HYPERTENSIVE

DISORDERS
IN PREGNANCY

HYPERTENSIVE DISORDERS
IN PREGNANCY

Hypertension in pregnancy
is the most common cause
of maternal and fetal
morbidity and mortality.
Pregnancy induced
hypertension (PIH) is
exclusively a human disease

What is
hypertension
in Pregnancy?

HYPERTENSION IN
PREGNANCY
Blood pressure more
than 140/90 mm Hg
Systolic blood pressure
more than 140 mm Hg
Diastolic BP more than
90 mm Hg

How would you

classify the
hypertensive
disorders in
pregnancy?

HYPERTENSIVE DISORDERS
IN PREGNANCY

categorised as
(a) Gestational
hypertension(PIH)
(b)
Preeclampsia and

What is
gestational
hypertension(Pregnancy
Induced

Pregnancy-induced hypertension
(Gestational hypertension)
(a)Gestational hypertension(PIH) is
defined as the maternal blood pressure
of systolic 140 or diastolic 90 mm Hg
or more on two occasions observed for
the first time in pregnancy .
The
blood pressure returns to normal
within 12 weeks of delivery.
No proteinuria

What is
preeclamp
sia?

PREECLAMPSIA
(b)Preeclampsia is
blood
pressure more than 140/90 mm
Hg after 20 weeks of
pregnancy and
Proteinuria of more than 300 mg
in 24 hours

What is
chronic
hypertensio
n?

CHRONIC HYPERTENSION
(c)Chronic hypertension is
blood pressure measurement of
140/90 mm Hg or greater on two
occasions before 20 weeks of
gestation (No gestational
trophoblastic disorders)
or BP
more than 140/90 mm Hg
diagnosed after 20 weeks of

What is
PREECLAMPSIA
SUPERIMPOSED
ON CHRONIC
HYPERTENSION?

PREECLAMPSIA SUPERIMPOSED
ON CHRONIC HYPERTENSION
(d)Preeclampsia superimposed
on chronic hypertension is
chronic hypertension and
proteinurea
In chronic hypertension
proteinuria occurs after 20
weeks of gestation or sudden
increase in BP, proteinuria and
low platelet count in a patient

DEFINITION- PREECLAMPSIA

Pre eclampsia is
BP
of
> 140/90 with
proteinuria of
> 300

What is the
pathophysiolo
gy of preeclampsia?

AETIOLOGY OF
PREECLAMPSIA
Exact cause is not
known, but placental
dysfunction seems to be
integral to the
development of the
syndrome in most
women.

PATHOPHYSIOLOGY
Preeclampsia is primarily a
disorder of placental dysfunction
leading to a syndrome of
endothelial dysfunction with
associated vasospasm.
Failure of villi to invade spiral
arterioles in early pregnancy
leading to ischemia and damage.
This leads to release of chemical
mediators into maternal

 This leads to 2 major pathological

changes:
1. Generalized vasospasm due to
increased sensitivity of vascular
system to circulating catecholamine
Hypertension
2. Multiple endothelial damage leading
to leakage of albumin and fluid into
interstitial space resulting in tissue
edema.
. The pregnant woman may manifest
dysfunction of multiple organ
systems, including the central
nervous, hepatic, pulmonary, renal,
and hematological systems.

What are the

predisposing
factors for preeclampsia ?

PREDISPOSING FACTORS FOR

PRE ECLAMPSIA
Age Young and Old(extremes of
reproductive age)
Parity Primigravidas:double the incidence
Social status lower:Increased incidence
Genetic predisposition run in families
Renal disorders
Obesity
Family history and past history
SLE
Thrombophilia

PREDISPOSING FACTORS FOR

PRE ECLAMPSIA
Larger placentamultiple pregnancy,
diabetes,
trohpoblastic disorders
Multiple pregnancies
20% in twin pregnancies
4% in singleton
pregnancies

PHYSIOLOGICAL CHANGES OF
BLOOD PRESSURE IN PREGNANCY
BP

12

24

40

P.O.A.(weeks)

What is
Eclampsi
a?

ECLAMPSIA

Eclampsia is
seizures in
preeclampsia after
excluding other
causes of fits

ECLAMPSIA

Eclampsia can occur

without hypertension
in 16%
Without proteinuria
in 14%

SYSTEMIC EFFECT OF
PREECLAMPSIA

Cardiovascular
Cardiac output in normal pregnancy
increase by 30-50%
In preeclampsia, the cardiac output is
either maintained or increased
There is increase in peripheral
resistance which may lead to
extravasation of fluid into the
extracellular space
Result in pulmonary edema

Cerebral
There is increase in cerebral vascular
resistance
Severe hypertension can lead to rupture
in the arterioles resulting in cerebral
haemorrhage
1/3 of patient die of eclampsia has
cerebral haemorrhage.
Other changes that occur are:
-cerebral edema
-thrombosis

Hematological
Expansion of blood volume is
approximately 20%
Hemoconcentration can lead to decrease in
regional perfusion
Increase in vascular tone result in
endothelial injury which result in
microangiopathic hemolysis
Manifestation can be in form of:
-thrombocytopenia
-anemia
- fragmentation of red blood cells

Endocrinological
There is alteration in vascular sensitivity
to the endogenous hormone
There is decreased in prostacyclin
production by placenta
This result in increased thromboxane
A2/prostacyclin ratio which lead to further
increase in vascular tone and blood
pressure

Hepatic
Periportal hemorrhagic necrosis in
periphery part of liver lobule
This lead to subcapsular hemorrhages
which lead to the epigastric pain seen
with imminent eclampsia
Renal
Renal perfusion rate decreased by 20%
resulting in 30% reduction in the
glomerular filtration rate
Glomerular capillary endotheliosis is
pathognomonic of preeclampsia
The swollen glomerular cells further

COMPLICATION OF
PREECLAMPSIA
MOTHER
FETAL

MATERNAL COMPLICATIONS
OF PREECLAMPSIA
1 Eclampsia
2 Because of high blood pressure
Cerebro-vascular accidents
and
congestive
cardiac failure
3 PPROM
4 Neurological deficit
5 Acute renal failure
6 Abruptio placenta
7 Postpartum hemorrhage (normal blood loss: Vaginal
delivery:500ml, caesarean:1000ml, caesarean
hysterectomy:1500ml)

8 Preterm labor
9 HELLP syndrome

MATERNAL
COMPLICATIONS
(1)Eclampsia(siezures)

()Occur in 1 in every 2000 pregnancies with

severe preeclampsia between 200 weeks of
gestation till 10 days postpartum
()38% in antenatal, 18% intranatal, 44% in the
postnatal
()Liver dysfunction,acute renal failure,adult
respiratory distress syndrome and
disseminated intravascular coagulopathy
(DIVC) are also known to occur with eclampsia
()Usually start in a sequence

 Unconcious for a brief moment

Twitching of muscle of face, tongue , and limbs
Eyeballs rolls and become fixed
Body goes in tonic spasm
Respiration ceases for around half a minute
with tongue protruding out
After this the muscle goes into alternate
contraction and relaxation
Twitching starts at one side of face followed by
one side of extremities and then the whole
body
Then patient goes into brief coma and does not
has memory of the preceding event when she
recover from the coma.

(2) High blood pressure:

Congestive Cardiac failure
(due to hypertension +/- fluid
overload)
Cerebro-vascular accidents
Fibrinoid necrosis of walls of
arterioles
rupture results in Cerebral
Haemorrhage

FETAL COMPLICATIONS
IUGR
Oligohydraminos

(AFI <5

cm)

Prone for fetal hypoxia

in labor
Still births

 For investigation please refer obs

today..sorry for the inconvenience

MONITORING FETAL
WELLBEING
Foetal kick count chart
Fetal heart rate
monitoring
Symphysio-fundal height
Cardiotocography (CTG)
Ultrasound studies

MONITORING FETAL
WELLBEING

CARDIOTOCOGRAPHYCTG
Reactive
CTG
Fetal heart rate 110-160
bpm
Base line variablity 5-

MONITORING FETAL
WELLBEING
Ultrasound examination
Amniotic fluid index (AFI)
Abdominal
circumference and Foetal weight IUGR
Doppler flow studies for
placenta perfusion
Biophysical profile

MANAGEMENT: PRINCIPLES

Management
depends on
severity of
condition and
period of gestation

MANAGEMENT: PIH
1. PB elevated repeat the measurement
after 15-20 mts
2. Enquire regarding the symptoms of
preeclampsia
3. Per abdomen examination
Assess fetal growth and rule out IUGR

4. Ultrasound
Assess fetal size, amniotic fluid index along
with umbilical artery Doppler analysis

MANAGEMENT: PIH
The following features mandates admission:
1. Persistence elevated BP > 150/100mmHg
2. Proteinuria of > 1+ after excluding UTI
3. Sign and symptoms of impending eclampsia

On admission: (preeclampsia profile

investigation)
1. Monitor 4 hourly BP, pulse rate, input/output
chart and daily protein
2. Initiate antihypertensive therapy (1 st line
therapy- Methyldopa or Labetolol)

MANAGEMENT: PREECLAMPSIA

AIM

To prolong the pregnancy to reduce the fetal

risks but balance with the risk to the mother

All patients diagnosed with preeclampsia

require admission to assess the severity
and to determine the further care plan.
Principle of management
Conservative management for mild cases
Active intervention and delivery in severe cases
Termination of pregnancy is a definitive
treatment

PREECLAMPSIAGRADING
Mild Preeclampsia
BP 140/mm Hg
Proteinuria 300 mg/ 24 hr urine
(+)
Moderare preeclampsia
BP 150/100 mm Hg
Proteinuria 400 mg/24 hr
urine (++)
Severe Preeclampsia
BP 160/100 m Hg
Proteinuria 500 mg/24 hr urine (+++)

SEVERE PRE-ECLAMPSIA
1. Control blood pressure
Antihypertensive drug (ex: alpha methyl Dopa)
Prolong the pregnancy

2. Prevent convulsion
Pritchards regimen (Magnesium Sulphate)
LD: 4g slow IV over 4-5min, 10gms IM (5gms
deep IM in each buttock)
MD: 5g every 4th hourly in alternate buttock till
24h after the fit or delivery whichever is later

3. Delivery of baby

INDICATION TO DELIVER
In severe preeclampsia where the systolic BP will
> 160mmHg and / diastolic BP > 110 mmHg
along with abnormal preeclampsia profile.
Parameter which indicates urgent delivery are as
follow:
1. POG: 38 weeks
2. BP > 160/110 mmHg despite therapy
3. Platelet < 100,000/ml
4. Serum fibrinogen < 150mg/dl
5. Proteinuria > 5gms in 24 hours
6. Uric acid > 450 mmol/L
7. Creatine > 1.2mg/dl
8. CTG,BPP: any acute compromise
9. Doppler: reversal of diastolic flow
10.Ophthalmoscope: grade IV changes