteroids for lung maturity. The risks and components of expectant management are outlined, including frequent monitoring of maternal status and fetal wellbeing by tests like NST, BPP, growth scans and Doppler. Indications for earlier delivery include worsening maternal status, non-reassuring fetal testing or signs of fetal compromise.

1. Dr. Renu Makwana (MBBS,
M.S, FICOG)- Management of
Hypertensive disorders of
pregnancy

3. Report of the ACOG Task Force on
Hypertension in Pregnancy
Severe Features of Preeclampsia (Any of these findings):
1. Hypertension: systolic >160 or diastolic >110 on two occasions at least
4 hours apart while the patient is on bed rest (unless antihypertensive
therapy is initiated before this time).
2. Thrombocytopenia (platelet count <100,000).
3. Impaired liver function (elevated blood levels of liver transaminases to
twice the normal concentration), severe persistent RUQ or epigastric pain
unresponsive to medication and not accounted for by alternative
diagnoses, or both.
4. New development of renal insufficiency (elevated serum creatinine
greater than 1.1 mg/dL, or doubling of serum creatinine in the absence
of other renal disease).
5. Pulmonary edema.
6. New-onset cerebral or visual disturbances.
Obstetrics & Gynecology, Vol. 122, No. 5, November 2013

5. The Case:-
Mrs A, Age 27 yrs, mother had eclampsia ,
normotensive till 3 wks ago, presents at 28 weeks POG
with BP 170/110, hospitalized GPE- Normal, BMI: 26,
BP- 170/110, edema feet + +
P/A- Fundal height dating, cephalic free, FHR normal,
liquor adequate.
Labs- Urine Protein ++, Sugar nil dipstick, CBC, KFT,
LFT – Normal, Urine PC ratio- 2 mg/dl

6. Q: Evaluation for the fetus ?
- USG FOR FWB/ AFI-
Mrs. A’s fetus is dating, AFI normal, cephalic
presentation, weight 1.2 kg, umbilical artery
doppler high resistance flow, uterine artery
bilateral notches, MCA normal.
Q.3. What management line ? Expectant management Or
Expeditious delivery ? Evidence in this regard.
-The basic management objectives for any pregnancy complicated by
preeclampsia:
(1) Termination of pregnancy with the least possible trauma to mother
and fetus.
(2) Birth of an infant who subsequently thrives .
(3) Complete restoration of health to the mother. In many women with
preeclampsia, especially those at or near term, all three objectives are
served equally well by induction of labour.

7. One of the most important clinical questions for successful
management is precise knowledge of fetal age.
Delivery is the only cure
Aggression
Management
Expeditious delivery
Within or after 48
hours
Expectant
management
No benefit to
mother
May reduce risk of
prematurity

11. Q. Who are the candidates we will not consider for expectant management
in the first place and what are the components of expectant management ?
Indications for delivery in patients < 34 weeks managed expectantly

12. Keep your obstetric room ready
•Well equipped room
•Oxygen
•Maternal and neonatal resuscitation equipments
•Eclampsia kit
•Protocols
•Documentation
Keep your obstetric room ready-Eclampsia kit
Airway , IV canula , sticking tape ,three way,
IV set ,Blood set, 100 ml NS, 500 ml GNS,
Inj Magsulf 16 amp, inj Labetolol 15 amp.,
inj midazolam
Lignocaine 2%
Folys catheter
Syringes 5 ml, 10 ml, 20 ml, bandages, gloves

13. Components of expectant management
•Control of HT- ICU setting – check BP every 15 min , once
stabilized, then every 4 hours-- 150/100
•Prevention of seizures- search for S/S of imminent eclampsia
every 4 hours-
•Corticosteroids for fetal lung maturity
•Assessment of fetal well being- no IUGR- EFM daily+weekly
USG+ Doppler, DFMC
if IUGR- EFM BD, Biweekly USG+ Doppler, DFMC
•Strict maternal monitoring to avoid complication- labs
alternate day, 24 hour urine protein once , not thereafter,
daily urine output
•Timely intervention

14. Drugs for Urgent Control of Severe Hypertension in Pregnancy
Drug (FDA
Risk*)
Dose and Route Concerns or
Comments
Labetalol (C) 1. IV Bolus Route:--
20 mg iv stat slowly over 2 min.
Observe for 10 min, if BP is not controlled
double the dose every time till either BP is
controlled or reached to maximum dose of
300 mg or undesirable side effects are seen.
2.For infusion:-
 40 ml/200 mg (10 Amp) of Labetalol in 250 ml
of IV fluid (NS/D-5/RL)
 Start infusion @ 20 mg/hr (30 ml/hr of such
solution or 8 drops/min).
 Wait for 30 min, if satisfactory response is not
obtained than double the dose after every 30
min until maximum dose of 160 mg/hr or
undesirable side effects are there.
 Once satisfactory response obtained, switch
over to oral Labetalol therapy.
3. Oral dose of Labetalol:-
200 -1200 mg per day in 2-3 divided doses
Because of a lower
incidence of maternal
hypotension and other
adverse effects, it is
the DOC.
It should be avoided in
women with asthma,
congestive heart
failure & any degree of
heart block.

15. Drugs for Urgent Control of Severe Hypertension in Pregnancy
Drug
(FDA
Risk*)
Dose and Route Concerns or Comments†
Alpha
Methyld
opa (B)
Oral dose:-
 250-500 mg TDS, Max up to 3 gm/day in 3-4
divided doses.
IV Infusion:-
 In hypertensive emergencies
250 to 500 mg IV over 30 to 60 minutes
every 6 hours up to a maximum of 1 g every
6 hours or 4 g/day.
Switch to the oral route at the same dosage
once blood pressure is under control.
Methyldopa is
contraindicated in patients
with active hepatic disease,
such as acute hepatitis and
active cirrhosis.
Nifedip
ine (C)
10 to 30 mg PO, 3-4 times/day. Max 120
mg/day.
 fast, irregular, pounding,
or racing heartbeat or
pulse
difficult or labored
breathing

16. Drugs for Urgent Control of Severe Hypertension in Pregnancy
Drug (FDA
Risk*)
Dose and Route Concerns or Comments†
Hydralazine
(C)
1. IV/IM Bolus
5 mg IV or IM
 Then 5 to 10 mg every 30
minutes;
 Once BP controlled repeat every
3 hours;
For infusion:-
 0.5 to 10.0 mg/h
A drug of choice
according to NHBEP;
long experience of safety
and efficacy
Causes uteroplacental
insufficiency , maternal
tachycardia
Nitroprusside
(C)‡
Constant infusion of 0.25 to 5.00
μg/kg per minute
DOC if Hypertensive
Encephalopathy.
Possible cyanide
toxicity if used for >4
hours; agent of last
resort

17. Drugs for Urgent Control of Severe Hypertension in Pregnancy
Drug (FDA Risk*) Dose and Route Concerns or Comments†
Clonidine ( C ) 0.2-04 mg PO/day Max 0.8
mg/day
 Rebound HTN including
hypertensive encephalopathy if
drug stopped suddenly.
 severe allergic reactions
Diazoxide (C) 30 to 50 mg IV every 15 minutes may arrest labor
 hyperglycemia
Nitroglycerin IV (C
)
5 mcg-20 mcg per min infusion Headache
Hypotension
Tachycardia
Continuous infusion >24 hours
produces tachyphylaxis

20. •Patellar reflexes disappear when the plasma magnesium level
reaches
• 10 mEq/L—about 12 mg/Dl —presumably because of a
curariform action. This sign serves to warn of impending
magnesium toxicity.
•When plasma levels rise above 10 mEq/L,
•breathing becomes weakened.
• At 12 mEq/L or higher levels,
• respiratory paralysis and respiratory arrest follow.
•magnesium is cleared almost exclusively by
• renal excretion
• Magnesium is anticonvulsant and neuroprotective- mechanisms
of action include: anticonvulsant action on cortex.
• blockage of calcium entry via voltage-gated channels (Arango,
2006; Wang, 2012a).

21. Magnesium safety and toxicity
Was recently reviewed by Smith and coworkers (2013). In more
than 9500 treated women, the overall rate of absent patellar
tendon reflexes was 1.6 percent; respiratory depression 1.3
percent; and calcium gluconate administration 0.2 percent.
They reported only one maternal death due to magnesium
toxicity.

22. Selective / Universal MgSO4 Prophylaxis

23. SOGC clinical practice guideline No. 258 - Recommendations
1 . For women with imminent preterm birth (≤ 31+6 weeks), antenatal
magnesium sulphate administration should be considered for fetal
neuroprotection . (I-A)
2 . Although there is controversy about upper gestational age, antenatal
magnesium sulphate for fetal neuroprotection should be considered from
viability to ≤ 31+6 weeks . (II-1B)
3 . For women with imminent preterm birth, antenatal magnesium sulphate for
fetal neuroprotection should be administered as a 4g IV loading dose, over 30
minutes, followed by a 1g/hr maintenance infusion until birth . (II-2B)
4 . For planned preterm birth for fetal or maternal indications, magnesium
sulphate should be started, ideally within 4 hours before birth, as a 4g IV
loading dose, over 30 minutes, followed by a 1g/hr maintenance infusion until
birth (II-2B)

24. Would you recommend corticosteroids for enhancing foetal lung maturity
for Mrs. A
Glucocorticoids for Lung Maturation
•Treatment does not seem to worsen maternal hypertension, and a decrease in
the incidence of respiratory distress and improved fetal survival has been cited.
•There is only one randomized trial of corticosteroids given to hypertensive
women for fetal lung maturation. This trial, by Amorim and colleagues (1999),
included 218 women with severe preeclampsia between 26 and 34 weeks who
were randomly assigned to betamethasone or placebo administration.
•Neonatal complications, including respiratory distress, intraventricular
hemorrhage, and death, were decreased significantly when betamethasone
was given compared with
•placebo.
•Thiagarajah 1984-role of glucocorticoids to ameliorate HELLP

26. The 2013 Task Force does not recommend corticosteroid treatment
for thrombocytopenia with HELLP syndrome.
A caveat is that in women with dangerously low platelet counts,
corticosteroids might serve to increase platelets
Mrs. A is being given expectant management, what are your guidelines for
monitoring her & her baby:

27. LOOK FOR ---WHILE WAITING
SYMPTOMS Physical Examination
•Headache
•Blurred or double vision
•Confusion
•Nausea ,Vomiting
•Epigastric or upper
abdominal pain
•Shortness of breath
•Uterine activity
•Vaginal bleeding
Upper Abdominal
tenderness
Tendon reflexes and clonus
Fluid intake and output
Daily weight

28. MUST DO—WHILE WAITING
Laboratory Testing (Twice weekly) Fetal Assessment
•Full blood count (FBC)
•Platelet count
•Serum transaminases
•Lactate dehydrogenase
•S. Creatinine
•Twice daily DFMC
•Daily CTG
•Twice weekly MBPP
•Weekly Doppler
•Growth scan every two
weeks
•Twice weekly Doppler if:
1. Presence of IUGR
2. Initial testing reveals
abnormal end-diastolic

30. What will be the maternal / foetal indications for delivery of Mrs. A
Expectant management of Severe Preeclampsia- Indications for immediate
delivery - Fetal indications
•Gestation more than or equal to 34 weeks
•33 - 34 weeks after steroid use
•Estimated fetal weight < 5th percentile by ultrasound
•Abnormal fetal testing
•Repetitive variable or late decelerations
•Biophysical profile BPP < 4 on 2 occasions at least 4 hours apart
•Persistent severe oligohydramnios ( AFI< 5 cm or maximum vertical pocket < 2
cm)
•Persistent REDF ON DOPPLER
•Rupture of membranes

31. Expectant management of Severe Preeclampsia- Indications for
immediate delivery - Maternal Indications
•Preterm labor or vaginal bleeding
•Eclampsia or encephalopathy
•Pulmonary edema or renal failure
•Persistent oliguria despite therapy
•Persistent thrombocytopenia
•Severe epigastric pain or cerebral symptoms
•Maternal request
•Severe hypertension unresponsive to maximum drug therapy
Mrs. A has now reached 32 weeks, foetal growth has marginally improved.
Doppler flows still show high resistance. BPS 8/10 but platelets have fallen to
60,000. What is the first diagnosis you would consider how further you would
confirm and manage

32. A
L
E
R
T

34. Now that HELLP has been dealt with we have to deliver the
patient. IOL Versus LSCS your preference and why? Mrs. A’s
Bishop’s score is 6. Protocol for management of labour
MgSO4, Antihypertensive, IV fluids
Platelets,FFP , blood along with
ice in heart and volcano in brain is all
needed

35. LABOUR MANAGEMENT
•Vaginal delivery preferred if possible,
cervical ripening can be done.
•Left lateral position
•IV fluids 75-125 ml/ hr. balanced salt
solution. Urine output should be
adequate
•Continuous EFM
•Assisted 2 stage
•Oxytocin 3 stage – no methergin
•Epidural analgesia can be used for pain
relief if coagulation profile normal
•For LSCS- regional anaesthesia is
preferred if NO COAGULOPATHY

36. Time to
Deliver

37. What post partum follow up you will advice for
Mrs. A?
All women with preeclampsia require close monitoring of vital signs,
fluid intake and output, lab values, and pulse oximetry for at least 48
hours after delivery

39. Thank You!!!