This document discusses hypertensive disorders in pregnancy, including chronic hypertension, pregnancy-induced hypertension, preeclampsia, eclampsia, and HELLP syndrome. It defines each condition and describes their signs, symptoms, risk factors, pathophysiology, investigations, complications and management approaches. Chronic hypertension refers to high blood pressure before 20 weeks of gestation. Pregnancy-induced hypertension occurs in the second half of pregnancy without proteinuria. Preeclampsia involves high blood pressure and proteinuria after 20 weeks. Eclampsia is preeclampsia with seizures. HELLP syndrome involves hemolytic anemia, elevated liver enzymes and low platelets. Prompt delivery is often needed to manage severe forms of

1. HYPERTENSIVE
DISORDER IN
PREGNANCY
BY;
DR.MALIHA

2. HYPERTENSION
• Hypertension is defined as changes of blood pressure recorded on at least 2-
ocassions of either:
• Diastolic BP > 90 mmHg,
• Systolic BP > 140 mmHg,
• Hypertensive diseases in pregnancy may be:
• Chronic (pre-existing) hypertension
• Pregnancy-Induced hypertension
• Pre-eclampsia
• Eclampsia
• HELLP syndrome

3. CHRONIC HYPERTENSION:
• It refers to BP of 140/90 mmHg before the start of pregnancy or before 20 weeks'
gestation.
• It is of a different etiology from pre-eclampsia, although it can predispose to the later
development of superimposed pre-eclampsia.
Causes:
• Essential hypertension (90%)
• Collagen vascular disease
• Coarctation of the aorta
• Renal disease:
Complications ;
• Maternal Risks:
• Pre-eclampsia
• Placental abruption
• Heart failure
• Intracerebral hemorrhage
•

4. FETAL COMPLICATIONS
• Placental insufficiency
• Growth restriction
• Preterm delivery
• Increased morbidity and mortality
Investigations:
• Creatinine, Urea & Electrolyte
• LFTS
• 24-hour urinary protein/creatinine clearance
• Renal scan
• Autoantibody screen
• ECG and Echocardiography
Management
• Mild Cases ie BP < 150/100
• No immediate indication to treat.
• Serial sonograms and antenatal testing
• Serial BP and urine protein assessment
• induce labour at term if the cervix is favorable.

5. SEVERE CASES:
• Start antihypertensive medication, the drug of choice being “methyldopa".
• Labetalol (a & B-blocker) and Nifedipine (calcium channel blocker) are acceptable
alternatives.
• The aim of anti-hypertensive medication is to maintain BP < 160/100 mmHg.
• Serial BP and urine protein assessment for early identification of super-imposed
preeclampsia.
• Mode of delivery:
• Await spontaneous labour
• Attempt vaginal delivery at 38 weeks' gestation
• If delivery planned before 34 weeks' mother should be given steroids for fetal lung
maturity.
• Continuous fetal monitoring is required in labour if the fetus is growth restricted.
•

6. 2. PREGNANCY-INDUCED HYPERTENSION:
• Also known as “gestational hypertension".
• It is defined as HTN arising for the first time in the second half of pregnancy and in the
absence of proteinuria.
• It is not associated with adverse pregnancy outcome and as such should be clearly
distinguished from pre-eclampsia.
• BP usually returns to pre-pregnancy limits within 6 weeks of delivery.
Diagnosis:
• No symptoms of pre-eclampsia are seen.
• Physical findings are unremarkable for pregnancy
• Laboratory tests are unremarkable and proteinuria is absent.
• The key findings are sustained elevation of BP>
Management:
• Conservative outpatient management is appropriate.
• Appropriate laboratory testing should be performed to rule out preeclampsia Delivery
should be aimed at the time of EDD
•

7. PRE-ECLAMPSIA:
• It is defined as
• HTN of at least 140/90 mmHg recorded on two separate occasions, at least 4 hours apart.
• In the presence of at least 300 mg protein in a 24-hour collection of urine
• Arising after the 20th week of gestation in a previously normotensive women.
• Resolving completely by the sixth week postpartum.
Risk Factors:
• Previous severe and early onset preeclampsia
• Extremes of age (>40 or < 18)
• Family history
• Obesity
• Primiparity
• Multiple pregnancy
• Long birth interval (>10 years)
• Fetal hydrops
•

8. • Hydatidiform mole
• Pre-existing medical conditions:
• Hypertension, Renal disease, Diabetes, Antiphospholipid antibodies,
PATHO-PHYSIOLOGY
• Trophoblast Invasion:
• Preeclampsia is clinical manifestation of failure of trophoblast invasion of the myometrial segments
of the spiral arteries.
• Due to this deficient trophoblast invasion, the small narrow caliber "Spiral Arteries which supply the
intervillous space, cannot transform into large “Sinusoidal Vessels.
• These changes don't allow the normal transformation of vascular supply to a low pressure, high-
flow system, resulting in inadequate blood flow to the placenta and fetus.

9. PATHOPHYSIOLOGY OF PRE ECLAPSIA

10. PATHOPHYSIOLOGY

11. SIGN AND SYMPTOMS

12. ORGAN-SPECIFIC CHANGES
• Cardiovascular system:
• Generalized vasospasm
• Increased peripheral resistance
• Reduced central venous pressure
• Hematological Changes
• Platelet activation and depletion
• Coagulopathy
• Decreased plasma volume
• Increased blood viscosity
• Renal Changes
• Proteinuria
• Decreased Glomerular filtration rate
• Decreased urate excretion
• Liver:Periportal necrosis, Subcapsular hematoma
• CNS: Cerebral edema, Cerebral hemorrhage

13. INVESTIGATIONS & COMPLICATIONS
• Investigations:
• Urinalysis by dipstick (quantitatively inaccurate)
• 24-hour urine collection (total protein & creatinine clearance)
• Full blood count
• Coagulation profile
• Blood chemistry (renal function, protein concentration)
• Plasma urate concentration
• Liver function
• Ultrasound assessment of:
• Fetal size,Amniotic fluid volume,Maternal and fetal well being,Dopplers U/S
•

15. Maternal Deaths: Most of the matemal deaths are due to failure to recognize a deteriorating
condition after delivery and result from multiple organ failure.
Mild preeclampsia:
• It is defined as BP <160 systolic and <110 diastolic with significant proteinuria and no maternal
complication
Signs:
• Elevation of BP, Fluid retention (non-dependent edema), Brisk reflexes, Ankle clonus, Uterus and
fetus small for gestational age
Management:
• Management is based on gestational age:
• Before 36 weeks' Gestation:
• Conservative inpatient management as long as the mother and fetus are stable.
Guidelines include:
• Monitoring BP every 4 hours
•

16. • Daily urine dipstick for protein.
• Daily fetal assessment with CTG
• Twice weekly 24-hour urine protein assessment.
• Weekly LFTs and electrolytes
• Regular U/S assessment
• Antihypertensive Drugs
• After 36 weeks' Gestation:
• Delivery is indicated: After 36 weeks' weeks gestation Or when the mother and fetus are
unstable after conservative management
• Dilute IV oxytocin is used for induction of labour.
• Continuous infusion of IV MgSO4 to prevent eclamptic seizures.

17. SEVERE PREECLAMPSIA:
• fined as BP > 160 systolic or > 110 diastolic in the presence of significant proteinuria or if maternal
complications occur.
Signs & Symptoms:
• Symptoms:
• Fontal headache, Visual disturbance, Epigastric pain, General malaise and nausea & Restlessness
• Signs:
• Agitation, Hyper-reflexia , Facial and peripheral edema, Right upper quadrant tenderness, Poor urine output
Management:
• Aggressive prompt delivery is indicated for severe preeclampsia at any gestational age.
• Administer IV MgSO4 to prevent convulsions.
• Lower BP using Labetalol or IV hydralazine.
• Methyldopa and nifedipine can be used too, but methyldopa is slow-acting (oral route) and nifedipine causes
severe headache.
• Attempt vaginal delivery with IV oxytocin infusion if mother and fetus are stable.
• However, delivery before term is usually be Caesarean section.
• If delivery is before 34 weeks, IM steroids (betamethasone) should be given to mother, for fetal lung
maturity,
•

18. ECLAPSIA

19. ECLAMPSIA:
• Eclampsia is defined as grand mal convulsions occurring in a woman with established
preeclampsia, in the absence of any other neurological or metabolic cause.
• Eclampsia is an obstetric emergency, and is a serious and life-threatening complication of
preeclampsia.
• Convulsions may occur antenatally (38%), intrapartum (18%), or postnatally within 48
hours(44%).
• Any convulsion in pregnancy should be considered to be eclamptic until proved otherwise.
Investigations:
• Test the urine for protein .
• Full blood count
• Clotting studies
• Urea/creatinin
• Liver function tests
• serum electrolytes , blood suger
Management:
• Call for help – senior obstetrician and anesthetist
• Maintain airway, breathing, and circulation
• Maintain IV line

20. Antihypertensive drugs:
• IV hydralazine : Direct relaxation of arteriolar smooth muscle
• Labetalol : Alpha- and beta-blocker
Anticonvulsant drugs:
• MgSO4 is the drug of choice.
• It acts as cerebral vasodilator and membrane stabilizer.
• IV bolus of 5 g to stop seizures, continuing maintenance infusion rate of 2 g/h.
• Overdose is associated with respiratory depression and cardiac arrest.
• Overdose can be reversed with Calcium gluconate.
Fluid Balance:
• Fluid restrict the patient to 100 ml/hour due to risk of pulmonary edema.
• Monitor renal function with the creatinine.
• If oliguria develops maintain CVP line.
• Avoid diuretics (decrease intravascular volume)
Delivery:
• It is the only definitive cure at any gestational age after stabilization of mother and the fetus.
• Vaginal delivery is not contraindicated if the cervix is favourable, and should be attempted with
IV oxytocin infusion.
•

21. • It gestation is<34 weeks steroids should be given to improve fetal lung maturity.
• Delivery is often by C-section
Indications for Urgent Delivery:
• BP persistently at 160/100 mmHg
• Elevated liver enzymes
• Low platelet count
• Eclamptic fit
• Anuria &Significant fetal distress
HELLP Syndrome:
• • It is a combination of hemolysis, elevated liver enzymes,and low platelets.
• It is seen in 5-10% of cases of severe pre-eclampsia.
Symptoms:
• Epigastric or RUQ pain (65%)
• Nausea and vomiting (35%)
Signs:
• Tenderness in Right Upper Quadrant (RUQ).
• Increased BP and other features of preeclampsia.

22. Complicatlons & Management:
Complication:
• DIC
• Placental abruption
• Fetal demise
• Ascites
• Hepatic rupture
Management:
• Prompt delivery at any gestational age is appropriate
• Use of maternal steroids may enchance postpartum normalization of liver enzymes
and platelet count.