Hypertension in

Pregnancy
Dwi Nurriana
dwi _nurri @ yahoo.com

Hypertension in
Pregnancy
A common complication of pregnancy
Associated with between 5-8% of pregnancies
It has serious repercussions for both fetal and
maternal well being

Hypertension in
Pregnancy
The outcomes depend upon the nature of the
hypertension affecting the pregnancy, which
can range from mild gestational hypertension
to severe preeclampsia with its associated
multisystemic complications

Hypertension in
Pregnancy
The most important cause of hypertension in
pregnancy is pre-eclampsia
It remains a leading cause of maternal and
perinatal mortality
It responsible for over 200 000 maternal
deaths each year worldwide

Classifications

Classifications

Diagnosis
Hypertension

Blood pressure should ideally be measured with

the patient either:

sitting
supine, in the left lateral position, with a 30o tilt
the sphygmomanometer at heart level

Diagnosis
Hypertension
The diastolic blood pressure ~ Korotkoff 5 (K5; the
disappearance of sounds)

Two diastolic blood pressure recordings over 90 mmHg

taken over 4 h apart are necessary to exclude transient

rises secondary to stress and/or white-coat hypertension

Hypertension
The level currently accepted as significant is a
pressure greater than 140/90 mmHg
The absolute blood pressure level provides the
best guide to fetal and maternal prognosis
A diastolic blood pressure of 90 mmHg
corresponds to the point of the curve inflexion
above which perinatal mortality is significantly
increased

Diagnosis
Proteinuria

In pregnancy, protein excretion may increase

significantly by up to 0.3 g/l of protein per 24 h

(0.5 g/24 h) which is accepted as normal

It is recommended that a 24 h measurement of

urinary protein be made

Preeclampsia
Hypertension of at least 140/ 90 mmHg on two
separate occasions at least 4 h apart arising de
novo in a previously normotensive woman after
the 20th week of gestation and accompanied
by significant proteinuria, all resolving by 6
weeks postpartum

Preeclampsia
2 or more, of the following symptoms
being present
hypertension
proteinuria
symptoms including headache,
photophobia,visual disturbance, epigastric
pain, alteration in the conscious state

Preeclampsia
Arising of the diastolic blood pressure of
15mmHg and the systolic blood pressure of
greater than 30mmHg above booking
values should be regarded as significant if
other features of pre-eclampsia syndrome
are present

Chronic Hypertension
Hypertension present prepregnancy or
diagnosed before the 20thweek
The hypertension is diagnosed during
pregnancy but does not resolve postpartum

Gestational
hypertension
A rise in blood pressure in the absence of
proteinuria detected after mid-pregnancy
Often a definitive diagnosis can only be made
retrospectively

Etiology of
Preeclampsia
Faulty interplay
between invading
trophoblast and
decidua

Genetic
Predisposi
tion

Decreased blood
supply to fetoplacental unit

Release of circulating
factor(s)
Endothelial cell alteration
Proteinuria

Hypertension

IUGR

Pathophysiology
The hematological system
Hemodynamics
A marked reduction in circulating
plasma volume in conjunction with a
redistribution of extracellular fluid
Platelets
A reduction in platelet count
predates the clinical signs of the
disease and may be due to an
immunologically mediated
consumption

Pathophysiology
The hematological system
Coagulation cascade
A diffuse vascular damage in
association with laying down of fibrin
is suggestive of activation of
coagulation
The hypercoagulability seen in
normal pregnancy is further
increased
Regulatory proteins
anti-thrombin III, protein C and
protein S and the levels of all the
proteins are reduced

Pathophysiology
The hematological system
Fibrinolytic system
Plasminogen is converted to
plasmin, which then acts on
fibrinogen to form fibrin, fibrin
degradation products and D-dimers

Pathophysiology
The Liver
Changes in liver function are
thought to occur secondary to
vasoconstriction of the hepatic
vascular bed
The histological events observed
include periportal fibrin deposition,
haemorrhage and hepatocellular
necrosis
In severe cases of hepatic
involvement, complications such as
hepatic rupture or infarction may be
seen

Pathophysiology
The Kidney
The initial change is that of defective
tubular function leading to a reduced
uric acid clearance and hence
hyperuricaemia
This precedes the impairment of
glomerular filtration ~ a relative loss
of intermediate weight proteins such
as albumin and transferrin ~
proteinuria
It causes a reduction in plasma
oncotic pressure and the
development of oedema

Pathophysiology
The Kidney
The characteristic, but not
pathognomonic lesion, is glomerular
endotheliosis, (swelling of the
endothelium and fibrin deposition
causing a reduction in the capillary
lumen, which resolves post partum)
Rarely acute renal failure may result
due to acute tubular or cortical
necrosis leading to maternal death

Pathophysiology
The Brain
The pathophysiology of eclampsia is
not fully elucidated
One possible explanation is that
localized cerebral vasospasm, and
hence reduced perfusion, causes
abnormal electrical activity,
therefore triggering an eclamptic fit

Pathophysiology
The Brain
A further theory is that endothelial
injury is caused by vascular over
distension due to hypertension
overcoming the cerebral
autoregulation ~ cerebral oedema
due to leakage of fluid into the
interstitial space
The main areas affected are the
occipital and parietal lobes ~ visual
disturbances
The commonest cause of death seen
in eclampsia is intracerebral

Investigations used to
distinguish preeclampsia

Maternal Investigations

Fetal Investigations

Hematological
Hepatic Function
Renal Function
Urine Tests
Blood pressure
monitoring

CTG
Ultrasound
Doppler
Biophysical profile

Diagnosing
Preeclampsia
Maternal

Haematological:
Sequential platelet counts are useful
in monitoring severe disease
progression rather than for initial
diagnosis
In the cases of reduced platelet
counts, clotting studies should be
performed

Diagnosing
Preeclampsia
Maternal

Hepatic function
Monitoring of hepatic involvement
by means of liver function tests,
(especially lactic dehydrogenase,
aspartate and alanine
transaminases), may aid diagnosis
and decisions regarding disease
severity

Diagnosing
Preeclampsia
Maternal

Renal function
A rise in serum creatinine and
urea suggests disease
deterioration
Another nonspecific measure of
renal function is serum uric acid
levels

Diagnosing
Preeclampsia
Maternal

Urine tests: A mid-stream urine to

exclude urinary tract infection
and a 24 h collection to identify
significant proteinuria should
follow initial dipstick
Blood pressure: This may be
monitored as often as every
15min during the acute phase of
severe disease

Diagnosing
Preeclampsia
Fetal

The cardiotocograph (CTG)

It must be emphasized that the CTG
only provides a snapshot view of
fetal health and further monitoring
may be justified when other factors
are considered, such as the presence
of pre-eclampsia or intra-uterine
growth restriction

Diagnosing
Preeclampsia
Fetal

Ultrasonography
The use of ultrasound varies from
simple measurements such as fetal
size, gestation, growth and
presentation to calculation of the
biophysical profile and Doppler
studies

Treatments

Chronic Hypertension
The aim of treatment is to reduce maternal
complications whilst being safe for the fetus
The drug of choice is methyldopa, although
labetalol is an alternative

Preeclampsia
Antihypertensives: hydralazine, labetalol,
methyldopa,nifedipine
Anticoagulants:magnesiumsulphate
Steroids: dexamethasone
Aspirin
Supportivemanagement
Delivery

Decision of Delivery
The aim of management is to stabilise the
patient and enable appropriate decisions to
be made regarding the timing and mode of
delivery
The route of delivery is influenced by such
factors as gestation, the presence of other
complications, (such as malpresentation),
and the urgency with which progression to
delivery must be made

POSTNATAL FOLLOW-UP
Counselling regarding future pregnancies plays
an important role in postnatal management
and psychological recovery
Patients have a 10-25% chance of developing
pre-eclampsia in subsequent pregnancies
The risk is higher if other factors such as antiphospholipid syndrome are present, and
depends on the gestational age at presentation

Risk Factors for Preeclampsia

Prophylaxis against
preeclampsia
Aspirin inhibits platelet thromboxane release
but does not affect the production of
prostacyclin in the endothelial cells
Improving the outcome of severe
preeclampsia
It should be initiated early in subsequent
pregnancies, especially in the early onset
preeclampsia
Low-dose aspirin can reduce the risk of
severe recurrent preeclampsia by about 15%

Gestational
hypertension
This is not associated with proteinuria
It appears after the 20th week of pregnancy
It will return to normal post-natally
True non-proteinuric gestational hypertension is
not associated with an increase in maternal or
fetal morbidity

Thank You
References :
Duckett RA, Kenny L, Barker PN. Hypertension in Pregnancy. Curr Obstet Gynaecol,
2001:II: 7-4
Hayman R. Hypertension in Pregnancy. Cur Obstet Gynaecol, 2004:14; 110
Soydemir F, Kenny L. Hypertension in Pregnancy. Cur Obstet Gynaecol, 2006: 16;
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