Hypertensive

disorder in
pregnancy

Introduction

Hypertensive disorders of pregnancy (HDP) remains as one of

common causes of maternal mortality in Malaysia.

Accounted for 14.1% of total maternal death

Complicates 10-20% of pregnancies

Definition

Elevation of BP 140 mmHg systolic and/or 90 mmHg diastolic,

on two occasions at least 6 hours apart.

Divided into:

Chronic Hypertension

Gestational Hypertension

Preeclampsia

Preeclampsia superimposed on Chronic Hypertension

Classification

Chronic hypertension: Hypertension present at booking visit or before 20

weeks

Gestational hypertension: New hypertension presenting after 20 weeks

without significant proteinuria

Pre-eclampsia: New hypertension presenting after 20 weeks with

significant proteinuria

Preeclampsia superimposed on Chronic Hypertension: Preexisting

Hypertension with the following additional signs/symptoms

i) New proteinuria after gestational week 20.

ii) A sudden increase in the severity of hypertension.

iii) Appearance of features of preeclampsia-eclampsia.

iv) A sudden increase in proteinuria in women who have preexisting proteinuria

early in gestation.

Classification

Eclampsia

Occurrence of generalized convulsion and/or coma in the setting of preeclampsia.

Complication of severe pre-eclampsia.

Can lead to:

Permanent neurologic damage from recurrent seizures or intracranial bleed

Acute renal failure

Fetal changes IUGR, Abruptio placenta, oligohydromnios, Intrauterine asphyxia

Preterm birth

Hepatic damage

Maternal or fetal death

Increased risk of stroke later in life

Fetal Complications Respiratory problems, mental retardation

Delivery of Fetus is the only cure for eclampsia!

Impending Eclampsia

Condition before a pregnant women develops fullblown eclampsia

Pre-eclamptic mother with following symptoms

severe headache

visual disturbance - temporary loss of vision, blurred

vision or light sensitivity

epigastric pain and/or vomiting

clonus

excessive weight gainwith generalised edema

caused byfluid retention

Lethargic or very irritable

Disoriented about the time, people and places in her

environment

About 1 in 10 pregnant women have problems with high blood

pressure.

About 1 in 20 pregnant women have pre-existing high blood

pressure.

About 1 in 20 pregnant women have gestational high blood

pressure and do not go on to develop pre-eclampsia.

Somewhere between 2 and 8 in 100 pregnant women develop

pre-eclampsia.

Eclampsia develops in around 1 in 200 women with preeclampsia.

Who is at risk?

Primigravida
Preeclampsia in a previous pregnancy
Age >40 years or <18 years
Last Pregnancy >10 years
Family history of pregnancy-induced hypertension
Chronic hypertension
Chronic renal disease
Diabetes mellitus (pregestational and gestational)
Multifetal gestation
High body mass index (BMI >35)
Smoking
Alcohol

What can we do?

Educate regarding the diagnosis of Hypertension in pregnancy,

and potential complications

Educate regarding BP treatment target < 140/90 mmHg,

Regular fetal and maternal surveillance

Monitor sign and symptom of impending pre-eclampsia

Empower patient to self-manage through therapeutic lifestyle

modification

Address transportation problems if any

Address adverse traditional beliefs and taboos

Refer early to nearest hospital or health clinic for combine care

Lifestyle Modifications

Eat healthy foods.

fruits, vegetables, whole grains, poultry, fish and low-fat dairy foods

Decrease the salt in your diet

Maintain a healthy weight

Increase physical activity.

Avoid smoking and alcohol

Manage stress

Enough sleep and rest, yoga, meditation, slow deep breathing

What to do if you diagnose

hypertensive in pregnancy?

Early identification of warning signs and symptoms

Explain and educate the mother and family about danger and
complications

Immediate referral to a hospital or health centre.

If possible ensure rapid transportation and reception of the

woman at the higher health facility

What to do in patients with

Severe/ Impending Eclampsia?

Make the referral to the higher health facility as soon as possible.

Communicate with the receiving hospital or health centre to alert

the medical team that a pregnant woman with severe preeclampsia is coming for urgent treatment

Reassure the woman and her family that when she arrives at the
health facility, the doctor will give her drugs to reduce her high
blood pressure (anti-hypertensive drugs) and to prevent her from
developing convulsions (anti-convulsant drugs).

What to do in patients with

Eclampsia?

Take actions as stated previously.

Refer her urgently unless she is already in advanced

labour in this case you should deliver the baby and
refer her and the baby to a hospital as soon as possible
after the birth.

When you transport a woman with eclampsia to the

health facility, make sure she is lying on her side with
her airway open

Dont let her lie on her back because she may find it
difficult to breathe if she has another fit

Lying on her side also means that if she vomits during a

fit, she is less likely to breathe the vomit into her lungs.

Persuading affected women to go

for medical treatment

Offer counselling to the woman and her family about the danger
of maternal and fetal complications and the advantage of getting
medical treatment urgently

They may not want to go to a health facility, because she may

prefer to go to the holy water, to a priest or other religious
leader, or to local healers.

You have a very important role to make sure that the woman and
her family understand that the fits are caused by the very high
blood pressure she is experiencing

Reassure her that the convulsions will stop progressively after the
baby is delivered

Postpartum

Hypertension and Eclampsia may occur in the postpartum period

as well. (Up to 6 weeks postpartum)

Regular BP check-up is advised and immediate referral to health

clinic or hospital if indicated

Anti-hypertension medications should be continued and slowly

tapered down

Summary

Hypertensive disorders of pregnancy are one of the common causes of maternal and
perinatal morbidity and mortality.

Known risk factors for pregnancy related hypertension include: being primigravida
before the age of 18 years or after 40 years, multiple pregnancies, personal or family
history of pre-eclampsia or eclampsia, having diabetes or kidney disease, or being
obese

Pre-eclampsia (raised blood pressure + significant proteinuria) is the most common

type of hypertension during pregnancy. Severe pre-eclampsia is characterised by
clinical manifestations such as headache, visual disturbance, epigastric pain, decreased
urine output, decreased fetal kick and development of generalised oedema.

Eclampsia is diagnosed when the pregnant woman develops convulsion or coma in the
absence of other causes. It is the leading cause of maternal and fetal death among all
types of hypertensive disorders of pregnancy.

In the management of hypertensive disorders of pregnancy, your primary role is

facilitating early referral

Case Study

Farah is a 42-year-old primigravida woman who is pregnant with

twins. She is very overweight for her height. She was in good
health until she reached gestational week 22, when she began to
complain of headaches and swollen feet and ankles.

a.Does Farah have any of the common risk factors for

hypertension? If yes, what are they?

b.Does she have any of the clinical features of hypertension? If

yes, what are they?

c.What complications could affect Farah and her baby if she has
untreated hypertension?

d.What action should you take in Farahs case and why?