HYPERTENSIVE

DISORDERS OF
PREGNANCY
BY
DR. JAMES E. OMIETIMI
DEPART. OF OBSTETRICS & GYNAECOLOGY
UPTH, PORT HARCOURT
 INTRODUCTION
Spectrum of disorders including Pre-Eclampsia,
Eclampsia, Chronic hypertension (either essential or
secondary to renal disease, endocrine disease, or
other causes), Chronic hypertension with
superimposed Pre-Eclampsia, and Gestational
hypertension.
2nd commonest indication for admission into the ANW
after prolonged pregnancy worldwide and here in
UPTH was found to be the commonest in the year
2003.
Accounted for 88 out of 588 (14.5%) of admissions
into ANW in the year 2003. Annual Report.
 CLASSIFICATION
PREGNANCY INDUCED HYPERTENSION
-PIH (without proteinuria)
-PIP (without hypertension)
-Pre-Eclampsia
CHT and CRD
CHT (without proteinuria)
CRD (proteinuria and hypertension)
CHT with superimposed PE
CHT due to endocrine disease
Cushing’s Dx. & Syndrome
Primary Hyperaldosteronism
Thyrotoxicosis
Pheochromocytoma
Acromegaly
CHT due to coarctation of the aorta
PRE-ECLAMPSIA AND
ECLAMPSIA
Pre-Eclampsia is a multisystem disorder of
unknown aetiology and unique to pregnant
women after 20 weeks gestation.
It is a progressive disease with a very
variable mode of presentation and rate of
progression.
It is pregnancy specific with reduced organ
perfusion secondary to vasospasm and
endothelial calsification.
Pre-Eclampsia is said to complicate 5% of
all deliveries.
It is said to affect 5.8% of primigravidae and
0.4% of secundagravidae.
RISK FACTORS;
• parity,
• race,
• multiple gestations,
• environmental factors,
• maternal age,
• maternal size
• history of chronic hypertension
 Definition and Diagnosis
Pre-Eclampsia can not be accurately defined
until its cause is known. It is described as a
syndrome comprising of hypertension and
proteinuria, +/- edema occurring after 20 weeks
gestation.
Hypertension -140/90 mm of Hg or more on
at least two occasions four hours or more apart
after the 20th week of pregnancy in a woman
known to be normotensive and in whom blood
pressure returns to normal by the sixth
postpartum week.
Proteinuria is defined as the excretion of 0.3 g
protein or more within 24 Hr or a measurement
of 1+ or more using reagent strips.
Classification
This is classified as mild or severe
forms as the latter is associated with
increased maternal and fetal morbidity.

Severe form is said to occur if one or

more of the conditions in the table are
present.
Definition of severe pre-eclampsia
1. Arterial pressure > 160mmHg systolic or >
110mmHg diastolic on two occasions at least 6 hrs
apart.
2. Proteinuria > 5g in 24 hour > 3 + urine dipstick
3. Oliguria < 400 ml of urine in 24 h
4. Cerebral signs – headache, blurred vision or
altered consciousness
5. Pulmonary oedema or cyanosis
6. Epigastric or right upper quadrant pain
7. Impaired liver function
8. Hepatic rupture
9. Thrombocytopenia
10. HELLP Syndrome
 Hypertensive Disorders During Pregnancy: Indications of
Severity

Abnormality Mild Severe

Diastolic blood pressure < 100 mg Hg 110mmHg or higher

Proteinuria Trace to 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

 Material Faculty Excessive
Vascular Placentation Trophoblast
Disease

Genetic
Immunologic or
Inflammatory
Factors

Reduced Uteroplacental
Perfusion

Vasoactive Agents: Noxious Agents:

Prostaglandins Cytokines
Nitric Oxide Lipid Peroxidases
Endothelins

Endothelial
Activation

Capillary Leak

Vasospasm Activation of
Coagulation

Edema Proteinuria

Hemo- Thrombo
concentration cytopenia

Hyper Oliguria Liver

tension Ischemia

Seizures Abruption
Pathophysiology
The summary is that as a result of the damage
to the endothelial cells, it looses its functions
and in addition also produces pro-coagulants,
vasoconstrictions and mitogens. The increased
pressor sensitivity of the maternal vessels
leads to profound vasospasm and reduced
organ perfusion which are characteristic of this
disorder.
COMPLICATIONS OF PRE-ECLAMPSIA

et FETUS  IUGR, Preterm delivery, Abruptio placenta, IUFD

MATERNAL

Kidneys - Proteinuria, ↓ GFR, ↑ Plasma Creatinine

Cardiovascular - ↓ Plasma Volume, ↓ CVP, AP ↑ & SVR

- Glomerular endothehosis  Renal failure (ATN, Cortical necrosis)
  Contractility usually unchanged.

Brain- HT encephatopathy, ischaemia and infarction, vasospasm, Haemorrhage,

Oedema, Eclampsia

Liver - Altered LFT, Periportal hepatic necrosis, Subcapsulaar haemorrhage, FDP,

HELLP.

Lungs- Leaking Capillaries  pulmonary Oedema, ARDS

Coagulation -Thrombocytopenia (↑ Platelet activation and consumption)

Prediction and Prevention
No ideal predictive tests that fulfil all described
criteria.Two most important predictive factors:
1. Nulliparity - Pre-Eclampsia in 5.8%
primigravida, 0.4% Secundagravida.
2. Family History - Considerable evidence
support significant genetic contribution
Aetiology & pathophysiology are still not
understood fully and this has hindered
development of effective preventive measures.
. Anti-platelet therapy -Low dose Aspirin
. Calcium Supplementation
 INVESTIGATIONS
Urinalysis, urine m/c/s
FBC
Clotting time
Serum E/U/Cr + Uric acid
LFTs
Biophysical profile
Ultrasound measurement of AC
 TREAT MENT

Delivery is the cure for Pre-Eclampsia. The

prime objective is to prevent convulsion.
The management ideally should be
multidisciplinary. It is based on the severity of
the disease and also influenced by gestational
age.
Management should include;
1. Treatment of hypertension

The risk of cerebral haemorrhage is a major

cause of maternal deaths (60%)

Significant risk of CVA occurs when MAP >

140mmHg (180/120).

The aim of treatment is to prevent intracerebral

haemorrhage while not affecting uteroplacental
blood flow and maternal renal functions.
Prolonged treatment of HT is advisable when
the fetus is immature in an attempt to delay
delivery.
However, this can only be undertaken provided
the mother is not placed at risk and that strict
monitoring of both the mother and the fetus is
carried out at frequent regular intervals,
hospitalization and bed rest may be all that is
required in some patients.
 Antihypertensive
therapies

Acute therapy-hydrallazine, labetalol

Prolonged therapy-methyldopa, nifedipine, hydralazine

ACE inhibitors not recommended

Diuretics not recommended except in pulmonary

edema
For Severe Pre-Eclampsia
Anticonvulsant-Mg-Sulphate,
Diazepam
Antihypertensives
- Follow by Delivery
Conservative management in severe
cases – Need to be cautious.
Maternal safety is paramount.
MANAGEMENT IN HOSPITAL
1. Detailed examination followed by daily scrutiny for
clinical findings such as headache, visual
disturbances, epigastric pain, and rapid weight gain.
2. Weight on admittance and every alternate day
thereafter.
3. Analysis for proteinuria on admittance and daily ward
urinalysis
4. Blood pressure readings in sitting position with an
appropriate-size cuff every 4 hours, except between
midnight and morning.
5. Measurement of plasma or serum creatinine, uric
acid, hematocrit, platelets, and serum liver enzymes,
the frequency to be determined by the severity of
hypertension.
6. Frequent evaluation of fetal size and amnionic fluid
 ECLAMPSIA
Eclampsia is defined as the new onset of
convulsions, before or during pregnancy or post
partum, unrelated to other cerebral pathologic
conditions in a woman with Pre-Eclampsia.
Incidence Reported rate 1:2000 to 1:3000
deliveries. The incidence is significantly higher in
non industrialized nations. Estimates in
developing countries varies from 1 in 100 to 1 in
1700.
Worldwide of estimated 500,000, maternal deaths
every year – 10 – 15% are associated with HDP.
Reported maternal mortality rates varies from
0.5% in US to 20%, perinatal mortality from 10% to
28%
Management Aim

1. Stop Convulsions and prevent

recurrence

2. Control the blood pressure

3. Avoidance of diuretics and limitation of

fluid administration

4. Correct fluid and electrolyte imbalance

5. Deliver the patient in the fastest possible

Anticonvulsants
- Diazepaml
- Phenytoin
- Chlomethiazole
- Magnesium sulphate

The anticonvulsant therapy should protect

the woman and her fetus from deleterious
effects of convulsion but should not expose
either to additional risks from the therapy.
Supportive Management

- Airways
- Nasogastric tube
- Oxygen
- Catheterization / Urinary output
monitoring
- Tepid sponge / Expose to fan
- Management of an unconscious
patients.
Complications

- Pulmonary Oedema
- Renal and hepatic failiure
- Hemiplegia
- Altered Consciousnes / Coma
- Some degree of Blindness
- Psychoses