Hypertensive Disorders in Pregnancy

This is hypertension that is present at the booking visit or before 20 weeks or if the woman is already  hypertensive  before  conception.  Most  women  with  chronic  hypertension  are  asymptomatic.  New  onset chronic hypertension should have further evaluation to find underlying cause e.g. renal artery  stenosis, chronic renal disease, Cushing syndrome etc. 

Pharmacological Treatment 

A: methyldopa (PO) 250–500mg 8hourly 

AND 

B: nifedipine (PO) 20mg 12hourly 

Pregnancy induced hypertension (gestation hypertension) 

Gestational  hypertension  or  pregnancy-induced  hypertension  (PIH)  is  the  development  of  new  hypertension in a pregnant woman after 20 weeks of gestation without the presence of protein in the  urine or other signs of preeclampsia. Usually disappears within 12 weeks postpartum  

Non-pharmacological Treatment 

• Adequate rest at home and avoid strenuous activities
• Eat a normal balanced diet and plenty of oral fluids
• Schedule antenatal visits every 2 weeks up to 32 weeks and every week thereafter
• Recommend to deliver in the hospital and should be delivered at 37 completed weeks of gestation

Pharmacological Treatment 

For mild hypertension 140–159 mmHg systolic and/or 90–109 mmHg diastolic. 

A: methyldopa (PO) 250–500mg 8hourly 

OR 

B: nifedipine (PO) 20mg 12hourly 

OR 

C: labetalol (PO) 100mg 12hourly a day 

Severe hypertension 

Severe  hypertension  is  Blood  Pressure  (BP)  of  160/110  mmHg  or  higher.  Admit  the  patient  to  hospital  

A: methyldopa (PO) 500mg 8hourly 

AND 

C: hydralazine 10mg (slow IV) stat (over 4-5 minutes); recheck the BP after 20 minutes if DBP is more/equal to 110mmHg give another dose of hydralazine (IV slowly) 5–10mg. 

AND 

B: nifedipine (PO) 20mg 12hourly 

OR 

C: labetalol (PO)100mg 12hourly 

Note: Ensure slow administration and monitor closely for hypotension if using hydralazine. 

Referral: Refer to the next level facility in case there is no improvement 

Is diagnosed when blood pressure is ≥ 140/90 mmHg after 20 weeks of pregnancy plus proteinuria  of 300 mg per 24 hours or >2+ on urine dipstick. Or elevation of BP in pregnancy with features of  end organ damage (eg pulmonary edema, renal or liver damage)   

Diagnostic Criteria 

• Most patients are asymptomatic, but symptoms may include headaches, dizziness, blurred vision, and epigastric pain.
• Blood pressure of ≥ 140/90 mmHg
• Proteinuria (≥ 300mg per 24 hours)
• Generalized edema may be present (not a necessary criteria)

Investigations 

• Urine for Proteinuria (qualitative/quantitative 24-hour urine collection)
• Obstetric Ultrasound and biophysical profile
• Urea, creatinine, electrolytes, liver function test and uric acid
• FBP and clotting profile
• Fundoscopy

Non-pharmacological Management 

Pregnancy < 37 weeks of gestation  

• Hospitalization and close monitoring
• Bed rest
• Monitoring BP, urine output, proteinuria, fetal movement and fetal heart beats (every day)
• ˂34weeks

Pregnancy >37 weeks of gestation: admit and deliver accordingly. 

Pre-eclampsia with Severe Features: 

This  is  diagnosed  when  BP  ≥  160/110  mmHg  (especially  diastolic  ≥110  mmHg),  or  BP  of  ≥140/90mmHg with features of end organ damage eg severe headache, epigastric pain, blurring of  vision  +/_vomiting,  pulmonary  oedema,  renal  or  liver  damage,  features  of  haemolysis  and  low  platelets 

Pharmacological Treatment 

C:  hydralazine  (IV)  5mg  in  10ml  sterile  water  over  4minutes’  initial  dose.  Followed  by boluses  5–10mg  as  needed  every  20  minutes  until  when  the  diastolic  BP  is  less  than  110mmHg) 

AND 

A: methyldopa (PO) 500mg 8hourly 

AND 

A: nifedipine (PO) 20mg 8hourly until BP is stabilized 

OR 

if hypertension is refractory to hydralazine 

C: labetalol (IV bolus)10–20mg stat repeat each 10–20 minutes, with doubling doses not  exceeding 80mg in any single dose for maximum total cumulative dose of 300 mg.   Antenatal corticosteroids (dexamethasone Inj. 6mg 12hourly for 48hours) if pregnancy 

Prophylaxis for Seizures 

Anti-convulsion treatment of choice is magnesium sulfate. 

A: Magnesium sulfate (IV) 1g hourly in 250mils of RL (OR 5g of 50% MgSO4 4 hourly or  alternate buttock) for 24 hours if GA is ≤34 weeks or until 24 hours post-delivery if GA  is≥34 weeks (Refer to eclampsia section) 

Obstetrical Management  

If at term deliver immediately when stable, preferably vaginal delivery

It is a life-threatening complications of pre-eclampsia characterized by Haemolysis, Elevated Liver  enzymes and Low Platelets 

Diagnostic criteria 

• Haemolysis
  • Abnormal peripheral smear
  • Total bilirubin > 1.2 mg/dL
  • Lactic dehydrogenase > 600 U/L
• Elevated Liver Functions
  • Serum glutamic oxaloacetic transaminase > 70 U/L o   Lactic dehydrogenase > 600 U/L
• Low Platelets
  • Platelets < 1,000,000/mm3

Management of HELLP syndrome 

The management is the same as for severe pre-eclampsia