Lecturer: Dra.

OB II: PREGNANCY HYPERTENSION Bagayao

THE CASE GESTATIONAL HYPERTENSION AND PREECLAMPSIA

27 y/o G1P0, 28 weeks AOG • BP returns to normal within 12 weeks after

Referral from a LHC delivery
UTZ result: SGA fetus
SLIUP compatible with 24 weeks and 2 days by fetal CHRONIC HYPERTENSION
biometry,cephalic anterios, placenta grade II; Adequate
• BP ≥140/90 mmHg before pregnancy or
AFI, EFW: 717 grams, SGA
diagnosed before 20 weeks gestation; or
BP: 160/100 mmHg BP 120/100 mmHg
• Hypertension first diagnosed after 20 weeks’
What is the admitting diagnosis? Basis. gestation and persistent after 12 weeks’
postpartum
G1P0, PU 28 weeks, CNIL
T/C Preeclampsia Severe SUPERIMPOSED PREECLAMPSIA (ON CHRONIC
Small for Gestational Age HYPERTENSION)

PROBLEM #1: HYPERTENSION • Women with hypertension only in early

CLASSIFICATION OF HYPERTENSIVE DISORDERS gestation who develop proteinuria after 20
COMPLICATING PREGNANCY (Working Group of the weeks of gestation
NHBPEP 2000)
Women with Sudden exacerbation of
• 35 y/o G3, 15 weeks hypertension and hypertension
• BP: 150/100 mmHg proteinuria before 20 Platelet count < 100,000
• 24⁰ urine protein = 500 mg weeks of gestation who- Elevation of liver enzymes
• Preeclampsia Creatinine level > 1.1
• Eclampsia mg/dL
Pulmonary edema
• Chronic Hypertension
RUQ pain / severe
• Superimposed Preeclampsia on Chronic headaches
Hypertension Substantial increase in
proteinuria
GESTATIONAL HYPERTENSION

• BP ≥ 14/90 mmHg for the first time during 35 y/o G3, 15 weeks
pregnancy after 20 weeks BP: 150/100 mmHg
24⁰ urine protein = 500 mg
Proteinuria

300 mg/24 hr urine sample Chronic Hypertension

(+) 1 dipstick urine

Urine/protein creatinin
ratio of 0.3 mg/dL

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 Lecturer: Dra.
OB II: PREGNANCY HYPERTENSION Bagayao

35 y/o G3, 28 weeks a. Gestational HPN

BP: 150/100 mmHg b. Preeclampsia
c. Chronic Hypertension
24⁰ urine protein = 500 mg
d. Chronic Hypertension with Superimposed
Preeclampsia

CLASSIFICATION OF PREECLAMPSIA
Chronic Hypertension
• Mild
ECLAMPSIA • “Non Severe”
• “Less Severe”
• Seizures that cannot be attributed to other • Severe
causes in a woman with preeclampsia o Preeclampsia + ≥1 of a series of
• 35 y/o, G5, 14 weeks brought to the ER due to complication
loss of consciousness with convulsive episodes o Without severe features
at home. BP = 180/110 mmHg o With severe features
o This is NOT eclampsia

Proteinuria

Is proteinuria still required?

PREECLAMPSIA

• In the absence of proteinuria, HPN with any of

the following
TRELICEP
Thrombocytopenia Platelet Count <100,000
/ml
Renal Insufficiency Creatinine > 1.1 mg/dL or
doubling of the creatinine
20 y/o G2, 32 weeks AOG, came in due to persistent
Liver Impairment Liver enzymes 2x normal
value headache and blurring of vision; BP = 160/100 mmHg.
Cerebral or Visual Admitted for hypertensive work-up. 24 hr urine albumin
Symptoms = 180 mg. Other labs normal. G1 was complicated by
Pulmonary Edema eclampsia. What is the diagnosis?
a. Gestational HPN
20 y/o G2, 32 weeks AOG, came in due to persistent b. Preeclampsia, severe
headache and blurring of vision; BP = 160/100 mmHg. c. Chronic HPN
Admitted for hypertensive work-up. 24 hr urine albumin d. Chronic HPN with superimposed
= 180 mg. Other labs normal. G1 was complicated by preeclampsia
eclampsia. What is the diagnosis?
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 Lecturer: Dra.
OB II: PREGNANCY HYPERTENSION Bagayao

• Magnesium sulfate is given

25 y/o G1 admitted at 31 weeks due to elevated BP: • Antihypertensives if indicated
150/100 mmHg. Hypertensive work-up revealed a • Ultrasonography, monitoring of FHT, symptoms
platelet count of 110,000 and SGPT that was twice and laboratory tests
elevated. 24-hr urine protein was 7 g. Urine output 600
cc/day. Which of the ff will make the preeclampsia of MAGNESIUM SULFATE IN SEVERE PREECLAMPSIA
this patient severe? Loading Dose 4-6 grams slow IV
a. Platelet count of 110,000 5 grams IM/buttocks
b. Urine protein of 7g/24 hrs Maintenance Dose 1-2 grams/hour x 24 hrs
c. BP: 150/100 mmHg Maintenance Dose:
d. SGPT: 138 IU/L • Given during labor and continued up to 24 hrs
postpartum
• Dose is reduced to half if creatinine ≥1.1 mg/dL
In which of the ff cases is preeclampsia NOT severe?
a. BP 130/100, platelet count of 80,000 When is antihypertensive therapy indicated?
b. BP 160/110, 24⁰ protein: 150 mg • Antihypertensive treatment should be started
c. BP 180/100, urine: crea ratio = 0.5 mg/dL in women with BP ≥ 160/100 mmHg. In a
d. BP 140/80, persistent headache woman with other markers of potentially
severe disease, treatment can be considered at
THE CASE lower degrees of BP.
At the ER Quality of Evidence: Moderate
• FHT: 147 bpm Strength of Recommendation: Strong
• MgSO4 was given (loading) Task Force on HPN in Pregnancy. ACOG 2013
• 140/90 mmHg
What work-up should be requested? Give 6.
LABORATORY RESULTS
CBC Hgb: 13.7 gm/dL
Platelet Count 275
Creatinine 69.98 mmol/L
SGPT 45
Urinalysis CHON +++
24⁰ Urine Albumin
LDH 385 U/L

THE CASE
Admitting diagnosis:
• G1P0, PU 28 weeks, CNIL
• Preeclampsia Severe
• SGA
Give the plan of management. Give 5.

An Algorithm in the Expectant Management of Severe

Preeclampsia Remote from Term (<34 weeks)
• Observe in labor and delivery suite for 24-48 hrs
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 Lecturer: Dra.
OB II: PREGNANCY HYPERTENSION Bagayao

SGPT 45
Observe in the labor and delivery suite 24-48 hrs Urinalysis CHON +++
•Magnesium sulfate for 24 hrs 24⁰ Urine Albumin 3,045 mg
•Antihypertensives if indicated LDH 385 U/L
•UTZ, moniroting of FHT and symptoms, labs

Any of the following present?

•Eclampsia
•Pulmonary edema
•Uncontrolled severe HPN
•Disseminated intravascular coagulation
•Abruptio placenta
•Non-reassuring fetal status
•IUFD

YES

Magnesium sulfate and delivery

A 28 y/o G1, 28 weeks, was brought to the ER because

of loss of consciousness accompanied by tonic-clonic
convulsion. BP: 180/120 mmHg. Which of the ff
management options is NOT correct?
a. Give magnesium sulfate
b. Start antihypertensives
c. Delivery after maternal stabilization
d. Steroids and expectant management
ANTENATAL CORTICOSTEROIDS
HELLP Syndrome • Betamethasone
H Hemolysis LDH >600 U/L • Dexamethasone
Total Bilirubin
>1.2 mg/dL
Abnormal PBS Q2: A 32 y/o G1, 32 weeks, was admitted due to BP
EL Elevated liver SGPT > 70 U/L elevation. Anticonvulsant and antihypertensive therapy
enzyme were given. Lab exams including 24 hr albumin were all
LP Low platelets <100,000 normal except for a platelet count of 80,000 and SGPT
of 85 U/L. Give the ideal management for the case.
a. Give steroids and do expectant management
THE CASE
b. Proceed immediately with delivery
Laboratory Results
c. Do emergency CS
CBC Hgb: 13.7 gm/dL
Platelet Count 275 d. Complete the steroids, continue MgSO4 and
Creatinine 69.98 mmol/L proceed with induction of labor

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 Lecturer: Dra.
OB II: PREGNANCY HYPERTENSION Bagayao

Q3: A 30 y/o G1 at 30 weeks was admitted with a • Given for 24 hrs

diagnosis of severe preeclampsia. Aside from the • Once a delivery decision is made and
elevated BP, patient is well and FHT is good. UTZ done continued for 24 hrs postpartum
revealed a singleton pregnancy with an EFW that AGA.
All labs normal except for an elevated serum creatinine ANTI-HYPERTENSIVE MEDS DURING PREGNANCY
of 1.8 mg/dL. Which of the following is CORRECT? Duley L., Drugs for treatment of very high blood
a. Reduce MgSO4 dose into half, complete pressure during pregnancy
steroids, then proceed with delivery Blood Pressure 160/110 mmHg
b. Withhold MgSO4 until Crea normalizes Purpose To prevent intracerebral
c. Give calcium gluconate hemorrhage
d. Give full dose of MgSO4 then deliver by CS
Drug Dose/Route Comments
LABETALOL 10-20 mg IV, Not readily
then 20-80 mg available locally
every 30 min;
max of 300 mg
HYDRALAZINE 5 mg IV or IM Long experience
then 5 mg every of safety and
30 min; max of efficacy, DOC
20 mg
NIFEDIPINE 10-20 mg PO Can be safely
then 10-20 mg used with MgSO4
every 2-6 hrs;
max 50 mg
IV D5W 90mL + Can be safely
NICARDIPINE Nicardipine 10 used with MgSO4
mg in soluset
Concentration =
0.1 mg/mL
Start drip at 10
ugtts/min
(equivalent to
1mg/hr)
Titrate every
hour
(increments of
1mg/hr)
Maximum dose
10 mg/hr
Note: The IV
infusion site
must be changed
Magnesium sulfate during expectant management every 12 hrs
Loading Dose 4-6 gram IV METHYLDOPA Max of 3 grams DOC
5 grams IM / buttocks (B) per day
Maintenance Dose 1-2 grams/hr NIFEDIPINE 30-120 mg/day Slow or long
PO acting
preparations

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 Lecturer: Dra.
OB II: PREGNANCY HYPERTENSION Bagayao

may be used; SL Does SGA mean IUGR?

preparation
should be
avoided
Labetalol 200 – 2,400 Not readily
mg/day PO available locally

What blood pressure is the aim of anti-hypertensive

therapy?
• The aim of anti-hypertensive therapy is to keep
the systolic BP between 140-155 and diastolic
BP between 90-100 mmHg
Quality of Evidence: Moderate
Strength of Recommedation: Strong
Task Force on HPN in Pregnancy. ACOG 2013

THE CASE
On admission
• MgSO4 was given x 24 hrs
• Hydralazine 5 mg IV given for 2 doses
• Dexamethasone 6 mg IM q12⁰ x 4 doses
HD1 (28 1/7 weeks)
• Methyldopa 500 mg q6

SGA
Laboratory Results
CBC
Platelet Count
Hgb: 13.7 gm/dL
275
Constitution
ally Small IUGR
Creatinine 69.98 mmol/L
SGPT 45
Urinalysis CHON +++
24⁰ Urine Albumin 3,045 mg
LDH 385 U/L

PROBLEM #2
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 Lecturer: Dra.
OB II: PREGNANCY HYPERTENSION Bagayao

Guidelines
Management of fetal growth restriction
• The assessment of growth requires at least two
measurements at least 2 weeks apart.

ETIOLOGIES
• Genetics
• Congenital Anomalies
• Infection
• Multiple Gestation THE CASE
• Maternal Nutrition • 27 y/o Primigravid, 28 weeks AOG (LMP &
• Environmental Toxin EUTZ)
• Placental Factors • Referral from a LHC
• UTZ result: SGA fetus
• SLIUP compatible with 24 weeks and 2 days by
fetal biometry, cephalic, anterior placenta grade
II; Adequate AFI, EFW: 717 grams, SGA

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 Lecturer: Dra.
OB II: PREGNANCY HYPERTENSION Bagayao

• Daily BP monitoring: 140 – 150/ 90-100 mmHg

• NST: Reactive
• Meds: MV, FeSO4 with folic acid, calcium,
aspirin and amino acids

INTERVENTION or MANAGEMENT

Steroid Therapy
• Antenatal administration of steroids before 34
weeks
Timing of Delivery
• Prenatal management is aimed primarily at
determining the IDEAL TIMING and MODE of
delivery
• Management is more complicated for
pregnancies between 25 and 32 weeks’
gestation, where each day gained in utero may
improve survival 1-2%.

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 Lecturer: Dra.
OB II: PREGNANCY HYPERTENSION Bagayao

• CST scan be done prior to induction to test the

fetal heart if it can tolerate labor prior to
induction
• A Bishop score <6 diminishes the probability of
success of induction of labor
• PgE2 (cervical and vaginal) are effective for
cervical ripening for women with unfavorable
cervices
THE CASE
Admitted at 34 weeks
• CST prior to induction of labor (negative)
• Dinoprostone inserted; followed by oxytocin
THE CASE • Delivered via OFE after 15 hrs of labor
Diagnosis Plan
How is postpartum hypertension managed?
• G1P0 • Cont. PN meds,
• Anti-hypertensives for:
• PU 28 5/7 weeks ASA and AA
o BP ≥ 150/100 mmHg or ≥ 160/100
• Preeclampsia • For biometry
with severe mmHg
every 2 weeks
features • Anti-hypertensive agents:
• BPS weekly
• SGA probably o Methyldopa
• NST 2x weekly
• IUGR o Diuretics
• FMC
• Avoid NSAIDs
When is the woman with severe preeclampsia
THE CASE
delivered?
G1P1 (0101) delivered; Preeclampsia Severe IUGR
• Pregnancies ≥ 34 weeks of gestation
• Discharged after 5 days:
complicated by severe preeclampsia is best
o Amlodipine in the evening; and
managed by delivery after maternal
o Lozartan + Thiazide in the morning for
stabilization
BP control;
o Tramadol + Paracetamol for pain
THE CASE
control
Summary of Antepartum Surveillance
o Ferrous sulfate and calcium x 3 months
30 weeks 32 weeks 34 weeks or until breastfeeding stops
EFW 1,050 gm 1,275 gm 1,425 gm • Regarding management, how does severe
BPS 8/8 8/8 8/8 preeclampsia differ from preeclampsia without
NST Reactive Reactive Reactive severe features and gestational hypertension?
UMA Elevated Elevated Elevated a. Giving of MgSO4
MCA (+) BS (+) BS (+) BS b. AOF delivery
c. Giving of antihypertensive
Admitted at 34 weeks GH and Severe Chronic
CS or Vaginal? Preeclampsia Preeclamps HPN
without ia
What is the mode of delivery? severe
• The mode of delivery should be determined features
after considering the presentation of the fetus MgSO 4  ✓ 
and the fetal condition, together with the AOG at 37 weeks 34 weeks 38 wks
likelihood of success of induction of labor after delivery
assessment of the cervix Anti- ✓ 160/110 ✓ 160/110 ✓
hyperten mmHg mmHg 160/110
sives mmHg
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 Lecturer: Dra.
OB II: PREGNANCY HYPERTENSION Bagayao

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