8. Hypertensive Disorder in Pregnancy.pdf

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1. Hypertensive Disorder in
Pregnancy (HDP)
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2. Presentation outline
❑Definition of hypertensive disorder of pregnancy
❑Risk factors
❑Types of HDP
❑Diagnosis
❑Management
❑Complication
❑Prevention
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3. Objectives
By the end of this session you will be able to:
Define HDP
Identifythe risk factors associated with HDP
Classify HDP
Identify the features of HDP
Diagnose a client with HDP
Manage a patient with HDP
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4. Blood pressure measurement
✓Sitting or in the semi-sitting position with a left-sided tilt
✓Don’t talk during b/n measurements
✓Cuff at heart level, back supported and arm supported
✓Use the correct positioning and cuff size (upto≈34cm)
✓Legs uncrossed and feet supported
✓Avoid exercise, tea/coffee, smoking in the last 30 minutes
✓Rest comfortably for five minutes before reading
✓Right arm used consistently
✓DiastolicBP should be taken as Korotkoff V (the absence of sound)
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5. Definition
HDPdefineas:
ariseinBloodPressureof≥140/90mmHgmeasured2
timeswithatleasta4-hourapart,OR
asinglepressurerecordingof160/110mmHgafter20
weeksofgestation,inlabororpostpartum
❑DeltaHypertension:ItisconditionwhereB/Pofapregnantpatient
remainswithinnormalrangebutacutelyincreasesfromherown
baselinelevels
✓SuchfemalescandevelopeclampticseizuresorHELLP
syndrome,inspiteofbeingnormotensive
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6. Epidemiology
Second commonest causes of maternal death in Ethiopia
Preeclampsia and eclampsia occurs during antepartum,
Intrapartum , and post partum period
Causes low birth weight , IUFD, IUGR, AP and prematurity
Pooled prevalence of hypertensive disorder of pregnancy
in Ethiopia were 6.82% (6-10%)
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7. Risk factors
Maternal age ≥35 years
Twins or molar pregnancy
Primigravida: Young or elderly (first time exposure to chorionic villi)
Previous history of preeclampsia
Family history of hypertension
Diabetes mellitus
Body mass index ≥25
New paternity
Pre-existing vascular disease
Alcohol consumption
Metabolic syndrome
Ethno-racial high incidence in African-American women
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8. Pathophysiology of preeclampsia
Theory of preeclampsia pathogenesis
➢This process underlies the “two-stage disorder”
➢Stage I-the placental syndrome—is caused by faulty endovascular
trophoblastic remodeling that downstream causes stage II—the
maternal syndrome.
➢Stage II can be modified by maternal conditions that also manifest
endothelial cell activation or inflammation
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9. Pathogenesis…
❖The pathophysiology imposes numberofmechanismshavebeen
proposedtoinvolves both maternal and fetal/placental factors
1.Placentalimplantationwithabnormaltrophoblasticinvasionofuterinevessels
2.Immunologicalmaladaptivetolerancebetweenmaternal,paternal
(placental),andfetaltissues
3.Maternal maladaptation to cardiovascular or inflammatory changes of
normal pregnancy
4.Geneticfactorsincludinginheritedpredisposinggenesandepigenetic
influences
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10. AbnormalTrophoblasticInvasion
❖Normalimplantationis
characterizedbyextensive
remodelingofthespiral
arterioleswithinthe
deciduabasalis
❖Endovasculartrophoblasts
replacethevascular
endothelialandmuscular
liningstoenlargethe
vesseldiameter.

11. AbnormalTrophoblasticInvasion
❖Inpreeclampsia,theremaybe
incompletetrophoblasticinvasion.
❖innormalplacentas;thedeeper
myometrialarteriolesdonotlose
theirendotheliallining and
musculoelastictissue,
❖Ingeneral,themagnitudeof
defectivetrophoblasticinvasionis
correlatewithseverityofthe
hypertensivedisorder

12. Classification of HDP
Classification is based on:
Gestational age
•Before 20 weeks or after
•Early before 34 wksor late after 34 wks
Blood pressure measurement
Protein in the urine
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13. Classification cont’d
HDP is an umbrella term, complicate up to 10% of pregnancies
1. Gestational Hypertension (transient hypertension): New onset of HTN
after 20 weeks of gestation withoutproteinuria in a previously
normotensive woman and resolve by 12 weeks postpartum
2. Preeclampsia: New onset of HTN after 20 weeks of gestation in a
previously normotensive woman with Proteinuria
Severity features may present or be absent
3. Chronic hypertension: HTN diagnosed or present before pregnancy
or before 20 weeks of pregnancy or
Persists longer than 12 weeks postpartum
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14. Classification cont’d
4.Chronichypertensionwithsuperimposedpreeclampsia:
HTNdiagnosedorpresentbeforepregnancyorbefore20weeksof
pregnancyandNewonsetofproteinuriaOR
✓AsuddenincreaseinBPthatwaspreviouslywell-controlledoran
escalationofantihypertensivetherapytocontrolBP
✓Newonsetofproteinuriaorasuddenincreaseinproteinuriaina
patientwithknownproteinuriabeforeorearlyinpregnancy
✓Significantnew end-organ dysfunctionconsistentwith
preeclampsiaafter20wksofgestationorpostpartum
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15. Classification of Preeclampsia
1.Pre-eclampsia without severe features
2.PRE-ECLAMPSIA with severity features
►Severity features are:
➢Headache, blurred vision, oliguria (<400 ml/24 hours),
➢epigastric pain or pain in right upper quadrant(pulmonary
edema)
➢Low platelet count (<100,000/µl) or thrombocytopenia
➢Elevated liver enzymes more than twice the upper limit of normal
➢Serum creatinine higher than 1.1mg/dl or a doubling or higher of
the baseline serum creatinine concentration in the absence of
other renal disease
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16. HDP indications for severity features
Abnormality 1. Without severity 2. With Severity
1.DBP
2.headache
3.visual disturbance
4.RUQ pain
5.oliguria
6.convulsion
7.serum creatinine
8.low platelet
(thrombocytopenia)
9.Elevated liver enzymes
(LFT)
10.pulmonary edema
-<160/100
-absent
-“
-“
-“
-“
-Normal
-Absent
-Minimal
-absent
-≥160/110 or more
-Present
-“
-“
-“
-“
-Elevated
-Present
-Marked
-present
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17. Classification of Preeclampsia…
3. Eclampsia: A patient with preeclampsia with generalized seizures
(grand mal seizures or coma)
➢Headaches or visual disturbances can precede eclampsia
➢Eclapsia is a diagnosis of exclusion
DDX for eclampsia
✓Cerebral malaria
✓meningitis
✓hypoglycaemia
✓previous seizure disorder
✓head injury or intracranial space-occupying lesions
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18. HDP
18HELLP Syndrome (Homolysis,ElevatedLiver enzymes,
andLowPlatelets):
❑HELLP Syndrome is considered a variant of preeclampsia
❑Complications
✓Eclampsia in-6%
✓placental abruption-10%
✓AKI—5%
✓pulmonary edema—10%
✓Stroke, hepatic hematoma, coagulopathy, acute respiratory
distress syndrome, and sepsis

19. Diagnosis
History Takings
Proper history taking is an important component in the diagnosis
and management of hypertensive disorders of pregnancy
Physical examination
In order to have a proper diagnosis:
General appearance should be checked from the gate
Take vital sign appropriately (special attention to BP)
Chest auscultation (for pulmonary edema)
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20. Lab. Investigation
Urinalysis for protein
Proteinuria in pregnancy is 300mg protein per 24-hour urine
specimen or
Two urine dipstick measurements of at least 1+ (30mg per dl)
taken six hours apart or
Complete blood count (CBC) including platelets count: if <
100,000/microliter
Liver enzymes; if elevated 2-3 times above the normal range
(normal value <42 IU/L)
Renal function Tests (Serum creatinine): if > 1.1mg/dl
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21. Manage Gestational HPN as an outpatient
❖Monitor blood pressure, proteinuria, and fetalcondition weekly
❖If blood pressure worsens or the woman develops features of pre-
eclampsia, manage as pre-eclampsia
❖Counsel the her & her family about danger signs indicating severe
pre-eclampsia or eclampsia
❖If spontaneous laborhas not occurred before term, induce laborat
term
❖Do not administer magnesium sulfate seizure prophylaxis unless the
patient develops severe hypertension or preeclampsia with severe
features
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22. Preeclampsia without severity feature mgt.
Gestational age less than 37 weeks
❖Twice weekly outpatient follow-up is preferred
❖Monitor blood pressure, fetalcondition, CBC, liver and renal
function tests twice weekly
❖Counsel about the danger signs
❖Encourage the woman to eat a normal diet
❖Orient on fetalmovement counting (kick chart) daily
❖Do not give anticonvulsant or antihypertensive rather give at labor
❖Delivery at 37 completed weeks
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23. Mgtof Preeclampsia with severity feature
Stabilizeherconditionfollowedbyhospitalizingdrug
administrationtopreventconvulsionandcontrolthe
hypertension
Administrationofanticonvulsant
Administrationofantihypertensivedrugasindicated
Evaluatethewomantochecktheprogressvitalsigns
Catheterizethebladdertomonitorurineoutput
Maintainastrictfluidbalancechart(monitortheamountof
fluidsadministeredandurineoutput)topreventfluidoverload
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24. What do you do if the women start convulsion ?
Shout for help to mobilize the team and call for emergency
equipment. If you are alone, the family may be your team
Airway: Turn woman onto her side, ensure airway is open and reduce
risk of aspiration of secretions, vomit or blood
After the convulsion, clear the mouth and throat as necessary.
If available, give oxygen at 4–6 L per minute by mask or cannula.
Breathing: If the woman is not breathing, begin ventilation with a bag
and mask
Circulation: assess B/P, pulse is absent, begin cardiac massage
Never leave the woman alone
Prevent from trauma
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25. What is your drug of choice for prevention
and treatment of convulsion?
Magnesium sulphate is the drug of choice for anticonvulsant
minimizing recurrence of convulsion,
comparatively with better maternal and neonatal outcomes
Magnesium sulphate requires two phases of administration:
loading
maintenance doses
The loading does is administered in both intravenous and
intramuscular routes while the maintenance dose is
administered only intramuscularly
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26. Preparation of Magnesium Sulphate
To administer the Magnesium sulphate loading dose using
magnesium sulphate 50% (1gm in 2 mL):
Take one 20 mL sterile syringe
Draw 8 mL (4 g) of magnesium sulphate 50% into syringe
Add 12 mL of sterile water for injection to make a 20%
solution.
Follow immediately with draw 10 mL (5 g) of Magnesium
sulphate 50% into each syringe and add 1 mL of 2%
lignocaine in each syringe and give deep IM injection in to
each buttock.
If the available syringe is 10 cc, draw 5 gm 50% Magnesium
sulphate plus 1ml of 2% lidocaine in 2 syringes give IM in to
each buttock.
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28. When to Repeat Magnesium sulphate?
If the woman is convulsing after 15 minutes of loading dose
Repeat half dose (2gm of magnesium sulphate) 20% (4
ml of Magnesium sulphate and 6 ml of distilled water or
normal saline) IV slowly over 2 minutes.
Record all doses on the magnesium sulphate monitoring
Sheet
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29. Maintenance dose
Before administering Magnesium sulphate check respiratory rate,
urine output and patellar reflex
Continue to give maintenance dose of MgSO4 and repeat the
dose every 4hr alternatively If findings are normal
(RR >12bpm
urine output >30ml/hour and
presence of patellar reflex
Give 5 gm of 50% magnesium sulphate solution with 1 mL of 2%
lidocaine by deep IM injection into alternate buttocks every four
hours
Continue treatment for 24 hours after birth or the last convulsion,
whichever occurs last
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30. What are the signs of Magnesium
sulphate toxicity?
Theparametersindicating the presence of magnesiumsulphate
toxicityare:
Respiratoryrate less than 12 breaths/min
Urineoutput less than30ml/hr
Patellarreflex is absent
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31. Magnesium sulphate toxicity monitoring & management
Closely monitor the woman for signs of magnesium toxicity:
Withhold or delay drug if:
Respiratory rate falls below 16 breaths per minute;
Patellar reflexes are absent;
Urinary output falls below 30 mL per hour over preceding four
hours.
Keep antidote ready
In case of respiratory arrest:
Assist ventilation (mask and bag, intubation)
Give calcium gluconate 1 g (10 mL of 10% solution) IV slowly
over three minutes, until respiration begins to counteract the
effect of magnesium sulphate
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32. Administering Diazepam
When magnesium sulphate toxicity occurs or when not available
give Diazepam as an alternative
Loading dose IV:
10 mg IV slowly over 2 minutes
If convulsions recur, repeat the same dose (10 mg)
Maintenance dose:
40 mg in 500 ml IV fluids (normal saline or Ringer‘s lactate) titrated
over 6-8 hours to keep the woman sedated but arousable
Note:
➢Stop the maintenance dose if breathing <16 breaths/minute
➢Do not give more than 100 mg in 24 hours
➢There is a greater risk for neonatal respiratory depression
because diazepam passes the placenta freely
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33. Diazepam...
❖ Diazepam is an alternative, but increases the risk of respiratory
depression and new-born apnoea, in babies who may already be
suffering from the effects of utero-placental ischemia & pre-term birth

34. Management of Sever HTN using anti-
Hypertensive drugs
The goal of antihypertensive therapy is to maintain the B/P up to
Systolic 140-155 and Diastolic 90-105 mmHg.
Antihypertensive medications should be started if the SBP is 160
mmHg or higher and/or the DBP is 110 mmHg or higher
Recommended drugs as an anti-hypertension are
Hydralazine
Nifedipine and
Labetalol
Aldomet (metyldopa)
Hydralazine or labetalol is the drug of choice for acute control
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36. Plan for delivery
Gestational age < 28 wks: termination of pregnancy (expectant mang'tis not
recommended)
Gestation > 28 to <34 weeks
For expectant management:
➢Transfer to maternity ward
➢Follow vital signs every 4 hours
➢CBC, every other day
➢Liver enzymes, and creatinine twice weekly
➢Fetalkick count daily
➢Fetalsurveillance twice weekly
➢Administer Dexamethasone 6 mg IM every 12 hours for 2 days or
Betamethasone 12 mg daily for 2 days
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37. Plan for delivery …
Gestation > 28 to <34 weeks
Indications for delivery are:
➢Failure to control hypertension with two antihypertensive drugs
with a maximum dose in 48 hours
➢Persistent maternal severity symptoms (severe headache,
visual changes and abdominal and/or epigastric pain with
elevated liver enzymes)
➢HEELP Syndrome
➢Eclampsia
➢Pulmonary edemaor left ventricular failure
➢IUFD and DIC
➢Severe renal dysfunctionHDP
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38. Gestation 34 to 37 weeks
In women with severe pre-eclampsia and a viable fetus, expectant
management may be recommended and can be closely
monitored
if absence of
Uncontrolled maternal hypertension
Worsening maternal status and
Fetaldistress
For women with pre-eclampsia at term (37 weeks):
regardless of severity features, giving birth is recommended
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39. Mode of delivery
❖Mode of delivery depends on gestational age, feto-maternal
condition, presentation& cervical condition
Indication for cesarean section:
✓Unfavourable cervix especially in seriously ill patients
✓Poor progress of labor
✓Patient has not entered active labor within 8 hrs of induction of labor
✓If there is evidence of fetal distress, or other Obstetric indications
Use of anesthesia: Spinal or general anesthesia
✓Except in patients with thrombocytopenia (platelets <100,000) or
bleeding disorders); spinal is preferred

40. Eclampsia managment
Treatment of eclampsia consists of:
†General measures
†Control of convulsions (to stop ongoing convulsion &
prevent subsequent convulsion)
†Blood pressure control, stabilization of the condition of
the mother & fetus.
†Fluid balance
†Delivery & intrapartum/postpartum care

41. General measures
✓Secure IV line & maintain intravascular volume & replace ongoing
losses; avoid overload
✓Position the patient on her side (left lateral) & in Trendelenberg(head
down) position to reduce risk of aspiration of secretions, vomitus or
blood
✓Aspirate (suction) the mouth & throat as necessary & ensure open
airway.
✓Give oxygen by mask at 6 liters per minute
✓Avoid tongue bite by placing an airway or padded tongue blade
between the teeth & protect the woman from injury

42. General measures ...
✓Place an indwelling catheter to monitor urine output
✓Observe vital signs, FHB & reflexes frequently, and auscultate the lung
bases hourly for crepitation indicating pulmonary edema
✓If pulmonary edema occurs, withhold fluids & administer a diuretic (e.g.
furosemide 40 mg IV stat)
✓Keep the patient in a quiet room, an attendant must always be present
beside her
✓Administration of broad-spectrum IV antibiotics is recommended

43. Fluid balance
✓Keeping strict input & output record is essential and determine serum
electrolytes
✓For unconscious patient, 5% DW & ringer's Lactate are infused over24 hrs
✓Replace extra fluid loss through vomiting, diarrhoea, sweating or blood loss
✓Nothing by mouth is allowed (if unconscious); when the patient becomes
conscious & can drink, oral feeding of fluid is started
Delivery : Delivery should take place as soon as the woman's condition has
stabilized, regardless of the gestational age.
✓Should take place within 12 hours of onset of convulsions

44. Prognosis
Poor prognosis if one or more of the following is present (Eden’s criteria):
Coma of 6or more hours
Temperature 39 degrees or more(malignant type of hyperpyrexia).
Pulse over 120/min
Systolic blood pressure over 200 mmHg
Respiratory rate over 40/min
More than 10 convulsions
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45. Complication of Preeclampsia
Maternal
❖Eclampsia
❖Accidental hemorrhage
❖Oliguria and anuria
❖Dimness of vision and even blindness
❖Preterm labor
❖HELLP syndrome
❖Cerebral hemorrhage
❖Acute respiratory distress syndrome
❖PPH
❖Sepsis
❖Maternal death
Fetal
➢Intrauterine fetal death
➢Intrauterine growth restriction
➢Asphyxia
➢Prematurity
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46. Prevention of pre-eclampsia
Prediction:
❖Currently, no screening tests for preeclampsia are predictably reliable, valid, and
economical
Prophylactic measures:
❖Dietary manipulation–low-salt diet, calcium or fish oil supplementation
❖Exercise–physical activity
❖Antioxidants–ascorbic acid (vitamin C), a-tocopherol (vitamin E), vitamin D
❖Antithrombotic drugs–low-dose aspirin
✓Aspirin 75 to 162 mgPO once per day (at bedtime) starting from 12 weeks of GA
until 36weeksOR
✓Stop 5 to 10 days before EDD to diminish the risk of bleeding during delivery
✓inhibits platelet thromboxane A2 biosynthesis

47. QUIZ 1
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48. Cont’d…
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Write MgSO4 administration protocol

49. Reference
William Obstetrics 26
th
Edition
Obstetrics Management Protocol for Hospitals, Ministry of
Health, Ethiopia 2021
World continuous Education and Ethiopian Ministry of
Health e-learning platform
Up-to-date 2024
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50. Thank you
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