This document provides guidelines for the management of hypertensive disorders during pregnancy, including pre-eclampsia. It discusses the epidemiology, risks, classification, pathophysiology, and management based on NICE guidelines. Key points include: hypertension complicates 10% of pregnancies, pre-eclampsia 2-8%; it is a leading cause of maternal death; risks include prematurity, fetal growth restriction, and maternal organ damage; treatment involves hospitalization, blood pressure monitoring, antihypertensive medications, timing of birth depending on gestational age and severity of symptoms.

1. Hypertensive disorders
during pregnancy:
Pre-eclampsia
NICE Guidelines Issued: Aug 2010 last modified: Jan 2011

2. Outline
Epidemiology
Risks to mother and baby
Classifying HTN in pregnancy
Pre-eclampsia
 Background
 Management (NICE guidelines)
 Anaesthetic considerations

3. Epidemiology
HTN affects 10% of all pregnancies
Pre-eclampsia complicates approx 2-8% of pregnancies
in UK
Severe pre-eclampsia complicates 0.25-0.5% of all
pregnancies in UK

4. Risk to mother
Second leading cause of maternal death in UK
 2006-2008 CMACE (previously CEMACH) Report:
 19 deaths attributed to pre-eclampsia/eclampsia
 0.83 per 100,000 mortalities
 1/3rd
of severe maternal morbidity is a consequence of
hypertensive disorders
 5% with severe pre-eclampsia or eclampsia admitted to ICU
Premature cardiovascular disease – chronic HTN, IHD,
CVE

5. Risk to baby
5% stillbirths in infants without congenital abnormality
occurred in women with pre-eclampsia (UK perinatal
mortality report)
Prematurity
 0.4% of women in their first pregnancy will give birth before
34 weeks as a consequence of pre-eclampsia
 8-10% of all preterm births result from HTN disorders
 Half of women with severe pre-eclampsia give birth pre-term
Small for gestational age babies
 20-25% of preterm births and 14-19% of term births in women
with pre-eclampsia being < 10th centile of birth weight for
gestation

6. Classifying hypertensive disorders
in pregnancy
Pre-existing/primary/essential HTN
Pregnancy induced HTN/gestational HTN - new onset
HTN in 2nd
half of pregnancy without significant
proteinuria (returns to normal within 3 months of
delivery)
Pre-eclampsia - new HTN presenting after 20 weeks with
significant proteinuria (can precede eclampsia)
Eclampsia - occurrence of seizures in a parturient who
may have no underlying pathology

7. Severity of hypertension
Mild HTN: DBP 90–99 mmHg, SBP 140–149 mmHg.
Moderate HTN: DBP 100–109 mmHg, SBP 150–159 mmHg.
Severe HTN: DBP > 110 mmHg, SBP > 160 mmHg

8. Key priorities of NICE guidance
Reducing the risk of hypertensive disorders in pregnancy
Management of pregnancy with chronic hypertension
Assessment of proteinuria in hypertensive disorders of
pregnancy
Management of pregnancy with gestational hypertension
Management of pregnancy with pre-eclampsia
Advice and follow up care at transfer to community care
NICE Guidelines Issued: Aug 2010 last modified: Jan 2011

9. Pre-eclampsia

10. Classic triad of symptoms
1. Hypertension
2. Proteinuria
3. Oedema

11. Pathophysiology (1)
CVS/RS
 Complex haemodynamically – relatively vasoconstricted
and hypovolaemic with a lower cardiac output, but total
body water increased
 More exaggerated responses to administered vaso-active
drugs and endogenous catecholamines
 Risk of pulmonary oedema due to low colloid oncotic
pressure and increased vascular permeability
 Narrowing of airways 2o
to mucosal oedema

12. Pathophysiology (2)
Renal
 Proteinuria (ischemic insult to glomeruli)
 Decreased GFR
 Decreased urate clearance so rising serum uric acid
 Occasionally oliguria
Haem
 Early on may get enhanced hypercoagulable state of
normal pregnancy
 Later on platelet activation and consumption increased
hence thromobocytopenia (15% of severe pre-eclampsia_
 DIC in 7% of severe pre-eclampsia

13. Pathophysiology (3)
Hepatic
 Abnormal LFTs
 Epigastric pain (tension on capsule of liver caused by
oedema or intrahepatic haemorrhage)
 HELLP
Neuro
 Headaches, visual disturbances, hyper-reflexia
 Seizures (eclampsia)
 Cerebral vasospasm (MRI, intracranial doppler studies),
cerebral oedema
 Intracranial haemorrhage

14. Pathophysiology (4)
Fetal
 Fetal compromise such as IUGR or oligohydramnios
 Poor placental perfusion
 Increased sensitivity to changes in maternal BP

15. Features of severe pre-eclampsia:
 severe HTN & proteinuria or
 mild or moderate HTN and proteinuria with >=1 of the following:
 symptoms of severe headache
 problems with vision, such as blurring or flashing before eyes
 severe pain just below ribs or vomiting
 Papilloedema
 signs of clonus (≥3 beats)
 liver tenderness
 HELLP syndrome
 platelet count falling to < 100
 abnormal liver enzymes (ALT or AST > 70)

16. Risk factors for pre-eclampsia

17. Aetiology of pre-eclampsia
 Not really known
 Only occurs in presence of placental tissue
 Defective invasion of the spiral arteries by cytotrophoblast cells,
so the low-pressure high-flow circulation necessary for fetal
well-being fails to occur
 ? Related to inhibition of nitric oxide pathway
 Increased uterine arterial resistance placental ischaemia
 Oxidative stress release of free radicals, cytokines, VEGF
endothelial dysfunction, vascular hyperpermeability, multi
organ dysfunction
 ? Dependent on immunological and genetic factors

18. Management of pregnancy
with pre-eclampsia
NICE Guidelines Jan 2011

19. Treatment of hypertension
Offer women with pre-eclampsia an integrated package
of care covering admission to hospital, treatment,
measurement of BP, testing for proteinuria and blood
tests
All women who have had pre-eclampsia should be
offered a medical review at the postnatal review (6–8
weeks after the birth)

20. Table 2 Management of pregnancy with pre-eclampsia
Degree of
hypertension
Mild hypertension
(140/90 to 149/
99 mmHg)
Moderate hypertension
(150/100 to 159/
109 mmHg)
Severe hypertension
(160/110 mmHg or
higher)
Admit to
hospital
Treat
Measure
blood
pressure
Test for
2nd
line anti-HTN agents methyldopa, nifedipine – only offer after
considering side-effect profiles for the woman, fetus and newborn baby

21. Measure
blood
pressure
Test for
proteinuria
Blood tests
Table 2 Management of pregnancy with pre-eclampsia
Degree of
hypertension
Mild hypertension
(140/90 to 149/
99 mmHg)
Moderate hypertension
(150/100 to 159/
109 mmHg)
Severe hypertension
(160/110 mmHg or
higher)
Admit to
hospital
Treat
Measure
blood
pressure
Test for
proteinuria

22. Timing of birth (1)
Consultant obstetrician should document in the woman's
notes the maternal (biochem, haem, clinical) and fetal
thresholds for elective birth before 34 weeks in women
with pre-eclampsia
Consultant obstetrician should write a plan for
antenatal fetal monitoring during birth

23. Timing of birth (2)
Manage pregnancy in women with pre-eclampsia
conservatively until 34 weeks
Offer birth to women with pre-eclampsia < 34 weeks,
after discussion with neonatal & anaesthetic teams & a
course of corticosteroids has been given if:
 severe hypertension develops refractory to treatment
 maternal or fetal indications develop as specified in the
consultant plan
Recommend birth for women who have pre-eclampsia
with severe HTN > 34 weeks when their BP has been
controlled & a course of corticosteroids has been
completed

24. Timing of birth (3)
Offer birth to women who have pre-eclampsia with mild
or moderate hypertension at 34+0 to 36+6 weeks
depending on maternal and fetal condition, risk factors
& availability of neonatal intensive care
Recommend birth within 24–48 hours for women who
have pre-eclampsia with mild or moderate HTN after
37+0 weeks

25. Post natal investigation,
monitoring and treatment
In women with pre-eclampsia who did not take anti-HTN
treatment and have given birth, measure BP:
 at least 4x/day whilst inpatient
 at least 1x between day 3 and day 5 after birth
 on alternate days until normal if BP was abnormal on days
3–5.
In women with pre-eclampsia who did not take anti-HTN
treatment & have given birth, start anti-HTN treatment
if BP is > 150/100 mmHg

26. Post natal investigation,
monitoring and treatment
Ask women with pre-eclampsia who have given birth
about severe headache & epigastric pain each time BP is
measured
In women with pre-eclampsia who took anti-HTN
treatment & have given birth, measure BP:
 at least 4x/day while the woman is an inpatient
 every 1–2 days for up to 2 weeks after transfer to
community care until the woman is off treatment and has
no HTN

27. Post natal investigation,
monitoring and treatment
For women with pre-eclampsia who have taken anti-HTN
treatment & have given birth:
 continue antenatal anti-HTN treatment
 consider reducing anti-HTN treatment if their BP falls
below 140/ 90 mmHg
 reduce anti-HTN treatment if their BP falls below 130/80
mmHg
If a woman has taken methyldopa to treat pre-
eclampsia, stop within 2 days of birth

28. Post natal investigation,
monitoring and treatment
Offer women with pre-eclampsia who have given birth
transfer to community care if all of the following
criteria have been met:
 there are no symptoms of pre-eclampsia
 BP, with or without treatment, is 149/99 mmHg or lower
 blood test results are stable or improving
Offer women who have pre-eclampsia & are still on
anti-HTN treatment 2 weeks after transfer to
community care a medical review

29. Haem & Biochem monitoring
In women who have pre-eclampsia with mild or
moderate HTN, or after step-down from critical care:
 Measure plt, transaminases, creatinine 48–72 hours after
birth or step-down
 Do not repeat these tests if results are normal at 48–72
hours
 If improving but still abnormal, or if not improving, then
rpt as clinically indicated
 In women with pre-eclampsia who have given birth and
have stepped down from critical care level 2, do not
measure fluid balance if creatinine is within the normal
range

30. Fetal monitoring (1)
CTG at diagnosis of pre-eclampsia
If conservative management of pre- eclampsia is
planned, carry out the following tests at diagnosis:
 ultrasound fetal growth & amniotic fluid volume
assessment
 umbilical artery doppler velocimetry
If results of all monitoring normal then do not routinely
repeat CTG more than weekly
In women who are at high risk of pre-eclampsia, only
carry out CTG if fetal activity is abnormal

31. Fetal monitoring (2)
Repeat CTG if any of the following:
 woman reports a change in fetal movement
 vaginal bleeding
 abdominal pain
 deterioration in maternal condition
For women with pre-eclampsia, write a care plan that
includes:
 the timing and nature of future fetal monitoring
 fetal indications for birth and if and when corticosteroids
should be given
 when discussion with neonatal paediatricians and obstetric
anaesthetists should take place and what decisions should
be made

32. Intrapartum care
During labour, measure BP:
 hourly in women with mild or moderate HTN
 continually in women with severe HTN
Continue use of antenatal anti-HTN treatment during
labour
Do not preload women who have severe pre-eclampsia
with IV fluids before establishing low-dose epidural
analgesia and combined spinal epidural analgesia

33. Managing 2nd
stage of labour
Do not routinely limit the duration of the second stage
of labour:
 in women with stable mild or moderate HTN or
 If BP is controlled within target ranges in women with
severe HTN
Recommend operative birth in the second stage of
labour for women with severe HTN whose HTN has not
responded to initial treatment

34. Medical management of severe pre-
eclampsia in critical care setting
Give IV magnesium sulphate if woman in critical care
has severe pre-eclampsia and has or previously has had
an eclamptic fit
Consider IV magnesium sulphate if severe pre-eclampsia
in critical care setting and birth is planned within 24
hours

35. Collaborative Eclampsia Trial regimen for
administration of magnesium sulphate
loading dose of 4 g should be given IV over 5 minutes,
followed by an infusion of 1 g/hour maintained for 24
hours
recurrent seizures should be treated with a further dose
of 2–4 g given over 5 minutes
NB. Do not use diazepam or phenytoin as an alternative to
magnesium sulphate in women with eclampsia

36. Anti-hypertensives in critical care
setting (1)
Treat women with severe HTN who are in critical care
during pregnancy or after birth immediately with one of
the following:
 labetalol (PO or IV)
 hydralazine (IV)
 nifedipine (PO)
In women with severe HTN who are in critical care,
monitor their response to treatment:
 to ensure that their BP falls
 to identify adverse effects for both the woman and fetus
 to modify treatment according to response

37. Anti-hypertensives in critical care
setting (2)
Consider using up to 500 ml crystalloid before or at
same time as the first dose of IV hydralazine in the
antenatal period
In women with severe HTN who are in critical care, aim
to keep SBP below 150 mmHg and DBP 80-100 mmHg

38. Corticosteroids in fetal lung
maturation
If birth is considered likely within 7 days in women with
pre-eclampsia:
 give two doses of betamethasone 12 mg IM 24 hours apart
in women between 24 and 34 weeks
 consider giving two doses of betamethasone 12 mg IM 24
hours apart in women between 35 and 36 weeks
NB. Do not use dexamethasone or betamethasone for
the treatment of HELLP syndrome

39. Fluid balance and volume
expansion
Do not use volume expansion in women with severe pre-
eclampsia unless hydralazine is the antenatal anti-
hypertensive
In women with severe pre-eclampsia, limit maintenance
fluids to 80 ml/hour unless there are other ongoing fluid
losses (for example, haemorrhage)

40. Indications for referral to
critical care level

42. Advice and follow up care at
transfer to community care (1)
Tell women who had pre-eclampsia that their risk of
developing:
 Gestational HTN in a future pregnancy ranges from 1 in 8
(13%) to 1 in 2 (53%) pregnancies
 Pre-eclampsia in a future pregnancy is up to about 1 in 6
(16%) pregnancies
 Pre-eclampsia in a future pregnancy is about 1 in 4 (25%)
pregnancies if their pre- eclampsia was complicated by
severe pre-eclampsia, HELLP syndrome or eclampsia and
led to birth before 34 weeks, and about 1 in 2 (55%)
pregnancies if it led to birth before 28 weeks

43. Advice and follow up care at
transfer to community care (2)
Increased risk of developing HTN
Relative risk of end stage renal disease increased but
absolute risk is low
Do NOT require routine screening for thrombophilia

44. Anaesthetic considerations (1)
Fluid balance and haemodynamics
 Pulmonary and pharyngeal oedema
 Pre-renal oliguria
 ? Need for invasive monitoring to guide fluid management
(art/CVC)
 Avoid or reduce pre-loading
Coagulation
 Impact on use of regional anaesthesia
 Epidural analgesia for vaginal delivery

45. Anaesthetic considerations (2)
Choice of anaesthetic in c-section
 Epidural vs Spinal vs GA
Potential difficult intubation – range of ETTs and
laryngoscopes and intubation aids
Use of drugs to attenuate hypertensive response to
laryngoscopy
 Magnesium, labetalol, nitrates, SNP, opioids, lignocaine
Interaction of magnesium and muscle relaxants (increased
sensitivity)

46. References
 http://www.oaa-anaes.ac.uk/assets/_managed/editor/File/Reports/2006-2008_CEMD_e
8th report of the Confidential Enquiries into Maternal Deaths in the United
Kingdom (2011)
 Hypertension in Pregnancy:The management of hypertensive disorders during
pregnancy. NICE Guidelines Issued: Aug 2010 last modified: Jan 2011
 Anaesthesia UK http://www.frca.co.uk/article.aspx?articleid=100463 Dr DJ
Dalgleish (2006)
 Oxford Handbook of Anaesthesia; Allman KG, Wilson IH (2012)
 The Eclampsia Trial Collaborative Group (1995) Which anticonvulsant for
women with eclampsia?
 Pre-eclampsia: pathophysiology, diagnosis, and managementhttp
://www.ncbi.nlm.nih.gov/pmc/articles/PMC3148420/ Vasc Health Risk
Manag. 2011; 7: 467–474