Safety pregnancy care:

Hypertensive disorders
in pregnancy

Dr. Piyamas Saksiriwuttho

Fetal diagnosis and therapy Division
Department of Obstetrics and Gynecology
Faculty of Medicine
Khon Kaen University

Introduction
Hypertensive disorders of
pregnancy are leading causes
of maternal mortality.
Worldwide: 50,000 women
die each year.

Introduction

Classifications

Classifications

Pre-existing
hypertension

Gestational HT

Pregnancy induced
hypertension(PIH)
Pre-eclampsia
Eclampsia

Superimposed
preeclampsia upon
chronic hypertension

Definitions
Pre-existing hypertension
Hypertension antedates pregnancy
and detected before 20 wks

Lasts more than 12 weeks

postpartum

Definitions
Gestational hypertension
Hypertension for first time after
20 wks without proteinuria
BP returns to normal before
12 wks postpartum

Definitions
Preeclampsia
Hypertension and proteinuria
after 20 wks

Eclampsia
Convulsions in a woman with
pre-eclampsia

Definitions
Superimposed pre-eclampsia
Increase SBP 30 mmHg or DBP 15 mmHg
in a patient with chronic hypertension

Pregnancy
induced hypertension

Predisposing factors
Primigravida
Pre-existing hypertension
Previous pre-eclampsia
Family history of pre-eclampsia
Hyperplacentosis
Obesity

Diagnosis PIH
Hypertensionn = 140/90 mmHg
Proteinuria = 300 mg/d / 1+

Mild & Severe Preeclampsia

Abnormality

Mild

Severe

< 110 mmHg

110 mmHg or higher

1+

Persistent 2+ or more

Headache

Absent

Present

Visual disturbances

Absent

Present

Upper abdominal pain

Absent

Present

Oliguria

Absent

Present

Convulsion

Absent

Present (eclampsia)

Serum creatinine

Normal

Elevated

Thrombocytopenia

Absent

Present

Liver enzyme elevation

Minimal

Marked

Fetal growth restriction

Absent

Obvious

Pulmonary edema

Absent

Present

Diastolic blood pressure

Proteinuria

Peripheral edema is not

a useful diagnostic criterion
Common in normal pregnancy
PIH can occur without edema

So its presence not ensure a

poor prognosis
Its absence not ensure a
favorable outcome

Treatment of preeclampsia
Expectant Treatment

Prevention of convulsions

Control of hypertension

Termination of pregnancy

Treatment of mild preeclampsia

(Effective treatment)

statement

Admit

statement

Bed rest

statement

Anti-HT
drugs

Thromboprophylaxis

Maybe effective but not

approved
Exercise
Workload reduction, or stress reduction
Activated protein C
Antithrombin
Heparin
L-arginine
Long-term epidural anesthesia
N-acetylcysteine
Probenecid
Sildenafil nitrate

Not effective

Salt restriction
Absolute bed rest
Diuretics drug
Low-dose aspirin

Termination of pregnancy in
mild preeclampsia when
Term pregnancy
Turn to be severe preeclampsia or
eclampsia
Fetal distress

Treatment of
severe preeclampsia

Admit
Bed rest

Prevention of convulsions
Magnesium sulfate (MgSO4)

Controlled blood pressure

Hydralazine

Termination of pregnancy
Vaginal delivery

Prevent of convulsions

Drug of choice
IV or IM or SC

MgSO4

Therapeutic level
4-7mEq/L

Stopped 24 hours after delivery

Mechanism of MgSO4
CNS depression
Mild Vasodilator
Mild diuresis
Inhibits platelet
aggregation
Increase PGI2 synthesis

Side effect of MgSO4

Loss of
patellar reflex

EKG
Changes

Calcium
gluconate

Cardiac arrest

Respiratory
depression

Cardiac depression

MgSO4 is monitored
4
1
3

Preserved
patellar reflex
2

Serum
Mg++ level

Urine output
>100ml/4hours

Respiratory rate
>16/min

Admit
Bed rest

Prevention of convulsions
Magnesium sulfate

Controlled blood pressure

Hydralazine

Termination of pregnancy
Vaginal delivery

Controlled blood pressure

1

Hydralazine

Labeteral

Diazoxide

Admit
Bed rest

Prevention of convulsions
Magnesium sulfate

Controlled blood pressure

Hydralazine

Termination of pregnancy
Route of delivery

Termination of Pregnancy

Route

Vaginal
delivery

Cesarean
Section

Treatment of Eclampsia

The same as severe preeclampsia

Prognosis
BP usually normalize after placental
delivery
Hypertension may persist

Postpartum eclampsia carries the worst

prognosis
Maternal mortality is about
2% in severe preeclampsia and
10% in eclampsia
Perinatal mortality rate is about
5% in mild cases,
25% in severe cases and
30% in eclampsia

Prevention: Low risk gr.

Intervention
with evidence of effectiveness
Ca++ supplementation prostacyclin (PGI2 )
Dose 1gm/d

Prevention: Low risk gr.

Intervention
with unknown evidence of effectiveness
Folate multivitamin supplementation
Iron folate supplementation
Pyridoxine
Exercise, workload or stress reduction
Healthy heart diet

Prevention: Low risk gr.

Intervention
with evidence of ineffectiveness
Low dose aspirin
Salt restriction
Magnesium, zinc, vit C, vit E supplementation
Calorie restriction during pregnancy in over
weight women
Prostaglandin precursors
Thiazide diuretics

Prevention: High risk gr.

Intervention
with evidence of effectiveness
Ca++ supplementation
Dose 1gm/d + aspirin 70-100 mg/d
Start before 16 wks. GA

Prevention: High risk gr.

Intervention
with unknown evidence of effectiveness
Folate multivitamin supplementation
Heparin, selenium, garlic
Iron folate supplementation
Pyridoxine
Workload or stress reduction
Salt restriction during pregnancy
Healthy heart diet

Prevention: High risk gr.

Intervention
with evidence of ineffectiveness
Magnesium, zinc, vit C, vit E supplementation
Calorie restriction during pregnancy in over wt
women
Prostaglandin precursors
Antihypertensive therapy

Thank you
for your attention