preeclampsia, Hypertension in pregnancy

1. PREGNANCY INDUCED
HYPERTENSION
dr. I Gede Mega Putra, O&G (C)
Obstetrics and Gynecology Departement
Faculty of Medicine Udayana University

2. Introduction
 Hypertensive disorders complicate 5 to 10 percent of all pregnancies, and
together they form deadly triad, along with hemorrhage and infection
 WHO systematically reviews maternal mortality : In developed countries,
16 % maternal deaths were due to hypertensive disorders. This percentage is
greater than three other leading causes: hemorrhage—13 percent, abortion
—8 percent, and sepsis—2 percent.
 Almost 16 percent of 3201 maternal deaths were from complications of
pregnancy-related hypertension. Over half of these hypertension-related
deaths were preventable.

3. Terminology
and classification
Gestational hypertension
Preeclampsia-eclampsia( mild and severe PE )
Superimposed Preeclampsia-eclampsia
Chronic(preexisting) hypertension.
Classification of hypertensive
disorders complicating pregnancy
describes into four types:
1
2
3
4

4. Diagnosis Hypertension
in Pregnancy
Hypertension is diagnosed empirically when appropriately taken
blood pressure exceeds 140 mm Hg systolic or 90 mm Hg
diastolic. Korotkoff phase V is used to define diastolic pressure.

5. Diagnosis Hypertension
in Pregnancy
Gestational Hypertension
Mild Preeclampsia
Systolic BP 140 or diastolic BP 90 mm Hg for first time during pregnancy, without
proteinuria and BP returns to normal before 12 weeks postpartum
BP 140/90 mmHg or over, but less than 160/ll0 mm Hg, after 20 weeks gestation
Proteinuria 0,3 gr / L in 24 hours or +1-2 on dipstick

6. Diagnosis Hypertension
in Pregnancy
Severe Preeclampsia
• BP160/110 mmHg or over, after 20 weeks gestation
• Proteinuria 5 gr in 24 hours or +3-4 on dipstick
• Oligouria, urine production less than 500 cc in 24 hrs along with increasing level of creatinin
serum
• Subjective complain : visual disturbance, persistent headache, epigastric pain
• HELLP syndrome (Hemolysis, Elevated Liver enzyme, Low Platelet count)
• Cyanosis and Intrauterine fetal growth restriction
Eclampsia
Seizures that cannot be attributed to other causes in a woman with preeclampsia

7. Diagnosis Hypertension
in Pregnancy
Superimposed Preeclampsia On Chronic Hypertension:
• New-onset proteinuria 300 mg/24 hours in hypertensive women but no
proteinuria before 20 weeks' gestation
• A sudden increase in proteinuria or blood pressure or platelet count < 100,000/L
in women with hypertension and proteinuria before 20 weeks' gestation
Chronic Hypertension
BP 140/90 mm Hg before pregnancy or diagnosed before 20 weeks' gestation not
attributable to gestational trophoblastic disease or Hypertension first diagnosed
before 20 weeks' gestation and persistent after 12 weeks postpartum

9. What is the diagnose when 32 weeks of
pregnancy come to you with blood
pressuere 150/100 with proteinuria +2
with complained nausea and headache?
?
Break
question

10. Pathofisiology
disease of theories
Abnormality
vascularization of
placenta theory
Placenta ischemic,
free radical, and
endotel dysfunction
Imunology intolerance between
mother and fetus theory
Cardiovascular
adaptation theory
Genetic deficiency
theory
Nutrition
deficiency theory
Inflammation
theory
1 2 3
4567

11. Abnormality vascularisation of
placenta theory
In normal pregnancy
In pregnancy induced hypertension
1 Remodeling the uterine spiral arterioles
2 invaded by endovascular trophoblasts
3
Replace the vascular endothelial and
muscular linings to enlarge the vessel
diameter & making the lining more firm
4 Easily distention and vasodilatation
5
reduced the blood pressure, vascular
resistance, and increasing blood flow in
utero-plasenta
2
Incomplete trophoblastic invasion shallow
invasion uterine spiral arterioles
3
muscularis lining uterine spiral arterioles
become rigid, hard to distention and
vasodilatation  failed remmodeling
4 mean external diameter is only half vessels
in normal
5
impairs placental blood flow 
diminished perfusion and a hypoxic
environment

12. In Normal
Pregnancy
Pregnancy
Induced
Hypertension

13. Placenta ischemic, free radical,
and endotel dysfunction
1 2 3 4
Remmodeling
failure in remmodeling and
cause ischemia and hypoxia
Free Radical
produce free radical
“hidroxyl”
Damage Sel
damage membran sel
And increased in lipid
peroxide
Dysfunction
caused endothelial
dysfunction
Endothelial dysfunction further cause:
1.Prostaglandin metabolism impairment  tromboxane >>
2.Platelet agregation
3.Glomerular endotheliosis
4.Increased capillary permeability
5.Increased vasopressor production
6.Coagulation factor stimulation.

14. In normal pregnant
Immune response don’t reject
conception product because
of HLA-G.
Imnonology intolerence between
mother and fetus theory
Women with pregnancy induced hypertension
•Decreased in HLA-G make intolerance maternal to placenta.
•Early in a pregnancy, extravillous trophoblast express reduced amounts
of immunosuppressive human leukocyte antigen G (HLA-G) 
defective placental vascularization.
•Beginning in the early second trimester, in preeclampsia a significantly
lower proportion of helper T cells (Th1) compared with normotensive
women.

15. Cardiovascular
adaptation theory
1
2
3
4
Women with pregnancy
induced hypertension
Loss refracter capability againts
vasoconstrictor in blood
vassels  blood vassels become
very sensitive with
vasopressor product  high blood pressure

16. Genetic deficiency
theory
• Association between HLA-DR4 and proteinuric hypertension.
• Angiotensinogen gene variant T235 had a higher incidence preeclampsia and fetal growth restriction.
• Some of the inherited thrombophilias considerations in the development of hypertensive disorders due to
pregnancy predispose some women to preeclampsia.
• Polymorphisms of the genes for TNF, lymphotoxin-alpha, interleukin-1B have been studied with varying
results.

17. Clinical trial from Ecuador with double
blind showed that women given calcium
suplementation 14% preeclampsia
compared with placebo 17%.
Nutrition deficiency
theory
Fish Oil
Fish oil consumption
could reduce the risk of
preeclampsia
Calcium
Calcium deficiency
increase risk of getting
preeclampsia/eclampsia

18. Increased capillary permeability manifest by edema and proteinuria.
Inflammation theory
In response to
ischemic
changes
release antiangiogenic and
metabolic factors and other
inflammatory mediators
provoke
endothelial cell
dysfunction
extreme activated
state of leukocytes in
the maternal
Tumor necrosis
factor- (TNF-) &
interleukins (IL
generate
highly toxic
radicals
injure endothelial cells, modify their
nitric oxide production, and interfere
with prostaglandin balance
production of the lipid-
laden macrophage
foam cells

19. Management
Hypertension in Pregnancy

20. Management of mild
Preeclampsia
Base on NICE Guidlines
(Nasional Institute for Health and Care Exellence)
Improving health and social care through evidence-based guidance
Outpatient Inpatient Obstetrics/active

21. Outpatient
Mild Preeclampsia
(NICE recommendation)
1
2
3
A.Tidak mutlak harus tirah baring, dianjurkan ambulasi sesuai keinginannya.
Tidak mutlak harus tirah baring, dianjurkan
ambulasi sesuai keinginannya
Do not recommend salt restriction during pregnancy solely to prevent
gestational hypertension or pre-eclampsia.
(NICE recommendation )
If conservative management of severe gestational hypertension or pre-
eclampsia is planned, carry out all the following tests at diagnosis:
ultrasound fetal growth and amniotic fluid volume assessment
umbilical artery doppler velocimetry
(NICE reccomendation )

22. 4
5
6
Laboratory test : complete blood count, homocystein urinalysis, renal
function test, random blood sugar
Advise women with more than one moderate risk factor for pre-eclampsia to
take 75 mg of aspirin* daily from 12 weeks until the birth of the baby. Factors
indicating moderate risk are
1.first pregnancy
2.age 40 years or older
3.pregnancy interval of more than 10 years
4.body mass index (BMI) of 35 kg/m2 or more at first visit
5.family history of pre-eclampsia
6.multiple pregnancy.
(NICE reccomendation )
Office visit every 1 week
Outpatient
Mild Preeclampsia
(NICE recommendation)

23. inpatient
Mild Preeclampsia
(NICE recommendation)
A.Tidak mutlak harus tirah baring, dianjurkan ambulasi sesuai keinginannya.
Indication Inpatient
If the result of fetal assesment are
doubtful or even poor, hospitalize for
termination
There are no improvement on patient
condition after 2 visit
If there is one or more abnormal
laboratory finding
If there any tendency to become severe
preeclampsia ( one or two sign or
symptomps of severe PE )
Maternal Monitoring
Laboratory Monitoring
Fetal Monitoring

24. inpatient
Mild Preeclampsia
(NICE recommendation)
Maternal Monitoring
Maternal Blood Pressure
Monitoring maternal blood
pressure Every 4 hours,
unless mother is sleeping
Sign Impending Eclampsia
• Epigastrial Pain.
• Mata berkunang-kunang
• Irritable
• Headache .
Edema on extremity
And face
Clinical sign of fluid
accumulation in
preeclampsia shoild be
monitored every day
Monitoring maternal weight
Body every day
Acumulation of fluid should
be monitored every day

25. inpatient
Mild Preeclampsia
(NICE recommendation)
USG Doppler
Umbilical artery doppler
Uterine arteri doppler
BPP
Biophysical Profile
Fetal Growth
Fetal growth shoul be
monitored
with USG every 3-4 weeks
Fetal Monitoring
NST
NST should be
twice a week
• Poor, deliver the baby
• Doubtful, re-evaluate NST, fetal well
being, one day after
• Good, continue the treatment for at
least 4 days
 If the pregnancy are preterm :
discharge from hospital
 If the pregnancy are term : deliver
the baby
 If there are subjective complains :
treat as severe PE case

26. inpatient
Mild Preeclampsia
(NICE recommendation)
Urine Laboratory
Urine labratory for
proteinuria should be
monitored when admission
and followed for next 2
days
Urine Production
monitor of Urine
production every day
Normal production 0,5-
1cc/Kg/hours
Laboratory Monitoring
Blood Test
Hematocrite, Platelet, Liver
function test, Kidney
function test monitored
every 2 weeks
Gestosis Index
Gestos index should be monitored for the
prognostic value in preeclamsia case

27. Management of Severe
Preeclampsia
Base on Clinical Medicine Emergency LANGE
Medical decision making
In a pregnant patient with hypertension, the presence of
proteinuria is enough to make a diagnosis of preeclampsia
Before confirmation of proteinuria, other diagnoses should be
considered.

28. Management of Severe
Preeclampsia
Base on Clinical Medicine Emergency LANGE
Pregnant Female (Usually > 20 weeks)
BP >140/90 And Proteinuria
Ask about symptoms of headache, abdominal
pain, visual disturbances, or edema
seizures No seizures
Eclampsia Preeclampsia
Hemolysis (anemia), Abnormal Liver Enzimes,
Thrombocytopenia
HELLP Syndrome
Initial treatment is focused on
stabilizing the patient. Place
the woman in the left lateral
decubitus position to improve
circulation
Initial Treatment

29. Algorithm of Severe
Preeclampsia
Base on Clinical Medicine Emergency LANGE
And NICE Guidlines
Severe preeclampsia
• Hospitalized
• Maternal and Fetal Evaluation 24 hours
• MgSO4 24 hours
• Anthyhipertensive if sistolik ≥ 160 mmHg dan
atau Diastolik ≥ 110 atau MAP > 125 mmHg
Tidak
Maternal distress and (or)
Non reassuring Fetal status
< 24 wks 24-<34 wks 34-36+6
wks
Delivery
Conservatif
37 wks
SuccessFailed
if required, a course of
corticosteroids has been
completed.
Termination
No Yes

30. Management of Severe
Preeclampsia
Base on Clinical Medicine Emergency LANGE
ABC
Apply supplemental
oxygen, cardiac
monitoring, and establish
intravenous (IV) access.
Avoid over hydration, as it
may result in pulmonary
edema
Antihypertensive therapy is
indicated in the setting of
severe hypertension
(systolic blood pressure
>160 mmHg or diastolic
blood pressure >1 1 0
mmHg)
Magnesium remains the
drug of choice for the
treatment of severe
preeclampsia and
eclampsia
The definitive treatment of
preeclampsia and
eclampsia is delivery of the
fetus
Antihypertensive MgSO4

31. Airway and
Breathing
Apply supplemental oxygen
Cardiac Monitoring
Apply Cardiac monitor
Intravenous Line
Establish IV access
ABC
Severe Preeclampsia
(NICE recommendation)

32. Antihypertensive
Severe Preeclampsia
(NICE recommendation)
• Dangerous hypertension can cause
cerebrovascular hemorrhage, hypertensive
encephalopathy and can trigger eclamptic
convulsions, afterload congestive heart failure
and placental abruption.
• Recommended that treatment lowering
systolic pressures to 160 mm Hg.
• Most of these were hemorrhagic—93 percent
—and all women had systolic pressures > 160
mm Hg before suffering their stroke.
• The three most commonly are hydralazine,
labetalol, and nifedipine.
Orally administered nifedipine as first-line
treatment for severe gestational hypertension.

33. Antihypertensive
Severe Preeclampsia
(NICE recommendation)
The use of antihypertensive drugs in attempts to prolong
pregnancy or modify perinatal outcomes in pregnancies.

34. Magnesium
Sulfat
Severe Preeclampsia
(NICE recommendation)
In more severe cases of preeclampsia, as well as in eclampsia, magnesium sulfate is an effective anticonvulsant
that avoids producing central nervous system depression in either the mother or the infant.

35. Definitive therapy
Severe Preeclampsia
(NICE recommendation)
Conservative Therapy
• If gestational age less than 37 weeks, without subjective complain and fetal well being is good.
• Bed rest.
• IVFD Ringer lactate 60 cc/hour
• Magnesium sulfate: first dose MgSO4 40% 10 gram intramuscular, continue with MgSO4 40% 5 gram
every 6 hours until 24 hours.
• Give antihypertension Nifedipine 3x10 mg (orally) if BP systolic < 180 mmHg and diastolic < 110
mmHg or clonidin 1 amp diluted into 10 cc and give first dose 5 cc in 5 minute, the rest 5 cc given if
BP still high.
• Evaluation with complete blood count, LF, RF, UL, Gestosis Index, Proteinuria @ 24 hours.

36. Definitive therapy
Severe Preeclampsia
(NICE recommendation)
Active Therapy
• If gestational age 37 weeks or more, fetus well beeing is not good, there are subjective complains, HELLP
Syndrome, failed for conservative treatment, or after 24 hours conservative treatment BP still 160/110 or higher
• Medication :
 Hospitalize the patient
 IVFD Ringer lactate 60 cc/hour
 Magnesium sulfate: first dose MgSO4 40% 10 gram intramuscular, continue with MgSO4 40% 5 gram every 6
hours until 24 hours after the baby has beeen delivered
 Give antihypertension Nifedipine 3x10 mg (orally) if BP systolic < 180 mmHg and diastolic < 110 mmHg or
clonidin 1 amp diluted into 10 cc and give first dose 5 cc in 5 minute, the rest 5 cc given if BP still high.

37. Definitive therapy
Severe Preeclampsia
(NICE recommendation)
Active Therapy
Obstetric Treatment :
• Cesarean Section done if the fetal well being assessment result is poor, patient still not in labor
• with unfavorable pelvic score, or in case of induction failure
• Induction (by using oxytocin) is performed if PS are favorable with normal result of NST
• In severe PE cases the patient has to be in labor in 24 hours.

38. THANK YOU