A Case Study

Mum arrives at the facility with strong contractions

- 34 yo G3P0+2 presents at 36 weeks with headache

- OB hx: 2 prior FSBs at term via SVD
- Medical history: HTN on aldomet
- Exam: baby longitudinal, vertex, SVE: cervix closed
- Vitals: BP 160/109, HR 109, RR 20 Urine: protein 3+

But experiences adverse outcomes during delivery

- Mum proceeds to develop worsening headache.

Repeat BP 170/115
- FHR pattern shows evidence of foetal compromise
- Diagnosis? Risk Factors? What do we do next?
Hypertensive disorders in pregnancy
Updated February 2022
Section 1

Pre-Test
01 A woman presents for
her ANC visit at 30
weeks. Her BP at this a. Chronic hypertension
time is 153/95. She
b. Gestational hypertension
denies any
headache/blurred vision c. Preeclampsia without severe
or abdominal pain. You features
test her urine and find
d. Preeclampsia with severe
no protein. The most features
likely diagnosis is?
02
01
Which of the
following has a. Prophylactic blood pressure
strong evidence medication

to support b. Vitamin D supplementation

prevention of c. Daily low dose aspirin

preeclampsia in d. Bed rest starting at 30 weeks
women with prior
preeclampsia?
03
01
Which of the
following lab a. Platelets <170,000mm3

abnormalities b. Elevated liver enzymes (AST/ALT)

may aid in the c. Creatinine <1.2mg/dl

diagnosis of d. Decreased uric acid

preeclampsia?
04
01
Which of the a. Labetalol IV
following is a
b. MgSO4 IV
first line
c. Methyldopa PO
medication for
d. Hydralazine PO
intrapartum BP
control?
05
01
In women with a. 5-10%
eclampsia, what
b. 10-20%
% of cases occur
c. 30-40%
postpartum?
d. 40-50%
Learning Objectives
● Classify hypertensive
disorders of pregnancy
● Understand risk factors for
PIH/eclampsia
● Appropriately diagnose
PIH/eclampsia
● Effectively treat PIH/eclampsia
● Prepare and administer
MgSO4 to a
pre-eclamptic/eclamptic
mother
Section 2

The Facts
Reducing the Global Burden:
Hypertensive disorders of
10%
pregnancy: Of pregnancies globally
are complicated by
Hypertensive hypertensive disorders
of pregnancy
disorders of
pregnancy (HDP) is
one of the leading 15%
of premature births
causes of maternal are directly related to
and fetal morbidity hypertensive
disorders of
and mortality pregnancy
worldwide

12%
of worldwide global
maternal deaths are due
to complications of
hypertensive disorders of
pregnancy
Section 3

Definitions
Hypertension in pregnancy

Systolic blood pressure

greater than or equal to
140 mmHg and/or
diastolic blood pressure
greater than or equal to
90 mmHg measured on
2 occasions and at least
4 hours apart
 Categories of hypertension in pregnancy

Chronic hypertension Gestational Preeclampsia/ Chronic HTN with

hypertension Eclampsia superimposed
preeclampsia
Hyper New onset Hypertension Features of
tension hypertension with proteinuria pre-eclampsia
confirmed pre- arising after 20 after the 20th developing in a
weeks gestation week of
conception or in the absence of woman who
prior to 20 gestation in a had
proteinuria and
weeks previously hypertension
other symptoms
normotensive
gestation prior to
Generally and
non-proteinuric
conception
resolves within 3
months woman
postpartum
 Classification of pre-eclampsia:
Preeclampsia WITHOUT Preeclampsia WITH severe features Eclampsia
severe features

- BP of 140/90 mm Hg Pre-eclampsia plus any of the following: - Pre-eclampsia plus

or more with - Elevated creatinine >1.2mg/dL evidence of new
proteinuria after the - Elevated liver enzymes
20th week of - Epigastric abdominal pain
onset seizure
gestation in a - Neurological complications (altered mental activity
previously status, blindness, stroke, clonus, severe
headaches)
normotensive and - Hematological complications (platelet count
non-proteinuric <150 000/μL, disseminated intravascular
women coagulation, hemolysis)
- Proteinuria (≥30 mg/mol - Uteroplacental dysfunction (fetal growth
protein or ≥2 + dipstick) restriction or stillbirth)
- Oligohydramnios
Section 3

Risk
Factors
 ● Extremes of age (maternal age <20 and>35 years)
● Black race
Maternal ●
●
Family history of Preeclampsia
Nulliparity (more common in primigravidae)
● Pre-eclampsia in a previous pregnancy
Risk Factors ● Diabetes
● Obesity
● Chronic hypertension/Renal disease
● Antiphospholipid syndrome
● Periodontal disease
● Vitamin D deficiency
● Inherited thrombophilias
● Inter-pregnancy interval of >10 years

Pregnancy ●
●
Chromosomal abnormalities
Hydatidiform mole
● Multiple pregnancy
Risk Factors ● In-vitro fertilization

-
Section 4

Prevention
 Prevention measures include:
Prevention measures
with MODERATE
3 evidence:
- Vitamin D
Prevention measures supplementation
with STRONG evidence:
- Women at high risk
should be started
2
Assess underlying risk:
on low dose Aspirin - Women may be
categorized as high
- Calcium or low risk based on
1
personal/family
supplementation history, underlying
- 1g/day disease and
pregnancy associated
risk factors
 Thrombocytopenia

Diagnosing preeclampsia: Platelet count < 100,000/mm3

Renal insufficiency
In the absence of proteinuria,
new onset hypertension and Serum creatinine >1.1mg/dl
any of the following may be
diagnostic of preeclampsia: Impaired liver function

Elevated AST/ALT to twice their

normal level
*Important: proteinuria is NOT
mandatory for the diagnosis. Pulmonary Edema

**Some degree of swelling is Crackling in lungs upon lung exam

normal in pregnancy but sudden or pt may have difficulty breathing
swelling of the face, hands and Cerebral/visual symptoms
legs is strongly suggestive of
pre-eclampsia Severe headache/blurring of vision
In suspected preeclampsia,
work-up should include:
- CTG reading if over 24 weeks gestation Foetal assessment
- Ultrasound assessment including:
- Foetal growth
- BPP including AFI assessment
- Doppers if available

- CBC - LFTs Lab investigations

- Urinalysis - Creatinine
- Uric Acid

- Thorough personal and family history

- Symptoms which may include: headache, Thorough H&P
blurred vision, epigastric pain, N/V, sudden
swelling, decreased urine output, decreased
foetal movement
Section 5

Management
General Principles of preeclampsia/eclampsia treatment:
Preeclampsia can range widely in terms of severity of disease and obstetric/foetal status.
Treatment should be based upon a woman’s individual circumstance

01 Blood pressure
control
Antihypertensives a needed

MgSO4 in the setting of

02 Seizure prophylaxis preeclampsia with severe
features/eclampsia

03
Delivery plan based on severity
Expedite delivery of disease
 Blood Pressure Control
Not ALL women with preeclampsia need blood pressure management
during labour. The following guidelines apply:

The goal is to lower BP to prevent cerebrovascular and cardiac

complications while maintaining utero-placental blood flow

Antihypertensive treatment is indicated for diastolic BP above

110 mm Hg and systolic pressure above 160 mm Hg

The goal is to maintain diastolic BP between 80 and 100mm Hg

and systolic BP between 130 and 150mm Hg

Patients with preeclampsia with severe features who have BP below

160/110 mm Hg may benefit from antihypertensive drugs because of
the possibility of unpredictable acceleration of the disease
 BP Medications
Antenatal medications
1
Intrapartum medications 3
First line agents are:

First-line medications are: - Methyldopa: Start at

125mg BD, increase as
- Nifedipine 10-20mg oral, HTN indicated to max of 500mg
repeat 10-20mg every 30 QID
minutes (maximum 40mg). management - Labetalol Start at 100mg
Maintain 10mg q 4-6 hrs BID, increase as indicated
- Hydralazine 5mg IV slowly to max of 400mg QID
over 10 minutes. Repeat - Hydralazine: Start at
5mg every 20 minutes 25mg BD, increase as
(maximum 20mg) indicated to max of 100 BD
- Labetalol 20mg IV slowly - Nifedipine (IR): Start at
over 10 minutes. Proceed 10mg BD, increase as
to 40mg then 80mg at 2 indicated to max of 40mg
10-20 minute intervals BD
(max of 300mg) If antepartum HTN, continue BP meds Intrapartum. For
others, BP management indicated if systolic BP
persistently >160 or diastolic BP persistently > 110
 Seizure prophylaxis
The basic principles of airway, breathing, circulation (ABCs) should
always be followed as a general principle of seizure management

Active seizures should be treated with intravenous magnesium

sulphate as a first-line agent

Prophylactic treatment with magnesium sulphate is indicated for

all patients with preeclampsia with severe features

Once a patient is started on MgSO4, Magnesium levels, respiratory

rate, reflexes, and urine output must be monitored to detect
magnesium toxicity
There is still a significant risk of seizures following delivery - up to
44% of eclampsia cases have been reported to occur postpartum (the
majority occur within the first 48 hours)
Preparation of 4g 20% solution of magnesium
sulfate from 50% ampule

1. Wash hands thoroughly with soap and running

water or use 70% alcohol hand rub and air dry
2. Using a 20-mL syringe, draw 12 mL of sterile
water for injection
3. Add 8 mL of MgSO4 50% solution* to 12 mL of
water for injection to make 20 mL of 20%
solution (4 g per 20 mL)
 MgSO4 dosing for preeclampsia with severe features or eclampsia

Loading dose - Followed by: If convulsions persist Maintenance dose:

initially: after 15 minutes:
4g of 20% MgSO4 10g 50% MgSO4 (5g in 2g of 20% MgSO4 5gm of 50% MgSO4
each buttock) IM q 4 hours in
IV over 5 minutes IV over 5 minutes
alternate buttocks
- Draw 10mL 50% or 1g/hr 20% IV
- 4g (20mL) MgSO4 in two - 2g (10mL) of
20% solution 20mL syringes 20% MgSO4 - Draw 10ml
- Add 1mL 2% 50% mgSO4 in
(preparation lignocaine to
(preparation
as described as described 20mL syringe
each
- Give deep IM in - Add 1mL 2%
previously) previously) lignocaine
each buttock
- Give deep IM
in buttock
 Monitoring for MgSO4 toxicity
Signs of MgSO4 should be evaluated before each repeat maintenance dose of MgSO4 is given

Respiration Monitor hourly. Should be >16 RR

Should be present. Absent patellar reflexes

Patellar reflex are the 1st sign of MgSO4 toxicity

Should be >30cc/hr. This is best monitored

Urine output with catheter. If catheter not possible, instruct
mum to urinate in bedpan

Mild signs of Stop MgSO4, IV ringers lactate 1L over 8 hours,

toxicity monitor for pulmonary oedema

Stop MgSO4, mechanical ventilation as needed, give

Severe signs Calcium gluconate 1 gm (10% of 10 ml) IV slowly over
of toxicity 10 minutes
 Additional notes on seizure prophylaxis

Contraindications to Phenytoin Diazepam

MgSo4
- May be used if - May be used if MgSO4
- Impaired renal MgSO4 is is contraindicated
function (consider contraindicated - Loading dose: 20mg IV
alternative - Dosage: 10 mg/kg slowly over 2 minutes
medication if loading dose infused - Maintenance dose:
Creatinine >1.5) IV slowly, followed by 40mg in 500ml IV fluid
- Myasthenia gravis maintenance dose titrated to keep woman
started 2 hours later at sedated but rousable
5 mg/kg
Fluid management Pulmonary Edema: Aggressive volume resuscitation
in women with
may lead to pulmonary edema.

preeclampsia/ Fluid restriction: Volume expansion has no

eclampsia demonstrated benefit, patients should be fluid
restricted when possible

Despite peripheral edema, Measurement of Ins and Outs: Careful

patients with Pre-eclampsia measurement of fluid input and output is advisable,
are intravascularly volume particularly in the immediate postpartum period
depleted
Fluid selection: If fluids are required, preferably use
Ringer’s Lactate or Normal saline. Avoid using
Dextrose or Dextrose- Saline infusion
 Delivery recommendations
Delivery is the definitive treatment for a woman with preeclampsia

Patients with cHTN, gestational hypertension, preeclampsia

with or without severe features should be delivered at 37 weeks
unless earlier delivery indicated

In patients with preeclampsia with severe features,

delivery should be considered at 34 weeks.

Prior to 37 weeks, expectant management can be

considered in order to treat with steroids for lung maturity

Immediate delivery indications: non-reassuring foetal status, severe

foetal growth restriction, eclampsia, placental abruption, pulmonary
edema, HELLP syndrome, persistent neurological symptoms

**Mode of delivery should be based on obstetric indication and severity of disease

 Postnatal care
Cont MgSO4
Up to 44% of seizures occur POST delivery:
continue MgSO4 for 24 hours post delivery (or 24
hours after the last convulsion)

HTN meds Continue antihypertensives as long as the

diastolic pressure is > 110mmHg. Pt may need to
be discharged on oral antihypertensive and
re-evaluated at postpartum visit

Monitor I&Os ● Continue to monitor urine output – if

<500cc/24 hours, limit fluid intake
● Watch closely for pulmonary oedema
Section 6

Complications
 Placental abruption
Complications Disseminated intravascular coagulation

of HELLP*

preeclampsia Cerebral hemorrhage

include:
Maternal or foetal death

*HELLP is a rare complication of preeclampsia which results

in hemolysis, elevated liver enzymes, and low platelets. It
can result in severe complications such as excessive
bleeding, liver rupture, seizure or stroke
Questions?
Questions?
Section 8

Post Test
01 A woman presents for
a. Chronic hypertension
her ANC visit at 30
weeks. Her BP at this b. Gestational hypertension
time is 153/95. She c. Preeclampsia without severe
denies any features
headache/blurred vision
d. Preeclampsia with severe
or abdominal pain. You features
test her urine and find
no protein. The most
likely diagnosis is?
02
01
Which of the a. Prophylactic blood pressure medication

following has b. Vitamin D supplementation

strong evidence c. Daily low dose aspirin
to support d. Bed rest starting at 30 weeks
prevention of
preeclampsia in
women with prior
preeclampsia?
03
01
Which of the a. Platelets <150,000mm3

following lab b. Elevated liver enzymes

abnormalities c. Creatinine <1.0mg/dl

may aid in the d. Decreased uric acid

diagnosis of
preeclampsia?
04
01
Which of the a. Labetalol IV
following is a b. MgSO4 IV
first line c. Methyldopa PO
medication for d. Hydralazine PO
intrapartum BP
control?
05
01
In women with a. 5-10%

eclampsia, what b. 10-20%

% of cases occur c. 30-40%

postpartum? d. 40-50%