Hypertensive Disorders &

Pre-eclampsia
Tharshana Muraley MBBS 1809-9671
Nurul Aina MBBS 1809-9606
 1. Definition of PIH and hypertensive disorder in pregnancy

Pregnancy induced hypertension (PIH)

● PIH or gestational hypertension is diagnosed with sustained elevation of BP ≥ 140/90

mmHg after 20 weeks of pregnancy without proteinuria. BP returns to normal baseline
postpartum.

Hypertensive disorders in pregnancy

● A group of high blood pressure disorders that can be classified into PIH (gestational
hypertension, preeclampsia & eclampsia) and pre-existing HTN in pregnancy (chronic
hypertension, secondary hypertension & pre-existing hypertension superimposed
preeclampsia).
2. Discuss the theory of PIH

Abnormal cytotrophoblast
Decreased uteroplacental
invasion of the spiral Placental ischemia
blood flow
arterioles

Maternal vascular
endothelium
becomes activated or
dysfunction

Decrease in
Increase vascular Increase in
formation of
sensitivity to endothelin and
vasodilators (Nitric
angiotensin 2 thromboxane
oxide & prostacyclin)

Reduce renal
pressure natriuresis

Hypertension
3. Classification of hypertensive disorders in pregnancy

1. Pregnancy induced hypertension (PIH)

Gestational Hypertension

● Elevated blood pressure of 140/90 mmHg or above after 20 weeks of gestation in a previously normotensive person
without any proteinuria
● This hypertension normalises by three months postpartum
● It is not associated with adverse pregnancy outcome and mild and moderate increases in blood pressure in this
setting do not require treatment
● Risk of development to pre-eclampsia

Preeclampsia

● Elevated blood pressure of 140/90 mmHg or above after 20 weeks of gestation in a previously normotensive person
accompanied with proteinuria of atleast 300 mg in a 24-h urine collection
● Hypertension in pregnancy: Elevated blood pressure of more than 140/90 mmHg prior to 20 weeks of gestation or
already having hypertension prior to pregnancy
● These patients are more prone to developed preeclampsia superimposed on hypertension.
● It can be either due to essential hypertension or secondary hypertension
● Hypertension with superimposed Preeclampsia: This is diagnosed when signs and symptoms of preeclampsia
develop in pre-existing hypertension
3. Classification of hypertensive disorders in pregnancy

Eclampsia

● Severe complication where there is a new onset of grand mal seizure activity and/or unexplained coma during
pregnancy or postpartum
● This may or may not be preceded by markedly elevated blood pressure or proteinuria but usually preceded by
symptoms of impending eclampsia
● This condition can be life threatening to both mother and fetus
3. Classification of hypertensive disorders in pregnancy

2. Pre-existing hypertension in pregnancy

Chronic Hypertension

● Blood pressure ≥140 mm Hg systolic and/or 90 mm Hg diastolic before pregnancy or 20 weeks of gestation
● When hypertension is first identified during a woman's pregnancy and she is at less than 20 weeks' gestation, blood
pressure elevations usually represent chronic hypertension.

Secondary Hypertension

● High blood pressure that's caused by another medical condition that can be caused by conditions that affect kidneys,
arteries, heart or endocrine system.
● Hyperaldosteronism, Hypercalcemia, Hyperthyroidism, Coarctation of Aorta, Renal vascular disease,
Pheochromocytoma, Cushing’s Syndrome, Obstructive sleep apnea
● The presence of secondary forms of hypertension adds considerably to both maternal and fetal morbidity and
mortality.

Preeclampsia superimposed on chronic hypertension

● Hypertension that is discovered preconception or prior to 20 weeks’ gestation

● New-onset proteinuria ≥300 mg/24 hrs after 20 weeks gestation in chronic hypertensive women
The following are common risk factors for developing high blood pressure in pregnancy:

● Mothers age < 20 years and > 35 years

● First pregnancy
● Previous history of hypertension during pregnancy
● Twin pregnancy
● Hypertension
● Diabetes Mellitus
● Excessive weight gain

of
Fullness of the as
4. Clinical features of Hypertensive disorder in pregnancy & PIH

History: Pre-eclampsia is usually asymptomatic, but headache, drowsiness, visual

disturbances, nausea/vomiting or epigastric pain may occur at a late stage.

Examination:

- Hypertension is usually the first sign, but it is occasionally absent until the late
stages
- Oedema is found in most pregnancies but in pre-eclampsia may be massive,
-

not postural or of sudden onset

-

- The presence of epigastric tenderness is suggestive of impending

complications
- Proteinuria, urine dipstick testing for protein should be considered part of the
clinical examination
- Clonus / brisk deep tendon reflexes ( hyper reflex i a)
- Papilloedema
H
eclampsia ( fits
5. Complications of Hypertensive disorder in pregnancy & PIH (maternal/fetal/newborn)

Maternal complications
● Eclampsia (Grand Mal Seizure)
● Cerebrovascular haemorrhage - Results from a failure of cerebral blood flow autoregulation at mean arterial pressures

⇐
above 140 mmHg
● Disseminated intravascular coagulation (DIC)
● Liver failure and rupture - Typically experience epigastric pain resulting in loss of protein in the urine
● Pulmonary oedema - The severe pre-eclamptic is particularly vulnerable to fluid overload and collection of excessive
-
fluid in the lungs
● Renal failure - Identified by careful fluid balance monitoring and creatinine measurement. Haemodialysis is required in
severe cases

The acronym HELLP Syndrome is a variant of severe preeclampsia

and is characterised by:

● Haemolysis (H)
● Elevated Liver enzymes (EL)
● Low Platelets counts / thrombocytopenia (LP)
● Patients can present with normal symptoms of impending
eclampsia, severe epigastric pain, jaundice and tea coloured

=
urine
● Needs urgent hospital admission for close monitoring and
-
decision concerning delivery
5. Complications of Hypertensive disorder in pregnancy & PIH (maternal/fetal)

Fetal complications

● Placental abruption
● Failure of baby to grow satisfactorily (abnormal growth in the womb)
● Tendency for baby to die in the womb i.e. being stillborn
● Intrauterine growth restriction (IUGR)
● Low birth weight
● Neonatal death
6. Related Investigations

INVESTIGATIONS EXPLANATION

Full Blood Count (FBC) - to diagnose HELLP Syndrome:

haemolysis (low Hb),
=
thrombocytopenia

Renal function ( Puma { electrolytes) - elevated urea may indicate

necrosis
↳ Acute tubular cortical glomerular damage
- Observe for acute tubular cortical
necrosis

Serum creatinine, Serum uric acid - elevated serum creatinine (>

75mmol/L) indicates renal
involvement and renal function
 FBC
7
→ RFT
B →
↳ LFT
↳ TFT

coag
0 →
↳
urine
pusespy
24 urine
↳
-

urine dipstick

Trohsaba * ultwpurd
I
1 GG
,

↳ Dooppun US

S : creative / Uric acid

6. Related Investigations

Liver Function Test (LFT) - deranged & elevated liver enzymes

may indicate liver involvement
(HELLP)
- Low serum albumin
- Elevated serum bilirubin in HELLP
Syndrome

Urine for microscopy - to rule urinary tract infection cause for

proteinuria

24-hour urine protein - if protein is present, quantification of

protein loss in 24 hour specimen is
mandatory.
- Severe preeclampsia more 1g/24-H

Coagulation profile - deranged due to liver dysfunction &

thrombocytopenia
6. Related Investigations

Ultrasound scan fetal - Monitor foetal growth parameters &

beware risk of IUGR
- Amniotic fluid index for
oligohydramnios

Doppler ultrasound scan - monitor vascular resistance

(resistance index) and end diastolic
flow in umbilical and middle cerebral
artery.
- Guides delivery timing

Cardiotocograph (CTG) - monitor foetal well-being

Manning’s biophysical profile - evaluate foetal well-being

7. Basic management

● Definitive treatment for hypertensive disorders in pregnancy is delivery, expectant management with close
-

observation may be appropriate especially- before 32 weeks gestation

● Women with chronic hypertension should be ideally evaluated prior to pregnancy, with a focus on the
presence of end-organ damage, evidence of secondary causes of hypertension (renal stenosis, primary
-
-
hyperaldosteronism & pheochromocytoma), medications adjustments and counselling regarding the risk of
preeclampsia and adverse fetal events

=
● Women with hypertensive disorders in pregnancy should have a comprehensive plan of care which includes
prenatal counselling, regular check-ups during pregnancy, timely delivery, appropriate intrapartum
- - -

monitoring & care and postpartum follow up.

● After delivery, women are advised to monitor their blood pressure reading, continue anti-hypertensive
•
medications if required and reduce the treatment if blood pressure falls below 130/80 mmHg.
● Measure the the platelet count, liver enzymes & serum creatinine 48-72 hours after birth and also carry out
urine dipstick test 6-8 weeks after delivery for women diagnosed with preeclampsia.
urine collection
PH count zig hr
-

↳< CPHD
Its osg
creative asg Cpe eclampsia)
> -

serum
urine dipstick
8. Drugs commonly used for hypertensive disorder in pregnancy: anti HPT, MgSO4,

bronchial ( contra)
Labetalol
→ asthma as
cardiogenic shock, THR m
Allergy
● Non-selective β-blockers with concurrent α1-blocking actions that produce peripheral vasodilation,
thereby reducing blood pressure.

÷
● Adverse effects - orthostatic hypotension, dizziness, bronchospasm
● Contraindications - used carefully in patients with bronchial asthma, cardiogenic shock, severe
bradycardia and hypersensitivity to this drug

Nifedipine ( Ca Channel Blocker → vasodilator

)
● Peripheral arterial vasodilator which acts directly on vascular smooth muscle and results in an
inhibition of calcium influx through these channels
● Adverse effects - headache, flushing, constipation, peripheral edema
● Contraindications - patients allergy to nifedipine, hepatic dysfunction, STEMI
gym , ,ay , , , any, , ng ay, ay, ay ayy .
8. Drugs commonly used for hypertensive disorder in pregnancy: anti HPT, MgSO4,

Methyldopa

● α2 agonist that is converted to methylnorepinephrine centrally to diminish adrenergic outflow from

the CNS
● Adverse effects - sedation, drowsiness, diarrhoea, headache
● Contraindications - patients with active hepatic disease, pheochromocytoma and direct Coombs
- - -

positive for haemolytic anemia

[Link]
Magnesium sulphate
>
→
sweating
headache muscle wasting
,
} At "

● transport of sodium, calcium and potassium across cell membranes. It slows the rate of SA node
impulse formation and prolongs conduction time along the myocardial tissue.
● Adverse effects - flushing (warmth, redness) & sweating, headache, muscle weakness
● Contraindications - patients with Myasthenia Gravis, renal impairment, cardiac ischemia
ANG , What impairment , cardiac ischemia
8. Drugs commonly used for hypertensive disorder in pregnancy: anti HPT, MgSO4,

Side Effects of MgSO4 Bed side monitoring

Respiratory depression Pulse oximetry

Cardiac arrest ECG

Muscle paralysis/poor reflexes Patella reflexes

Renal dysfunction Urinary catheter

Cox;)
Presti depression
lhhgfgy →
↳
cardiac arrest

hyporetuxia
( Ect)
( patella)
t
renal
dysfcx
) .

( catheter)