Hypertensive Disorders in Pregnancy

1.Classifications:
i)Chronic Hypertension-Hypertension that is present at the booking visit or before 20
weeks,or if the patient is already taking anti-hypertensive medications
ii)Gestational Hypertension-New hypertension presenting after 20 weeks of
gestation,without significant proteinurea
-Also called as Pregnancy Induced Hypertension(PIH)
iii)Pre-eclampsia-New hypertension presenting after 20 weeks of gestation, with significant
proteinurea.
-Further classified into 3 categories:
a)Mild-Systolic is 140-149mmHg,Disatolic 90-99mmHg
b)Moderate-Systolic is 150-159 mmHg,Diastolic is 100-109mmHg
c)Severe(2 definitions)-Systolic is 160mmHg and above,Diastolic is
110mmHg and above
-Mild or moderate hypertension,with symptoms
and /biological,haematological impairment
iv)Eclampsia-Occurance of tonic-clonic convulsions in patient with pre-eclampsia
v)Pre-eclampsia superimposed on chronic hypertension
-Difficult to define,but usually associated with worsening hypertension and proteinurea

2.Other definitions of terms used:

i)HELLP syndrome-Haemolysis,elevated liver enzymes and low platelet count
ii)Significant proteinurea-Urine dipstick ++ or a validated 24-hour urine collection result
shows greater than 300 mg protein.

3.Risk factors of developing pre-eclampsia:

Epidemiology
Obesity(more than 35)
Nulliparity
Extreme ages (40 years or
older)

Abnormal pregnancy
Multiple pregnancy
UTI
Previous history of preeclampsia
Pregnancy interval of more
than 10 years

4.Clinical features of pre-eclampsia

Symptoms
Headache
Visual disturbance
Epigastric pain
Progressive edema(Face,hands,feet)

Medical Disorders
Hypertension
Renal diseases
Diabetes Mellitus
Autoimmune disease(SLE)

Signs
Weight gain
Ankle clonus
Brisk deep tendon reflexes
Nondependent edema
Fundoscopic examination(Hypertensive
retinopathy, Pappiloedema)

5.Investigations:
a)Laboratory
Investigations
FBC
Urine Dipstick Test
24 hour urine collection
Renal function test
Liver function test
Serum Uric acid

Descriptions
-Detect anemia,and platelet count(HELLP
syndrome)
-To detect proteinurea
-Done if urine dipstick test is positive
-Proteinurea(300mg/24 hours is significant)
-Increased BUN(due to oliguria)
-Reduced creatinine clearance rate
-Elevated enzymes
-Level corresponds to severity of preeclampsia
-Higher levels indicate poor prognosis

b)Imaging
Investigations
Ultrasound

Findings
-Fetal maturity
-AFI
-placental maturity
-umbilical artery Doppler velocimetry

Management of Hypertensive Disorders in Pregnancy

Scenario: Mdm PIH, a 28 years old primagravida, currently in 24 weeks period of

amenorrhea, presented to KK Sg.Buloh for regular antenatal check-up. During her visit,
her blood pressure reading was noted to be 150/90mmHg.
1.What is the next step?
Measure her blood pressure again in 4-6 hours time.

She came back later to check her blood pressure reading agin,and it was found to be
155/92mmHg.
2.What is the next step?
i)History taking and physical examination to look for features of severe-preeclampsia
ii)Perform urine dipstick
-If significant proteinurea(++ and above),treat as Pre-Eclampsia
-If no significant proteinurea(+ and below),treat as PregnancyInduced Hypertension

Management or Pregnancy-Induced Hypertension

1.Prescribe oral anti-hypertensives to stabiles the BP
2.Treated as out-patient basis.Increase the frequency of visits for close observation of
BP.Urine dipstick is done to detect significant proteinurea.Review medications in every
visit(side effects and BP control)

Management of Pre-eclampsia
1.Admit the patient to nearest hospital. Inform the patient regarding the importance for hospital
admission(close observation, facilities available in case of emergency)

2.In the hospital,series of investigations are perform:

a)24 hour urine collection for protein- To look for significant proteinurea (more than
3g/300mg)
b)Laboratory investigations-Look for target organ damage,HELLP syndrome,fetal prognosis
-Done 2 times/week
i)FBC-Look for anemia secondary to hemolysis (HELLP syndrome)
-Thrombocytopenia(HELLP syndrome)
ii)Renal function test-Abnormal values secondary to end organ damage
iii)Liver Function Test-Raised liver enzymes(HELLP syndrome)
v)Uric acid-Levels correspond to fetal prognosis(ideal value should be Gestational week X
10)
vi)LDH-Raised in haemolysis(HELLP syndrome
vii)Coagulation Profile-Look for presence of DIVC

c)Imaging
i)Transabdominal Ultrasound scan-Fetal wellbeing
-Amniotic fluid index
-Growth parameters(Pre-eclampsia may lead to
IUGR)
-Doppler flow to detect uteroplacental insufficiency
3.Perform a close maternal and fetal observation:
a)Maternal surveillance
i)Vital signs 4 hourly
b)Fetal surveillance
i)Daily CTG
ii)Daily fetal kick chart
iii)Biweekly ultrasound and Doppler flow
iv)Growth chart once in 2 weeks-Head circumference,Biparietel diameter,Abdominal
circumference,femur length
-Values are plotted in the growth chart

4.Start the patient on anti-hypertensive medications.Types:

a)Oral antihypertensive-Given for patients with mildly elevated BP(less than 160mmHg)
i)Methyldopa-400 mg TDS
-1 st line medication(usually prescribed in KK)
ii)Labetolol-400mg TDS
-Contraindicated in asthmatic patients
iii)Nifedipine-20mg QID
-Fastest action compared to other anti-hypertensives
-Side effects are hypotension,reflex tachycardia,headache,increased risk of
IUGR
iv)Prazocin-30mg/day
-Last resort medication(Usually not frequently given in the wad)

b)Intravenous antihypertensive-Given for patients with highly elevated BP(more than 160
mmHg)
-Bolus dosage is given initially,followed by continuous
infusion
-Choice of agent depends on how fast you want to bring
down the BP.
i)Hydralazine-Slow acting(usually gives affect in the following day)
-Given for patients with bradycardia
ii)Labetolol-Rapid acting
iii)GTN-Last resort medication(If BP still not controlled)

*If BP is not controlled,increase the dosage of medication/change to a different antihypertensives

*Anti-hypertensives are continued through-out the pregnancy period
*Once IV antihypertensives has been started,decision to or to not deliver has to be
made.
-If choose to deliver,stabilize the BP and deliver
-If choose not to deliver(preterm,no features of HELLP,warning features),aim to taper down IV
antihypertensive and top up oral medications

5.Goal of treatment is to control the BP during the antenatal period. Target of

delivery:
a)Mild pre-eclampsia-38 weeks POG. Patient is induced
-If there are contraindications to vaginal delivery, C-section is done
b)Severe pre-eclampsia-Immediate delivery(Induction or C-section)
c)Eclampsia-Maternal stabilization, followed by delivery(C-section)

6.As an overall,in management of Pre-eclampsia,4 features are evaluated:

a)Are there features of severe pre-eclampsia?
-If features are present,rapid control of BP is required/immediate delivery to prevent
eclampsia
b)Is the blood pressure adequately stabilized?
-If adequately controlled,maintain the current therapy.
-If not,step-up the regime
c)Are there derangements of biochemical profile?
-To look for target organ damage.If present,treat accordingly
-To look for HELLP syndrome.If present,plan for delivery
d)Is the fetus affected?
-Main complication is IUGR.If present,manage it accordingly

7.Criteria for continuous wad admission:

-Persistent proteinurea
-Uncontrolled BP
-IUGR
-Derangements of biochemical profile

Management of Eclampsia
1.Perform routine steps involved in obstetric emergencies(call specialist,monitor vital signs)
2Start Medications:
a)Seizure
-Magnesium sulphate loading dose is given(4g given within 10-15 minutes).This is followed
by continuous infusion of 1g/hour for 24 hours
-If second episode of fits occur,give a further 2g of bolus magnesium sulphate
-If repeated seizures occurs,diazepam is used.Patient might have to be intubated and
ventilated to protect airway.
b)Hypertension-Antihypertensive medications listed above
-IV is usually given since patient may not tolerate orally
3.Monitoring
a)Maternal monitoring
i)Vital signs every 15 minutes.Urine output hourly
ii)Magnesium toxicity-Deep tendon reflexes hourly
-Toxocity is characterized by confusion,hypo/areflexia,respiratory
depression,hypotension
-If present,give 1g calcium gluconate over 10 minutes
b)Fetal-Continous CTG monitoring

4.Immediate delivery irrespective of gestational age(definitve treatment) once mother has

been stabilized

Postpartum
1.Monitoring for 5 days-BP,urine protein
-Done due to chances of postpartum eclampsia

Future pregnancy
1.2 years interval is adviced
2.Low dose aspirin is given after confirmation of pregnancy(Prophylaxis)

*Role of magnesium sulphate in pregnancy:

a)Used in Pre-eclampsia-Prevent patient from fitting(patients with previous episode of
eclampsia in previous pregnancy)
-Stop fitting episode
-Prevent further fitting
-Prevent patient with HELLP syndrome to fit
b)Tocolytic agent
c)Nueroprotective agent for fetus-Studies have shown that magnesium sulphate improves the
neurodevelopmental status in preterm neonates,in comparison with
preterm neonates who were not exposed to Magnesium Sulphate