1. Hypertension in
Pregnancy
Dapinderjit Gill
Ross University MS3
S

2. Hypertension S Gestational HTN
S Transient HTN of
Disorders in pregnancy
Pregnancy S Preeclampsia
S Mild
S Severe
Classification of the
American College of S Eclampsia
Obstetricians and
Gynecologists S Chronic HTN preceding
pregnancy
S Chronic HTN with
superimposed pregnancy-
induced hypertension
S Superimposed
preeclampsia
S Superimposed eclampsia

3. Gestational
Hypertension
S

4. Gestational HTN
S sustained systolic blood pressure at or
above 140mmHg, or a diastolic blood
pressure of 90mmHg or greater
S increase in BP must be present on at least
two separate occasions, 6 hours or more
apart
S HTN in late pregnancy (>20 weeks
gestation) in the absence of other findings
suggestive of preeclampsia
S if BP returns to baseline by 12 weeks
postpartum = dx. of Transient hypertension
of pregnancy

5. Gestational HTN
S 5-10% of pregnancies that proceed beyond 1st trimester
develop gestational HTN
S increased incidence of up to 30% in multiple gestation
S 15-25% of women initially diagnosed with gestational
HTN develop preeclampsia
S Earlier onset of gestational HTN are more likely to
progress to preeclampsia

6. Pathophysiology
Changes seen in patients
S Cardiovascular effects
S Elevated BP
S Increased cardiac output
S Hematologic effects
S Third spacing of fluid due to increased
blood pressure and decreased plasma
oncotic pressure
S Renal effects
S Atheroscleroticlike changes in renal
vessels (glomerular endotheliosis) 
decreased glomerular filtration rate and
proteinuria
S Uric acid filtration is decreased

7. Pathophysiology
Changes seen in patients
S Neurologic effects
S Hyperreflexia/hypersensitivity (does not correlate with severity of
disease)
S In severe cases, grand mal seizures
S Pulmonary effects
S Pulmonary edema may occur due
to decreased colloid oncotic pressure
S Fetal effects (severe gestational HTN)
S Vasospasm  Decreased intermittent placental perfusion  IUGR,
oligohydramnios, low birth weight

8. Pathophysiology
Mechanisms
S Uterine vascular changes
S Trophoblastic-mediated vascular changes  decreased
musculature in spiral arterioles  development of low
resistance, low pressure, high-flow system
S Inadequate maternal vascular response
S Endothelial damage is also noted within the vessels
S Hemostatic changes
S Increased PLT activation with increased endothelial fibronectin
and decreased antithrombin III and alpha-2-antiplasmin 
further endothelial damage is thought to promote further
vasospasm

9. Pathophysiology
Mechanisms
S Changes in prostanoids
S During pregnancy, both PGI2 (vasodilation and decreased
PLT aggregation) and TXA2 (vasoconstriction and PLT
aggregation) are increased with balance favored to PGI2
S In preeclampsia, TXA2 is favored
S Changes in endothelium-derived factors
S Decrease in Nitric oxide  promoting
vasoconstriction

10. Gestational HTN
S Mild: outpatient with weekly visits, bed rest
S Antihypertensive therapy:
S Indicated if diastolic pressure is repeatedly above 110mmHg
S Hydralazine (Apresoline) 5mg increments IV until acceptable
BP is obtained (diastolic pressure to 90-100mmHg range)
S Other medications that can be used in pregnancy (oral):
S methyldopa 250mg BID/TID max 3g/day
S Labetalol 100mg max 2400mg/day
S Nifedipine 30-60mg max 120mg/day
S Magnesium sulfate in severe gestational HTN for seizure
prophylaxis

11. Chronic Hypertension
S

12. Chronic HTN
S HTN present before 20th week of gestation or
beyond 6 weeks postpartum (>12 weeks
postpartum from uptodate.com)
S 15% of gestational HTN cases go on to
develop chronic HTN
S 25% risk of developing superimposed
preeclampsia or eclampsia
S Close monitoring of maternal BP and follow
appropriate fetal growth and well-being
S Pt. should be encouraged to increase the
amount of time she rests

13. Preeclampsia
S

14. Preeclampsia
S Development of HTN with proteinuria
induced by pregnancy generally in
the second half of gestation
S More frequent at the extremes of
reproductive years
S More common in women who have
not carried a previous pregnancy
beyond 20 weeks
old women or young lady?

15. Preeclampsia
S Mild:
S BP: systolic > 140mmHg and/or diastolic > 90mmHg
S Proteinuria: >300mg on 24h collection of +1 on single
sample
S Severe:
S BP: systolic > 160-180mmHg and/or diastolic > 110mmHg
S Proteinuria: >5g on 24h collection or +2 on single sample
S Multisystem alterations: cerebral or visual
disturbances, oliguria, pulmonary
edema, cyanosis, epigastric or right upper quadrant
pain, thrombocytopenia

16. Preeclampsia

17. Preeclampsia
S Mild preeclampsia
S If immature fetus  bed rest mainly in
lateral decubitus position
S HTN therapy if needed
S Severe preeclampsia
S Magnesium sulfate 4g loading dose with 1-3g/hr infusion rate
S Antihypertensive therapy
S Induction or cesarean delivery
S fetal pulmonary maturity depending on gestational age should be
considered (>=34weeks)

18. Eclampsia
S

19. Eclampsia
S addition of convulsions in a woman with preeclampsia
S occurs in 0.5-4% of deliveries
S most cases occur within 24h of delivery with about 3% of
cases diagnosed between 2-10 days postpartum
S 25% have eclamptic seizures before labour, 50% during
labour, and 25% after delivery

20. Eclampsia
S Anticonvulsant therapy
S Diazepam or similar drugs
S Magnesium sulfate to prevent further seizures
S Maintain adequate airway, oxygenation, restraining gently
as needed and inserting a padded tongue blade

21. HELLP Syndrome
S

22. HELLP Syndrome
S HTN patients with hemolysis
(H), elevated liver enzymes
(EL), low platelet count (LP)
S 4-12% of pt. with severe
preeclampsia and eclampsia
develop HELLP syndrome
S first sx. often missed:
nausea, emesis, and non-specific
viral-like syndrome

23. HELLP Syndrome
Treatment:
S cardiovascular stabilization, correction of coagulation
abnormalities, and delivery
S PLT transfusion before or after delivery if PLT count is
<20,000/mm3 (advised at <50,000/mm3 before cesarean)
S <32 weeks gestation; steroid therapy may help stabilize
maternal PLT count

25. References
Beckmann, Charles R.B., Ling, Frank W., Smith, Roger
P., Barzansky, Barbara M., Herbert, William N.P., Laube, Douglas
W. “Obstetrics and Gynecology”. 5th edition Lippincott Williams &
Wilkins. pp. 188-196
Magloire, Lissa etc. “Gestational Hypertension”. May
2011.<uptodate.com>
August, Phyllis et. al. “Management of hypertension in pregnancy
and postpartum women”. May 2011 <uptodate.com>