Hypertensiv

e in
Pregnancy
A. Kurdi, Syamsuri

INTRODUCTION
Hypertensive disorders complicate 510% pregnancies
Contributes greatly to maternal
morbidity and mortalityalong with
hemorrhage and infection

HYPERTENSIVE DISEASE
Hypertension =
Blood pressure >140 mmHg systolic or 90
mmHg diastolic

4 types:

Gestational hypertension
Preeclampsia and eclampsia
Chronic hypertension
Preeclampsia superimposed on chronic
hypertension

HYPERTENSIVE DISEASE
Condition

Criteria

Gestational
hypertension

- BP>140/90 mmHg after 20 weeks gestation

- Previously normotensive

Preeclampsia

- Gestational hypertension
- Proteinuria (>300 mg/24 hr, protein :
creatinin ratio > 0.3, or dipstick 1+) OR
- Multi organ involvement
- Convulsion (= eclampsia)

Chronic
hypertension

- BP>140/90 mmHg before pregnancy or

before 20 weeks gestation

Preeclampsia
superimposed

- History of chronic hypertension

- New-onset proteinuria

PREECLAMP
SIA
Is a pregnancy-specific syndrome
that can affect every organ system
Proteinuria

Preeclamp
sia
BP>140/90
mmHg

Multi
organ
involveme
nt

Thrombocytopenia (PLT < 100,000/mcL

Renal insufficiency (Creatinine >1.1 mg/dL)
Liver involvement (AST or ALT 2x normal)
Cerebral symptoms (Headache, visual disturbances,
convulsions)
- Pulmonary edena

PREECLAMPSIA SEVERITY
Non
severe

Sever
e

Abnormalit
y

Systolic BP

< 160

> 160

Diastolic BP

< 110

> 110

Convulsion
(eclampsia)

Proteinuria

(-)/(+)

(-)/(+)

Abnormalit
y

Headache

(-)

(+)

Visual
Disturbances

(-)

(+)

Upper
Abdominal
Pain

(-)

(+)

Oliguria

(-)

(+)

Non
severe

Sever
e

(-)

(+)

Normal

Thrombocytop
enia

(-)

(+)

Serum
transaminase

Minimal

Marked

Fetal growth
restriction

(-)

Obviou
s

Pulmonary
edema

(-)

(+)

Serum
creatinine

ECLAMPSIA
Eclampsia =
Preeclampsia + convulsion that
cannot be attributed to another cause

Generalized seizures
May appear before, during, or after
labor

RISK FACTORS
Maternal age & parity:
Young, nulliparous preeclampsia
Older superimposed preeclampsia

Obesity
Multifetal gestation
Hyperhomocysteinemia
Metabolic syndrome
History of preeclampsia

ETIOPATHOGENESIS
Characterized by abnormalities
that result in vascular endothelial
damage with resultant vasospasm,
transudation
of
plasma,
and
ischemic and thrombotic sequelae
Fetus is NOT a requisite
preeclampsia to develop

for

ETIOLOGY
Proposed theories
preeclampsia:

for

mechanisms

of

Placental
implantation
with
abnormal
trophoblastic invasion of uterine vessels
Immunological
maladaptive
tolerance
between maternal, paternal (placental), and
fetal tissues
Maternal maladaptation to cardiovascular or
inflammatory changes of normal pregnancy
Genetic
factors
including
inherited
predisposing genes and epigenetic influences

ABNORMAL
TROPHOBLASTIC
INVASION Preeclampsia
Normal Implantation
- Extensive
remodeling - Incomplete
of spiral arterioles within
trophoblastic invasion
decidua basalis
- Decidual vessels become
- Endovascular trophoblasts
lined with endovascular
replace
vascular
trophoblasts
endothelial and muscular - Deeper
myometrial
arterioles do not lose
linings enlarge vessel
endothelial
lining
and
diameter
musculoelastic tissue
- Mean external diameter
of normal placenta vessels

ABNORMAL
TROPHOBLASTIC
INVASION

ABNORMAL
TROPHOBLASTIC
INVASION

Gestational
hypertension
Preeclampsia
Preterm
delivery
- Growth-restricted fetus
- Placental abruption

IMMUNOLOGICAL
MALADAPTIVE TOLERANCE

Loss of maternal immune tolerance to

paternally-derived placental and fetal
antigens
Possibly associated factors:
Immunization from previous pregnancy

First pregnancy, molar pregnancies,

women with trisomy-13 fetus higher
risk of preeclampsia

OTHER FACTORS
Nutritional factors
Diet high of antioxidant decreased blood
pressure
However, supplementation with antioxidant
vitamins C or E showed no benefits

Genetic factors
Preeclampsia is a multifactorial, polygenic
disorder
Result of interaction of hundreds of inherited
genes

PATHOPHYSIOLO
GY

MANAGEMENT:
TERMINATE PREGNANCY
OR NOT?
-

> 37 wks, OR
> 34 wks with:
In labor or PROM
Maternal or fetal distress
IUGR
Placental abruption

Preeclampsia

Terminate
pregnancy

Yes

Yes

No

< 37 wks
Outpatient
Maternal and fetal
evaluation 2x/wk

> 37 wks
Maternal or fetal distress
In labor or PROM

EXPECTANT
MANAGEMENT

Severe preeclampsia
-

Non severe
preeclampsia
-

Expectant management
Outpatient
Close evaluation:
- 2x/wk Blood
pressure, ultrasound
- 1x/wk
thrombocyte, liver
function

Expectant management
-Available ICU & NICU
-Viable fetus
-Hospitalization
-Stop MgSO4 in 24 hrs
-Evaluate mom & baby every day

> 34 wks
In labor or PROM
Maternal/fetal distress
> 1 contraindication for
expectant management

Evaluation in delivery room

for 24-48 hrs
- Corticosteroid for lung
maturation, prophylaxis
MgSO44, anti HT
- Ultrasound, BPP, lab
examination
Contraindication for expectant
management:
-Eclampsia
- Fetal
distress
-Lung edema
- Abruptio
placenta
-DIC
- IUFD
-Uncontrolled HT
- Unviable
fetus
Complications:
-Persistent symptoms
HELLP
-Severe renal dysfunction
- In
labor
-Reversed end diastolic flow PROM
-Severe
- IUGR
Yes: oligohydramnios
Terminate
pregnancy

Yes:
Deliver
after
stabilizatio
n
Yes:
- Corticostero
id for lung
maturation
- Deliver
after 48 hrs

MANAGEME
NT
Clinical management
algorithm for suspected
severe preeclampsia at <34
weeks

Note:
HELLP = Hemolysis, elevated liver
enzyme levels, low platelet count
L&D = Labor & delivery
UOP = Urine output

MANAGEME
NT
Indications
for delivery in women <34 weeks gestation
managed expectantly
Corticosteroid therapy for lung maturation and delivery
after maternal stabilization:
-

Uncontrolled severe
hypertension
Eclampsia
Pulmonary edema
Placental abruption

DIC
Nonreassuring fetal status
Fetal demise

Corticosteroid therapy for lung maturation; delay delivery

48 hr if possible:
- PROM or in labor
- Thrombocytopenia <
100,000/L
- Hepatic transaminase 2x
normal
- Fetal growth restriction

- Oligohydramnios
- Reversed end-diastolic
doppler flow in umbilical
artery
- Worsening renal dysfunction

MANAGEME
NT
ANTI
CONVULSANT
st
MgSO
4 is recommended as 1 line
eclampsia treatment
RCOG guideline:
Loading dose: 4 g for 5-10 minutes
Maintenance: 1-2 g/hr for 24 hrs after delivery or
after the last convulsion
2 g bolus IV if convulsion re occur
Monitor urine output, patella reflex, RR, O 2
saturation

MANAGEME
NT
ANTI
Recommended for:
HYPERTENSIVE

BP systolic > 160 mmHg or diastolic > 110

mmHg

BP target:
Systolic < 160 mmHg and diastolic < 110
mmHg

1st choice anti hypertensive:

Short-acting oral nifedipine (10 mg tablet/15-30 minutes
max dose 30 mg)

Other alternative: methyldopa

250-500 mg per oral 2-3x/day, max dose 3 g/day
250-500 mg/6 hrs IV, max dose 1 g/6 hrs for crisis HT