This document discusses hypertensive disorders of pregnancy, including definitions, classifications, signs and symptoms, risk factors, pathophysiology, diagnosis, and management of conditions such as chronic hypertension, preeclampsia, eclampsia, and gestational hypertension. Key points include: - Hypertension is a leading cause of maternal death. Preeclampsia accounts for 80% of hypertensive disorders and occurs more frequently in young or older primigravid women. - Preeclampsia is defined as new hypertension and proteinuria after 20 weeks of gestation. It is a multisystem syndrome caused by abnormal placentation leading to endothelial dysfunction. - Management involves monitoring for worsening

1. Hypertensive Disorders of Pregnancy
Hypertension: High: blood pressure: elevation of
the arterial BP above the normal range(>140/90)
• Is the second common cause of maternal death.
Note:
– Measure the BP in the sitting position with cuff at the
level of the heart.
– Allow the mother to sit 5 – 10 minutes before
measuring
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2. HTN cont..
Classification:
• There are more than 80 ways of classifying
hypertensive disorders of pregnancy.
Let us the see one of them:
1. Chronic hypertension
2. Pregnancy Aggravated hypertension(PAH)
– Preeclampsia superimposed on chronic hypertension
3. Pregnancy induced hypertension (PIH)
– Pre eclampsia- eclampsia
– Gestational hypertension
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3. HTN Cont…
Pregnant woman with BP > 140/90mmHg
Before 20 Weeks > 20 weeks
No proteinuria Proteinuria No proteinuria Proteinuria
Chronic HTN Pre eclampsia Gestational HTN Preeclampsia
Superimposed on
Chronic HTN
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4. HTN Cont…
1. Chronic hypertension: Elevated BP that
predates the pregnancy, documented before
20 weeks of pregnancy, or present 6 weeks
postpartum
• Diagnosis is made if BP is raised on two
consecutive occasions with at least 4 hours
interval.
A. Mild chronic HTN: BP <160/100 mmHg
B. Severe Chronic HTN: BP > 160/110mmHG
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5. HTN Cont…
2. Pre eclampsia- eclampsia: Elevated BP and proteinuria
that occurs after 20 weeks of gestation. Eclampsia is
the severe form of preeclampsia, the new onset of
seizure or coma in a woman with pre eclampsia.
3. Pre eclampsia superimposed on chronic HTN:
• An acute increase in the level of hypertension and new
onset of protienuria, in a woman with chronic HTN
4. Gestational HTN: Elevated BP without protienuria
developed after 20 weeks of gestation in regresses
postpartum
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6. HTN Cont…
1. Pre Eclampsia
Incidence: B/n 5 – 8 % of all pregnancies are
complicated by hypertension and therefore
those preeclampsia acoounts for 80%.
• Occurs more frequently in:
– Young primigravidae
– First pregnancies from new partner
– Mother over 35 years of age
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7. HTN Cont…
Pathophysiology of Pre eclampsia:
• It is important to distinguish preeclampsia
from chronic or gestational HTN.
• Pre eclampsia is more than HTN; its systemic
syndrome, and several of its ‘non
hypertensive’ complications can be life
threatening when BP elevations is quite mild.
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8. HTN Cont…
Etiology/Causes:
• The exact cause is unknown but it is taught to
be due to abnormal placentation; the
physiological changes in the uteroplacental
arteries do not extend beyond the
deciduomymetrial junction leaving a
constricting segment b/n radial arteries and
decidual portion leading to HTN.
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9. HTN Cont…
Pathological Changes:
• In normal pregnancy CO, HR, and blood
volume increase while peripheral resistance
and responsiveness to angeotensin II decrease
 No hypertension.
• In pre eclampsia:
1. Endothelial cell damage affects capillary
permeability. Plasma leaks from the damaged
vessels producing edema with in the tissue.
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10. HTN Cont…
2. The reduced intravascular compartment causes
hypovolemia and haemoconcentartion. In severe
cases lung becomes congested with fluid and
pulmonary edema develops. Oxygenation is
Impaired and cyanosis occurs.
3. With vasoconstriction and damage to the
endothelium the coagulation cascade is activated.
Increased platelet consumption produces
thrompocythopnia and Disseminated
intravascular Coagulation (DIC) occurs.
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11. HTN Cont…
• Poor perfusion to the trophoblast  release
of one or more of the clotting factors which
damage the endothelial cells producing
vasoconstriction substances.
• As the process fibrin and platelets deposit
occur. This will occlude blood flow to many
organs, particularly the Kidneys, Liver, Brain
and Placenta.
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12. HTN Cont…
4. In Kidneys: vasospasm of the afferent
arterioles result in decreased renal blood
flow damage to the endothelial cells of the
glomrulus (Glumerulo endohetliosis) allow
plasma protein to urine Proteinuria
5. In severe cases liver is affected
intracapsular hemorrhage necrosis and edema
of the liver cells  epigastric pain
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13. HTN Cont…
6. The brain becomes edematous and this in
conjunction with hypertension and DIC can
produce necrosis of the blood vessels and
thrombosis resulting in head aches, visual
disturbance and convulsion.
7. In the uterus vasoconstriction reduces the
uterine blood flow and vascular lesions occur
in the placental bed placental abruption.
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14. HTN Cont…
8. Reduced blood supply to the choriodecidual
spaces  reduced oxygenation
intrauterine growth restriction (IUGR)
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15. HTN Cont…
Classification of Pre eclampsia:
1. Mild Pre eclampsia
– BP>140/90 but less than 160/110mmHg
– Protienuria ++ on dipsticks or 3gm/24hrs in
absence of UTI
– Generalized edema
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16. HTN Cont….
2. Severe Pre eclampsia:
• Criteria to diagnose for severe pre eclampsia:
– BP >160 systolic, 110 diastolic
– Protienuria > 5gm/24 hrs or +++ urine drip
– Oligouria: less than 400 ml/24 hrs
– CNS: Visual changes, head ache, mental status
change
– Pulmonary edema
– Epigastric (RUQ) pain
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17. HTN Cont…
S/S of severe preeclampsia cont…
– Impaired liver function tests
– Thrompocythopnia<100,000
– IUGR
– Oligohydramnious
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18. HTN Cont…
Diagnosis of Pre eclampsia:
• The two essential feature of pre eclampsia are
Hypertension & Protienuria.
A. Blood Pressure (BP):
A rise of 25mmHg above mother’s normal
diastolic or 90 mmHg on two occasions at
least 4 hrs apart.
NB: Taking BP in early pregnancy helps to know
changes in BP later
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19. HTN Cont…
B. Protienuria:
• In absence of UTI is indication of renal damage
• Is the most serious manifestation
• Usually the last manifestation of pre eclampsia
• Is an index of severity of pre eclampsia.
Protienuria Albux:
+ = 300mg/L +++ =3gm/L
++= 1gm/L ++++ =10gm/L
NB: The urine should be of midstream
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20. HTN Cont..
Other causes of proteienuira like:
• Contaminate urine
• Chronic nephritis
• Heart failure
• Pyelonephritis should be ruled out.
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21. HTN Cont…
3. Oedema
It is important to note:
• Oedema is not included in the above
definition as oedema, whilst of concern to the
woman, is probably of little clinical
importance. It occurs equally in pregnant
women with or without pre-eclampsia.
• However, the rapid development of
generalised oedema may be abnormal and
commonly seen in women with pre-eclampsia.
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22. HTN Cont…
Effects of pre eclampsia:
A. On the mother:
– Eclampsia
– Placental abruption
– Damage to heart, kidneys, lungs and brain
– Damage to the capillary in the fundus of the eye leading
to blindness
B. On the fetus:
– LBW
– Intrauterine hypoxia
– IUFD
– Pre term baby requiring resuscitation.
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23. HTN Cont..
The role of Midwife in detection of pre
eclampsia:
• Pregnancy induced hypertension (pre
eclampsia) is unlikely to be prevented, early
detection and appropriate management ca
minimize the severity of the condition
( ECLAMPSIA)
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24. HTN Cont…
A midwife is in a unique position to identify those
woman with pre disposion to pre eclampsia:
• History taking at booking visit will include:
– Adverse social circumstances or poverty
– Family tendency towards hypertension
– Mothers age and parity
– A new partnership
– A past history of pre-eclampsia
• Note: Checking of BP, Wt, Urine for protein are
essential elements of ANC
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25. HTN Cont…
Management of Mild Pre eclampsia / PIH:
Aims of care:
• To provide rest and tranquil environment
• To monitor the condition and
• To prevent its worsening by giving appropriate
care and treatment.
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26. HTN Cont…
Note: The ultimate aim is to prolong pregnancy
until the fetus is sufficiently mature enough to
survive, while safeguarding the mother’s life.
Management then depends on:
1. Severity of the pre eclampsia
2. Duration of the pregnancy and
3. Respond to treatment
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27. HTN Cont…
General principles:
• Reduce vasospasm
• Prevent eclampsia
• Prevent renal and liver impairments
• Deliver a health baby
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28. HTN Cont…
Management:
• Rest
• Sedation
• Diet rich in protein, fiber, vitamins
• Taking BP every 4 hrs, urine for protein daily
• Abdominal palpation daily to rule out
placental abruption
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29. HTN Cont…
• Fetal kick chart
• Anti hypertensive e.g. Methyldopa/Aldomet
• Anti conversant: e.g. Diazepam/Vallium
• Anti thrombin agents: e.g. Aspirin
• Investigation for maturity and placental
dysfunction: Ultrasound, estimation of
placental steroids, Shake test for surfactant,
Lechtin/sphingomyellin ratio of liquor to
indicate lung maturity.
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30. HTN Cont…
Ambulatory Care:
• Bed rest at home as much as possible,
minimum ½ an hr after meal + 10 hours per
day
• Sedation: e.g. Diazepam BID or TID
• Weekly follow up and if any risk factor occurs
admit to hospital.
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31. HTN Cont…
Hospital Care:
• Investigations
• Bed rest
• Sedation
• Diet: Normal ward diet
• Antihypertensive:
– Methyldopa
– Hydralazine
– Nifedipne
– Propranol
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32. HTN Cont…
• Nursing care:
– Quite area
– Observation 4 hourly
– Laying on side
– Ally anxiety
Management of Labor:
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33. HTN Cont…
Indications of delivery in pre-eclampsia:
A. Maternal
– GA > 38 weeks
– Platelet count <100,000 cells/mm3
– Progressive deterioration in liver and renal
functions
– Suspected abruption placenta
– Persisting severe head aches, visual disturbance,
nausea, epigastric pain or vomiting
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34. HTN Cont…
B. Fetal:
• Severe fetal growth restriction/ retardation
• None reassuring fetal heart rate patterns
/NRFHRP/
• Oligohydramnious
NB: The “cure” for pre eclampsia is delivery.
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35. HTN Cont…
First Stage of labor:
• The MW should remain with the mother
• BP(Mean arterial pressure/MAP) ½ hourly
MAP = systolic+2Diastolic
3
• MAP should be less than 105.
• Fluid balance:
– Be careful of fluid overload
– Oxytocin should be administered with caution b/s it
has anti diuretic effect.
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36. HTN Cont…
– Urinary catheter should be inserted and urine output
should be measured hourly: >30ml/hr reflects adequate
renal function.
• Plasma volume expanders
• Pain relive
• Fetal heart rate monitoring
Second stage of labor:
– Vacuum or forceps to shorten 2nd stage
• Third stage of labour
• Do not use ergametrine/Use Oxytocine
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37. HTN Cont…
Following delivery: The maternal condition
should be monitored at least 4 hourly for the
first 24 hrs.
Management of severe pre eclampsia
• Should be managed as eclampsia!!!!
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38. HTN Cont…
S/S of impending or imminent eclampsia:
The following s/s should alert the MW to the
onset of ECLAMPSIA:
• Sharp rise in BP
• Diminished urinary output
• Increase in proteinuria
• Severe persisisting frontal headache
• Confusion: Cerbral edema
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39. HTN Cont…
• Visual disturbance(Flushing light,- Retinal
edema)
• Epigastric pain: Liver damage
• Nausea and vomiting
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40. Eclampsia…
Definition: Eclampsia is defined as the occurrence
of one or more convulsions or coma in
association with syndrome of pre-eclampsia.
Incidence: in developed countries: 1 in 200 deliveries.
in developing countries: 1 in 100 deliveries
Note: Eclampsia can be prevented by properly managing
pre-eclampsia although it is difficult when it is
fulminating pre – eclampsia.
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41. Eclampsia Cont…
Stages of fit:
1. Premonitory stage: lasts about 10 -20 seconds.
Patient is restless, twitching of facial muscles,
eye roll, respiration becomes spasmodic.
2. Tonic stage: Lasting about 10 – 20 seconds,
general muscle rigidity, and whole body goes in
to tonic spasms, Backaches, features distorted
by grimace, tongue may be bitten, breathing
ceases and pt becomes cyanosed.
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42. Eclampsia Cont…
3. Colonic stage: Lasting about 60 – 90 minutes.
Convulsive movements frothy saliva fills the
mouth, may be stained. The woman becomes
unconscious.
4. Stage of coma: Snoring breathing continued
and may be persistent for minutes or hours.
Further convulsive movements sometimes
recur with or without pt gaining from
consciousnes.
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43. Eclampsia Cont…
DDx: (other causes of convulsion):
• Epilepsy
• Cerebral malaria
• Brain damage
Prevention: Careful and frequent observations
in the antenatal period by detecting and
treating pre-eclampsia should almost prevent
eclampsia.
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44. Eclampsia Cont…
Aims of treatment:
• To prevent further convulsions
• Once convulsions are controlled, termination
of pregnancy will result in improvement of the
generalized vasospasm.
• Control the blood pressure.
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45. Eclampsia Cont…
Emergency Care:
• Clear air way, do not leave the pt alone.
• Oxygen administration continuously to
improve tissue oxygenation.
• Prevent pt from injury during fit:
– Place a padded spatula b/n her teeth to prevent
from biting her tongue or the tongue can block air
ways.???
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46. Eclampsia Cont…
– Turn her one side
– Lower her head to drain secretions from mouth
and throat.
– Do not attempt to control the convulsions as it
seems to stimulate the fit.
• Suctions is continued to clear nose and
pharynx of froth secretions.
• Sedation: Diazepam 10 mg IV & 10 mg IM is
commonly used.
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47. Eclampsia Cont…
Management:
1. Anti convulsing therapy:
A. Magnesium Sulphate:
• There has been world wide variation in clinical
practice for the treatment and prevention of
eclampsia
• MgSO4 was the most effective drug in
reducing death and further fits
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48. Eclampsia Cont…
• MgSO4 is a CNS depressant.
• It affects neuromuscular impulse transmission,
which reduces the hyper- reflexia associated
with severe pre-eclampsia.
• Vasodilitatory effect:
– decrease BP
– reduces cerebral ischemia
– blocks some of the neuronal damage associated
with ischemia
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49. Eclampsia Cont…
MgSO4 Recommendations for
use:
• Following a seizure to prevent the next seizure
• For women with severe pre-eclampsia who
are hyper-reflexic and immediate birth is
required, and
• For women with severe pre-eclampsia who
are requiring transfer to another unit for birth.
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50. Eclampsia Cont…
Dose of MgSO4:
A. Loading Dose:
• Give 4gm of MgSO4 IV over 5 minutes
• Follow promptly with 10 g of 50% MgSO4
solution: Give 5 g in each buttock as deep IM
injection with 1 ml of 2% lidocaine in the same
syringe. Ensure aseptic technique whine giving
the IM injection.
• Warn the woman that feeling of warmth will e
felt MgSO4 is given.
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51. Eclampsia Cont…
• If convulsion reoccur after 15 minutes, give 2
gm of 50% of MgSO4 solution over 5 minutes.
B. Maintainance Dose:
• Give 5g of MgSO4 solution with 1 ml of 2%
lgnocaine in the same syringe by deep IM
injection in to alternate buttocks every 4 hrs.
• Continue treatment for 24 hrs after delivery or
the last convulsion whichever comes first.
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52. Eclampsia Cont…
Closely Monitor the woman for the signs of the
toxicity of MgSO4:
• Before repeating the administration ensure
that:
– RR is at least less than 16/minute
– Patellar reflex are present(DTR)
– Urinary output is at least 30ml pr hr over 4 hrs
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53. Eclampsia Cont…
Withhold MgSO4 if:
• RR falls below 16/mn
• Patellar reflexes are absent
• Urinary out put falls below 30ml/hr over the
preceding 4 hrs
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54. Eclampsia Cont…
Keep antidote ready:
• In case of respiratory arrest:
– Assist ventilation (mask and bag, anesthesia
apparatus, intubation)
– Give Calcium guconate 1gm (10ml 0f 10%
solution) IV slowly until calcium gluconante begins
to antagonize the effects of MgSO4 and
respiration begins.
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55. Eclampsia Cont…
B. Diazepam:
Use Diazepam only if MgSO4 is not available.
A. Loading dose:
• Diazepam 10mg IV slowly over 2 minutes.
• If convulsions reoccur repeat the loading dose.
B. Maintain ace dose:
• Diazepam 40mg in 500 ml IV fluids (NS or RL)
• Do not give more than 100 mg/24hrs(risk of
respiratory depression)
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56. Eclampsia Cont…
2. Treatment of Hypertension:
• If the diastolic BP is 110 mmHg or more, give
antihypertensives.
• The goal is to keep the diastolic BP b/n 90 and
100 mmHg to prevent cerebral hemorrhage.
• Hydralazine is the drug of choice.
Dose of Hydralazine:
• Give Hydralazin 5mg IV slowly every 5 minutes
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57. Eclampsia Cont…
until BP is lowered(less than 110mmHg). Repeat
hourly as needed or give Hydralazine 12.5 mg IM
every two hrs as needed.
• If Hydralazine is not available, use labetolol or
nifedipine:
– Labetolol 10mgIV
Or
– Nifedipine 5mg under the tongue, if no
response(Diastolic BP still> 110mmHg) after 10
minutes, give additional 5mg under the tongue.
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