009 hypertension in pregnancyadmin.indepreview.com/article/vol. 16 no. 02/009... · ·...

Indep Rev Apr-June 2014;16(4-6) IR-317

Key Concepts Classes of hypertension in pregnancy. Risk factor for hypertension in pregnancy. Causes of hypertension in pregnancy. Invtrapartum and postpartum care in hypertension in pregnancy

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Article received on: 13/06/2014Accepted for Publication: 20/06/2014Received after proof reading: 06/07/2014

Hypertension complicates 15 – 20 % of pregnancies. According to world health organization hypertension is included in major three contributing factors for maternal death.

A number of variants of hypertension complicate pregnancies. There is a classification proposed by International Society of study of hypertension in pregnancy.

Classification:- A - Gestational Hypertension:-Hypertension and or Protein urea

developing during pregnancy, > 20 weeks labour or purpeurium in a previously normotensive non-protein uric women.1. Gestational hypertension 2. Gestational preteinurea 3. Gestational hypertension along with proteinurea (Pre-eclampsia)

B - Chronic Hypertension:- (before 20th week)1. Chronic hypertension (without protein-

urea)2. Chronic renal disease (Proteinurea)3. Chronic hypertension with superimpo-

sed pre-eclampsia.

AbstractHypertension in pregnancy in syndrome companied of increased blood pressure and proteinurie. This can be classified into four types; Gestational hypertension chronic hypertension, unclassified hypertension and eclampsia. The management hypertension in pregnancy comprises of prenatal, arterial, intrapartum and post natal management. Regular anti-hypertensive therapy is required to prevent complications such as eclampsia and plan delivery when patients reaches at term.

Key words: Gestational hypertension, Methyldopa, Labetalol, MgSO4 elampsia.

Article Citation: Qurashi S, Hypertension in Pregnancy. Indep Rev Apr-June 2014;16(4-6): 166-174.

HYPERTENSION IN PREGNANCY

Correspondence Address:Dr. Saima Qurashi MBBS, FCPSAssistant Professor of Gynae & Obs.Independent University Hospital, Faisalabad.

Dr. Saima Qurashi MBBS, FCPSAssistant Professor of Gynae & Obs.Independent University Hospital, Faisalabad.

Indep Rev Apr-June 2014;16(4-6) 166-174.

C - Unclassified hypertension and / or proteinureaD – EclampsiaDefinitionsHypertension in Pregnancy:-A. Diastolic B.P ≥ 110 mm Hg on any one

occasionB. Diastolic B.P ≥ 90 mm Hg on two

occasion ≥ 4 hours apart.C. B.P for > 140 / 90 mm Hg on two

occasions ≥ 4 – 6 hours apart.

Proteinurea in PregnancyA. One 24 hours collection of urine with

total protein excretion ≥ 300 mg / 24 hours OR

B. Two clean – catch – midstream or catheter Specimens of urine collected ≥ 4 hours apart with ≥ 2 + on reagent strip.

Identifying Risk Factor for Pre-eclampsiaIt is important to identify high risk patients for hypertensive disorders of pregnancy. There are certain points in history that can suggest cause of pre-eclampsia.1. Primigravidas2. Extremes of reproductive age3. Multi fetal gestation4. Pre -eclampsia in a previous pregnancy 5. History of chronic hypertension or

renal disease6. Obesity 7. Gestational Diabetes mellitus8. ThromboPhilia 9. Family history of pre- eclampsia10. Smoking11. Antiphospholiped Antibody Syndrome

Screening tests for Pre-eclampsia

Numerous Clinical and biochemical markers have been proposed to predict which women are destined to develop pre-eclampsia. Mean BP in second trimester Rollover test Intravenons infusion of Angiotensin-II Micro albuminurea Hematocrit level Serum uric acid level

These tests can be affered to patients but they are relatively non-specific tests and mostly of them are invasive tests.

Currently, Doppler ultrasound of uterine artery velocity wave forms is the only method used in clinical practice.

Abnormal uterine Doppler flow velocity wave forms at 20 wks gestation are associated with three to six fold increase in risk of pre-eclampsiaFindings in Pre-eclampsia:- High resistance index Early diastolic notching

Preventive MeasuresThere are certain options to prevent pre-eclampsia that can be used in pre-pregnancy or in prenatal time.

Pre-Pregnancy Evaluation of risk factors is mandatory Systemic evaluation and complete

examination is required in all high risk patients.

Control and management of chronic hypertension prior to pregnancy

Provide dietary advice in the form of diet charts that includes protein or salt

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2HYPERTENSION IN PREGNANCY

167Indep Rev Apr-June 2014;16(4-6) 166-174.

restriction Control of Diabetes Magnesium or Zinc supplementation Fish oil supplementation may be helpful

Pre-natal Period Calcium supplementation results in

modest reduction in risk and severity Low dose aspirin usage leads to 19%

reduction in risk of pre-eclampsia and 16% reduction in fetal or neonatal deaths. It should be started from visibil ity of cardiac activity on ultrasound till 36 completed weeks of gestation.

Heparin or LMWH reduces chance of pre-eclampsia in thrombophilias.

ManagementsPre-eclampsia continues to be a disease of theories and no one theory can explain its aetiopathogenesis. Probably the basic defect is placental ischemia followed by release of oxidative stress markers in maternal tissues causing vasospasm and various lesions in target organs, leading to clinical syndrome of disease.

To screen the population we have to ask certain points in history.History Teen age pregnancy Age > 40 years Long interval between pregnancies Nulliparity

Partner related Factors Change of partner Pregnancy due to assisted reproductive

techniques

Genetic

Genetic predisposition Family H/O pre-eclampsia Race and ethnicity → more common in

blacks and Asians

Underlying disorders Chronic hypertension Diabetes mellitus Renal disease Obesity BMI > 30 Maternal low birth weight PCOD Sickle cell disease Anti phospholipid Antibody syndrome

Pregnancy related Multiple pregnancy Molar pregnancy Hydrops fetalis UTI Smoking Previous H/O pre eclampsia

Current Maternal ConditionSee any visible odema especially facial, abdominal wall or generalized. Pulse, BP, temp monitoring Ask aboput headache, blurring of vision Epigastric pain, decreased urine output Maternal hyperreflexia, clonus Papillodema

Foetal Fundal height and SFH Lie. Presenting part FHS audible or not Clinically amount of liquor.

InvestigationsInitial CBC and Serum platelets

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Management of pregnancy with Gestational Hypertension

Degree of hypertension

Mild HTN 140/90 – 149/99 mm Hg

Moderate HTN 150/100 to 159/109 mm Hg

Severe HTN 160/110 or higher

Admit to hospital No (on outpatient basis)

No (Daycare monitoring)

Yes, evaluate other signs of Imminent eclampsia

Measure B.P Not more than once or twice in a week

At least twice a week (daily)

At least 2 hourly monitoring in ward

Test for proteinurea At each visit using reagent strip reading device

At each visit urine for protein

Daily urine for protein or urinary protein creatinine ratio

Visits Weekly Twice weekly visit Admission and strict surveillance

Blood tests

Only those for routine antenatal care and s.platelets, s.uric acid. SGPT,SGOT

Test RFT’s, Electrolytes, CBC, LFT’s, S. platelets, S. uric acid on weekly basis

Test at presentation and then bi weekly LFT’s, RFT’s, S. platelets, Clotting profile, CBC, electrolytes, S. uric acid

Treatment

Needs further enquiry, if B.P persists for > 140/90. Start oral labetalol or Aldomet according to B.P

Start, oral labetalol on first reading � Aldomet � Calcium Channel blockers

1/ V antihypertensive in ward

Biophysical profile / Growth scan

Growth scan after 2 weeks + biophysical profile

Biophysical profile weekly + growth scan after 2 weeks

Biweekly biophysical profile + weekly growth scan.

Doppler USG 2 weekly Weekly weekly

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Urine for protein 24 hour urinary proteins Serum uric acid levels Liver Transaminases Ultrasonography

Subsequent Clotting profile Renal function tests, electrolytes Creatinine Clearance Fundoscopy Biophysical profile, Growth scan,

Doppler USG

DrugsAntihypertensiveAt Initial visitAfter confirmation of Diagnosis of gestational hypertension or in mild to

moderate pre-eclampsia start oral Tab. Aldomet (Methy L DOPA) 250 mg TDS and increase the dose upto 2-3 g/day according to B.P.

It not settle then add either calcium channel blocker or oral labetalol. Use of more than two antihypertensives need admission and intensive monitoring.Oral Calcium channel blokersNifidipine or adalat Retard → Dose may range from 20 mg → 80 mg daily

Oral Labetalol: from 100 mg tablets to 600 mg daily. Highest dose is upto 2400 mg / day

Severe Hypertension OR in severe Preeclampsia



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Treat women with severe hypertension or pre-eclampsia with the use of these drugs

Intranvenous use of labetalol Intravenous use of hylralazine Oral Nifidipine (use of MgSO4) (MAGPIE TRIAL)

Drugs not safe in pregnancy Do not use ACE Inhibitors → they cause

oligohydramnios and fetal renal hypoplasia

B-blockers: are not safe in pregnancy, cause fetal growth restriction.Use only in Cardiac disease or hypertension associated coarctation of aorta

Planning of delivery1. If patient has mild gestational

hypertension alone, with proper antenatal surveillance, wait for spontaneous onset of labour upto 40 weeks of gestation, provided no other obstetric indications for induction or surgery.

2. If patient has moderate hypertension or pre-eclampsia of mild to moderate degree, it is better to deliver this patient at 37 completed weeks of gestation.

3. If patient has mild to moderate pre-eclampsia before term, try to achieve term with strict maternal and foetal monitoring. If there are sign and symptoms of imminent eclampsia give prophylative dose of magnesium sulphate and delivery is mandatory within 24 hours and mode of delivery is decided according to bishop score. Usually cesarean section is preferred choice due to premature gestation.

4. If there is severe pre-eclampsia, and or

sign and symptoms of imminent eclampsia, delivery is mandatory.

Eclampsia ProtocolEclampsia is occurrence of fits or tonic clonic seizures in hypertensive disorders of pregnancy.

Aims of Managements1. Recussitation of patient2. Control of fits3. Control of hypertension4. Planning of delivery5. Prevention of complicationsAll the aims can be achieved by good and effective1. Nursing Care2. Obstetric Care3. Postpartum Care

Ideally patient needs extensive monitoring in intensive care unit. High dependency units are eligible to have care of eclampsia women.

One to one care is mandatory in all eclampsia patients

Nursing CareEfficient nursing care is required in eclampsia. Keep in dark, clean comfortable and

isolated room / cabin with proper facilities available

Unconscious, irritable patients need silence in room. There should be no exposure to flashy lights or Noisy environment.

Well trained staff Nurse should know the change of position, support to neck and maintenance of airway with proper and



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Oxygen supply. Two I/V lines should be saved Catheterize the patient to maintain urine

output chart Take sample for blood grouping and

crossmatching, CBC, RBS, clotting profile including PT, APTT

Suction machines should be available near to patients bed.

Obstetric Care 2nd or 3rd year resident should monitor

eclamptic patients Optimal outcome can be achieved with

following steps.

Resuscitation Maintenance of airway to prevent tongue

fall Monitoring of breathing and respiration.

If respiratory rate is more than 18 / min, inform senior on call and anesthetist. patient may need assisted ventilation

I/V lines should be saved Do suction, if there is frothing or

excessive secretions from mouth.

Maintain vitals including Pulse B.P, R/R after every ½ hour Temperature record 2 hourly Urine output, input chart, and reflexes

after every hour

Control of fitsDrug of choice for control of fits is Magnesium Sulphate .Diazepam can also be used in non-availability of magnesium sulphate.

Protocol for Magnesium Sulphate Administration

Provide information to the attendants about use of mgSo4 and take verbal consent.

Loading Dose14 gm of MgSo4 is given as a loading dose. 4 gm ( 8 cc ) diluted in 12 cc N/S Slow 1/V in 15 – 20 min 5 gm ( 10 cc ) 1/M in each buttock.

Maintenance Dose:5 gm ( 10 cc ) 1/M 4 hourly on alternate

buttock for 24 – 48 hours.OR

1/V infusion of 1 gm / hr ( for 24 hours after last fit )

If Seizures Recur:MgSo4 2 gm 1/V repeated

ORIncrease the infusion rate to 2 gm/hr

Monitoring:1) Check the deep tendon reflexes after

every 15 min for 2 hours, then hourly.2) Check the respiratory rate every 15

mins for 2 hours then hourly.3) Measure and record the O2 saturation

hourly.4) Check the blood pressure every 15 mins

for 2 hours, then hourly.5) Check the urine output hourly.

MgSo4 blood levelsBlood levels ( mg/dl ) Symptoms / Signs

4 – 8 Therapeutic level

9 – 12Nausea, warmth, flushing somnolence,

double vision, slurred speech, weakness15-30

loss of patellar reflexes. Muscular paralysis and respiratory arrest



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30 – 35Cardiac arrest

Antidote10 ml 10% Calcium gluconate slow ( in 20

min )1/V x Stat

Control of HTNRoutinely used drugs that are relatively cheap, routinely available and easy to administer are selected by department of Gynae and Obstetrics.

Planning of delivery1. If patient is at term with alive foetus and

poor bishop score Emergency Cesarean

section is done2. If patient is at term with dead foetus and

score is more than 4, trial of vaginal delivery is given with strict surveillance of mother

3. If eclampsia is at Premature gestation and at more than 28 weeks and bishop score is unfavourable ,Cesarean section is offered .Trial of vaginal delivery can be in cases of advanced bishop score.

Intrapartum Care Give trial of labour with proper analgesia

preferably with epidural anaesthesia. Centrally acting drugs like nalbuphine and tramodol can be used

Strict monitoring of maternal condition including uterine contraction and



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Indep Rev Apr-June 2014;16(4-6) 166-174.

va g i n a l exa m i n a t i o n i s o f fe re d depending upon condition.

Care of fetus includes continuous electronic foetal monitoring or hourly CTG monitoring or by auscultation with Doppler sonicaid after over ½ hour.

Try to shorten 2nd stage of labour with forceps or / Vaccum extraction.

Use only syntocinon (10 units I/V stat) in active management of 3rd stage of labour

Regional anesthesia is contraindicated if patient has a clotting abnormality

Post natal Care Maintain high dependency care for 24 –

48 hours depending upon maternal condition.

Stop anticonvulsant 24 hours after the last episode fit.

Use antihypertensive as necessary and with physician advice

Neurological assessment if atypical episodes occur

Prevention of complications Use of diuretics like frusimde for

prevention of pulmonary odema and use of mannitol infusion to decrease intracranial pressure and cerebral odema.

Antibiotic cover is administered to all eclampsia patient to prevent septicemia

Monitoring and balance of input and output is achieved to prevent renal complications.

Arrangement of blood and fresh frozen plasma at least 2- units is done to prevent and manage clotting, abnormalities.

Thromboprophylaxis is achieved in high risk patients.

Consider CT scan of brain if symptoms persist or focal signs are not recovered.


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009 hypertension in pregnancyadmin.indepreview.com/article/vol. 16 no. 02/009... · ·...

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