HYPERTENSIVE DISEASES

IN PREGNANCY
DR LUCIO PEDRO DM
MD FACOG

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 OUTLINE
• Classification
• Definition
• Pathophysiology
• Symptoms
• Prevention
• Risk Factors
• Management
• Risk of expectant management vs early delivery
• Complications
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 CLASSIFICATION
• Preeclampsia
– Without Severe features
– With Severe features
• Chronic Hypertension
• Chronic Hypertension with superimposed
preeclampsia
• Gestational Hypertension
• Eclampsia
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 DEFINITION
• Preeclampsia without severe features
– SBP >= 140 but <160 OR DBP >= 90 but < 110
on 2 occasions at least 4 hours apart after 20
weeks of gestation in a woman with previously
normal BP
– AND Proteinuria
• >= 300mg/24 hrs urine collection
• Protein/creatinine ratio >= 0.3
• Dipstick >= 1+

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 DEFINITION
• Preeclampsia with Severe Features (Any of
these findings)
– SBP>= 160 OR DBP>= 110 at least 4 hours apart (and
proteinuria)
– Thrombocytopenia (<100,000/mL)
– Impaired Liver Function (Twice Normal Transaminases)
– Severe persistent RUQ or Epigastric pain
– Progressive renal insufficiency (creatinine >1.1 mg/dl or
doubling serum creatinine concentration)
– Pulmonary edema
– New-onset cerebral or visual disturbances 5
 DEFINITION
• Gestational Hypertension
– Same as PEC but without proteinuria or systemic
findings

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 DEFINITION
• Chronic Hypertension
– HTN that predates 20 weeks gestation

• Superimposed Preeclampsia
– Is CHTN in association with preeclampsia
• Without severe features
• With severe features

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 DEFINITION
• Eclampsia
– Is defined as the presence of new-onset Grand mal
seizures in a woman with preeclampsia

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 PATHOPHYSIOLOGY
• PEC is a multisystem disease that affects all
organ systems
• The placenta is evident as the root cause of
preeclampsia which is mainly due to poor
placentation
– Reduced trophoblast invasion results in fail
vascular remodelling of maternal spiral arteries

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 SYMPTOMS
• Preeclampsia
– Swelling of the face or hands
– Headache that will not go away
– Seeing spots or changes in eyesight
– Pain in upper right quadrant or stomach
– Nausea or vomiting (in second half of pregnancy)
– Sudden weight gain
– Difficulty breathing

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 PREVENTION
• Aspirin low dose (60-80mg) have been shown
to slightly reduce preeclampsia and adverse
perinatal outcomes.
• Calcium may be useful to reduce the severity
of preeclampsia in populations with low
calcium intake.

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 RISK FACTORS
• Primiparity
• Previous Preeclamptic pregnancy
• Chronic hypertension or chronic renal disease or both
• Multifetal pregnancy
• In vitro fertilization
• Family history of preeclampsia
• Type 1/2 DM
• Obesity
• System lupus erythematosus
• Advanced maternal age (older than 40 yrs)
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 MANAGEMENT
• GHTN / PEC without Severe Features
– Serial assessment of maternal symptoms
– Fetal movement & kick counts (Daily by mother)
– Serial BP (Twice Weekly)
– Assessment of Hb, Platelets, liver enzymes, and
Serum creatinine (Weekly)
– Assessment of Proteinuria once weekly
– Physician preference  however NO
antihypertensive maybe required
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 MANAGEMENT
• GHTN / PEC without Severe Features
– Ultrasonography to assess fetal growth (q 3 weeks) and
AFI (weekly)
– NST weekly for GHTN and twice weekly for PEC
without severe features
– BPP if NST is nonreactive
– If evidence of fetal growth restriction – assessment with
umbilical artery Doppler is recommended
– Expectant management with maternal and fetal
monitoring is suggested up to 37 0/7 weeks of gestation
and NOT beyond
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 MANAGEMENT
• PEC with Severe Features
– Inpatient Care
– Daily NST, Twice weekly AFI, USG q 2wks
– Delivery is suggested at 34 0/7 weeks
– Administration of corticosteriods for lung
maturity if GA <34 weeks
– Antihypertensive therapy is recommended
– Delivery decision should not be based on amount
of proteinuria or change in the amount of
proteinuria
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 MANAGEMENT
• PEC with Severe Features
– Pre viable pregnancy  delivery after maternal stabilization is
recommended
– It is suggested that corticosteriods be administered and delivery
deferred for 48hrs if maternal and fetal conditions remain stable with
a viable fetus at 33 6/7 wks or less and any of the following
• PPROM
• Labour
• Low platelet (<100,000)
• Persistently abnormal transaminases (>= twice normal)
• IUGR (<5%tile)
• Oligohydramnios (AFI<5)
• Reversed end-diastolic flow on umbilical doppler studies
• New-onset renal dysfunction or increasing renal dysfunction
• HELLP syndrome
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 MANAGEMENT
• PEC with Severe Features
– Recommended that corticosteriods be given if the fetus is
at 33 6/7 wks or less, but that delivery not be delayed
after initial maternal stabilization regardless of GA for
women complicated with any of the following
• Uncontrolled severe hypertension
• Eclampsia
• Pulmonary edema
• Abruptio placentae
• DIC
• NRFHRT

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 MANAGEMENT
• PEC with Severe Features
– MgSO4 administration – up to 24 hrs postpartum
– BP monitoring is suggested in hospital for at least
72 hrs postpartum and again at 7-10 days after
delivery or earlier in women with symptoms
– Fluid therapy
• Fluid restrict: rate of 60 to max 125 ml per hour or
1ml/kg/hour

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 MANAGEMENT
• Chronic HTN
– Antihypertensive therapy is recommended for women
with persistent chronic HTN with SBP >= 160 or
DBP>= 105
– Patients on Antihypertensive, it is suggested that BP
levels be maintained between 120/80 and 160/105
– Delivery is recommended >= 38 wks if No additional
maternal or fetal complications
– Labetalol, Nifedipine, or Methyldopa are the
recommended antihypertensive

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 MANAGEMENT
• Chronic HTN
– For women who are at a great increased risk of
adverse pregnancy outcomes (Hx of early-onset
preeclampsia and preterm delivery at > 34 0/7
wks of gestation or preeclampsia in > one prior
pregnancy), initiating the administration of daily
low-dose aspirin (60-80mg) beginning in the late
first trimester is suggested to reduce the
incidence and morbidity of preeclampsia.

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 MANAGEMENT
• Chronic HTN and Superimposed
Preeclampsia
– Antenatal surveillance and management as
preeclampsia
– For women with superimposed preeclampsia with
severe features, administration of intrapartum-
postpartum parenteral MgSO4 to prevent
eclampsia is recommended

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 MANAGEMENT
• Chronic HTN and Superimposed
Preeclampsia
– For women with superimposed preeclampsia
without severe features and stable maternal and
fetal conditions, expectant management until 37
wks is suggested
– Superimposed preeclampsia with severe features,
delivery at 34 wks is recommended

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 MANAGEMENT
• Chronic HTN and Superimposed
Preeclampsia
– Delivery soon after maternal stabilization is
recommended irrespective of GA or full
corticosteriod benefit with any of the following
complications;
• Uncontrolled severe hypertension
• Eclampsia
• Abruptio placentae
• DIC
• NRFHRT 23
 MANAGEMENT
• For women with preeclampsia in prior
pregnancy, preconception counselling and
assessment is suggested

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 MANAGEMENT
• Eclampsia
– Call for help
– Airway and Breathing – LLL, O2,
– Circulation – IV lines; labs; RBS
– MgSO4 – 4-6 g loading dose IV or IM
– Maintenance dose @ 1-2g/hr
– Foley catheter
– Multidisciplinary approach

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 MANAGEMENT
• Eclampsia
– If 2nd seizure
• Reload MgSO4 2g stat and increase maintenance dose
to 1.5 to 2g/hr
– If 3rd seizure despite 2 sets of MgSO4
• Give 10mg Diazepam IV slowly
– If continues to seize
• Call anesthesia; thiopentone infusion; intubate!

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 MANAGEMENT
• Eclampsia
– Control BP
• labetolol/nifedipine/methyldopa/hydralazine
– Assess Fetal wellbeing
– Give Corticosteriods if < 34 weeks GA
– DELIVER!
– Maintain MgSO4 for 24 hrs postpartum or last
seizure, whichever occurs last.
– Keep in hospital at least 4 days
– Monitor BP until 6 weeks postpartum 27
 RISK
• Risk associated with Expectant management
include
– The development of severe hypertension (10-15%)
– Eclampsia (0.2-0.5%)
– HELLP syndrome (1-2%)
– Abruptio Placentae (0.5-2%)
– Fetal growth restriction (10-12%)
– Fetal Death (0.2-0.5%)

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 RISK
• Risk associated with immediate delivery
– Increased rates of admission to the neonatal ICU
– Neonatal respiratory complications
– Slight increase in neonatal death

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 COMPLICATIONS
• Placenta Abruption
• IUGR
• Oligohydramnios
• HELLP syndrome
• Intracranial bleeding and permanent neurologic damage
• Acute renal failure
• Hepatic damage, subcapsular hematoma, and rarely hepatic
rupture
• DIC
• Increased risk of recurrent preeclampsia/eclampsia with
subsequent pregnancy
• Maternal or fetal death 30
 REFERENCE
• ACOG, Hypertension in Prenancy; Task
force, 2013
• Cunningham et.al, Williams Obstetrics 23rd
ed; Pregnancy Hypertension; 2010, pg 706-79

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 Thank You

Questions?

EMERGENCY NUMBER
647-6403
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