Hypertension in

Pregnancy

Triono Adisuroso, MD, SpOG, MMed, MPhil

Fetal Medicine, Reproductive Health & Human Genetics

Head of Department of Obstetrics and Gynaecology
Permata Cirebon Hospital
Faculty of Medicine at The University of Swadaya Gunung Jati Cirebon
 Introduction

Preeclampsia is a major cause of maternal

mortality and morbidities, perinatal deaths,
preterm birth, and IUGR.
2-8% of maternal mortality worldwide.
15-20% in developed countries: chronic
hypertension, diabetes, and obesity.
Eclampsia
2-3 cases/10,000 births in Europe
10-30 times higher in developing countries than high-
income countries.
 Healthy nulliparous women:
2-7%
75% of cases mostly mild.
The onset mostly near term, or
intrapartum.
Frequency and severity:
Multifetal pregnancy.
Chronic hypertension.
Previous preeclampsia.
Diabetes mellitus.
Thrombofilia.
Pathogenesis
 Definitions
Hypertension:
BP 140 mmHg (systolic) or 90 mmHg
(diastolic).
At least two occasions and 4-6 hours apart.
After 20 weeks pregnancy.
Normotensive beforehand.
Accurate diagnosis (cuff size, arm position at
heart level, calibration) in obese women.
 Definitions contd

Proteinuria:
300 mg every 24 hours or
300 mg/L ( 1+ on dipstick) at least two
random urine samples and 4-6 hours apart.
 Classifications

Preeclampsia eclampsia:
Chronic hypertension
Chronic hypertension with superimposed
preeclampsia
Gestational hypertension
Gestational hypertension:
BP elevation after 20 weeks + absence
proteinuria.
Chronic hypertension:
Hypertension occurs prior to pregnancy.
Superimposed preeclampsia:
Chronic hypertension in association with
preeclampsia.
Preeclampsia:
Hypertension + proteinuria.
Diagnosis
 Preeclampsia
Hypertension.
Proteinuria.
Thrombocytopenia (platelet
<100,000/microliter).
Impaired liver function (elevated liver
transaminases levels twice or more).
Renal insufficiency (creatinine 1.1 mg/dL);
oliguria (<500 mL per day).
Pulmonary edema.
New onset of cerebral or visual disturbances.
Severe Preeclampsia
 HELLP syndrome
Hemolysis, elevated liver function, and low
platelet.
10-20% of severe preeclampsia.
Epigastric or right upper quadrant pain.
Headache, visual change, nausea and vomiting.
Complications: Placental abruption (9-20%),
Disseminated vascular coagulation (5-60%), Acute
renal failure (7-35%), Eclampsia (4-9%), Pulmonary
edema (3-10%), Subcapsular liver hematoma
(<2%), retinal detachment and cerebrovascular
bleeding (less frequent).
 Organ involvements
Renal involvement
Proteinuria
Creatinine >90 mol/L
Oliguria: <20 mL/hour
Hematological involvement
Thrombocytopenia <100,000 /L
Hemolysis: schistocytes or red cell blood
fragment, raised bilirubin, raised LDH (>600
mIU/L), decreased haptoglobin
Disseminated intravascular coagulation (DIC)
Liver involvement
Raised serum transaminases.
Severe epigastric and/or right upper quadrant
pain.
Neurological involvement
Convulsion (eclampsia).
Hyperreflexia with sustained clonus.
Persistent, new headache.
Persistent visual disturbances (photopsia,
scotomata, cortical blindness, reversible
encephalopathy syndrome, retinal
vasospasm).
Stroke
Pulmonal edema
Fetal growth restriction
 Predictions
Early prediction would allow for close
surveillance and preventive strategies.
Identifications of demographic factors,
biophysical findings, and biochemical analytes,
alone or combination.
Tests: BMI 34 kg/m2, AFP, uterine arteries
Doppler, kallikrenuria, fibronectin.
 Clinical presentations

Many organ systems: CNS, lungs, liver,

kidneys, systemic vasculature, coagulation,
heart, placenta, and fetus.
Nausea and vomiting.
HELLP syndrome.
Eclampsia (1-% of severe preeclampsia).
Cortical blindness.
Management
Anti-hypertensions
 Fluid management

?Colloid or crystalloid.
250 mL bolus (prior to parenteral hydralazine,
regional anesthesia, or immediate delivery).
300 mL challenge (initial management for
oliguria).
 Eclampsia treatment
Resuscitation
Prevention of seizure
Diazepam iv: 2 mg/min max 10 mg.
Clonazepam: 1-2 mg over 3-5 mins.
Magnesium sulphate (MgSO4).
 MgSO4
Initial dose
4 g MgSO4 40% (10 mL) diluted in 100 mL normal
saline over 15-20 minutes.
Maintenance dose
Infusion: 4 g MgSO4 40% (10 mL) diluted in 500
mL normal saline and given in 1-2 g/hour (20-30
gtt/hour).
Or
10 g MgSO4 40% intramuscularly (5 g in each
buttock)
 MgSO4
Antidotum!!!:
10% Ca gluconas i.v. over 3-5 minutes. (Must
be available before administering MgSO4)
Monitoring:
Blood presure.
Respiratory rate: 16 per minute.
Deep tendon reflexes.
Urine output (30 mL/hour or 0.5
mL/kgBW/hour).
Oxygen saturation.
Antenatal MgSO4 for fetal neuroprotection
Fetal surveillance
 Corticosteroid

Antenatal corticosteroid for fetal lung

maturation
Dexamethasone: 2 x 5 mg for 2 days.
Betamethasone: 1 x 12 mg for 2 days.
Prevention
Thanks