Clinical Seminar Presentation at Health Services Department Ignatius Ajuru University of Education 23/10/18

1. Hypertension in Pregnancy
Dr. Chinedu Ibeh(MBBS, MPH, MWACP)
Clinical Seminar Presentation
Health Services Department
Ignatius Ajuru University of Education
23/10/18

2. Learning objectives
● By the end of this presentation, we should be able to
○ Diagnose Hypertension in Pregnancy
○ Classify hypertensive disorders in pregnancy
○ Identify the risk factors
○ Elicit the Clinical features
○ Order relevant investigation
○ Manage and refer where necessary

3. Outline
•Introduction
•Epidemiology
•Hypertensive Disorders
•Chronic Hypertension
•Gestational Hypertension
•Preeclampsia/Eclampsia
● Chronic HPT
superimposed with
Preeclampsia
● Pathogenesis
● Risk factors/Clinical fxt
● Investigations
● Management

4. Introduction
● Hypertension is defined as having a blood
pressure greater than 140/90 mm Hg
● Gestational hypertension is BP >140/90
measured on 2 separate occasions, 4-6 hrs apart,
without proteinuria & dx after 20 wks of
gestation.

5. Epidemiology
● Leading cause of maternal deaths globally
○ Complicates about 2-10% of pregnancies.
○ with an estimated 50,000-60.000 preeclampsia
related deaths worldwide
● Incidence is 7x higher in developing countries
(2.8% of live births) than in developed countries
(0.4%).

6. Hypertensive Disorders in Pregnancy
● Chronic Hypertension
● Chronic Hypertension Superimposed with
Preeclampsia
● Gestational Hypertension
● Preeclampsia-Eclampsia

8. Hypertensive disorders cont.d
● Pre-eclampsia is gestational hypertension plus
proteinuria
● Severe pre-eclampsia involves a BP greater than
160/110, with additional medical signs and
symptoms.
● HELLP Syndrome is a type of preeclampsia:
○ Hemolytic anemia, elevated liver enzymes and

9. Hypertensive disorders cont.d
● Eclampsia: this is when
○ Tonic-clonic seizures appear in a pregnant
woman
○ with high blood pressure and
○ Proteinuria.
● Pre-eclampsia and eclampsia are components of a
common syndrome.

11. Risk factors
● Maternal causes
○ Obesity
○ Primiparity
○ Mothers under 20 or over 40 years old
○ Past history of DM, HTN, RD.
○ Adolescent pregnancy.
○ Chronic hypertension
○ New paternity.
○ Thrombophilia
○ Having a donated kidneys
● Pregnancy
○ Previous Preeclampsia
○ Multiple gestation (twins or
triplets, etc.)
○ Placental abnormalities:
■ Hyperplacentosis: Excessive
exposure to chorionic villi.
■ Placental ischemia.Family
history
Family history
○ Family history of preeclampsia.
○ African American race

12. Signs and Symptoms
● High blood pressure
is the major sign.
● Other signs specific
to relevant organ
damage
–Edema
–Sudden weight gain
–Blurred vision or sensitivity
to light
–Nausea and vomiting
–Persistent headaches
–Epigastric pains

13. Investigations
● Full blood count with platelet count
● Serum creatinine
● Liver function test
● 24 hr urine protein or protein or
● Protein creatinine ratio
● Obstetric scan
● Umbilical Artery Doppler

14. Diagnostic criteria: Gestational High BP +
● Proteinuria: >300 mg/24 hr urine; protein/creatinine
≥ 0.3; or Dipstick reading of 1+ OR
● Serum creatinine: >1.1mg/dL
● Platelet count: < 100, 000/uL
● LFT: Elevated concentrations of transaminases

15. Management
● No specific treatment,
● Close monitoring to rapidly identify
○ Pre-eclampsia and
○ its life-threatening complications
■ HELLP Syndrome and
■ eclampsia).
•

16. Management cont.d
● Close monitoring
○ Serial assessment of maternal symptoms and
fetal movement(daily by the woman)
○ Serial measurement of BP(2x weekly)
○ Assessment of platelets counts and liver
enzymes(weekly)

17. Management cont.d
● Drug treatment- options are limited,
○ Methyldopa,
○ Nifedipine
○ Hydralazine, and
○ Labetalol are most commonly used
○ Corticosteroids for lung maturity
● Delivery of Placenta
○ Timing of delivery: preeclampsia (no complication)= 37wks 0/7
○ plan for labor and delivery includes selection of a hospital with
provisions for advanced life support of newborn babies.

18. Mana Management cont.d:
Mode of delivery
● Vaginal or C/S
● This is determined by
○ Gestational age
○ Fetal presentation
○ Cervical status
○ Maternal conditions
○ Fetat conditions

19. Mana Management cont.d
● For women with severe preeclampsia ≥ 34 weeks,
delivery soon after maternal stabilization is advised
● For women with severe preeclampsia ≤ 34 weeks 0/7,
expectant management is recommended only in
facilities with adequate maternal and neonatal
intensive care facilities

20. Agents for urgent BP control in Pregnancy
Drug Dose Comments
Labetalol
10-20 mg IV, then 20-80 mg
every 20-30 mins to a max of
300mg
First line agent, fewer adverse
effects, contraindicated in
Asthma, CCF
Hydralazine
5 mg Iv or IM, then 5-10mg every
20-40mins
Higher or frequent doses
associated with maternal
hypotension, fetal distress
Nifedipine
10-20 mg orally, rpt in 30mins if
needed, then 10-20 mg every 2-6
hrs
May observe reflex tachycardia
or headache

21. Common Oral Antihypertensive Agents in Pregnancy
Drug Dose Comments
Labetalol 200-2400 mg/d orally in 2-3
divided doses
Avoid in patients with
Asthma and CCF
Nifedipine 30-120 mg/d orally of a slow
release preparation
Avoid sublingual form
Methyldopa 0.5-3g/d orally in 2-3 divided
doses
May not be effective in
control of severe
hypertension

22. MAGNESIUM SULFATE
● Effective anticonvulsant
● No CNS depression •
Indications:
● Severe Preeclampsia
● Eclampsia
● Mild Preeclampsia in labor - ?
● Not given to treat hypertension
Dosage Schedule
CONTINUOUS IV INFUSION •
● Loading Dose – 4-6 gms
MgSO4 in 100 ml of IV fluid
over 15 – 20 mins •
● Maintenance Infusion – 2 g/hr in
100 ml IV fluid

23. MAGNESIUM SULFATE
INTERMITTENT IM INJECTIONS
● Loading Dose – 4g 20% sol MgSO4
IV at rate not > 1g/min
● 5 g 50% MgSO4 deep IM to each
buttock (+ 1 ml 2% LIDOCAINE)
● If convulsions persist after 15 mins
2 g 20% IV at rate not > 1g/min
Maintenance –
● 5 g 50% deep IM every 4 hrs
● provided that:
○ urine output >100 ml/4 hrs
○ patellar reflex is present -
○ respirations are not
depressed

24. Place of Magnesium Sulfate
● For women with Severe Preeclampsia
○ Administration of intrapartum-postpartum
Magnesium Sulfate is recommended to prevent
eclampsia is recommended
● For women with Eclampsia
○ Parenteral Magnesium Sulfate is recommended
● For women with Preeclampsia undergoing C/S
○ Continued intraoperative administration of
Magnesium Sulfate is recommended to prevent
eclampsia is recommended
Loading dose
of 4-6 g
followed by a
maintenance
dose of 1-
2g/hr for at
least 24hrs.

25. Complications
Mother
● Severe hypertension
● Eclampsia
● HELLP Syndrome
● Abruptio placenta
● DIC
● Liver infarction
● Pulmonary edema
● Increased mortality
Fetus
● Prematurity
● Fetal Growth
restriction
● Fetal death

26. Prevention of Preeclampsia?
● Antiplatelet?
● Antioxidants?
● Salt Restriction?
● Calcium supplementation?
● Magnesium supplementation?
● Bed rest?
● Moderate Exercise?
● However, no concrete evidence yet to validate any of this in
preventing Preeclampsia

27. Going forward…
● For all women in postpartum period(Irrespective of
Preeclampsia status)
○ Educate them on signs and symptoms of
Preeclampsia and importance of prompt
reporting
● For postpartum women with preeclampsia
○ Parenteral Magnesium sulphate is advised

28. Finally...
● Thank you for your attention!
● Questions...
● Contributions...

29. Reference
Hypertension in pregnancy. Report of the American College of Obstetricians andGynecologists’ Task Force on
Hypertension in Pregnancy.
American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy.
Obstet Gynecol. 2013 Nov;122(5):1122-31. doi: 10.1097/01.AOG.0000437382.03963.88