Hypertension Disorders In

Pregnancy

Overview:
PIH
Chronic hypertension
Postpartum Hypertension
Pre eclampsia
Eclampsia
Hellp syndrome

PIH
Hypertension in second half of pregnancy
in the absence of proteinuria or other
markers of pre eclampsia.

Affects 6- 7% of pregnancies
At increase risk of going on to develop PE
The risk increase with earlier onset
hypertension
Delivery should be aimed at the time of
EDD
BP usually returns to pre pregnancy limits
within 6 weeks of delivery.

Chronic hypertension

Complicates 3-5% of pregnancies

Definition: hypertension present before
conception or 20 weeks of POG or persist more
than 6 weeks postpartum.
Increase risk of developing PE
Delivery should be planned around time of EDD.

Post partum hypertension

Hypertension arising in postpartum period
It is important to determine whether this is
physiological, pre existing chronic hypertension or
new onset pre- eclampsia
*Remember BP peaks on the 3rd to 4th day
postpartum.
Symptoms such as epigastric pain or visual
disturbance and new onset proteinuria are more
suggestive of postpartum PE

Postnatal management of hypertension

Medication

Side effects

Breastfeeding

methyldopa

Postnatal
depression

yes

nifedipine

Tachycardia and
flushing, headache

yes

labetalol

Avoid in asthma

yes

hydralazine

Tachycardia,
headche, diarrhea

yes

Postnatally methyldopa should be changed to a beta blocker because

of the risk of postnatal depression
The bp may stay raised for up to 6 months.
If still raised after this, it is important to look for secondary causes of
hypertension.

Secondary causes of hypertension

Renal disease
Cardiac disease, eg. Coarctation of the aorta
Endocrine causes, eg: cushing's syndrome, conn's
syndrome or rarely, phaeochromocytoma.
Women with chronic hypertension are at risk of:
Superimposed PE
Fetal growth restriction
Placental abruption

PE overview
Multisystem disorder characterized by hypertension and
proteinuria and is thought to arise from the placenta.
It is the leading cause of maternal morbidity and mortality in
the UK
It is a common cause of prematurity and hospital admissions.
Affects up to 10% of pregnancies (mild form)
Severe PE affects up to 1% of pregnancies.

Definition:

bp >140/90 and 300mg proteinuria in 24h urine collection

women already hypertensive: rise in systolic bp >30 mmhg
or diastolic bp >15mmhg

Risk factors of PE
Previous severe/early
onset pre eclampsia
Age > 40 or teenager
Family histoy mother
or sister
Obesity, bmi > 30
Primiparity
Multiple pregnancy
Long birth interval
Fetal hydrops

Hydatidiform mole
Pre- existing medical
condition:
1.hypertension
2.renal disease
3.diabetes
4.antiphospholipid
antibodies
5.thrombophilias
6.connective tissue disease

Clinical picture
Symptoms

Signs

Headache esp frontal

Hypertension >140/90, severe

>170/110

Visual disturbance esp flashing lights

Proteinuria >300mg in 24h

Epigastric or RUQ pain

Facial oedema

Nausea and vomiting

Epigastric/ RUQ tenderness (liver

involvement and capsule distention)

Rapid oedema esp face

Hyperreflexia and or clonus ( >3

beats) sign of cerebral irritability

* symptoms usually occur only with

severe disease.

Uterine tenderness or vaginal

bleeding from placental abruption
Fetal growth restriction on US

Lab investigation:
FBC
high hb due to hemoconcentration
thrombocytopenia
anemia if hemolysis
Coagulation profile
prolonged PT and APTT
Biochemistry
increase urate
increase urea and cretinine
abnormal LFTs ( increase transaminases)
increase LDH marker of hemolysis
increase proteinuria > 300mg protein/ 24hr

Severe complication of PE

Eclampsia
Hellp (hemolysis, elevated liver enzyme, low
platelets)
Cerebral hemorrhage
Disseminated intravascular coagulation
Renal failure
Placental abruption

Management- Outpatient
who? appropriate if:
bp systolic <160/ <110 diastolic and can be
controlled
no or low (<1+ / < 300mg per 24h) proteinuria
asymptomatic
difficult to distinguish from gestational
hypertension
What do we do?
1-2 per week review bp and urine
weekly review blood biochemistry

Mild to moderate PE
Who?
Bp <160 systolic and diastolic <110 with
significant proteinuria and no maternal
complication (significant proteinuria- >2+ protein
and >300mg proteinuria/ 24h)
What do we do?
4hr BP
24hr urine collection
daily urinalysis
daily fetal assessment - CTG
regular blood test ( every 2- 3 days unless
symptoms and signs worsen)
regular US assessment ( fortnightly growth and
twice weekly doppler/ liquor volume depending
on severity of PE)
* if BP increase >160 systolic or >110 diastolic
antihypertensive therapy should be started.

Severe PE
Definition: bp >160 systolic or >110 diastolic with significant
proteinuria or if maternal complication occurs.
Bp management:
initially: use nifedipine 10mg ( can be given twice half an hour
apart)
stabilization of bp with antihypertensive medication
if bp remains high, start IV labetalol infusion.
IV hydralazine may be used in some units

Other management:
take PE profile
strict fluid balance chart (consider catheter)
CTG monitoring of fetus until condition stable
US to see:
IUGR
weight if severely preterm
assess condition using fetal and umbilical artery doppler
* if <34 weeks IM dexa should be given and pregnancy may be
managed expectantly unless maternal or fetal condition worsen.

Treatment of severe PE:

The only treatment is delivery, but this can be
delayed with intensive monitoring if <34weeks
PE often worsen for 24h after the delivery.
Indication of immediate delivery:
worsening thrombocytopenia or coagulopathy
worsening liver or renal function
severe maternal symptoms, esp epigastric pain
fetal reasons: fetal distress or reversed umbilical
artery flow
hellp syndrome or eclampsia.

Eclampsia
Defined as occurance of tonic clonic seizure in
assosiation with diagnosis of PE.
It complicates around 1-2% of PE pregnancies
It may be the initial presentation of PE and occur
without hypertension or proteinuria
Fits may occur antenatally- 38%, intrapartum- 18%,
postnatally within first 48h -44%
It is an obstetric emergency
A sign of severe disease, most women who die with
PE or eclampsia do so from other complications
such as blood loss, intracranial hemorrhage or
hellp.

HELLP syndrome
Serious complication regarded by most as a variant
of severe PE manifesting with hemolysis, elevated
liver enzyme and low platelets.
Incidence is estimated at 5- 20 % of PE pregnancies.
Maternal mortality is around 1% with perinatal
mortality estimates of 10- 60 %
Commonly, liver enzyme increase and platelets
decrease before hemolysis occurs
Syndrome is usually self limiting, but permanent
liver or renal damage may occur.

Symptoms include:
epigastric pain or RUQ pain 65%
nausea and vomiting 35 %
Signs include:
tender RUQ
increase in BP and other features of PE
Eclampsia may coexist.
Delivery is indicated.
*Although platelet levels may be very low, platelet
infusions are only required if bleeding or for surgery
and if <40.
What to do if Eclampsia occurs?
Admit for atleast 7days

Initial steps

Call for help

Left lateral position
Maintain airway
Mouth Suction

Control fits

IM MgSo4 regime or IV MgSo4

regime

Control Bp

IV hydralazine infusion or IV labetolol

infusion

Assessment of pregnancy once pt

stable

Consider delivery once stable.

CTG
US
VE once stable ( vaginal delivery is
not contraindicated if cx is
favourable)
Monitoring: VS monitoring, strict IO
chart, CVP line ( if it is assosiated
with maternal hemorrhage and
fluid balance is difficult or if
creatinine rises)

MgSo4 protocol
1ampule 2.5g
Monitor:
patellar reflex is present hourly
RR > 12bpm
urine output >100ml over 4h
serum MgSo4 within therapeutic ranges 1.7- 3.5
IV regime:
loading dose: IV MgSo4 4g slow bolus over 10- 15 mins
maintainance dose: IV MgSo4 1gm/hr for 24h
IM regime:
loading dose: IM10mg (5mg on each buttock)
maintanence dose: 5mg every 4hr for 24hr
Recurent fit: IV 2g bolus

Toxicity:
Absent deep reflex
Respiratory depression
Cardiac arrest
Antidote
IV 10 % calcium gluconate 10mls over 35min
Requires ECG monitoring before and after
due to risk of cardiac arrthymias.

Antihypertensive agent:
IV hydralazine
5- 10mg for 20 min repeat every 20- 30 mins
25mg in 500ml NS, 10dpm every 20 min
SE: tachycardia, hypotension, headache,
tachyphylaxis
IV labetolol
10- 20mg for 5mins, repeat every 5mins
SE: complete heart block, pulmonary edema,
bronchoconstriction
Oral nifedipine
10mg stat
SE: flushing, tachycardia
Others
Parenteral nitroglycerin and sodium nitroprusside