Hypertensive Disorders in

Pregnancy
Selly Septina, SpOG

Classification
by the working group of the
NHBPEP (2000)
1. Gestational hypertension
2. Chronic hypertension
3. Preeclampsia
4. Eclampsia
5. Preeclampsia superimposed on chronic
hypertension (superimposed preeclampsia)

I. Gestational hypertension
BP

>= 140/90 mmHg for first time during

pregnancy
No proteinuria
BP returns to normal < 12 wk postpartum
Final diagnosis made only postpartum
May have other signs & symptoms of
preeclampsia , eg. epigastric discomfort or
thrombocytopenia

II. Chronic hypertension

BP

>= 140/90 mmHg before pregnancy or

diagnosed before 20 wk , not attributable
to GTD or
Hypertension first diagnosed after 20 wk
and persistent after 12 wk postpartum

Underlying causes of
Chronic Hypertension

Essential familial hypertension

Obesity
Arterial abnormalities
Endocrine disorders
Glomerulonephritis
Renoprival hypertension
Connective tissue disease
PCKD
ARF

III. Preeclampsia

Preeclampsia
Mild preeclampsia
BP >= 140/90 mmHg after 20 wk gestation
Proteinuria >= 300 mg/24hr or >=1+ dipstick

Severe preeclampsia
Anyone who meets at least two of the
following signs:

BP >= 160/110 mmHg

Proteinuria 5 g/24hr or >= 2+ dipstick (persistent)
Cr > 1.2 mg/dl
Platelets < 100,000 /mm3
Microangiopathic hemolysis
Elevated ALT or AST
Persistent headache , visual disturbance ,
epigastric pain

IV. Eclampsia
Seizures

that cannot be attributed to other

causes in a woman with preeclampsia

Seizures

are generalized
May appear before , during or after labor
10% develop after 48 hr postpartum

V. Superimposed preeclampsia
New

onset proteinuria >= 300mg/24 hr in

hypertensive women but no proteinuria
before 20 wk
A sudden increase in proteinuria or BP or
platelet count < 100,000 in women with
hypertension and proteinuria before 20 wk

Diagnosis

Gestational HT
Also

called transient HT
Final Dx : after delivery , by exclusion
BP : resting BP , Korotkoff phase V is
used to defined diastolic pressure
GHT may later develop preeclampsia
10% of eclamptic seizures develop before
overt proteinuria is identified
BP rise , increase both mother and fetus
risks

Preeclampsia

Diastolic hypertension >= 95 , increase fetal

death rate 3 fold
Worsening proteinuria resulted in increasing
preterm delivery
Epigastric pain from hepatocellular necrosis ,
ischemia and edema that stretches Glisson
capsule
Thrombocytopenia from platelet activation &
aggregation , microangiopathic hemolysis
induced by severe vasospasm

Risk factors for preeclampsia

Nulliparous

Advanced

maternal age
Race and ethnicity (genetic predisposition
& envoronmental factor)
Multifetal gestation
Obesity
BMI > 35 kg/m2

Superimposed preeclampsia
1. Hypertension (>=140/90) is documented
antecedent to pregnancy
2. Hypertension is detected before 20 wk ,
unless there is GTD
3. Hypertension persists long after delivery

Additional previous Hx or family Hx of HT

End organ damage : LVH , retinal change
Risk abruption , IUGR , preterm & death

Etiology?

Etiology
1. Abnormal trophoblastic invasion of uterine
vessels
2. Immunological intolerance between
maternal and fetoplacental tissues
3. Maternal maladaptation to cardiovascular
or inflammatory changes of normal
pregnancy (vasculopathy)
4. Dietary deficiencies
5. Genetic influences

Complications

Cardiovascular system
Increase

after load
Preload diminish
Endothelial activation with extravasation
Decreased cardiac output
Hemoconcentration from generalized
vasoconstriction and endothelial
dysfynction
Decreased blood volume

Blood and coagulation

Thrombocytopenia

from platelet activation,

aggregation & consumption
Increased platelets activating factor &
thrombopoietin
Clotting factors decrease
Erythrocytes rapid hemolysis (increase
LDH , schizocyte , MAHA)

Kidney
RPF

& GFR reduced

Uric acid elevated
Creatinine clearance reduced , oliguria
Diminished urinary Ca due to increased
tubular reabsorption
Urine sodium elevated
Urine osmolality , U:P Cr , FE Na :
prerenal mechanism

Liver
Periportal

Elevated

hemorrhage in liver periphery

transaminase
HELLP syndrome
Bleeding cause hepatic rupture(mortality
30%) , subcapsular hematoma
Conservative treatment
Recombinant factor VIIa

HELLP syndrome
No

strict definition
Incidence 20% of severe preeclampsia or
eclampsia
Factors contributing to death : include
stroke , coagulopathy , ARDS , ARF ,
sepsis
Insufficient evidence : adjunctive steroid

Brain
Headache

& visual symptoms associated

with eclampsia
Two cerebral pathology related
1. gross hemorrhage due to ruptured a.
caused by severe HT
2. more widespread , edema hyperemia ,
ischemia , thrombosis & hemorrhage
caused by preeclampsia

Can we predict preeclampsia?

Prediction
Biological

, biochemical & biophysical

markers
To identify markers of

faulty placentation
reduced placental perfusion ,
endothelial cell activation & dysfunction ,
activation of coagulation

HOW?

Uric acid
Decreased

renal urate excretion in

preeclampsia
Serum uric acid exceeding 5.9 at 24 wk
(PPV 33%)
Not useful in differentiating GHT from
preeclampsia

Fibronectin
Endothelial

cell activation
Low sensitivity 69%
Positive predictive vaules 12%
Higher levels by 12 wks (PPV 29% NPV
98%)

Coagulation activation
Thrombocytopenia

and platelet

dysfunction
Increased destruction cause platelet
volumes increase (younger platelet)
Preeclampsia : PAI-1 increase increased
relative to PAI-2 because of endothelial
cell dysfunction

Cytokines
Released

by vascular endothelium &

leukocytes , and macrophages &
lymphocytes at decidua
Interleukin , TNF , CRP : inflammatory
response
Possibly predictive preeclampsia

Fetal DNA
Fetal

DNA in maternal serum

At the time endothelial activation , fetal
cells released into maternal circulation
Elevations after 28 wk indicate impending
disease

Uterine artery doppler

Impaired

trophoblastic invasion of spiral

arteries , leading to reduction in
uteroplacental blood flow
8-22 wk , sensitivity 78% , PPV 28% ,
unreliable in low risk pregnancies
Combined inhibin A & activin A , sensitivity
86%
Combined hCG & AFP , sensitivity 2-40%

Can we prevent preeclampsia?

Prevention
Salt

restriction : ineffective
Inappropriate diuretic therapy
Low dietary calcium increased risk GHT
Fish oil capsules : modify abnormal PG
balance : ineffective
Low dose aspirin (60mg) : ineffective
Antioxidants : vitamin C & E : reduced
endothelial cell activation , reduction in
preeclampsia

Antioxidant
39%

reduction in risk of preeclampsia (RR

0.61)
Reduced risk of SGA infant (RR 0.64)
More preterm birth (RR 1.38)
No difference in develop preeclampsia
among low & high risk (RR 0.66 & 0.44)
GA : no diff (<20wk VS before & after
20wk)

The Cochrane Database of systematic Reviews 2005

Dietary salt
Reduce

dietary salt intake vs continue a

normal diet
No effect in preeclampsia (RR 1.11)
Insuffient evidence for reliable conclusions
about effect of advice to reduce diet salt

The Cochrane Database of Systematic reviews 2005

Folic acid supplement

Reduction

in risk of preeclampsia in
supplemented groups ( 200 ug & 5 mg/d)
In low serum folate pregnancy & women
with Hx preeclampsia
Odd ratios of preeclampsia no diff
between receive folic 200 ug VS 5 mg/d
(0.46 VS 0.59)

Ped & Perinatal Epid 2005: 19 : 112-124

Management

Management
Early

prenatal detection
Antepartum hospital management
Termination of pregnancy
Antihypertensive drug therapy

1. Early prenatal detection

Early

preeclampsia without overt HT :

increased surveillance
New-onset diastolic BP 81-89 mmHg or
sudden abnormal wt gain (> 2 lb/wk during
3rd trimester)
OPD surveillance unless overt HT ,
proteinuria , visual disturbances or
epigastric discomfort

2. Antepartum management
Admit

if new onset HT , esp persistent or

worsening HT or develop proteinuria
Detail examine : headache , visual
disturbances , epigastric pain , weight gain
Proteinuria at least every 2 d
BP q 4 hr , except midnight & morning
Creatinine , hematocrit , platelets , liver
enzymes.

Antepartum management
Evaluate

fetal size , AF
Reduced physical activity
Sedative not prescribed
Ample, not excess, protein & calories diet
Sodium & fluid intake not limit or forced
Further Mg depend on : severity ,
Gestational Age , condition of cervix

Preeclampsia-Initial Evaluation
Serial

blood pressure measurements

Urine protein excretion
Fetal monitoring
Tests to rule out HELLP and other
complications: Hematocrit, platelets, uric
acid, alanine aminotransferase (ALT),
aspartate aminotransferase (AST), lactic
dehydrogenase (LDH)

Chronic Hypertension Management

Generally,

deliver at term, unless

superimposed preeclampsia, HELLP
syndrome
Avoid ACE inhibitors (renal failure,
oligohydramnios, pulmonary hypoplasia,
IUGR) and atenolol (IUGR)

Severe PreeclampsiaManagement
Seizure

prophylaxis
Blood pressure control
Delivery

Preeclampsia-Term Pregnancy
Delivery

is a short-term goal
Induction of labor is appropriate after
maternal-fetal observation/stabilization
Cesarean reserved for standard obstetric
indications
Cesarean may be recommended in cases
of severe preeclampsia where delivery is
remote

Preeclampsia-Preterm
Pregnancy
Mild

preeclampsia - expectant
management is acceptable under certain
conditions
Close maternal-fetal surveillance
Ability to intervene either if conditions
worsen or if acceptable gestational age
reached
In-hospital vs. home care?

Preeclampsia-Preterm
Pregnancy
Severe

preeclampsia - controversial
Delivery for poor maternal condition is
likely to be necessary over the short term
Sibai has advocated expectant
management for selected patients to
attempt to reduce perinatal morbidity and
mortality due to prematurity

Preeclampsia-Preterm
Pregnancy
Expectant

management of severe
preeclampsia at preterm gestational age:

Hospitalization
Magnesium sulfate for seizure prophylaxis, at
least during initial observation period
Blood pressure control to range of 140155/90-105 (labetalol or nifedipine)
Daily assessment of maternal-fetal condition

Preeclampsia-Preterm
Pregnancy
weeks corticosteroids for fetal
lung maturation

24-34

24-32 weeks ongoing daily surveillance if

stable
33-34 weeks deliver after 48 hours

Deliver

for HELLP syndrome, severe

headache, uncontrolled hypertension,
eclampsia

3. Termination of pregnancy
Delivery

is the cure for preeclampsia

Headache , visual disturbances or
epigastric pain : indicative convulsions
(imminent eclampsia)
Oliguria : ominous sign
SPE : objectives to forestall convulsions ,
prevent intracranial hemorrhage , &
serious vital organ damage

Termination of pregnancy
Preterm

: conservative justified in mild

preeclampsia, closed observation and
monitoring to complications
severe preeclampsia : prompt delivery

vaginal delivery
c-section if indicated

Induction

of labor not harmful to infants ,

but unsuccessful 35%

4. Antihypertensive drug
To

prolong pregnancy , or modify perinatal

outcomes

Antihypertensive drug

blocker (Labetolol) , calcium channel

blockers (Nifedipine , Isradipine) no
benefit

5. Delayed delivery with

Superimposed Pre Eclampsia (SPE)
SPE

remote from term

Conservative or expectant management in
selected group
Sibai 1985 : SPE 18-27 wk : perinatal
mortality 87% , no mothers died , placental
abruption eclampsia , consumptive
coagulopathy , RF , encephalopathy ,
intracerebral hemorrhage , ruptured
hepatic hematoma

Delayed delivery with SPE

Indications

for delivery : uncontrollable BP,

fetal distress , placental abruption , renal
failure, HELLP synd , persistent symptom
Average pregnancy prolong 8d

Glucocorticoids
Not

worsen maternal HT
Decrease RDS , improve fetal survival
No evidence : benefit to ameliorate
severity of HELLP syndrome
Transient improve hematological lab :
platelet counts
2 Maternal death , 18 stillbirth

Eclampsia-Management
Preeclampsia

complicated by generalized
tonic-clonic convulsions OR
Fatal coma without convulsions also
Major complications included placental
abruption (10%) , neuro deficit (7%) ,
aspiration pneumonia (7%) , pulm edema
(5%) , arrest (4%) , ARF (4%) , death (1%)

Eclampsia
Duration

of coma variable
Hypercarbia , lactic acidemia , fetal brady
cardia
High fever
Proteinuria
Diminished urine output , hemoglobinuria
Pronounced edema
Proteinuria & edema disappear within 1 wk
BP return within a few days to 2 wk PP

Eclampsia
Differential

diagnosis : epilepsy ,
encephalitis , meningitis , cerebral tumor ,
cysticercosis , ruptured cerebral aneurysm
Prognosis always serious
6% of Maternal death relate to eclampsia
Among PIH patient , maternal death 16%

Treatment
1. control of convulsions using IV MgSO4
2. Intermittent IV or oral of antihypertensive
drug to lower Diastolic BP <100
3. Avoidance of diuretics , limit IV fluid
adminstration , avoid hyperosmotic agents
4. Delivery

Continuous IV regimen
4-6 gm MgSO4 dilute in 100 ml fluid , admin
over 15-20 min
Begin 2 g/hr in 100 ml IV maintenance
Measure Mg level at 4-6 hr , adjust level
between 4-7 mEq/L
MgSO4 discontinued 24 hr after delivery

Intermittent intramuscular
Give

4 g MgSO4 IV , rate not exceed 1

g/min
Follow with 10 g MgSO4 : 5 g injected
each buttock through 3 inch long , 20
gauge needle , (add 1 ml of 2% lidocaine)
If convulsions persist after 15 min , give 2
g more IV slowly
Give 5 g MgSO4 IM q 4 hr
MgSO4 discontinue 24 hr after delivery

MgSO4
Effective

anticonvulsant without producing

CNS depression in either mother or infant
Not given to treat HT
Exert specific on cerebral cortex
10-15% after MgSO4 : subsequent
convulsion
Sodium amobarbital & thiopental , if
excessive agitate in postconvulsion state
In Eclampsia , admin for 24 hr after onset
of convulsion

MgSO4
Almost

totally cleared by renal excretion

Monitor urine output , DTR , RR
Maintained level 4-7 mEq/L
IM & IV regimen , no significant difference
Mg level
Mg 10 mEq/L : patellar reflex disappear
> 10 mEq/L : respiratory depression
> 12 mEq/L : respiratory paralysis & arrest
Cr >1.3 : half dose MgSO4

MgSO4

Fetal effects
Promptly cross placenta
Neonatal depression occurs only if severe
hypermagnesemia at delivery
Decrease in beat-to-beat variability
Possible protective effect against cerebral palsy
in VLBW infants
Substantial gross motor dysfunction reduced
No serious harmful effects

Compared with anticonvulsants

MgSO4

reduce recurrent sz 50%

compared to diazepam , reduce maternal
& perinatal morbidity (not sig)
Maternal mortality reduced compared to
phenytoin (not sig) , less neonatal
intubation & NICU admission
Prevent eclamptic sz superior to phenytoin
Lower risk placental abruption

Antihypertensive
Hydralazine

suggested if persistent
systolic > 160 , or diastolic > 105 mmHg
(NHBPEP2000)
5-10 mg doses at 15-20 min inervals
Satisfactory response ante or intrapartum :
diastolic 90-100
Seldom another antihypertensive needed
FHR deceleration when BP fell to 110/80

Antihypertensives
: IV 1& nonselective -blocker
Lower BP more rapidly , associated
tachycardia
NHBPEP(2000) : recommends 20 mg IV
bolus , if not effective within 10 min ,
followed by 40 mg , then 80 mg q 10 min
but not exceed 220 mg total dose per
episode treated
Labetolol

Antihypertensives
Nifedipine

10 mg Oral , repeated in 30 min

, if necessary (NHBPEP 2000)
Fewer dose required to achieve BP control
without increased adverse effects
Sublingual : potent & rapid :
cerebrovascular ischemia , MI , conduction
disturbance , death
Not superior to other hypertensives

Persistent postpartum HT
Hydralazine

10-25 mg IM q 4-6 hr
If HT persists or recur : oral labetolol or
thiazide diuretic are given
Two mechanisms :

1. Underlying chronic hypertension ,

2. Mobilization of edema fluid

Diuretics & hyperosmotic agents

Diuretics

: deplete intravascular volume ,

compromise placental perfusion , limited
used to pulmonary edema
Hyperosmotic agents : leaks of agents
through capillaries into lungs & brain
promote accumulation of edema

Fluid therapy
Lactate

Ringers Solution , rate 60 ml to

125 ml/hr
Unless unusual fluid loss : N/V , diarrhea ,
excessive blood loss
Oliguria : maternal blood volume
constricted, admin IV fluid more vigorously
Women with eclampsia already has
excessive extracelular fluid

Pulmonary edema

Most often do so postpartum

Aspiration should be exclude
Majority have cardiac failure
Decrease plasma oncotic pressure , increase
extravascular oncotic pressure , increase
capillary permeability , hemoconcentration ,
reduced CVP , PCWP
Excessive colloid & cyrstalloid cause pulm
edema

Invasive monitoring
Use

of pulmonary artery catheterization

Reserved for women with severe cardiac
disease , renal disease , refractory
hypertension , oliguria , pulmonary edema
Pulmonary edema by more than one
mechanism
If questionable pulmonary edema :
furosemide IV , hydralazine IV

Delivery
After

eclamptic sz , labor often ensues

spontaneously or can be induced
successfully even in remote from term
Because lack of normal pregnancy
hypervolemia , so less tolerant of blood
loss at delivery

Analgesia & anesthesia

GA

caused by tracheal intubation, sudden

HT ,pulm edema , intracranial hge
Epidural preferred : no serious maternal or
fetal complication , lower MAP , Cardiac
output not fall

Thank you for your attention