SLIDE HPT IN PREGNANCY MFM

1. Hypertension in
pregnancy
DR SHARI NOR
MFM CONSULTANT
SWCH

2. Introduction
Definition
Classification
Prediction
Prevention
Treatment
Recurrence risk

4. Cause of death due to HDP
Year Deaths from HDP Total of maternal death Percentage
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
18
18
18
12
20
22
25
14
18
24
25
170
131
122
124
125
127
136
133
154
147
130
10.6
13.7
14.8
9.7
16.0
17.4
15.1
10.6
11.7
16.3
20.0
TOTAL 214 1,499 16.2%
Commonest medical disorder in pregnancy
5th leading cause maternal death
Increasing number of maternal death

5. DEFINITION OF HYPERTENSION
•Systolic blood pressure ≥ 140 mmHg and/or
Diastolic blood pressure ≥ 90 mmHg
–At least 2 BP reading
–4 hours apart (ambulatory), overnight rest
(hospitalization)
1. Guideline management of HDP - Society of Obstetrics
Medicine Australia & New Zealand 2008

6. Recording BP
Position
◦ Hospitalization –
◦ Ambulatory- sitting
Apparatus
◦ Mercury sphygmomanometer
◦ Aneroid, automated device
◦ Correct cuff size
SBP- first sound heard (K1)
DBP- disappearance of sounds completely (K5)
Where K5 is absent, K4 (muffling) isaccepted.

7. Blood pressure should be measured with the woman rested and seated at a
45-degree angle with the arm at the level of the heart.
Appropriate sized cuff should be used.
To avoid incorrect measurement of blood pressure, if the mid-arm
circumference is greater than 33 cm, a large cuff should be used.

9. Classification of hypertension
in pregnancy
-isshp 2013-
Chronic hypertension Gestational hypertension
Pre eclampsia (de novo or
superimposed on chronic
hypertension )
White coat hypertension
Classification

10. Chronic hypertension
High BP predating pregnancy
Due to secondary causes of hpt (5-10%):-
- vascular disorders
-Endocrine disorders
--renal disorders
About 90-95% of chronic hpt is due to essential hpt

11. Proteinuria
spot urine protein/creatinine >30 mg/ mmol or
>300mg/day or
at least 1g/L [‘2 + ’] on dipstick testing)
-It’s the presence or absence of proteinuria that is
important
-only when spot urine protein/creatinine ratio is above
230mg/mmol (nephrotic range)
-isshp-

12. Other maternal organ dysfunction
Uteroplacental dysfunction
􏰀 renal insufficiency
􏰀 liver involvement
􏰀 neurological complications
􏰀 hematological complications
􏰀 f etal growth restriction

13. White coat hypertension
Up to one in four patients with elevated clinic or office blood pressure
have white coat hypertension
Ambulatory blood pressure (ABP)
-blood pressure (BP) at regular intervals
-usually every 20–30 minutes over a 24 hours
-while patients undergo normal daily activities, including sleep.

15. Pathophysiology
Poor placentation
•Impaired trophoblast
invasion
•Failure to destroy
muscular layer of spiral
arterioles
Placental oxidative
stress
•Poorly perfused
placenta
Stimulation of a
systemic
inflammatory
response
•Antiangiogenic factors
•Diffused maternal
endothelial dysfunction

16. Prediction and prevention
Early recognition of women at risk of preeclampsia will enable the
identification of high-risk women who may benefit from enhanced
surveillance and prophylaxis

17. Clinical history
Risk factors assessed in screening for pre-eclampsia:
age; risk of pre eclampsia is almost doubled in women over 40 years of
age
parity; risk of pre-eclampsia is tripled in nulliparous women
a family history of preeclampsia; risk of pre-eclampsia is tripled in
women with a family history of pre-eclampsia —

18. multiple pregnancy; risk of pre-eclampsia is tripled in
women with multiple pregnancies
history of pre-eclampsia in a previous pregnancy, especially
if severe or early onset ; even increased seven-fold in
women who have had pre-eclampsia in a previous
pregnancy
pre-existing medical conditions such as diabetes, chronic
hypertension, renal disease, thrombophilias and
autoimmune disease

19. Biochemical markers
Uric acid Renal impairment and an increased breakdown of purines in
the ischaemic placenta leading to overproduction of uric acid
may explain increased serum uric acid levels in pregnant
women destined to develop pre-eclampsia.
Proteinuria Early detection of proteinuria in women with new-onset
hypertension helps to differentiate those women with pre-
eclampsia from gestational hypertension, thereby influencing
further management.
Maternal
fibronectin
Inflammation vascular injury is generally associated with
increased expression of fibronectin, particularly in the blood
vessel walls.

20. PAPP-A in chromosomally normal pregnancies, there is evidence
that low maternal serum PAPP-A is associated with an
increased risk of subsequently developing PE.
PP13 low PP13 in the first trimester seems to be a better
predictor of early onset and severe PE than mild PE at term
Angiogenic
factors (sfLt)
A cleaved form of soluble-Flt-1 has been reported to
increase during third trimester in women who will develop
PE within five weeks and at the time of the disease
Angiogenic
factoe (PIGF)
PE is associated with decreased serum PlGF in the early
onset5
Angiogenic
factor (seng)
Soluble endoglin (sENG) was also observed to increase in PE

21. heamodynamics
Poor placentation with deficient remodeling of the spiral arteries has
been associated with subsequent development of the early-onset forms
of PE, IUGR, and other associated complications
A feature of uterine artery screening is that the detection rates are
better for the pre-term and/or early form of PE than for severe or mild
PE

23. Prediction in our practice
1st TM biochemical (11-13w)
PAPPA, PLGF
20w UAD scan
2nd tm (16w) Sflt

24. Aspirin
Activation of platelets, as well as an imbalance of thromboxane–
prostacyclin activity occurs during the pre- clinical phase of pre-
eclampsia.
It showed that anti-platelet agents reduce the risk of pre-eclampsia by
17%
NICE GUIDANCE advises women at high risk or more than one moderate
risk of preeclampsia to take 75 mg of aspirin daily from 12 weeks until
the birth of the baby

25. high risk
1. hypertensive disease during a previous pregnancy
2. chronic kidney disease
3. autoimmune disease such as systemic lupus
erythematosis or antiphospholipid syndrome
4. type 1 or type 2 diabetes
5. chronic hypertension.

26. Calcium supplementation
Calcium acts by reducing smooth muscle contractility and
vasoconstriction by its effect on parathyroid and intracellular calcium. It
might also have an indirect effect on smooth muscle function by
increasing magnesium levels.
The Cochrane review of trials found that calcium supplementation
during pregnancy is a safe and relatively cost-effective means of
reducing the risk of high blood pressure in women with increased risk,
and women with low dietary calcium

27. recommendation
A daily intake of at least 1 g (e.g. 1.5–2 g) of calcium reduces the
incidence of pre-eclampsia in high-risk women and women with low
dietary intake of calcium

28. Management of chronic hypertension

29. Management of chronic hypertension

30. Management of chronic hypertension

31. Management of gestational
hypertension

32. Management of chronic hypertension

33. Management of chronic hypertension

34. Management of chronic hypertension

35. Management of chronic hypertension

36. Management of chronic hypertension

37. Management of chronic hypertension

38. Management of chronic hypertension

39. Management of chronic hypertension

40. Management of chronic hypertension

41. Management of chronic hypertension

42. Management of chronic hypertension

43. Management of chronic hypertension

44. Women with pre-eclampsia are admitted to hospital
and be monitored daily
Allow outpatient monitoring once patient is stable,
has easy access to monitoring services and can be
readmitted to hospital if her clinical condition
deteriorates
Consider inpatient monitoring until delivery if
indicated
Management of chronic hypertension

45. DO NOT treat mild hypertension
To measure blood pressure at least 4
times a day
Test kidney function, FBC, electrolytes,
transaminases and bilirubin
Management of PRE ECLAMPSIA

47. When to refer to critical care…

50. MgSO4
◦ Severe pe
◦ Fit
◦ Consider delivery within 24 h
Do not use diazepam or phenytoin as
an alternative
Loading 4g over 5 min
Infusion 1g/h for 24 h
2-4g over 5 min if recurrent seizure

56. Postnatal care
POST PARTUM

58. Postnatal follow up

59. Long term health risk