Jumarni Binti Abdurachman

Aizuddin Azim Bin Zainuddin

Definition
Chronic HPT
Gestational HPT (PIH)
Pre-eclampsia
Eclampsia
Raised BP; EITHER

Systolic BP > 140mmHg previously
normotensive
Diastolic BP > 90mmHg





An increase of 15 mmHg and 30 mmHg diastolic and
systolic BP levels above baseline BP is no longer
recognized as hypertension if absolute values are below
140/90 mmHg. Nevertheless, this warrants close
observation, especially if proteinuria and hyperuricaemia
are also present (CPG 2008)




Chronic hypertension - hypertension that is present at the booking visit or
before 20 weeks or if the woman is already taking antihypertensive
medication when referred to maternity services. It can be primary or
secondary in etiology.

Eclampsia - convulsive condition associated with pre-eclampsia.

Gestational hypertension (PIH) - is new hypertension presenting after 20
weeks without significant proteinuria.

Pre-eclampsia - new hypertension presenting after 20 weeks with significant
proteinuria.

Severe pre-eclampsia - pre-eclampsia with severe hypertension and/or with
symptoms, and/or biochemical and/or haematological impairment.

Significant proteinuria- if the urinary protein:creatinine ratio is greater than 30
mg/mmol or a validated 24-hour urine collection result shows greater than 300
mg protein.


New onset of hypertension after
20 weeks gestation
Molar
pregnancy
Primigravida
Multiple
pregnancy
DM
Polyhydramnios
Hydrop
fetalis
Previous
h/o PIH




Maternal Fetus
Eclampsia
Renal failure
Thrombocytopenia
Abruptio placenta
Sub-capsular hemorrhage
and liver dysfunction
-- HELLP
Heart failure
Pulmonary oedema
Retinal hemorrhage

IUGR
Fetal hypoxia &
IUD
Degree of hypertension


Mild hypertension
(140/90 to 149/99
mmHg)

Moderate hypertension
(150/100 to
159/109 mmHg)

Severe hypertension
(160/110 mmHg or
higher)

Admit to hospital

No Yes Yes (until blood pressure is
159/109 mmHg or lower)


Treat

No oral labetalol as first-line
treatment to keep:

diastolic blood pressure
between 80100 mmHg
systolic blood pressure less
than 150 mmHg


oral labetalol as first-line
treatment to keep:

diastolic blood pressure
between 80100 mmHg
systolic blood pressure
less than 150 mmHg


Measure blood pressure

Not more than once a
week

At least twice a week

At least four times a day
Test for proteinuria

At each visit

At each visit Daily
Blood tests

Only those for routine
antenatal care

Test kidney function,
electrolytes, full blood count,
transaminases, bilirubin

# Do not carry out further
blood tests if no proteinuria at
subsequent visits
Test at presentation and
then monitor weekly:
kidney function,
electrolytes, full blood
count, transaminases,
bilirubin


Fetal kick chart
Daily CTG
U/S (detect growth restriction- fetal growth &
AFI)
Umbilical blood flow monitoring by doppler
SHOULD NOT USE:
ACE inhibitors
blocker agent (propanolol) : a/w fetal growth
restriction in long term use
Diuretics : reduce plasma volume thus may cause
IUGR

DO NOT REDUCE blood pressure TOO QUICKLY. It
may compromise utero-placental blood flow

Only CURE is
DELIVERY
Indications for delivery
Inability to control maternal
blood pressure
Progressive deterioration in
renal/hepatic function
Signs/symptoms of impending
eclampsia
Progressive thrombocytopenia
Severe IUGR/signs of fetal
distress


Hypertension that is present at the booking
visit or before 20 weeks or if the woman is
already taking antihypertensive medication
when referred to maternity services. It can
be primary or secondary in etiology.


Renal disease - Glomerulonephritis
- Renal artery stenosis
- Diabetic nephropathy
- Polycystic kidneys

Endocrine causes - Phaechromocytoma
- Conns Syndrome
- Cushings

Others -Coarctation of aorta


Women with chronic hypertension may require a
change in the type of antihypertensive agent
used pre-pregnancy
The drugs of choice in pregnancy:
Methyldopa
labetalol
Atenolol has been shown to lead to fetal growth
restriction.
The use of ARBs & ACEIs is contraindicated in
pregnancy.
High blood pressure with proteinuria
Also known as
Gestational proteinuric hypertension
Preeclamptic toxemia (PET)
Affects many organs i.e. placenta, kidney,
liver, heart, brain
Reduced blood flow
Clinically diagnosed in the presence of de novo hypertension after gestational
week 20, and one or more of the following:
i. Significant proteinuria.
ii. Renal insufficiency: serum creatinine >90 mol/l or oliguria.
iii. Liver disease: raised transaminases and/or severe right upper quadrant or
epigastric pain.
iv. Neurological problems: convulsions (eclampsia), hyperreflexia with clonus or
severe headaches, persistent visual disturbances (scotoma).
v. Haematological disturbances: thrombocytopenia, coagulopathy, haemolysis.
vi. Fetal growth restriction.
This is followed by normalisation of the BP by three months postpartum.
Oedema is no longer part of the definition of preeclampsia. Either excessive
weight gain or failure to gain weight in pregnancy may herald the onset of
preeclampsia.
Moderate risk
Primigravida
Extremes of age (<20, >40)
Pregnancy interval >10 years
Family history of pre-eclampsia
Multiple pregnancy
High risk
Hypertensive disease in previous pregnancies
Chronic kidney disease
Autoimmune (e.g. SLE, antiphospholipid
syndrome)
Diabetes mellitus
Chronic HPT
Maternal
Eclampsia
Renal failure
Thrombocytopenia
Abruptio placenta
HELLP (hemolysis, elevated liver enzymes, lo platelet
count)
Heart failure
Pulmonary edema
Retinal hemorrhage *fundoscopy during physical
examination
Fetal (reduced placental blood flow)
IUGR
Fetal hypoxia
Intrauterine death (IUD)
Headache
Nausea, vomitting
Blurring of vision, papilloedema
Hyperreflexia
Epigastric pain liver involvement
Sudden increase of edema (e.g. facial
puffiness)
Lethargy hemolytic anemia
Routine test
Full blood count
Hb anemia
Platelet count <150
Liver function
Elevated liver enzymes (e.g. AST)


Renal values
Serum creatinine >150 umol/L
Serum uric acid >5.6 mg/dL
Sensitive indicator of renal damage in pre-
eclampsia
Oliguria <500mL/24hr
Proteinuria

Proteinuria
1. 24-hour urine protein
>300mg/ 24hr significant
>5g/ 24hr impending eclampsia
2. Urine dipstick
+, ++ or +++
To rule out renal disease, UTI,
contamination, etc
Transabdominal ultrasound to look for
growth restriction (abdominal circumference)
Doppler ultrasound to assess umbilical
artery blood flow
Cardiotocography
Fetal kick chart

Cure: To deliver
Same as gestational hypertension in
pregnancy
High BP, proteinuria + convulsion
Life-threatening, an obstetric emergency
Secure airway
Keep patient at left lateral decubitus position
Reduce risk of aspiration
Improves uterine blood flow (relieves obstruction
of vena cava by gravid uterus)
Protect patient from injuring herself
IV MgSO4 4g for 5 min
Then, 1g/hr for 24 hours
Further dose of 2-4g for 5 min
if recurrent seizures
If BP high, IV bolus Labetolol 20mg
Consider delivery of baby
Do vaginal examination for possibility of
vaginal delivery
If not possible, do caesarean section