Hypertensive Disorders in

Pregnancy

Dr Selly Septina, SpOG

Classification by the working group of
the NHBPEP (2001)
1. Gestational hypertension
2. Chronic hypertension
3. Preeclampsia - Eclampsia
4. Preeclampsia superimposed on chronic
hypertension (superimposed preeclampsia)
 I. Gestational hypertension
BP >= 140/90 mmHg for first time during
pregnancy
No proteinuria
BP returns to normal < 12 wk postpartum
Final diagnosis made only postpartum
May have other signs & symptoms of
preeclampsia , eg. epigastric discomfort or
thrombocytopenia
 II. Chronic hypertension
BP >= 140/90 mmHg before pregnancy or
diagnosed before 20 wk , or
Hypertension first diagnosed after 20 wk
and persistent after 12 wk postpartum
 Underlying causes of
Chronic Hypertension
Essential familial hypertension
Obesity
Arterial abnormalities
Endocrine disorders
Glomerulonephritis
Renoprival hypertension
Connective tissue disease
CKD
III. Preeclampsia
Mild preeclampsia

BP >= 140/90 mmHg after 20 wk gestation

Proteinuria >= 300 mg/24hr or >=1+ dipstick

 Severe preeclampsia
Anyone who meets at least two of the
following signs:

BP >= 160/110 mmHg

Proteinuria 5 g/24hr or >= 2+ dipstick
(persistent)
Cr > 1.2 mg/dl
Platelets < 100,000 /mm3
Microangiopathic hemolysis
Elevated ALT or AST
Persistent headache , visual disturbance ,
epigastric pain
 Eclampsia
Seizures that cannot be attributed to other
causes in a woman with preeclampsia
Seizures are generalized
May appear before , during or after labor
10% develop after 48 hr postpartum
IV. Superimposed preeclampsia
New onset proteinuria >= 300mg/24 hr in
hypertensive women but no proteinuria
before 20 wk
A sudden increase in proteinuria or BP or
platelet count < 100,000 in women with
hypertension and proteinuria before 20 wk
Diagnosis
 Gestational HT
Also called transient HT
Final Dx : after delivery , by exclusion
BP : resting BP , Korotkoff phase V is
used to defined diastolic pressure
GHT may later develop preeclampsia
10% of eclamptic seizures develop before
overt proteinuria is identified
BP rise , increase both mother and fetus
risks
 Preeclampsia
Diastolic hypertension >= 95 , increase
fetal death rate 3 fold
Worsening proteinuria resulted in
increasing preterm delivery
Epigastric pain from hepatocellular
necrosis , ischemia and edema that
stretches Glisson capsule
Thrombocytopenia from platelet activation
& aggregation , microangiopathic
hemolysis induced by severe vasospasm
 Risk factors for preeclampsia
Nulliparous
Advanced maternal age
Race and ethnicity (genetic predisposition
& environmental factor)
Multifetal gestation
Obesity
BMI > 35 kg/m2
 Superimposed preeclampsia
1. Hypertension (>=140/90) is documented antecedent to
pregnancy
2. Hypertension is detected before 20 wk , unless there
is history of HT
3. Hypertension persists long after delivery

Additional previous Hx or family Hx of HT

End organ damage : LVH , retinal change
Risk abruption , IUGR , preterm & death
Etiology?
 Etiology
1. Abnormal trophoblastic invasion of uterine
vessels
2. Immunological intolerance between
maternal and fetoplacental tissues
3. Maternal maladaptation to cardiovascular
or inflammatory changes of normal
pregnancy (vasculopathy)
4. Dietary deficiencies
5. Genetic influences
Complications
 Cardiovascular system
Increase after load
Preload diminish
Endothelial activation with extravasation
Decreased cardiac output
Hemoconcentration from generalized
vasoconstriction and endothelial
dysfynction
Decreased blood volume
 Blood and coagulation
Thrombocytopenia from platelet activation,
aggregation & consumption
Increased platelets activating factor &
thrombopoietin
Clotting factors decrease
Erythrocytes rapid hemolysis (increase
LDH , schizocyte , MAHA)
 Kidney
GFR reduced
Uric acid elevated
Creatinine clearance reduced , oliguria
Diminished urinary Ca due to increased
tubular reabsorption
Urine sodium elevated
Urine osmolarity , U:P Cr , FE Na :
prerenal mechanism
 Liver
Periportal hemorrhage in liver periphery
Elevated transaminase
HELLP syndrome
Bleeding cause hepatic rupture(mortality
30%) , subcapsular hematoma
Conservative treatment
Recombinant factor VIIa
 HELLP syndrome
No strict definition
Incidence 20% of severe preeclampsia or
eclampsia
Factors contributing to death : include
stroke , coagulopathy , ARDS , ARF ,
sepsis
Insufficient evidence : adjunctive steroid
 Brain
Headache & visual symptoms associated
with eclampsia
Two cerebral pathology related
1. gross hemorrhage due to ruptured a.
caused by severe HT
2. more widespread , edema hyperemia ,
ischemia , thrombosis & hemorrhage
caused by preeclampsia
Can we predict preeclampsia?
 Prediction
Biological , biochemical & biophysical
markers
To identify markers of
faulty placentation
reduced placental perfusion ,
endothelial cell activation & dysfunction ,
activation of coagulation

HOW?
 Uric acid
fibronectin
Coagulation activation
cytokines
fetal DNA
uterine artery doppler
Can we prevent preeclampsia?
 Prevention
Salt restriction : ineffective
Inappropriate diuretic therapy
Low dietary calcium increased risk GHT
Fish oil capsules : modify abnormal PG
balance : ineffective
Low dose aspirin (60mg) : ineffective
Antioxidants : vitamin C & E : reduced
endothelial cell activation , reduction in
preeclampsia
 Antioxidant
39% reduction in risk of preeclampsia
Reduced risk of SGA infant
More preterm birth
No difference in develop preeclampsia
among low & high risk
GA : no diff (<20wk VS before & after
20wk)
The Cochrane Database of systematic Reviews 2005
 Dietary salt
Reduce dietary salt intake vs continue a
normal diet
No effect in preeclampsia
Insuffient evidence for reliable conclusions
about effect of advice to reduce diet salt

The Cochrane Database of Systematic reviews 2005

 Folic acid supplement
Reduction in risk of preeclampsia in
supplemented groups ( 200 ug & 5 mg/d)
In low serum folate pregnancy & women
with dx preeclampsia
Odd ratios of preeclampsia no diff
between receive folic 200 ug VS 5 mg/d
(0.46 VS 0.59)
Ped & Perinatal Epid 2005: 19 : 112-124
Management
 Management
Early prenatal detection
Antepartum hospital management
Termination of pregnancy
Antihypertensive drug therapy
 1. Early prenatal detection
Early preeclampsia without overt HT :
increased surveillance
New-onset diastolic BP 81-89 mmHg or
sudden abnormal wt gain (during 3rd
trimester)
Closed surveillance unless overt HT ,
proteinuria , visual disturbances or
epigastric discomfort
 2. Antepartum management
Admit if new onset HT , esp persistent or
worsening HT or develop proteinuria
Detail examine : headache , visual
disturbances , epigastric pain , weight gain
Proteinuria at least every 2 d
BP q 4 hr , except midnight & morning
Creatinine , hematocrit , platelets , liver
enzymes.
 Antepartum management
Evaluate fetal size
Reduced physical activity
Sedative not prescribed
protein & calories diet
Sodium & fluid intake not limit or forced
Further Mg depend on : severity ,
Gestational Age , condition of cervix
 Preeclampsia-Initial Evaluation
Serial blood pressure measurements
Urine protein excretion
Fetal monitoring
Tests to rule out HELLP and other
complications: Hematocrit, platelets, uric
acid, alanine aminotransferase (ALT),
aspartate aminotransferase (AST), lactic
dehydrogenase (LDH)
 Chronic Hypertension -
Management
Generally, deliver at term, unless
superimposed preeclampsia, HELLP
syndrome
Avoid ACE inhibitors (renal failure,
oligohydramnios, pulmonary hypoplasia,
IUGR) and atenolol (IUGR)
 Severe Preeclampsia-
Management
Seizure prophylaxis
Blood pressure control
Delivery
Preeclampsia-Term Pregnancy
Delivery is a short-term goal
Induction of labor is appropriate after
maternal-fetal observation/stabilization
Cesarean reserved for standard obstetric
indications
Cesarean may be recommended in cases
of severe preeclampsia where delivery is
remote
 Preeclampsia-Preterm
Pregnancy
Mild preeclampsia - expectant
management is acceptable under certain
conditions
Close maternal-fetal surveillance
Ability to intervene either if conditions
worsen or if acceptable gestational age
reached
In-hospital vs. home care?
 Preeclampsia-Preterm
Pregnancy
Severe preeclampsia - controversial
Delivery for poor maternal condition is
likely to be necessary over the short term
Sibai has advocated expectant
management for selected patients to
attempt to reduce perinatal morbidity and
mortality due to prematurity
 Preeclampsia-Preterm
Pregnancy
Expectant management of severe
preeclampsia at preterm gestational age:
Hospitalization
Magnesium sulfate for seizure prophylaxis, at
least during initial observation period
Blood pressure control to range of 140-
155/90-105 (labetalol or nifedipine)
Daily assessment of maternal-fetal condition
 Preeclampsia-Preterm
Pregnancy
28-34 weeks corticosteroids for fetal
lung maturation
28-32 weeks ongoing daily surveillance if
stable
33-34 weeks deliver after 48 hours
Deliver for HELLP syndrome, severe
headache, uncontrolled hypertension,
eclampsia
 3. Termination of pregnancy
Delivery is the cure for preeclampsia
Headache , visual disturbances or
epigastric pain : indicative convulsions
(imminent eclampsia)
Oliguria : ominous sign
objectives to forestall convulsions ,
prevent intracranial hemorrhage , &
serious vital organ damage
 Termination of pregnancy
Preterm : conservative justified in mild
preeclampsia, closed observation and
monitoring to complications
severe preeclampsia : prompt delivery
vaginal delivery
c-section if indicated
Induction of labor not harmful to infants ,
but unsuccessful 35%
 4. Antihypertensive drug
To prolong pregnancy , or modify perinatal
outcomes
blocker (Labetolol) , calcium channel
blockers (Nifedipine , Isradipine)
 5. Delayed delivery with Superimposed
Pre Eclampsia (SPE)
SPE remote from term
Conservative or expectant management in
selected group
Sibai 1985 : SPE 18-27 wk : perinatal
mortality 87% , no mothers died , placental
abruption eclampsia , consumptive
coagulopathy , RF , encephalopathy ,
intracerebral hemorrhage , ruptured
hepatic hematoma
 Delayed delivery with SPE
Indications for delivery : uncontrollable BP,
fetal distress , placental abruption , renal
failure, HELLP synd , persistent symptom
Average pregnancy prolong 8d
 Glucocorticoids
Not worsen maternal HT
Decrease RDS , improve fetal survival
No evidence : benefit to ameliorate
severity of HELLP syndrome
Transient improve hematological lab :
platelet counts
2 Maternal death , 18 stillbirth
 Eclampsia-Management
Preeclampsia complicated by generalized
tonic-clonic convulsions OR
Fatal coma without convulsions also

Major complications included placental

abruption (10%) , neuro deficit (7%) ,
aspiration pneumonia (7%) , pulm edema
(5%) , arrest (4%) , ARF (4%) , death (1%)
 Eclampsia
Duration of coma variable
Hypercarbia , lactic acidemia , fetal brady
cardia
High fever
Proteinuria
Diminished urine output , hemoglobinuria
Pronounced edema
Proteinuria & edema disappear within 1 wk
BP return within a few days to 2 wk PP
 Eclampsia
Differential diagnosis : epilepsy ,
encephalitis , meningitis , cerebral tumor ,
cysticercosis , ruptured cerebral aneurysm
Prognosis always serious
6% of Maternal death relate to eclampsia
Among PIH patient , maternal death 16%
 Treatment
1. control of convulsions using IV MgSO4
2. Intermittent IV or oral of antihypertensive
drug to lower Diastolic BP <100
3. Avoidance of diuretics , limit IV fluid
adminstration , avoid hyperosmotic agents
4. Delivery
 Continuous IV regimen
4-6 gm MgSO4 dilute in 250 ml fluid , admin
over 15-20 min

Begin 2 g/hr in 100 ml IV maintenance

Measure Mg level at 4-6 hr , adjust level
between 4-7 mEq/L

MgSO4 discontinued 24 hr after delivery

 Intermittent intramuscular
Give 4 g MgSO4 IV , rate not exceed 1
g/min
Follow with 10 g MgSO4 : 5 g injected
each buttock through 3 inch long , 20
gauge needle , (add 1 ml of 2% lidocaine)
If convulsions persist after 15 min , give 2
g more IV slowly
Give 5 g MgSO4 IM q 4 hr
MgSO4 discontinue 24 hr after delivery
MgSO4
Effective anticonvulsant without producing
CNS depression in either mother or infant
Not given to treat HT
Exert specific on cerebral cortex
10-15% after MgSO4 : subsequent
convulsion
Sodium amobarbital & thiopental , if
excessive agitate in postconvulsion state
In Eclampsia , admin for 24 hr after onset
of convulsion
 MgSO4
Almost totally cleared by renal excretion
Monitor urine output , RR, DPR
Maintained level 4-7 mEq/L
IM & IV regimen , no significant difference
Mg level
Mg 10 mEq/L : patellar reflex disappear
(DPR)
> 10 mEq/L : respiratory depression
> 12 mEq/L : respiratory paralysis & arrest
Cr >1.3 : half dose MgSO4
 MgSO4
Fetal effects
Promptly cross placenta
Neonatal depression occurs only if severe
hypermagnesemia at delivery
Decrease in beat-to-beat variability
Compared with anticonvulsants
MgSO4 reduce recurrent sz 50%
compared to diazepam , reduce maternal
& perinatal morbidity (not sig)
Maternal mortality reduced compared to
phenytoin (not sig) , less neonatal
intubation & NICU admission
Prevent eclamptic sz superior to phenytoin
Lower risk placental abruption
 Antihypertensives
Nifedipine 10 mg Oral , repeated in 30 min
, if necessary (NHBPEP 2000)
Fewer dose required to achieve BP control
without increased adverse effects
Sublingual : potent & rapid :
cerebrovascular ischemia , MI , conduction
disturbance , death
Not superior to other hypertensives
 Persistent postpartum HT
Hydralazine 10-25 mg IM q 4-6 hr
If HT persists or recur : oral labetolol or
thiazide diuretic are given
Two mechanisms :
1. Underlying chronic hypertension ,
2. Mobilization of edema fluid
Diuretics & hyperosmotic agents
Diuretics : deplete intravascular volume ,
compromise placental perfusion , limited
used to pulmonary edema
Hyperosmotic agents : leaks of agents
through capillaries into lungs & brain
promote accumulation of edema
 Fluid therapy
Lactate Ringers Solution , rate 60 ml to
125 ml/hr
Unless unusual fluid loss : diarrhea ,
excessive blood loss
Oliguria : maternal blood volume
constricted, admin IV fluid more vigorously
Women with eclampsia already has
excessive extracelular fluid
 Pulmonary edema
Most often do so postpartum
Aspiration should be exclude
Majority have cardiac failure
Decrease plasma oncotic pressure ,
increase extravascular oncotic pressure ,
increase capillary permeability ,
hemoconcentration , reduced CVP ,
PCWP
Excessive colloid & cyrstalloid cause pulm
edema
 Invasive monitoring
Use of pulmonary artery catheterization
Reserved for women with severe cardiac
disease , renal disease , refractory
hypertension , oliguria , pulmonary edema
Pulmonary edema by more than one
mechanism
If questionable pulmonary edema :
furosemide IV , hydralazine IV
 Delivery
After eclamptic sz , labor often ensues
spontaneously or can be induced
successfully even in remote from term
Because lack of normal pregnancy
hypervolemia , so less tolerant of blood
loss at delivery
 Analgesia & anesthesia

GA caused by tracheal intubation, sudden

HT ,pulm edema , intracranial hge
Epidural preferred : no serious maternal or
fetal complication , lower MAP , Cardiac
output not fall
Summary
Thank you for your attention

Any questions
???