HYPERTENSIVE DISORDERS

IN PREGANCY

OBJECTIVES
At the end of this session you should be able to:
1.

Outline diagnostic features of pre-eclampsia

2.

Classify pre-eclampsia according to severity

3.

Outline risk factors for pre-eclampsia

4.

Outline maternal and fetal complications of preeclampsia.

5.

Describe the management of pre-eclampsia and

eclampsia.

I. INTRODUCTION

Synonyms:
Toxemia of pregnancy, pre-eclampsia, EPH gestosis,
pregnancy induced hypertension.

Pre-eclampsia commonly manifests after the 20th week of

pregnancy.

Prevalence of pre-eclampsia: varies from one place to another

Severe pre-eclampsia and eclampsia

Are serious and potentially fatal

Third commonest cause of maternal mortality

Occurs prior to, during or after delivery

II. DIAGNOSIS OF PRE-ECLAMPSIA

When SBP > 140 mm Hg, DBP > 90 mm Hg

in a woman known to be normotensive prior
to pregnancy.

The diagnosis requires 2 such abnormal BP

measurements recorded at least 6 hours apart.

III. RISK FACTORS

Young maternal age

Nulliparity: 85% of pre-eclampsia occur in
primigravida.
Increased placental tissue for gestational age:
Hydatiform moles, twin pregnancies
Family history of pre -eclampsia
Diabetes mellitus
Renal diseases,
Chromosomal abnormality in the fetus (eg, trisomy).

RISK FACTORS cont

Worrisome signs for pre-eclapmsia

development

Rapid increase of weight during the latter of

pregnancy

An upward trend in diastolic BP even while still

within normal range

IV. CLASSIFICATION OF PRE ECLAMPSIA:

ACCORDING TO SEVERITY
1.
2.
3.

1.

Mild pre-eclampsia
Moderate pre-eclampsia
Severe pre-eclampsia
Mild to Moderate Pre eclampsia
Diagnostic Features
Systolic BP is 140 -160 mmHg
Diastolic BP is 90 100 mmHg
Proteinuria up to ++

2. Severe pre-eclampsia
Also called Imminent eclampsia
Symptoms
Severe & persistent occipital or frontal headaches
Visual disturbance: blurred vision, photophobia
Epigastric and/or right upper-quadrant pain
Signs
Diastolic BP > 11ommHg, systolic BP > 160mmHg
Proteinuria +++ or more
Altered mental status
Hyper-reflexia
Oliguria

HELLP SYNDROME
Is a severe form of pre-eclampsia

Affects approx 10% of women with severe

preeclampsia and 30-50% of women with eclampsia.

Characterized by:

Hemolysis,

Elevated liver enzymes

Low platelet count.

Increased mortality rate and DIC

V. PATHOPHYSIOLOGY

There are several theories and etiologic mechanisms.

Vasospasm theory: Most favored theory

Vasospasms vasoconstriction resistance

arterial BP

Eclampsia:
Cerebral arterial vasospasm cerebral edema or
infarction and/or cerebral hemorrhage

VI. COMPLICATIONS OF SEVERE PREECLAMPSIA AND ECLAMPSIA

Maternal complications

CVS

Haemoconcentration (cause: vasoconstriction and vascular

permeability)

Hamatological changes HELLP DIC

Kidneys

Decr RBF GFR RTN and RCN acute RF

Proteinuria due to permeability to large protein,

Oliguria both renal perfusion and GFR decrease.

COMPLICATIONS OF SEVERE PRE

ECLAMPSIA AND ECLAMPSIA cont
Brain

Cerebral edema

Infarction, cerebral hemorrhage

Blindness: Due to -?retinal artery vasospasms and

retinal detachment

Fever 39C: a grave sign, may be a consequence of

intracranial hemorrhage.

Coma may be a result of CVA

COMPLICATIONS OF SEVERE PRE

ECLAMPSIA AND ECLAMPSIA cont
RS : Pulmonary oedema and cyanosis
Utero-placental perfusion
Vasospasms decr perfusion distress and
death
Histological changes in the placental bed: acute
artherosis lipid rich cells of the uteroplacental
arteries

Fetal complications

IUFD, IUGR

MAJOR CAUSES OF MATERNAL DEATH

Cerebrovascular accident (CVA)

Pulmonary oedema

Cardiac failure,

Renal failure

VII. WORK UP - INVESTIGATIONS

Urine analysis

A 24-hour urine collection

Quantity of urine and protein

Uric acid level:

Proteinuria

GFR and creatinine clearance decrease in uric acid

levels.

LFT Transaminases
USS fetal wellbeing, if the GA is < 20/40 R/O
moles.

VIII. MANAGEMENT OF PRE ECLAMPSIA

1.

MILD - MOD PRE ECLAMPSIA

A: Dispensary & Health centre

Antihypertensives

Aldomet 250 mg 8 hourly for 7 days,

Bed rest at home

REFER within one week to Hospital for further

management

MANAGEMENT OF PRE ECLAMPSIA

1. MILD - MOD PRE ECLAMPSIA cont
B. Hospital

Antihypertensives: Aldomet,

Bed rest at home,

Sequential work ups,

Fetal movements monitoring,

Schedule antenatal clinic every 2 weeks up to 32 wks and

weekly thereafter

MANAGEMENT OF PRE ECLAMPSIA

1. MILD - MOD PRE ECLAMPSIA cont
B. Hospital

Strongly advice the woman to deliver in a hospital

Plan delivery at 38/40

Advice the mother to come to the health facility in case of

severe headache, blurred vision, nausea or upper abdominal
pain.

Manage as severe pre-eclampsia: If not responding to

treatment i.e. if the systolic BP is > 160 mmHg, or the
diastolic BP is > 100mmHg or there is proteinuria +++

MANAGEMENT OF SEVERE PRE ECLAMPSIA

AND ECLAMPSIA
Note: Severe pre-eclampsia is managed like
eclampsia
Management protocol for eclampsia

Keep airway clear

Control convulsions
Control BP
Control fluid balance
Antibiotics
Investigations
Deliver the mother

MANAGEMENT CONT
BP CONTROL

Keep SBP between 140 -160 mm Hg and DBP between 90

-110 mm Hg

?Why these levels: Avoid potential reduction in either

uteroplacental blood flow or cerebral perfusion pressure.

Drugs:

Anti HPTs: Hydralazine, nifedipine, or labetalol

Diuretics are not used except in the presence of pulmonary

edema

MANAGEMENT: CONTROL CONVULSIONS

I. An overview on MgSO4.

Mechanism:

Cerebral vasodilator reducing cerebral

vasospasm ischemia (brain).

Superior to other anti-convulsants used to control and

prevent fits;

Important part of mgt of eclampsia

Recurrence rate after MgSO4 = 10 -15%

Improves maternal and fetal outcome

CONTROL CONVULSIONS - REGIMEN

1. INTRAMUSCULAR REGIMEN
i. Loading dose

Give MgSO4 4 g (i.e. 20mls of 20% solution) +

200mls NS or sterile water I.V over 5 minutes

Follow promptly with 10g (i.e. 20ml of 50%

solution), 5g in each buttock as deep I.M with
1ml of 2% lignocaine in the same syringe

MANAGEMENT CONT

CONTROL CONVULSIONS - REGIMEN

1. INTRAMUSCULAR REGIMEN cont
ii. Maintenance dose
MgSO4 5 g (i.e. 10ml of 50% solution) + 1 ml
lignocaine 2% 4 hourly in alternate buttocks.
NOTE:

IM inj. are painful and are complicated by local

abscess formation in 0.5% of cases.

The intravenous (IV) route is therefore preferred

MANAGEMENT CONT
CONTROL CONVULSIONS - REGIMEN

2. INTRAVENOUS REGIMEN
i. Loading dose
MgSO4 4 g (i.e. 20mls of 20% solution) + 200mls
NS I.V over 5 minutes
ii. Maintenance dose
MgSO4 4 g (i.e. 20ml of 20% solution) IN 500ml NS
4 hourly for 24 hrs after the last fits

MANAGEMENT CONT
CONTROL CONVULSIONS - REGIMEN

Recurrent fits (any regimen):

Therapeutic dose may not have been reached

Give 2g (i.e. 10ml of 20% solution) i.v. over 5

minutes

Treatment duration:
Continue for 24 hours after delivery or last
convulsion, whichever occurs first

MANAGEMENT CONT
Magnesium toxicity

Causes loss of deep tendon reflexes, followed by

respiratory depression and ultimately respiratory
arrest.
Thus, before repeating MgSO4, ensure that;

RR 16/min
Patellar reflexes are present
Urinary output is at least 30ml per hour over 4 hours
Otherwise withhold or delay MgSO4
Keep antidote ready
In case of respiratory arrest: Assist ventilation and administer
calcium gluconate

MANAGEMENT CONT
DELIVER THE MOTHER

Delivery should be within 6-8 hours of onset

of fits
Vaginal delivery is the safest mode of delivery
Assessment

R/O contraindications to SVD

Bishop score
If the cervix is favourable - induce labour
Otherwise prepare for C/S

MANAGEMENT CONT
Management of labour

1st stage

Relieve pain: pethidine 25 mg iv every 2-4 hours

Augmentation of labour

Monitor FHR,

2nd stage: Assist with vacuum extraction

3rd stage: Active management

Oxytocin 10 IU i.m after delivery of anterior shoulder

Cord traction

Squeezing clots after delivery of the placenta

MANAGEMENT CONT
Management of labour

If there is delay perform C/S

Post delivery:

Continue observation for at least 48 hrs post

delivery

Record and monitor BP and urine output for at

least 48 hours after delivery,

Keep the pt in hospital until BP stabilizes,

Continue with aldomet PO until BP back to

normal