"Comprehensive Management of Hypertensive Disorders During Pregnancy: Diagnosis, Treatment, and Prevention Strategies for Ensuring Maternal and Fetal Health through Early Detection and Multidisciplinary Care Approaches to Improve Pregnancy Outcomes"

Hypertensive disorders during pregnancy, such as gestational hypertension, chronic hypertension, preeclampsia, and eclampsia, are significant contributors to maternal and perinatal morbidity and mortality worldwide. The management of these conditions requires early detection, timely intervention, and a multidisciplinary approach to ensure the health and safety of both the mother and the fetus.

Diagnosis typically begins with regular blood pressure monitoring during prenatal visits, with special attention given to women with risk factors such as obesity, diabetes, kidney disease, or a history of hypertension. Once a hypertensive disorder is detected, close monitoring and individualized treatment plans are essential.

Treatment strategies vary based on the type and severity of the hypertensive disorder. For mild cases, lifestyle modifications such as dietary changes, physical activity, and stress management may be recommended. In more severe cases, antihypertensive medications such as labetalol, nifedipine, or methyldopa are often prescribed to lower blood pressure safely during pregnancy. Regular monitoring of maternal and fetal health is crucial, with tests such as ultrasounds, non-stress tests, and Doppler flow studies helping assess fetal well-being.

In cases of preeclampsia, the condition can progress rapidly, so frequent monitoring for symptoms such as severe headaches, visual disturbances, and abdominal pain is vital. Magnesium sulfate is often administered to prevent seizures in women with severe preeclampsia or eclampsia.

Prevention of hypertensive disorders in pregnancy involves early risk assessment and interventions such as low-dose aspirin for high-risk individuals, along with continued prenatal care. Delivery, often the definitive treatment for severe preeclampsia or eclampsia, must be carefully timed based on maternal and fetal conditions.

Overall, the successful management of hypertensive disorders in pregnancy hinges on a collaborative, patient-centered approach that prioritizes both maternal and fetal health, ensuring the best possible outcomes for both.

1. Management of hypertensive disorders in pregnancy Presenter - Dr.Shreya Moderator- Dr Manuja Assistant professor, VVH

2. Contents Gestational hypertension Preeclampsia-eclampsia management Antihypertensive drugs in pregnancy MgSO4 uses and regimes Status epilepticus HELLP Syndrome management Chronic hypertension management

3. Gestational hypertension Previously normotensive, non-proteinuric women. Lacks proteinuria and other systemic features. Blood pressure typically returns to normal within three months after delivery. Arias: Practical guide to high risk pregnancy DEFINITION : New onset high blood pressure after 20 weeks of gestation, during labor, or within the first 24 hours postpartum.

4. Classification (NICE 2019) 15–25% of women with gestational hypertension subsequently progress to develop the clinical syndrome of preeclampsia. Prevalence 6-15% in nulliparous,multiparous 2-4% SEVERE - systolic BP of 160 mmhg or more and/or diastolic BP of 110 mmhg (To be confirmed within shorter interval of minutes) MILD - systolic BP of 140-159 mmhg and/or diastolic BP of 90-109 mmhg

5. Early detection Prevent Progression Management depends on severity of hypertension and gestational age. GESTATIONAL HYPERTENSION WITHOUT RISK FACTORS Can be managed as outpatients Objectives

6. Gestational hypertension with risk factors Criteria to IDENTIFY high risk women with gestational HTN BP>/= 150/100 mmhg Gestational age < 30 weeks Evidence of end organ damage(elevated serum creatinine , liver enzymes ,LDH, decreased platelet count) Oligohydramnios Fetal growth restriction Abnormal uterine and or Umbilical Doppler velocimetry Pre-existing vascular/kidney disease

7. MATERNAL At least one visit per week is recommended 1) levels of BP at home ( Aim for BP of 135/85 mmHg ) , offer pharmacological treatment if BP remains above 140/90 mmHg ( NICE Guidelines 2019) (160/110 mmHg for ACOG) 2) Evaluation of symptoms 3) Presence of proteinuria –dipstick once or twice a week 4) CBC, liver enzymes, renal function tests at presentation and then weekly- NICE Guidelines 2019,( weekly evaluation of platelets,serum creatinine,liver enzymes(ACOG 2019)(coagulation profile as and when required. Assessment at every visit

8. FETAL 1)DFMC 2)Measurement of uterine fundal height 3) NST is not mandatory if fetal growth and uterine, umbilical and cerebral fetal Dopplers are normal at initial visit.( It may be inconclusive before 32 wk) 4)Carry out ultrasound assessment of fetus at diagnosis and if normal, repeat every 3-4 weeks, if clinically indicated – NICE Guidelines 2019 5) AFI ,every weekly(ACOG 2019) 6)Repeat NST if any of the following occurs Women reports reduction in fetal movement Vaginal bleeding Abdominal pain Deterioration of maternal condition

9. Gestational hypertension with risk factors Admission Objective – Pharmacologic control of BP(is to avoid hypertensive crisis and potential complications like stroke,HF,Pulmonary edema) and early detection of preeclampsia , end organ damage and fetal decompensation Evaluation includes -24 hr urine collection for protein -Platelet count, LDH and liver enzymes once or twice per week -Coagulation profile are unnecessary if the platelet count and LDH are within normal limits

10. Fetal surveillance is of great importance in the expectant management of women with severe gestational hypertension( ultrasound for fetal growth, AFI, Umbilical and cerebral doppler every two weeks and weekly CTG) Expectant management is terminated in following situations- Development of proteinuria - Elevation of BP above threshold - Decreased fetal movements -Poor fetal growth -Development of other signs of preeclampsia -Imminent symptoms Arias: Practical guide to high risk pregnancy

11. HYPITAT trial (Hypertension and pre eclampsia intervention trial 2009) Results showed that one with gestational hypertension and preeclampsia are likely to have better neonatal and maternal outcomes with induction of labour >= 37wks in comparison with expectant management.

12. NICE 2019

13. NICE 2019

14. Timing and Mode of delivery Do not offer planned early birth before 37 weeks to women with gestational hypertension whose blood pressure is lower than 160/ 110 mmHg, unless there are other medical indications For women with gestational hypertension whose blood pressure is lower than 160/110 mmHg after 37 weeks, timing of birth, and maternal and fetal indications for birth should be agreed between the woman and the senior obstetrician. If planned early birth is necessary, offer a course of antenatal corticosteroids and magnesium sulfate if indicated

15. Conditions precluding expectant management Maternal Uncontrolled BP(160/110mmhg or more)not responsive to antihypertensives Persistent headaches ,refractory to treatment Epigastric pain unresponsive to analgesics Visual disturbances ,motor deficit or altered sensorium Stroke , MI, HELLP syndrome New or worsening renal dysfunction (s . Creatinine >1.1mg/dl or twice baseline Pulmonary edema Eclampsia Suspected acute placental abruption fetal Abnormal fetal testing Fetal death Fetus without expectation for survival at the time of maternal diagnosis ( lethal anomaly , extreme prematurity ) Persistent revered end-diastolic flow in the umbilical artery JAMES TEXTBOOK OF HIGH RISK PREGNANCY

16. INTRAPARTUM CARE 2)control of blood pressure 1)prevention of seizures Labour management may be done using WHO partograph Maternal vitals Fetal monitoring Labour monitoring

17. During labor: measure BP: -Hourly ,in women with hypertension (non severe) -every 15-30 minutes until BP is less than 160/110 mmhg in women with severe hypertension Do not preload women with severe gestational hypertension with IV fluids Consider operative or assisted birth in the second stage of labour for women with severe hypertension whose hypertension has not responded to initial treatment Third stage of labour- AMTSL, ergometrine is contraindicated Magnesium sulfate therapy should be initiated if there is progression to Pre eclampsia with severe features, The evidence regarding the benefit-torisk ratio of magnesium sulfate prophylaxis is less supportive of routine use in preeclampsia without severe features(ACOG 2019)

18. Postnatal investigation, monitoring and treatment 1.In women with gestational hypertension who have given birth, measure blood pressure 2. reduce antihypertensive treatment if their blood pressure falls below 130/80 mmHg. Daily for the first 2 days after birth • at least once between day 3 and day 5 after birth • as clinically indicated if antihypertensive treatment is changed after birth. 3) If a woman has taken methyldopa to treat gestational hypertension, stop within 2 days after the birth and change to an alternative treatment if Necessary. NICE 2019

19. 4)For women with gestational hypertension who did not take antihypertensive treatment and have given birth, start antihypertensive treatment if their blood pressure is 150/100 mmHg or higher. [2010, amended 2019] Offer all women who have had gestational hypertension a medical review with their GP or specialist 6 to 8 weeks after the birth. Offer women who have had gestational hypertension and who remain on antihypertensive treatment, a medical review with their GP or specialist 2 weeks after transfer to community care. [2010, amended 2019]

20. PRE-ECLAMPSIA 15 to 20% GESTATIONAL HYPERTENSION

21. Pre-eclampsia

22. PRE ECLAMPSIA DEFINITION: Appearance of high blood pressure (>140/90mmHg) after 20 weeks of pregnancy for the first time in the presence of proteinuria In the absence of proteinuria symptoms suggestive of end organ dysfunction to be considered.

23. Non severe Pre-eclampsia -(systolic BP- 140-159 mmhg and diastolic BP-90-109 mmhg)+ Proteinuria (1+ in automated urine dipstick or PCR >0.3 or 24hr urine protein >300mg ) Severe Pre-eclampsia- 1) Systolic BP 160mmhg or more and or diastolic BP 110 mmhg or more recorded on at least 2 occasions atleast 6 hrs apart . 2)Proteinuria of >/=5g in 24hrs CLASSIFICATION

24. Non severe Pre-eclampsia

25. SEVERE PREECLAMPSIA CRITERIA May or may not be present

26. Patient management ( domiciliary treatment has no role in established preeclampsia) Admit patient for safe confinement Maternal surveillance Fetal surveillance Arias: Practical guide to high risk pregnancy

27. Risk factors of PE

28. General measures 1. Measurement of blood pressure at least four times per day. 2. Measurement of body weight at weekly intervals to assess if the women is gaining weight at a rapid rate 3. Urinary dipstick evaluation for protein in the first urine voided every morning. 4. Proteinuria in a 24-hour specimen may be repeated if dipstick proteinuria worsens drastically. 5. CBC with platelet count, AST, ALT weekly/twice per week depending on maternal condition and ensuing clinical progression. 6)Ophthalmic examination Coagulation profile is not necessary in the presence of normal platelet count. (Done in cases of abnormal platelet count bleeding disorder, deranged LFT, abruption and HELLP syndrome ) Arias: Practical guide to high risk pregnancy

29. 6.Presence of severe headache or scotomas, altered mental status, epigastric or right upper quadrant pain, nausea/vomiting, shortness of breath and decreased urine output. 7. Consider using either the fullPIERS validated risk prediction models to help guide decisions about the most appropriate place of care and thresholds for intervention- NICE Guidelines 2019 . FullPIERS is intended for use at any time during pregnancy • fullPIERS models do not predict outcomes for babies.

30. Pre-eclampsia Integrated Estimate of risk Calculator The fullPIERS model is a tool developed for predicting adverse maternal outcomes following the diagnosis of preeclampsia within 48 hours after admission to the hospital.

31. AIM: Timely referral to higher centre Model predicts maternal outcome in Pre eclampsia (doesn’t tell about fetal outcome)

32. HDP-Gestosis score: Effective and feasible prediction policy- FOGSI 2019 Risk factor Score Age >35yrs 1 Age <19yrs 1 Maternal anemia 1 Obesity (BMI>30) 1 Primigravida 1 Short duration of sperm exposure 1 Women born as small for gestational age 1 Family history of CVD 1 Polycystic ovary syndrome 1 Interpregnancy interval >7 yrs 1 Conceived with assisted reproductive treatment 1 MAP>85mmhg 1 Chronic vascular disease 1 Excessive weight gain during pregnancy 1

33. Risk factor Score Maternal hypothyroidism 2 Family history of pre-eclampsia 2 GDM 2 Obesity (BMI>35) 2 Multifetal pregnancy 2 HDP in previous pregnancy 2 Pre-gestational diabetes mellitus 3 Chronic hypertension 3 Mental disorders 3 Inherited /acquired thrombophilia 3 Maternal chronic kidney disease 3 Autoimmune disease(SLE/APLAS/RA) 3 Pregnancy with assited reproductive (OD or Surrogacy)treatment 3 When total score is =/> 3; pregnant woman should be marked as ‘At risk for Preeclampsia ’.

34. FETAL SURVEILLANCE Daily fetal movement count(10 Counts/12 hr,post meal 1 hr-3 count) FHR monitoring ( NST ) with liquor assessment ( AFI ) weekly/biweekly Umbilical and cerebral Doppler fortnightly/weekly if associated with growth restriction Weekly measurement of fundal height and abdominal girth. Carry out ultrasound assessment of fetus at diagnosis and repeat at every second week.(NICE 2019)

35. NICE 2019

36. NICE 2019

37. Management of mild Pre-eclampsia

38. Gestational age <32 weeks 32-36 weeks >/=37 weeks Initial assessment : - BP>/=150/100 -Proteinuria -Platelets<1L -oligohydramnios -IUGR -Elevated UA S/D ratio -unreliable patient Yes In patient management No Out patient management Continuous assessment -Daily BP,maternal weight,DFMC -Daily dipstick for protein -Platelets,liver enzymes, s.creatinine x 2 times/week -Ultrasound for fetal growth every 3 weeks -NST twice weekly -UA/MCA Doppler every week Stable Continue expectancy Deliver at 37 weeks Unstable May require early delivery Delivery

39. Management of severe pre-eclampsia

40. Seizure prophylaxis Termination of pregnancy Anti hypertensive drugs Corticosteroids

41. Antihypertensive drugs Offer pharmacological treatment if BP remains above 140/90 mmHg Aim for BP of 135/85 mmHg(NICE 2019) Labetalol is the antihypertensive of choice in pregnancy. ACEi and ARBs are contraindicated Consider Nifedipine for the women in whom Labetalol is not suitable

42. Methyldopa if both Labetalol and Nifedipine not suitable. The goal of antihypertensives is to maintain BP at a level so as to prevent cardiovascular and central nervous system consequence without compromising utero placental blood flow. Antihypertensive medicines do not prevent preeclampsia nor do they reverse the primary pathogenic process of placental under perfusion.

43. Strict BP monitoring Explain impending symptoms Compliance with antihypertensives Non severe PE Day To Week Severe preeclampsia Gestational hypertension 1-3weeks

44. CHIPS TRIAL ,done to set the target BP in HDP Tight’ control of pregnancy hypertension results in less severe maternal hypertension. Tight’ control does not increase adverse outcomes for the baby. CHIPS has provided evidence that use of a simple algorithm for ‘tight’ BP control, aiming for a diastolic BP of 85 mmHg,

45. LABETALOL MOA - Peripheral alpha-1 and (non selective) beta-1 and 2 receptor antagonist Acts by decreasing PVR with little or no effect on CO Oral -alpha:beta- 1:3, IV -1:7 DOSAGE - Oral- Initial dose 100mg BD the dose may be increased accordingly to patients response , Max- 2400mg/day in 4 divided doses(FIGO and ACOG ), 1200mg /day (Arias, FOGSI 2019 )

46. -( Intermittent dosing )- 20mg initial dose over 2 min period, followed by 40-80mg every 20min, until the therapeutic response is achieved , Max dose per treatment cycle-300mg( ACOG guidelines 2019, FOGSI 2019), 220mg (Arias 2019,Williams obstetrics) -( Continuous IV use )- 500mg(100ml) of drug added to 400ml NS (1mg/ml) and administered at an initial rate of 20mg/hr(20ml/hr) -If BP does not fall in 20min ,the dose is doubled and continued to be doubled every 20min until the expected range is obtained or max 300mg/hr is given. IV route

47. PHARMACOKINETICS When given orally undergoes first pass metabolism, only 25% of drug is absorbed Elimination – 50-55% urine,rest in bile, feces Half life 5.5 hrs Bioavailability 25% Oral -Onset – 20-120min -Peak- 1-4h -Duration- 8-12h( its dose dependent) IV -Onset – 5min -Peak- 30min -Duration- 4h( its dose dependent)

48. It is the first line drug of choice both acute severe hypertension and maintenance treatment of hypertensive disorders in pregnancy. Its advantages over hydralazine for rapid reduction of BP is it does not cause severe hypotension, headache , tachycardia and has no effect on uteroplacental blood flow. SIDE EFFECTS Chest pain Nausea Dizziness, shortness of breath Tremors To be avoided in asthmatics Rarely it may cause bradycardia and hypoglycaemia in neonates

49. NIFEDIPINE -The usual oral dose(SR or retard tablets) is 10-30mg orally every 6hrs, max dose- 180mg /day MOA - Calcium channel blocker vascular smooth muscle relaxation decrease PVR DOSAGE - Oral – -Severe hypertension crisis- 10mg initial dose followed by repeat dose if necessary after 20min, then 10-20mg every 2-6hrs, max daily dose-180mg( ACOG Guidelines 2019 ), 120mg/day ( FOGSI Guidelines 2019 and ARIAS )

50. PHARMACOKINETICS -Onset- 5-10min -Peak-30min -Duration- 6h - Elimination - kidneys

51. SIDE EFFECTS- facial flushing, tachycardia headache , postural hypotension, constipation Theoretical risk of potential synergy between magnesium, resulting in severe hypotension or neuromuscular blockade leading to respiratory failure( risk is <1%) Sublingual usage – occasional angina and MI (No evidence for the same in healthy young population ), - Its no longer recommended as it causes sudden maternal hypotension and fetal distress due to placental hypoperfusion.

52. HYDRALAZINE The main obstetric use is to rapidly lower BP via IV in patients with severe preeclampsia and hypertensive crisis. DOSAGE -5mg IV or IM, then 5-10mg IV every 20-40min to max cumulative dosage of 20mg; or constant infusion of 0.5-10mg/hr. MOA - Acts directly on smooth muscle fibres of arterial circulation. Vasodilation by release of NO.

53. PHARMACOKINETICS - 0nset- 5min -Peak-30min -Duration-3-8h -Hydralazine is acetylated in liver at a rate that is genetically determined slow acetylators respond to relatively small doses of medication whereas fast acetylators are relatively resistant to the hypotensive effect of drug( majority of Asians are rapid acetylators)

54. SIDE EFFECTS Upto 50% patients - tachycardia , hypotension ,palpitations , headache, anxiety ,nausea, facial flushing, epigastric pain 10% patients hydralazine causes reversible lupus like syndrome, it is limited to slow acetylators usually responds to discontinuation. It causes decreased uteroplacental blood flow when the hypotensive effect is rapid or severe

55. METHYLDOPA PHARMACOKINETICS – -Maximum effect in 4-6 hrs -duration - 8hrs -drug is primarily excreted in the urine MOA - methyldopa induces the synthesis of alpha-methylnorepinephrine which stimulates alpha receptors(centrally acting adrenergic agonist ) decrease sympathetic outflow decrease PVR DOSAGE - 250mg TID , Max- 2000mg/day

56. SIDE EFFECTS- Postural hypotension Excessive sedation and depression if uptitrated (should be avoided in women with history of depression ) 10% of patients may have positive coombs-hemolytic anemia (known to cause autoantibodies against RBCs) and abnormal LFT In some long term administration causes salt water retention (to be careful in patients with chronic hypertension can lead to “rebound” hypertension.

57. Why labetalol?

58. Why not Methyldopa

59. Why not Methyldopa

60. Other drugs used in chronic hypertension PROPRANOLOL- MOA- Non selective beta blocker Dose – 40-60mg BD, max- 480-640mg/day PRAZOSIN – MOA - Postsynaptic alpha blocker , Does not cause changes in CO, can be used in patients with chronic hypertension who fail to adequately expand plasma volume during pregnancy. Dose - Start with 1mg HS (to avoid first dose hypotension), can increase the dose to 2-3mg BD to achieve adequate control.

61. Summary Labetalol > Nifedipine > Methyldopa – NICE Guidelines 2019 IV Labetalol / Oral Nifedipine /IV Hydralazine (severe hypertensive crisis)- NICE Guidelines /ACOG Guidelines 2019

62. Corticosteroids (FOGSI 2019) Corticosteroids are recommended in all women delivering before 34 completed weeks and in case of elective cesarean delivery before 38 completed weeks. Intramuscular dexamethasone: 6 mg 12 hourly 4 doses or Intramuscular betamethasone: 12 mg 24 hourly 2 doses can be used for reducing neonatal respiratory distress. Even a single dose of steroid at least an hour prior to delivery can reduce the neonatal respiratory distress syndrome remarkably.

63. Prevention of seizures Magnesium sulphate –MOA-(REDUCES CEREBRAL VASOSPASM) Reduced presynaptic release of the NT Glutamate. Blockade of glutamatergic NMDA receptors Blockage of calcium entry via voltage-gated channels It can also decrease PVR and MAP, and increases CO with myocardial depression

64. The MAGPIE Trial: • a randomised placebo-controlled trial. • Claims that magnesium sulphate given during labour and for at least 24 h postpartum will reduce the risk of seizures in women with severe pre-eclampsia or imminent eclampsia.

65. Guidelines for Intravenous Magnesium Sulfate Administration(zuspan regimen) Loading dose: 4g IV administered over 5 to 10min; concentration not to exceed 20%) Maintenance dose :1 to 2 g/h by controlled infusion pump x ≥24h after the seizure

66. Guidelines for Intramuscular Magnesium Sulfate (Pritchard’s Regime) Intravenous loading dose : Give 20 mL of 20% magnesium sulfate (4 g) slow intravenous in 3–5 minutes at a rate not exceeding 1 g/min Intramuscular loading dose: 5gram (5 ampoules of 50% w/v MgSO4 +0.5 ml 2% Lignocaine) deep IM (In 10 cc syringe& with 20-G long needle) in each buttock. Maintenance dose : Give 5 g magnesium sulfate (10 mL of 50% solution) deep IM injection in alternate buttock every 4 hours.

67. Monitoring for magnesium toxicity : Urine output should be at least 30 mL/hour Deep tendon reflexes should be present Respiration rate should be . 14 breaths/minute Pulse oximetry should be >/= 96% Any change in these indices makes it necessary to reevaluate the rate of administration. Magnesium sulfate is discontinued 24 hours after delivery or after last convulsion.

68. Contraindications * Impaired renal function. * Heart block, myocardial damage. * Myasthenia gravis. *Drug interaction: Nifedipine, anesthetic drugs.

69. mmol/L mEq/L mg/dL Effect 2–3.5 4-7 5-9 Therapeutic range >3.5 >7 >9 Loss of patellar reflexes >5 >10 >12 Respiratory paralysis >12.5 >25 >30 Cardiac arrest Serum Magnesium Concentration and Toxicities Routine serum magnesium levels are not required

70. Other regimens(MgSO4) Sabai regimen – loading dose – 6g IV diluted in 100ml of IV fluid(5% D given over 15-20 min Maintenance dose- 2g/hr infused at 100ml/hr Low dose regime of Sardesai It was proposed as weight of Indian females is less than western counterparts and standard Pritchard may lead to magnesium toxicity in some Regime – loading dose 4g of 20% MgSO4 is given slow IV over 4-6min Maintenance dose-2g of 20% MgSO4 is given IV every 3 hrs, can be given IM also. Dhaka regimen ( for Indian women with low BMI) Loading dose- 4g IV in dilution + 3g IM in each buttock (10g) Maintenance dose- 2.5g IM given 4hrly in alternate buttock.

71. Zuspan regime Loading dose 4g iv(20%) slowly over5-10mins Maintenance dose 1b iv/hour(50%) by infusion pump Sibai regime Loadingdose 6g iv infusion over 20mins Maintenance dose 2g/hr iv infusion Dhaka regime Loading dose 4g iv slow infusion over 15 min 3g IM in each buttock Maintenance dose 2.5gIM in alternate buttock every 4hours

72. The treatment of respiratory depression - IV calcium gluconate , 10 mL of a 10% solution, given over 10 minutes. Ca++ antagonizes the effect of magnesium by increasing the amount of acetylcholine liberated by the action potentials at the neuromuscular junction. For severe respiratory depression and arrest, immediate tracheal intubation and mechanical ventilation is life saving.

73. Other uses of MgSO4 Tocolysis – 8-10 mEq/L Neuroprotective effect in Preterm babies Acute exacerbation of bronchial asthma or COPD Anti arrhythmic (Torse de pointes) Constipation Barium poisoning

74. Delivery The mode of delivery is determined after considering the presentation of the fetus the fetal condition the gestational age Maternal condition Cervical status

75. Vaginal prostaglandins are preferred mode of induction of labour Maternal pain relief during labour can be provided with systemic opioids or epidural analgesia. Restrict intravenous maintenance fluid to 80mL/hour unless there are other ongoing losses.

76. Gestational age <24 weeks 24-30 weeks >34 weeks Initial assessment : - severe IUGR -Platelets<1L -Elevated AST,ALT,LDH -HELLP -oligohydramnios -Reversal of UA D -Non reassuring FHR -Suspected abruption,lobour Seizure prevention Blood pressure control Immediate delivery YES Unstable Seizure prevention Blood pressure control Immediate delivery NO -Seizure prevention -Blood pressure control -Betamethasone -Deliver in 48-72 hrs -Daily fetal and maternal monitoring -Antihypertensive therapy -Betamethasone Seizure prevention Immediate delivery Stable Continue expectancy

77. Third stage should be actively managed ,ergometrine not to given in case of PPH as it can cause further increase in BP Haemorrhage is poorly tolerated in the severe preeclamptic patient due to the constricted intravascular volume. A blood loss of 1000 mL during a caesarean section corresponds to approximately 35–40% of the blood volume of a pregnant woman with severe preeclampsia.

78. Regional anaesthesia is the anaesthesia of choice in patients with severe preeclampsia. As stimulation of tracheal intubation may cause sudden severe hypertension , such spikes inturn can cause pulmonary edema , cerebral edema or intracranial haemorrhage , and also tracheal intubation may be particularly difficult and thus hazardous in women with airway edema due to pre-eclampsia (ACOG 2017, Williams ) The main contraindication to regional anaesthesia in these patients is the presence of coagulopathy or severe thrombocytopenia (platelet count , 50,000 mm3 ) Analgesia and anaesthesia in pre eclampsia

79. Indications of general anaesthesia Contraindications to regional anaesthesia Fetal compromise requiring urgent delivery Pulmonary edema Hemodynamic instability Following eclampsia James high risk pregnancy

80. Postpartum care in preeclampsia 1) In women with pre-eclampsia who did not take antihypertensive treatment and have given birth, measure blood pressure: • at least 4 times a day while the woman is an inpatient • once daily for next 2weeks or more till they are off antihypertensives • In women with pre-eclampsia who did not take antihypertensive treatment and have given birth, start antihypertensive treatment if blood pressure is 150/ 100 mmHg or higher. .

81. 3) For women with pre-eclampsia who have taken antihypertensive treatment and have given birth: • continue antihypertensive treatment ,same same antepartum • reduce antihypertensive treatment if their blood pressure falls below 130/80 mmHg. Antihypertensives can be stopped once b.p remains normal for 48hours

82. 4) If a woman has taken methyldopa to treat pre-eclampsia, stop within 2 days after the birth and change to an alternative treatment if necessary 5)Advise women to keep the BMI(18.5 to 24.9kg/m2) Likelihood of recurrence of PE if interpregnancy interval is more than 10yrs 6) Offer women who had pre-eclampsia and still have proteinuria (1+ or more) at 6–8 weeks after the birth, a further review with their GP or specialist at 3 months after the birth to assess kidney function

83. HELLP syndrome Criteria for the Diagnosis of HELLP Syndrome Haemolysis ( microangiopathic hemolytic anemia) Abnormal peripheral blood smear (burr cells, schistocytes) Elevated bilirubin >/= 1.2 g/dL Low serum haptoglobin l Increased LDH . twice the upper limit of normal (. 600 U/L) Elevated liver enzymes Elevated AST, ALT >/=twice the upper limit of normal (>/=72 IU/L) - Low platelet count (< 100,000/mm3)

84. SUB CLASSIFICATION ( Mississippi classification)

85. Tennessee criteria any two of three criteria partial hellp.

86. 85% with hypertension 15%with normal b.p recoding 28w to 37 w

87. Maternal Morbidity Associated with HELLP Syndrome Abruptio placenta 10-15% Disseminated intravascular coagulation 10-15% Pulmonary oedema 6–8% Acute renal failure 5–8% Adult RDS 1–2% Death 1%

88. Management of HELLP SYNDROME Arias: Practical guide to high risk pregnancy

89. Management The clinical course of women with HELLP is usually progressive with sometimes sudden deterioration of maternal and fetal condition. Hence a diagnosis of HELLP syndrome is an indication for immediate delivery if the pregnancy is > 34 weeks or at any gestational age if pulmonary oedema, renal failure, placental abruption, severe liver dysfunction or bleeding, nonreassuring fetal status, or uncontrollable hypertension is present.

90. Vaginal delivery is a consideration only if the cervix is ripe, the gestational age is > 32 weeks, the FHR is reactive and there are no indications for caesarean delivery. If vaginal delivery is not foreseen within 12 hours after the onset of induction, it is better to perform caesarean section.

91. Platelets are given when the platelet count is below 50000/mm3 and particularly if the patient shows signs of altered haemostasis. After delivery the platelet count will reach a nadir in 24–48 hours but will rapidly increase after the 3rd postpartum day. If the platelet count continues to drop and liver enzymes to increase after 4 days postpartum, the validity of the initial diagnosis of HELLP syndrome should be reassessed. With supportive care alone, 90% of patients with HELLP syndrome will have platelet count more than 1L and reversed trend (decrease) in liver enzymes values within 7 days after delivery.

92. Use of Corticosteroids are not recommended for treatment of HELLP. (NICE 2019) Recurrence rate of HELLP-7% 18% of these women will develop PE in next pregnancy

93. Post partum follow up of HELLP Repeat PIH PROFILE after 48 to 72 hours of delivery B.p monitoring at least 4times per day for first 2 days On 3-4 th day of delivery Platelets and LFT normalises If any increase after 4th day validate the initial diagnosis of HELLP

94. Preeclampsia Eclampsia (1.9%-3%)

95. Eclampsia

96. Eclampsia is an extremely severe form of preeclampsia. It is characterized by sudden new onset of generalized tonic-clonic convulsion or coma in pregnancy or postpartum, unrelated to other cerebral conditions, in patients with signs and symptoms of preeclampsia. Eclampsia can be Antepartum-38-53% Intrapartum – 15-20% - Postpartum period-11-44%(witihin 48hrs) Most antepartum eclampsia occurs in the third tr imester (90%).

97. ECLAMPSIA Risk factors Patho physiology Symptoms Same as Pre eclampsia Cerebral vasospasm,ishchemia and vasogenic edema,cerebral hyperperfusion Generalised tonic clinic seizures

98. Maternal outcome in eclampsia Major maternal complications include -Placental abruption (7–10%), -DIC (7–11%), -HELLP syndrome (9.7–20%), -Acute renal failure (5–9%), -Pulmonary oedema (3–5%), -Aspiration pneumonia (2–3%), -Cerebral haemorrhage and cardiopulmonary arrest (2–5%). The most common causes of maternal death are intracranial bleeding and acute renal failure secondary to abruption placentae.

99. The risk of death is higher for women developing antepartum eclampsia, more than 30 years of age and those without prenatal care but it is greatest when eclampsia develops before 28 weeks of gestation. Hypertension may be severe (20–54% of cases) or mild (30–60% of cases). Unfortunately, in approximately 15% of the cases, hypertension and proteinuria may not be present. However, when seizures develop in a pregnant woman without a history of seizures disorders, eclampsia should be the diagnosis unless proven otherwise. The presence of haemoconcentration, elevated liver enzymes, elevated LDH, and thrombocytopenia also help in correct diagnosis when high blood pressure and proteinuria are not present.(

100. Fetal outcomes Prematurity IUGR Perinatal mortality (30-40%) Foetal hypoxia

101. AIM OF MANAGEMENT Control of convulsions Safe and timely delivery Prevent recurrence of seizure

102. Management Control of convulsions Call for help Left lateral position If suitable, an oral airway may be inserted without trauma to mouth and teeth Suction oral secretion Give oxygen by mask at 8–10 L/minute Elevate bedside rails and pad them to avoid injury Use physical restraints if necessary Pulse oximetry to monitor hypoxaemia Once the seizure end, secure IV line Give loading dose (4 g) of magnesium sulfate over 15–20 minutes followed by maintenance dose of 1 g/hour as continuous IV infusion

103. Magnesium sulfate is the drug of choice in treatment of eclampsia. If another seizure occurs when the patient is on maintenance dose of magnesium sulfate an additional 2 g bolus of magnesium sulfate should be given over 5 minutes. Other antiepileptics –Phenytoin, Diazepam, Phenobarbitone NOT to be used as an alternative to MgSO4 (NICE Guidelines ) Benzodiazepines and Phenytoin are justified only in the context of antiepileptic treatment or when MgSO4 is contraindicated or unavailable (myasthenia gravis ,hypocalcemia , moderate to severe renal failure ,cardiac ischemia ,heart block or myocarditis )- ACOG Guidelines 2019

104. Brain imaging should be considered in cases refractory to MgSO4 ( ACOG2019)

105. Fetal heart rate tracing shows fetal bradycardia following an intrapartum eclamptic convulsion.Bradycardia resolved and beat-to-beat variability returned approximately 5 minutes following seizure . Because of maternal hypoxemia and lactic acidemia caused by convulsions , usually recovers within 2-10minutes If persists >10 minutes another cause of bradycardia ,such as abruption or imminent delivery should be considered

106. Control of hypertension – same as pre-eclampsia Role of diuretics -Use of diuretics in the antepartum period should be limited to eclamptic women with concomitant pulmonary oedema. To be given after delivery

107. Delivery of the fetus -Delivery is the only definitive treatment for eclampsia. The mode of delivery should be decided depending on the fetal presentation, fetal condition and likelihood of success of induction of labour. Caesarean delivery may be indicated in the presence of prolonged fetal bradycardia, unripe cervix, FGR, inadequate blood pressure control and poor progress in labour. Third stage should be actively managed with the use of oxytocin. Ergometrine or its combination with oxytocin is best avoided for prevention of haemorrhage as it can further increase blood pressure.

108. The anaesthesia of choice for eclamptic patients is regional, spinal or epidural. The only contraindication to regional block anaesthesia is a platelet count , 50,000/mm Role of Mannitol in eclampsia – -lethargy ,confusion, blurred vision to obtundation and coma – mental status changes generally correlate with degree of involvement seen in CT and MRI imaging studies. -These patients to be treated with mannitol

109. Post partum care About 44% of eclampsia occur in the postpartum period and it is important to be vigilant. The incidence of postpartum eclampsia declines after 4th postpartum day and the patient may be discharged. Oral administration of antihypertensive agent (labetalol, calcium channel blockers) should continue in the postpartum period until complete normalization of the blood pressure is demonstrated. Patients can be slowly weaned off the antihypertensive therapy as an outpatient. An assessment of blood pressure and proteinuria should be done at 6 weeks postnatal checkup. If the hypertension or proteinuria persists beyond 6 weeks, they should be further evaluated by a medical specialist

110. Chronic hypertension

111. Incidence 0.5 to 5% B.P more than 140/90 , 4 hours apart Before 20 w Persistence of high blood pressure even after 20w

112. Aetiology Primary or essential hypertension Secondary hypertension Renal – Renal parenchymal disease (glomerulonephritis, reflux nephropathy, adult polycystic disease) Renovascular hypertension (renal artery stenosis) Endocrine Diabetes with vascular involvement Thyrotoxicosis Pheochromocytoma Primary aldosteronism Cushing syndrome

113. Collagen vascular disease Systemic lupus erythematosus Scleroderma Others Aortic coarctation Increased intracranial pressure

114. Pre- pregnancy advice Advise women who take angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers(ARBs),thiazide like diuretics : that there is an increased risk of congenital abnormalities if these drugs are taken during pregnancy.

115. Blood pressure <150/100 >150/100 No risk factors Risk factors present Antihypertensive treatment Beta blocker Calcium channel blocker Methyldopa Stable Unstable (develop complications ) Continue outpatient management deliver at term Admit to hospital may need early delivery -Self-monitoring of BP -Ultrasound for fetal growth every 3-4 weeks -Uterine artery Doppler at 20 weeks -UA-MCA Doppler at 28 weeks

116. Pre-eclampsia superimposed on chronic hypertension Diagnosis – worsening hypertension , new onset proteinuria , neurological symptoms (headache, visual disturbances ) To be treated same as severe pre-eclampsia

117. NICE 2019

118. References Williams Obstetrics The FIGO Textbook of Pregnancy Hypertension(2016) FOGSI Guidelines of HDP 2019 ACOG Practical bulletin ,VOL.133, Jan 2019 NICE guidelines June 2019( Hypertension in pregnancy –diagnosis and management ) Arias’ high risk pregnancy (2019) High risk pregnancy management options (James)

119. Thank you