Pregnancy Induced Hypertension

Supervised by: dr. Pim Gonta, Sp. OG

Presented by :
Adi Wibowo (2013 061 068 )
Astrid Paula (2013 061 129)
Yurika Elizabeth S. (2014 061 124 )
Elita Mulyadi (2014 061 - 129)

Definition
Pregnancy induced hypertension is a condition of
high blood pressure during pregnancy with blood
pressure 140/90 mmHg.

Epidemiology
Hypertensive disorder in pregnancy are major cause of maternal, fetal and neonatal
morbidity and mortality in both developing and developed countries.
Hypertension is the most common medical problem in pregnancy, complicating up
to 15% of pregnancies and accounting for about quarter of all antenatal admissions.

Type

Classification

Definition

Chronic Hypertension

Hypertension before pregnancy or before 20 weeks of gestation,

and/or after 12 weeks postpartum

Preeclampsia-eclampsia

Preeclampsia : hypertension and proteinuria at or beyond 20

weeks of gestation in previously normotensive woman
Eclampsia : preeclampsia with seizure and or coma.

Chronic hypertension with

superimposed preeclampsia

Chronic hypertension with signs of preeclampsia or protenuria.

Gestational hypertension

Hypertension without proteinuria, developing after 20 weeks of

gestation and goes away after 12 weeks post-partum in a
previously normotensive nonproteinuric woman

Risk Factor

First pregnancy

Hyperplacentosis
(mola hidatidosa, multiple pregnancy, diabetes mellitus,
hydrops fetalis and macrosomia)

Extreme age (under 20 or above 40)

Family history of preeclampsia or eclampsia

Kidney diseases and hypertension before pregnancy

Obesity

Etiology
1.

Placental implantation with abnormal trophoblastic

invasion of uterine vessels

2.

Immunological maladaptive tolerance between

maternal, paternal (placental), and fetal tissues

3.

Maternal maladaptation to cardiovascular or

inflammatory changes of normal pregnancy

4.

Genetic factors including inherited predisposing genes

and epigenetic influences.

Diagnostic
Criteria *

Pathophysiology

In normal implantation: the uterine spiral arterioles are invaded by endovascular trophoblasts
these cells replace the vascular endothelial & muscular linings to enlarge the vessel
diameter

In preeclampsia: incomplete trophoblastic invasion impairs placental blood flow

Pathophysiology

With such shallow invasion, decidual vessels, but not myometrial vessels, become lined with
endovascular trophoblasts their mean external diameter is only half that of vessels in
normal placentas

Gestational Hypertension

Managed based on:

Severity
Gestational age
Presence of preeclampsia

Treatment of Gestational Hypertension

There are two choices:

1. Conservative using medication such as anti-hypertensive therapy (if systolic >160mmHg or
diastolic >110 mmHg)
-Blocker: Labetalol 200 mg PO every 8-12 hours
2. Termination according to gestational age

Chronic Hypertension*
The drug of choice that can be used for chronic hypertension
treatment :

Blocker
Labetalol (First choice agent)
- Initial dose 100-400 mg per oral every 6-12 hours.
- If no initial response, give boluses 50 mg
If the BP not decreased by 10 minutes, can be repeated in
doses of 50 mg, to a maximum dose of 220 mg, at 10
minute intervals.

 Hydralazine
2,5 mg (IV) initial dose, followed by 5 10 mg doses at 15 20
minutes interval.
Maximum dose : 20 mgs

Ca Channel Blocker
Nifedipine

Initial dose 10-30 mg (Oral) every 4-6 hours

Reaches peak level ini 30 minutes after ingestion.

Pregnancy Termination

Pregnancy needs to be delivered earlier if the patient has

high risk factor to develop complication and showing
unstable condition.

Methyldopa
Site of action : Central Nervous System
Initial dose 250 mg 3 times a day. The dose increased
up to total 2 g/ day according to patients response.
Maximum effect reached in 4-6 hours.

Treatment of Pre-Eclampsia

The main intention on the therapy of pre-eclampsia is to

maintain the blood pressure within normal range, prevent
eclampsia and organ failure.

Choices of therapy for pre-eclampsia:

- Termination
- -Blocker (Labetalol, Hydralazine)
- Ca Channel Blocker (Nifedipine)
- MgSO4
-Glucocorticoid

Treatment of Pre-Eclampsia (Termination)

Main Therapy
Termination of pregnancy was done by considering the blood pressure, gestational age,
maternal and fetal outcome.
Termination management according to the gestational age:
28-33 weeks -> delivery postponed 24-48 hours, Betamethasone administration 12 mg
every 24 hours for 2 doses
<24 weeks -> Survival rate 10%, should be done considering the maternal complication

Treatment of Pre-Eclampsia

Criteria to interrupt expectant manager and deliver:

Blood pressure persistently 160/100 or greater despite
treatment
Urine output <400 ml in 24 hours
Platelet Count <50.000/mm
Sign or Organ Failure
Minimal or absent of fetal growth
Oligohydramnios

Treatment of Pre-Eclampsia (MgSO4)*

Magnesium Sulphate administered for seizure prevention

Loading dose: 30ml of 20% magnesium sulfate in 100 ml of normal

saline over 15-20 minutes

Maintenance dose: Add 20 gr magnesium sulfate to 1000 ml normal

saline and give intra venously 100 ml/hour

Treatment of Pre-Eclampsia (MgSO4)

Magnesium Sulfate should be administered with the following condition:
- Urine output at least 30 ml/hour
- Deep tendon reflex present
- Respiration rate >14 breaths/minute
- Pulse oximetry >96%

Toxicity of magnesium sulfate should be treated with Calcium Gluconate 10%

10 ml over 3 minutes

Eclampsia
Treatment of Eclamptic Seizure:
Place the patient in lateral decubitus
Suction oral secretion
Oxygen mask at 8-10 L/minute
Elevate bedside rails
Pulse Oximetry
Once Seizure ends, start IV fluid (LR at 125ml/hour)
Loading dose 6 g of magnesium sulfate over 15-20 minutes followed by
maintenance dose of 2 g/hour
If BP >150/100, give IV bolus Labetalol 20 mg initially, 40 mg and 80 mg in
15 minutes interval.

Eclampsia
The management of elevate blood pressure is necessary. The first
line anti-hypertensive therapy is Labetalol (IV) bolus 20 mg.

Once the blood pressure is in adequate level, oral Labetalol 200400 mg every 12 hours should be administered.

Eclampsia
Eclampsia may occur ante, intra and post partum.

Treatment of postpartum care, magnesium sulfate should be

administered following 24 hours post-partum

Complications
Lack of blood flow to the placenta, can lead to Fetal complications
include

intrauterine growth restriction

low birth weight
preterm birth, that can lead to breathing problems for the baby
intrauterine fetal death

Placental abruption
HELLP syndrome
Cardiovascular disease

Other complications
intracerebral hemorrhage
pulmonary edema
due to capillary leak, myocardial dysfunction, excess IV fluid
administration
acute renal failure
due to vasospasm, acute tubular necrosis [ATN], or renal cortical necrosis,
proteinuria greater than 4-5 g/d
hepatic swelling with or without liver dysfunction
hepatic infarction/rupture and subcapsular hematoma
which may lead to massive internal hemorrhage and shock
consumptive coagulopathy - associated with placental abruption

Thank You