HYPERTENSION in PREGNANCY

Hartono Hadisaputro
Fetomaternal Division
Departement of Obstetric Gynaecology
Medical Faculty of Diponegoro University
Dr. Kariadi Hospital Semarang
Terminology

Hypertension in Pregnancy
Pregnancy Induced Hypertension
Preeclampsia - Eclampsia
Classification and Definition
1. Chronic Hypertension
Hypertension pressent before pregnancy,
diagnosed before 20 weeks gestations or
failing to resolve within 12 weeks
postpartum.
2. Preeclampsia Eclampsia
Ussualy occuring after 20 weeks, defined
by hypertension and proteinuria.
3. Preeclampsia Eclampsia
New onset proteinuria in those without
proteinuria at start of pregnancy. An
increase in proteinuria, blood perssure
levels or thrombocytopenia or abnormal
liver enzumes in those who already had
proteinuria at the start of pregnancy.
4. Gestational Hypertension
De nuvo hypertension during pregnancy
without proteinuria.
Include woman with feature of
preeclampsia who have not manifestated
proteinuria. Reclassified 3 months post
partum as transient hypertension if
blood pressure returned to normal.
Risk Factor of Preeclampsia
1. Age :
High incidence of teen age probably
cause by the social neglect : poor ante
natal, poor nutrition and concealed
pregnancy.
Increased incidence of preeclampsia in
woman age more than 35 years.
Probably because of the unmasking of
latent hypertension.
2. Parity
Hypertension in pregnancy is mainly
disease of primi gravida.
Combination of age and parity leads high
risk of severe preeclampsia.

3. Race
4. Family Factors :
There is familial tendency to the
development of preeclampsia-eclampsia.
5. Genetic Factors :
Blood group
Fetal sex : male babies more than
female babies.
6. Dietary Factors :
Total energy and protein.
Body live : incidence of preeclampsia
is higher in obese woman.
7. Environmental Factors :
Climate and season
Altitude
Urban rural
8. Behavioral and Socio Economics
Factors
Cigarrette smoking
Physical activity
Social economics factor
9. Hyperplasentosis :
Multiple pregnancy
Hydrops fetalis
Diabetes mellitus
Hydatidiform mole
Prevention of Preeclampsia

1. Non Medical.
2. Medical ( currently there is no
preventive therapy for preeclampsia ).
Non Medical Prevention
1. Salt restriction
no evidence that salt restriction
has role in prevention of
treatment of hypertension
pregnancy.
2. Dietary supplementation :
a. Fish oil : rich of omega
b. Antioxidant vitamin : vit.C, vit.E,
-carotene, NAC.
c. heavy metal element : Zn, Mg, Calcium.
3. Bed rest
4. Life style change
Medical Prevention
1. Diuretics : proof no benefit in
hypertension in
pregnancy, reduce more
hypovolemia.
2. No evidence that it can prevent
preeclampsia.
3. Calcium : 1500 2000 mg/day.
4. Zinc : 200 mg/day.
5. Magensium : 365 mg/day.
6. NO
7. Antithrombotic agent :
low dose aspirin
dipyridamole
subcutaneous heparin
8. Antioxidant : vit.C, vit.E and
-carotene, NAC.
Maternal Changes in Preeclampsia
A. Cardiovascular :

CARDIOVASCULAR NORMAL PREGNANCY PREECLAMPSIA

Cardiac out put increased same/in/decreased

Blood volume increased decreased

decreased 1st and 2nd
Peripheral resistance trimester at the same increased
term
Arterial blood pressure idem increased

Uteroplacental blood flow not applicable decreased

Cerebral blood flow increased same

Hepatic blood flow increased same

increased until 34 weeks

Renal blood flow decreased
at the same term
B. Weight Changes
weight gain
fluid retention : oedema can be part
of normal pregnancy
80% pregnant woman with hypertension
and proteinuria have some oedema
60% pregnant woman with hypertension
have oedema
40% normal pregnant have oedema
C. Blood Chemistry
vasospasme hypovolemia and
hemoconcentration
increased of hematocrit and uric acid
reduce of serum albumin
hyperlipidemia
thrombocytopenia
lowering of antithrombin III
elevation of fibronectin
Clinical Aspects
A. Classification
Gestational Hypertension
Preeclampsia
Eclampsia
Superimposed Preeclampsia ( on chronic
hypertention )
Chronic Hypertension
B. Diagnosis
1. Gestational Hypertension
blood pressure 140 mmHg for 1st
time during pregnancy
no proteinuria
blood pressure return to normal 12
weeks
2. Preeclampsia
Minimum crtiteria :
blood pressure 140 mmHg after 20
weeks gestation
proteinuria 300 mg/24 hours or
+ 1 dipstick
 Increased certainty of preeclampsia :
blood pressure 160 mmHg
proteinuria 2.0 gr/24 hours or + 2
dipstick
creatinine serum 1,2 mg/dl
plateletes 100.000/m3
increased LDH
persistent headache / cerebral or
visual disturbance
persistent epigastric pain
3. Eclampsia
seizures that can not be ettributed
to other causes in woman with
preeclampsia.
4. Superimposed Preeclampsia ( on chronic
hypertension )
new onset proteinuria 300 mgr/24
hours in hypertensive woman but no
proteinuria before 20 weeks
gestation.
5. Chronic Hypertension
blood pressure 140 mmHg before
pregnancy or diagnosed before 20
weeks gestation.
hypertension first diagnosed after 20
weeks gestation and persistent after
12 weeks postpartum.
Hypertensive Disoreder During Pregnancy
indication of severity

ABNORMALITY MILD SEVERE

Diastolic blood pressure 100 mmHg 110 mmHg / higher
Proteinuria trace to + 1 persistent + 2 / more
Headache absent present
Visual disturbance absent present
Upper abdominal pain absent present
Oliguria absent present
Convulsion absent present
Creatinine serum normal elevated
Thrombocytopenia absent present
Liver enzym elevation minimal marked
Fetal growth restriction absent obvious
Pulmonary oedema absent present
Management of Preeclampsia
A.MILD PREECLAMPSIA
1. Definition
is a pregnancy-specific syndrome
of reduced organ perfusion
secondary to vasospasm and
endothelial activation.
With minimum criteria of sign :
Blood pressure 140 mmHg
Elevation of 30 mmHg systolic
Elevation of 15 mmHg diastolic, is not
include in the definition of hypertension
Proteinuria 300 mg/24 hours or + 1
dipstick
Oedema : local oedema is not include in the
definition of preeclampsia except general
oedema
2. Management :
a. Ambulatory care :
not necessary absolute bed rest
regular diet
not restriction on salt
prenatal vitamin
no other medication
hospital visit for every week
b. Hospital Care
1. Indication of mild preeclampsia to be
admitted to hospital :
persistent hypertension within 2 weeks
persistent proteinuria within 2 weeks
abnormal laboratory test
abnormal fetal growth
any evidence od 1 or more signs and
symptoms of severe preeclampsia
2. Maternal fetal evaluation of mild
preeclampsia during hospitalization
Maternal evaluation
blood pressure every 4 hours
present fascial / abdominal
oedema
weight gain
observe symptoms of impending
eclampsia
Laboratory examination
urine prtein every 2 days
hematocrites and plateletes count 2
times a weeks
liver function test 1 to 2 times a week
liver function test
plasma or creatinine serum
urine production every 3 hours
Fetal examination :
daily fetal movement
nonstress test twice a week
biophysical profile
ultrasound
Doppler ultrasound
3. Medical Therapy
similar to the ambulatory care.
4. Obstetric Management
the obstetric management depends on the
gestational age.
If there is not in labor :
a. Gestational age 37 weeks
If the sign and symptom of mild
preeclampsia are not worsened then
the pregnancy can be maintain until
term.
b. Gestational age 37 weeks
the pregnancy should be maintain
until development of the onset of
the labor.
if the cervix is favorable, an
induction of labor can be
consistered.
if the patient are in labor, the
course of the labor should be
followed by Friedman curve.
5. Mode of Delivery
the delivery can be expected to be
spontaneous vaginally.
B. SEVERE PREECLAMPSIA
1. Definition
severe preeclampsia with one or
more of the following signs and symptoms :
blood pressure
with patients at rest systolic 160
mmHg
diastolic 110 mmHg
proteinuria : 5 gr in 24 hours urine
collection
 oliguria : 24 hour output 400-500 ml
elevated creatinine serum
epigastric or right upper quadrant
tenderness
pulmonary oedema or cyanosis
cerebral or visual disturbances
impaired liver function
microangipathic hemolysis
thrombocytopenia
HELLP syndrome
2. Subcategories of severe preeclampsia
severe preeclampsia can be divided into 2
categories :
severe preeclampsia without impending
eclampsia
severe preeclampsia with impending
eclampsia ( headache, epigastric pain,
nausea and vomitting )
3. Basic management of severe
preeclampsia :
Consideration :
to plan the medical therapy :
administering drug for the
medication of the complication.
to plan the obstetric management :
depend on the gestational age :
a. expentant, conservative management
gestational age 37 weeks.
b. active, aggressive management
gestational age 37 weeks
to terminate the pregnancy
after administering drug for
stabilizing the mother.
4. Plan for Medical Therapy :
a. Admitted to hospital soon.
b. Bed rest on side.
c. Infusion of Dextrose 5% 500cc and
Ringer lactate 500 cc 2 : 1, 60 125 cc/h.
d. Magnesium sulfate to prevent and
controle convulsion :
10 gr i.m MgSO4 40%,
5 gr 40% i.m alternating buttocks
and stop 24 hours after delivery.
e. Antihypertension
first choice is a methyldopa 250 mg
twice time/day depend on the respons to
hypotensive agent
can be add nifedipin 10 mg twice/day
C. ECLAMPSIA
1. Definition
eclampsia is preeclampsia that is
complicated by generalized tonic-clonic
convulsion and follow by coma.
2. Differential diagnosis :
hypertensive encephalopathy
cerebrovascular accident
metabolic disorders
iatrogenic
infectious etiology
thrombotic thrombocytopenic purpura
3. Medical therapy :
4 gr MgSO4 20% i.v ( 1 gr/minute )
10 gr MgSO4 40% I.m
addition 1.0 ml lidocain
if convulsion persist after 15 minute,
give 2 gr 20% i.v
1 gr/minute, obese 4 gr i.v
use 3 inch long gauge needle
hypotensive agent like in severe
preeclampsia
 HELLP SYNDROME
1. Definition
the presence of hemolysis ( H ),
elevated liver enzymes ( EL ), as
evidence of hepatic dysfunction and
(LP) as evidence of low plateletes or
thrombocytopenia in a woman
considered to have preeclampsia
eclampsia ( Weinsteinb, 1928 ).
2. Pathogenesis
Unknown specific trigerring event
Pertubation of endothelial homeostasis
Altered platelet and erythrocyte
activation / endothelial interactions
Inflamatory response
Increased oxidative stress / decreased
free radical scavenging capacity
Enchanced pressor sensitivity
3. Diagnose
a. Diagnosis of HELLP Syndrome is
based :
Microangiopathic hemolytic
Anemia
Hepatic dysfunction
 Thrombocytopenia :
from the peripheral blood smear :
Schistocytosis, burr cells,
helmet cell
Early marker of HELLP
syndrome
Increase lactic dehydrogenase
(LDH)
Decrease serum haptoglobine
 Liver dysfunction :
increase asparatic transaminase
(AST)
increase alanin transaminase ( ALT )
increase lactic dehydrogenase (LDH)
Renal dysfunction
b. Practice point :
Nonspecific sign / symptoms :
nausea, vomitting, malaise, headache
Sign / symptom of preeclampsia :
epigastric pain, hypertension,
proteinuria
Evidence of intravascular hemolysis
Evidence of hepatocyte injury / dysfunction
Thrombocytopenia :
plateletes 150.000
4. Differential Diagnosis of
Preeclampsia HELLP Syndrome
Thrombotic microangiopathy
Fibrinogen consumptive disorder : DIC
Connective tissue disorder : SLE
Primary renal disease
Miscellaneous
5. Maternal Mortality
Cardiopulmonary failure
Coagulopathy
Intracerebral hemorrhage / stroke
Hepatic rupture
Post caesarian shock
Multiple organ failure
Miscellaneous co morbidities
6. Maternal Morbidity
Hematologic / coagulation
Cardiopulmonary
Central nervous system
Renal
Hepatic / gastrointestinal
7. Therapy :
Follow the medical therapy of
preeclampsia eclampsia
Laboratory examination for plateletes
and LDH every 12 hours
If maternal platelet count 50.000/cc
or a sign of consumptive coagulopathy,
must examine the prothrombine time,
partial thromboplastine time,
fibrinogen.
 Dexamethasone rescue :
ante partum : 10 mg i.v
every 12 hours
post partum : 10 mg i.v
every 12 hours X 2
than 5 mg i.v 12 hours X 2
Plasma exchange
plasmapheresis and fresh frozen plasma
Nitrid oxide donor
Antioxidant : vitamin C and vitamin E
8. Obstetric Management :
Indication for termination of
pregnancy
Mode of delivery
vaginal or caesarian delivery