1. Hypertensive Disorders in
Pregnancy
Dr. Md Shahid Iqubal
P.G Student,
Deptt. Of Medicine, NMCH

2. Introduction
• Hypertension is one of the most common
medical complication during pregnancy
• Increased maternal and perinatal morbidity
and mortality.

3. DATA REPORTS
• Incidence of hypertensive disorder in pregnancy
worlwide-10% of all pregnant women
Preeclampsia-3-5%
in India - 8-10%
preeclampsia 7.8% (prevalence)
• in Asia and Africa One tenth of all maternal
deaths are associated with hypertensive disorder
in pregnancy.

4. Hypertension in Pregnancy
• Blood pressure ≥ 140/90 mmHg
• Documented on two occasions
• At least 4 hours apart
• Not more than 7 days apart
Other Criteria-
• SBP increased by 30mmHg
• DBP increased by 15mmHg
• Mean Arterial Pressure increased by 20mmHg

5. Normal Blood Pressure changes in Pregnancy
• Decreases during the
first trimester,
• Reaching its lowest point
at 20 weeks,
• Returns to prepregnancy
levels during the third
trimester.

6. Classification of Hypertension in
Pregnancy
1. Gestational Hypertension
2. Pre-eclampsia
3. Eclampsia
4. Pre-eclampsia superimposed on chronic Hypertension
5. Chronic hypertension with pregnancy

7. Gestational hypertension
• New onset of hypertension after 20 weeks of
gestation or within the first 48 hours of
delivery without proteinuria or other features
of preeclampsia, followed by return of B.P. to
normal within 12 weeks post-partum
• associated with development of HTN later in
life
• associated with development of diseases
related to hypertension (CVD, CKD)

8. Gestational HTN: MANAGEMENT
 Mild Gestational HTN (systolic BP ≥140 to < 160
mm Hg, diastolic≥90 to < 110 mm Hg)
• Managed as outpatients
• Daily fetal movement/kick counting
• Fetal growth monitoring every 3-4 weeks
• No antihypertensive therapy
Severe Gestational HTN (SBP ≥160 mmHg or
DBP≥110 mmHg)
• is treated with antihypertensive agents

9. PRE-ECLAMPSIA(PE)
Diagnostic criteria:

10. Risk Factors for Preeclampsia
• Primigravida: Young or elderly
• Family history: Hypertension, preeclampsia
• Placental abnormalities:
• Obesity: BMI >35 kg/m2, Insulin resistance.
• Pre-existing vascular disease
• Thrombophilias [antiphospholipid syndrome, protein C, S
deficiency, Factor V Leiden

11. Etiopathogenesis
• Imbalance between vasodilator and
vasoconstrictor
vasodilator vasoconstrictor
NO
PGI-2
Angiotensin-II
Endothelin-I
ThromboxanA2

12. Basic mechanism of different organ damage:
Multisystem Disease
• Increased vasoconstriction- HTN
• Decreased organ perfusion- uteroplacental- IUGR
kidney-oliguria, liver- ischemia, HELLP, brain-
seizures, PRES
• Increased endothelial dysfunction (capillary
leak)- edema, proteinuria, ascitis, Pulmonary
oedema, pleural effusion
• Activation of coagulation: DIC, low platelets,
HELLP
• Haemoconcentration

13. Clinical Types Of Pre-eclampsia
 Non- severe:-
• BP≥140/90 mm Hg but <160/110 mmHg without significant proteinuria.
 Severe:
• A persistent systolic BP ≥ 160 mm Hg or diastolic pressure >110 mm Hg.
• significant proteinuria -present
• Oliguria (<400 mL/24 h).
• Platelet count <100,000/mm3.
• HELLP syndrome.
• Cerebral or visual disturbances.
• Persistent severe epigastric pain.
• Retinal hemorrhages, exudates or papilledema.
• Intrauterine growth restriction of the fetus.
• Pulmonary edema
• S.creat>1.1mg/dl

14. • ONSET: usually insidious and the syndrome runs a slow course.
 SYMPTOMS:
• Preeclampsia is principally a syndrome of signs and when symptoms
appear, it is usually late.
• Mild symptoms: Slight swelling over the ankles which persists on rising
from the bed in the morning or tightness of the ring on the finger is the
early manifestation of edema due to preeclampsia.
• Alarming symptoms:
• Headache —
• Disturbed sleep,
• ↓ urinary output—
• Epigastric pain—due to hemorrhagic gastritis or due to subcapsular
hemorrhage in the liver,
• Eye symptoms—there may be blurring, scotomata, dimness of vision
,usually regained 4-6 weeks following delivery
Clinical Features of Pre-eclampsia

15.  SIGNS-
• Abnormal weight gain: 4 lb a week in later months of pregnancy is
significant.
• Rise of blood pressure: The diastolic pressure usually tends to rise first
followed by the systolic pressure.
• Edema: Visible edema over the ankles on rising from the bed in the
morning is pathological.
• Pulmonary edema—due to leaky capillaries and low oncotic pressure.
• Abdominal examination –scanty liquor or growth retardation of the
fetus.
• Ophthalmic examination: retinal haemorrhage, nicking of veins,
• Vein/arteriole diametre- ratio 3:2 to 3:1
• Thus, the manifestations of preeclampsia usually appear in the following
order—rapid gain in weight→ visible edema and/or hypertension →
proteinuria
Clinical Features of Pre-eclamsia

16. Investigations:Pre-eclampsia
• Urine: Proteinuria: Presence of total protein in 24 hours urine of
more than 0.3 g or more OR urine protein/creatinine ratio>0.3
,on at least two random clean-catch urine samples tested 4 hours
apart in the absence of urinary tract infection is considered
significant.
• Test for protein in urine by multiple reagent strip (dipstick) as
follows: Trace = 0.1 g/L; 1+ =0.3 g/L; 2+ = 1.0 g/L; 3+ = 3.0 g/L; 4+
= 10.0 g/L
• Blood values: A serum uric acid level (biochemical marker of
preeclampsia) > 4.5 mg/dL.
• Serum creatinine level may be more than 1 mg/dL.
• Thrombocytopenia and abnormal coagulation.
• Hepatic enzyme levels may be increased.
• Antenatal fetal monitoring:
• daily fetal kick count, ultrasonography for fetal growth and liquor
pockets, cardiotocography, umbilical artery flow velocimetry and
biophysical profile(NST)

17. Screening tests for prediction and
prevention of PRE-ECLAMPSIA
• Doppler ultrasound of high resistance index in the uterine artery,
second trimester is associated with six fold increase in rate of
preeclampsia .Presence of diastolic notch at 24 weeks’ gestation in the
uterine artery can predict the possible development of preeclampsia.
• Development of renal dysfunction: ↑serum uric acid and appearance
of microalbuinuria are observed to be the predictors of preeclampsia.
• Absence of end-diastolic frequencies or reverse diastolic flow
patterns in the umbilical artery.
• Average mean arterial pressure (MAP) in second trimester > 90 mm
• Roll over test: This screening test is done between 28 and 32 weeks.
After resting in the left lateral position turning to a supine position
induces a rise in diastolic pressure of 20 mmHg or more is a positive
test indicative of tendency to develop pre-eclampsia.

18. Uterine Artery DOPPLER
In preeclamptic mother:
Showing early diastolic NOTCH
Decreased EDF(due to high
resistance)
In normal mother

19. Prophylactic Measures For Prevention Of
Preeclampsia
• Regular antenatal check
• Antithrombotic agents:
• Low-dose aspirin 60 mg daily .Aspirin in low doses is known to
inhibit cyclo-oxygenase in platelets thereby preventing the
formation of thromboxane A2 without interfering with prostacyclin
generation.
• LDA to be started in high risk woman (prior h/o PE, renal disease,
DM, autoimmune disease) at 12 to 28 weeks and continued untill
delivery.
Heparin or low-molecular-weight heparin is useful in women
with thrombophilia and with high risk pregnancy.
• Calcium supplementation (2 g/day)
• Antioxidants, vitamins E and C and nutritional supplementation
with magnesium, zinc, fish oil and low-salt diet have been tried but
are of limited benefit.

21. <34 weeks Close to 37 weeks or
>34 weeks
• Antihypertensive therapy

22. drug Mode of Action dose
Methyl-dopa Central and peripheral
antiadrenergic action
250–500 mg tid or qid
Labetalol Adrenoceptor antagonist
(α and β blockers)
100 mg tid or qid
Nifedipine Calcium channel blocker 10–20 mg bid
Hydralazine Vascular smooth muscle
relaxant
10–25 mg bid
Commonly Used drugs in the Management of Preeclampsia

23. Hypertensive Crisis in Pregnancy
• Defined as persistent (lasting 15 min or more),
acute-onset, severe hypertension, systolic BP
greater than 160 mmHg or diastolic BP >110
mmHg in the setting of pre-eclampsia or
eclampsia.
• Treated with intravenous antihypertensive
medications
• Goal- systolic blood pressure between 140
mmHg and 150 mmHg and diastolic pressure
between 90 mmHg and 100 mmHg

24. drug Onset of
Action
dose Schedule Maximum dose Maintenance
dose
Labetalol 5 min 10–20 mg IV every
10 minute
300 mg IV 40mg/hr
Hydralazine 10 min 5 mg IV every 30
minute
30 mg IV 10mg/hr
Nifedipine 10 min 10–20 mg oral, can
be repeated in 30
minute
240 mg/ 24 hr 4-6 hr interval
Nitroglycerine
Sodium
nitroprusside
0.5-5 min 5 μg/minute IV
0.25-5
μg/kg/minute IV
Short-term
therapy when
the oher drugs
have failed
Commonly Used drugs in the Management of Hypertensive Crisis

25. Postpartum Monitoring
• The patient is to be watched closely for at least 48 hours,
the period during which convulsions usually occur.
• Antihypertensive drug treatment should be continued if the
BP is high (systolic >150 mm Hg or diastolic >100 mm Hg).
• Oral nifedipine 10 mg at every 6 hours is given until BP
remains below the hypertensive levels for at least 48 hours.
• Oral furosemide 20 mg a day for 5 days also used
• Magnesium sulfate (for at least 24 hours) may be needed in
women with severe hypertension and symptoms of acute
fulminant preeclampsia during the postpartum period.
• In breastfeeding women, labetalol, nifedipine or enalapril
may used on discharge.

26. Acute Fulminant Preeclampsia
(Preeclamptic State)
• onset of the preeclamptic manifestations is acute, there is rapid deterioration
in an established case of preeclampsia with severe hypertension over a short
period of time.
• There is a constant threat of convulsion, cerebral hemorrhage, cardiac failure
or placental abruption.
• TREATMENT: the patient should be adequately sedated by midazolam 1–2 mg
IV, may be repeated in 5–10 minutes time or diazepam 10 mg IV(slow).
• Prophylactic anticonvulsant therapy is to be instituted urgently.
Administration of magnesium sulfate is recommended .
• The blood pressure is to be stabilized by IV antihypertensive drugs Labetalol
(IV) or Hydralazine (IV).
• Obstetric management: As there is a constant threat of eclampsia
• In cases with pregnancy beyond 37th completed weeks or where the condition
fails to improve within 6–8 hours, delivery should be seriously considered
irrespective period of gestation.

27. Eclampsia
• Preeclampsia when complicated with grandmal seizures
(generalized tonic-clonic convulsions) and/or coma is called
eclampsia.
• The hospital incidence in India ranges from 1 in 500 to 1 in 30.
• Onset of fits-
• Antepartum (50%): Fits occur before the onset of labor.
• Intrapartum (30%): Fits occur for the first time during labor.
• Postpartum (20%):Fits occur for the first time in puerperium,
usually within 48–72 hours of delivery.
• Fits occurring beyond 48 hours but less than 4 weeks after delivery
is accepted as late postpartum eclampsia.

28. Clinical Features Of Eclampsia
Stage of eclamptic convulsion-
• Premonitory stage: The patient becomes
unconscious. There is twitching of the muscles of
the face, tongue, and limbs. This stage lasts for
about 30 seconds.
• Tonic stage:. This stage lasts for about 30
seconds.
• Clonic stage: Biting of the tongue occurs. This
stage lasts for 1–4 minutes.
• Stage of coma: The fits are usually multiple,
recurring at varying intervals.

29. Differential Diagnosis Of Eclampsia
• Epilepsy,
• Hysteria,
• Encephalitis,
• Meningitis,
• Puerperal cerebral thrombosis
• Cerebral malaria
• Intracranial tumors.
 Absence of previous history of convulsion with presence of
edema, hypertension and proteinuria along with fits or coma
during pregnancy or soon after, points to the diagnosis of
eclampsia.

30. Management: Eclampsia
• PREDICTION AND PREVENTION: In majority of
cases, eclampsia is preceded by severe
preeclampsia.
• Thus the prevention of eclampsia rests on
early detection and effective treatment with
judicious termination of pregnancy during
preeclampsia

31. FIRST AID TREATMENT OUTSIDE THE HOSPITAL:
• BP should be stabilized and convulsions should be
arrested Magnesium sulfate [4 g IV loading dose
with 10 g IM is given.
• Labetalol- 20 mg IV is given to control
hypertension.
• Diuretic -if pulmonary edema.
• Diazepam, if used, should be given 5 mg slowly
over 1 minute period
Management: Eclampsia

32. MANAGEMENT
• Supportive care: (i) to prevent injury from fall, (ii) prevent
aspiration, (iii) to maintain airway and (iv) to ensure
oxygenation.
• a tongue blade is inserted between the teeth. To put
patient in the Left lateral position to avoid aspiration.
• oropharyngeal suctioning,
• oxygenation is maintained through a face mask (8–10
L/minute) to prevent respiratory acidosis. Oxygenation is
monitored using a pulse oximeter.
• ABG analysis is needed when O2 saturation falls below
92%.
• Sodium bicarbonate is given when the pH is below 7.10.
Management: Eclampsia

33. • Monitoring:
• pulse, RR and blood pressure- Half hourly.
• urinary output -Hourly.
• Fluid balance: Crystalloid solution (Ringer’s
solution) is started as a first choice. Total fluids
should not exceed the previous 24 hours
urinary output plus 1000 mL (insensible loss
through lungs and skin). Normally, it should
not exceed 2 litres in 24 hours.
Management: Eclampsia

34. Specific Management: Eclampsia
• Anticonvulsant regime:
• Magnesium sulfate is the drug of choice.
• It acts as a membrane stabilizer and
neuroprotector. It reduces motor endplate
sensitivity to acetylcholine.
• Magnesium blocks neuronal calcium influx.
• It induces cerebral vasodilatation, dilates uterine
arteries, increases production of endothelial
prostacyclin and inhibits platelet activation.

35. Regimen Loading dose Maintenance
Intramuscular
(Pritchard)
4 g (20% solution) IV over 3–5
minute followed by 10 g (50%),
deep IM(5 gm in each buttock)
5 g (50%) IM 4 hourly in
alternate buttock
Intravenous
(Zuspan or Sibai)
4–6 g IV slow over 15–20
minute
1–2 g/h IV infusion
Regimens of MgSO4 for the Management of Severe Preeclampsia and Eclampsia
 Monitoring of Magnesium Toxicity -
 Loss of deep tendon reflexes
 Decreased respiratory rate (<12 per minute)
 Urine output (< 30 mL/h)
 Chest pain, heart block, pulmonary edema
 Oxygen saturation monitoring.(Pao2<95%)
• Stop MgSO4 if toxicity occur.
• The therapeutic level of serum magnesium is 4–7mEq/L

36. • Magnesium sulfate is continued for 24 hours after the last
seizure or delivery whichever is later. For recurrence of fits,
further 2 g IV bolus is given over 5 minute in the above
regimens. If the patient seizes, despite magnesium therapy,
midazolam 1–2 mg IV is given (and may be repeated in 5–
10 minutes time).
 Management for Magnesium Toxicity
 Stop magnesium therapy
 Estimation of serum magnesium and creatinine levels
 Injection calcium gluconate 10 mL (10% solution), IV
slowly.
 Fluid loading and forced diuresis
Specific Management: Eclampsia

37. • Other regimens are: (1) Lytic cocktail using
chlorpromazine, promethazine and pethidine. (2)
Diazepam (Lean) and (3) Phenytoin
Status eclampticus:
• Thiopentone sodium 0.5 g dissolved in 20 mL of
5% dextrose is given intravenously very slowly.
• If the procedure fails, use of complete anesthesia,
muscle relaxant and assisted ventilation.
• In unresponsive cases, cesarean section
Specific Management: Eclampsia

38. INDICATIONS OF INTUBATION:
• Patient remains unconscious in post seizure
period
• Seizures not controlled
• Signs of aspiration
• Persistent hypoxia
Management: Eclampsia

39. Treatment of complications:
• Prophylactic use of antibiotics pulmonary and
puerperal infection.
• Pulmonary edema: Furosemide 40 mg IV followed
• by 20 g of mannitol IV
• Heart failure: Oxygen inhalation, IV furosemide and
digitalis are used.
• Anuria: Dopamine infusion (1 μg/kg. urine output
returns to normal following delivery.
• Hyperpyrexia:cold sponging and antipyretics.
• Psychosis : Chlorpromazine or trifluoperazine
Management: Eclampsia

40. Obstetric Management:Eclampsia
• seizure controlled and baby mature- delivery
should be done
• seizure controlled and baby immature-(<37
weeks)- delivery recommended in NICU setup
• Seizure not controlled-
• if seizure not controlled after 6-8 hr of
anticonvulsant therapy – terminate the
pregnancy
• During labour- dose of antihypertensive and
anticonvulsants may be increased.

41. CHRONIC HYPERTENSION IN
PREGNANCY
• Chronic hypertensive disease (CHD) is defined
as the presence of hypertension of any cause
before the 20th week of pregnancy and its
presence beyond the 12 weeks after delivery.
• Majority of women with CHD are low risk and
have satisfactory maternal and fetal outcome
without any antihypertensive therapy.

42. ESSENTIAL HYPERTENSION IN
PREGNANCY
• incidence 1% to 3%.
• The diagnostic criteria are:
• BP≥140/90 mm Hg during pregnancy before 20th week
• Cardiac enlargement on chest radiograph and ECG,
• Presence of medical disorders,
• persistent rise of BP after 42 days following delivery
 Management-
 BP<160/100- rest, low salt diet, frequent BP monitoring(1-2
weeks)
 BP>160/100- antihypertensive drugs should be used.
• If antihypertensive drugs taking before pregnancy, care
should be taken to adjust the dose during pregnancy,
especially, during midpregnancy when BP tend to fall.

43. HELLP Syndrome
• This is a rare complication of pre-eclampsia
• Hemolysis:
• LDH > 600 U /L
• PBS showing schistocytes, burr cells.
• Serum bilirubin ≥ 1.2 mg/dL
• Elevated Liver enzymes:
• AST and ALT >70 IU/l
• Low Platelet count:<1 lakh/cubic mm
 Management- antiseizure prophylaxis with magnesium sulfate
• Corticostreroids- ↑ platelet count, improves perinatal outcome
• Platelet transfusion- if platelets<50000/cumm

44. Take Home Message
• Preeclampsia and eclampsia are the leading causes of maternal
mortality and morbidity in India and worldwide.
• basic pathology of Preeclampsia is endothelial dysfunction and
vasospasm.
• By uterine artery doppler ,pre-eclampsia can be early detected
• Acute fulminant preeclampsia has high risk of eclampsia,
Prophylactic anticonvulsant therapy MgSO4 recommended.
• Termination of pregnancy is the definitive treatment of
Preeclampsia and eclampsia.
• First line antihypertensives are Labetalol ,Hydralazine.
• Goal of SBP <160 mm of Hg and DBP<100– 105 mm of Hg.
• MgSO4 is recommended in the management of eclampsia, HELLP
Syndrome and severe preeclampsia.
• Daily low dose Aspirin is given in pre-eclampsia in high risk woman.
• Parenteral labetalol should be avoided in women with asthma,
heart disease, and CHF.