Hypertensive Disorder in

1
Pregnancy (HDP)
By: Birhan T.
(MSc)
HDP
2 Objectives

 By the end of this session you will be able to:

 Define HDP
 Identify the risk factors associated with HDP
 Classify HDP
 Identify the features of HDP
 Diagnose a client with HDP
 Manage a patient with HDP

HDP
3 Definition

 HDP define as:

 a rise in Blood Pressure of ≥ 140/90 mm Hg measured

2 times with at least a 4-hour apart, OR

 a single pressure recording of 160/110 mmHg after 20

weeks of gestation, in labor or postpartum.

HDP
4 Epidemiology
 Second commonest causes of maternal death in
Ethiopia
 Preeclampsia and eclampsia occurs during antepartum,
Intrapartum , and post partum period

 Causes low birth weight , IUFD, IUGR, AP and

prematurity

 Pooled prevalence of hypertensive disorder of

pregnancy and preeclampsia in Ethiopia were 6.82%
HDP
5 Classification of hypertensive
disorders in pregnancy
 Classification is based on:
 Gestational age (before 20 weeks or after)
 Blood pressure measurement
 Protein in the urine

 A rise in blood pressure is whole mark in a diagnosis

of hypertensive disorder during pregnancy

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6 Classification cont’d
 Gestational Hypertension: New onset of HTN at after
20 weeks of gestation without proteinuria in a
previously normotensive woman.
 Preeclampsia: New onset of HTN after 20 weeks of
gestation in a previously normotensive woman with
Proteinuria
 Severity features may present or be absent
(thrombocytopenia, renal insufficiency etc..).

 Eclampsia: A patient with preeclampsia with

generalized seizures (grand mal seizures or coma).
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7 Classification cont’d

Chronic hypertension: HTN diagnosed or present

before pregnancy or before 20 weeks of pregnancy or

 Persists longer than 12 weeks postpartum

Chronic hypertension with superimposed

preeclampsia: a sudden increase in BP that was
previously well controlled and

 New onset of proteinuria or sudden increase in

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proteinuria in a patient with known proteinuria before
8 Risk factors
 Maternal age ≥35 years
 Twins pregnancy
 Previous history of preeclampsia
 Family history of hypertension
 Family history of diabetes mellitus
 Body mass index ≥25
 Alcohol consumption
 Urinary tract infection/ cardiac disease

HDP
 Assessment
9

History Taking

 Proper history taking is an important component in the diagnosis and

management of hypertensive disorders of pregnancy
Physical examination
 In order to have a proper diagnosis:
 General appearance should be checked from the gate
 Take vital sign appropriately (special attention to BP)
 Chest auscultation (for pulmonary edema)

HDP
 Lab. Investigation
10
 Urinalysis for protein

 Proteinuria in pregnancy is 300mg protein in a 24-hour urine specimen

or

 Two urine dipstick measurements of at least 1+ (30mg per dl) taken

six hours apart or

 Complete blood count (CBC) including platelets count: if <

100,000/microliter

 Liver enzymes; if elevated 2-3 times above the normal range (normal
value <42 IU/L)

 Renal function Tests (Serum creatinine): if > 1.2mg/dl

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11
Classification of Preeclampsia
1. PRE-ECLAMPSIA with severity features
► Severity features are:
 Headache, blurred vision, oliguria (<400 ml/24 hours),

 epigastric pain or pain in right upper quadrant, difficulty

breathing (pulmonary edema)

 Low platelet count (<100,000/µl).

 Elevated liver enzymes more than twice the upper limit of

normal.

 Serum creatinine higher than 1.1mg/dl or a doubling or higher of

HDP the baseline serum creatinine concentration in the absence of

other renal disease.
12 HDP indications for severity

Abnormality Without severity With Severty

1. DBP -<100 -110 or more
2. headache -absent -Present
3. visual disturbance - “ - “
4. RUQ pain - “ - “
5. oliguria - “ - “
6. convulsion - “ - “
7. serum creatinine -Normal -Elevated
8. low platelet -Absent -Present
9. elevated LFT -Minimal -Marked
10. pulmonary edema -absent -present

HDP
13 Management of Preeclampsia with
severity feature
 Stabilize her condition followed by hospitalizing drug administration to
prevent convulsion and control the hypertension

 Drug administration: anticonvulsant and antihypertensive drug as

indicated

 Evaluate the woman to check the progress vital signs

 Protect the woman from injury

 Catheterize the bladder to monitor urine output.

 Maintain a strict fluid balance chart (monitor the amount of fluids

administered and urine output) to prevent fluid overload.
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 Never leave the woman alone.

14 What do you do if the women start
convulsion ?
 Shout for help to mobilize the team and call for emergency
equipment. If you are alone, the family may be your team.

 Airway: Turn woman onto her side to prevent aspiration. Ensure her
airway is open and reduce risk of aspiration of secretions, vomit or
blood. After the convulsion, clear the mouth and throat as necessary.

 If available, give oxygen at 4–6 L per minute by mask or cannula.

 Breathing: If the woman is not breathing, begin ventilation with a bag

and mask.

HDP Circulation: assess B/P, pulse is absent, begin cardiac massage

15 What is your drug of choice for prevention
and treatment of convulsion?
 Magnesium sulphate is the drug of choice for anticonvulsant
 minimizing recurrence of convulsion,
 comparatively with better maternal and neonatal outcomes.

 Magnesium sulphate requires two phases of administration:

 loading
 maintenance doses.
 The loading does is administered in both intravenous and
intramuscular routes while the maintenance dose is administered
only intraMUSCULAR.

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 Preparation of Magnesium Sulphate
16
To administer the Magnesium sulphate loading dose using
magnesium sulphate 50% (1gm in 2 mL):
 Take one 20 mL sterile syringe
 Draw 8 mL (4 g) of magnesium sulphate 50% into syringe
 Add 12 mL of sterile water for injection to make a 20%
solution.
 Follow immediately with draw 10 mL (5 g) of Magnesium
sulphate 50% into each syringe and add 1 mL of 2%
lignocaine in each syringe and give deep IM injection in
to each buttock.
 If the available syringe is 10 cc, draw 5 gm 50%
Magnesium sulphate plus 1ml of 2% lidocaine in 2
syringes give IM in to each buttock.
HDP
17 Loading dose
 Give 4 g of 20% magnesium sulfate solution IV over five
minutes.
 Follow promptly with 10 g of 50% magnesium sulfate
solution: Give 5 g in each buttock as a deep IM injection
with 1 mL of 2% lidocaine in the same syringe.
 Ensure aseptic technique when giving magnesium
sulfate deep IM injection.
 Warn the woman that she will have a feeling of warmth
when the magnesium sulfate is given.

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18 When to Repeat Magnesium
sulphate?
If the woman is convulsing after 15 minutes

 repeat 2gm of magnesium sulphate 20% (4 ml of

Magnesium sulphate and 6 ml of distilled water or
normal saline) IV slowly over 2 minutes.

 Record all doses on the magnesium sulphate

monitoring Sheet.

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19 Maintenance dose
 Before administering Magnesium sulphate check
respiratory rate, urine output and patellar reflex.
 Continue to give maintenance dose of MgSO4 and repeat
the dose every 4hr alternatively If findings are normal
 (RR >16bpm
 urine output >30ml/hour and
 presence of patellar reflex),
 Give 5 gm of 50% magnesium sulfate solution with 1 mL
of 2% lidocaine by deep IM injection into alternate
buttocks every four hours.
 Continue treatment for 24 hours after birth or the last
convulsion, whichever occurs last.
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20 What are the signs of Magnesium
sulphate toxicity?

The parameters indicating the presence of

magnesium sulphate toxicity are:

 Respiratory rate less than 16 breaths/min

 Urine output less than 30ml/hr

 Patellar reflex is absent.

HDP
 Magnesium sulphate toxicity monitoring &
21 management

Closely monitor the woman for signs of magnesium toxicity:

Withhold or delay drug if:
 Respiratory rate falls below 16 breaths per minute;
 Patellar reflexes are absent;
 Urinary output falls below 30 mL per hour over preceding
four hours.
Keep antidote ready. In case of respiratory arrest:
 Assist ventilation (mask and bag, intubation);
 Give calcium gluconate 1 g (10 mL of 10% solution) IV
slowly over three minutes, until respiration begins to
counteract the effect of magnesium sulfate.
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 Administering Diazepam

22  When magnesium sulphate toxicity occurs or when not available give

Diazepam

Loading dose IV:

 10 mg IV slowly over 2 minutes. If convulsions recur, repeat 10 mg.

Maintenance dose:

 40 mg in 500 ml IV fluids (normal saline or Ringer‘s lactate) titrated over 6-8

hours to keep the woman sedated but arousable

 Note:

 Stop the maintenance dose if breathing <16 breaths/minute.

 Do not give more than 100 mg in 24 hours.

 There is a greater risk for neonatal respiratory depression because

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diazepam passes the placenta freely.

23 Management of Sever HTN using
anti-Hypertensive drugs
 The goal of antihypertensive therapy is to maintain the B/P up to
Systolic 140-155 and Diastolic 90-105 mmHg.

 Antihypertensive medications should be started if the systolic blood

pressure is 160 mmHg or higher and/or the diastolic blood pressure is 110
mmHg or higher.

 Recommended drugs as an anti-hypertension are

 Hydralazine
 Nifedipine and
 Labetalol.
HDP  The drug of choice for antihypertension is Hydralazine.
24 Hyrdalazine

 Dosage and route of administration

 Intravenous treatment:
 Administer 5 mg IV, slowly (over 3-4 minutes) (risk of maternal
hypotension)

 Repeat every 20 -30 minutes until BP goal is achieved (DBP 90-

105mmhg and SBP 140-155mmhg).

 If BP is not controlled after administering a total of 20mg,

another agent should be used (Nifedipine)

HDP
25 Lebetalol
 Dosage and route of administration

 Intravenous treatment:

 Administer 10 mg IV. If response is inadequate after 10 minutes, administer

additional 20 mg IV.

 The dose can be doubled to 40 mg and then 80 mg with 10-min. intervals

between each increased dose until blood pressure is lowered below
threshold.

 The maximum total dose is 300 mg; then switch to oral treatment.

 Note: Women with congestive heart failure, hypovolemic shock or

predisposition
HDP to bronchospasm (asthma) should not receive labetalol.
26 Alpha methyldopa

 Dosage and route of administration

 Oral treatment:

 Administer 750 mg orally.

 Repeat dose after three hours until the treatment goal
is achieved.
 The maximum dose is 3 g in 24 hours.

HDP
 Nifedipine

27
Dosgae and route of administration

 Oral treatment

 Administer 5–10 mg under the tongue. Or oral

 Repeat dose after 30 minutes if response is

inadequate until optimal blood pressure is reached.

 The maximum total dose is 30 mg in the acute

treatment setting.

HDP
 Cont’d medication
28 Once blood pressure is reduced to non-severe levels, ongoing
treatment should be continued using oral medication.
Nifedipine
 Administer 10–20 mg every 12 hours.
 The maximum dose is 120 mg per 24 hours.
Alpha methyldopa
 Administer 250 mg every six to eight hours.
 The maximum dose is 2000 mg per 24 hours.
Labetalol
 Administer 200 mg every six to 12 hours.
 Repeat dose after one hour until the treatment goal is achieved.
 The maximum dose is 1200 mg per 24 hours.
Note: Women with congestive heart failure, hypovolemic shock or
predisposition to bronchospasm (asthma) should not receive labetalol
HDP
 Plan for delivery
29

Gestation > 28 to <34 weeks

 For expectant management:

 Transfer to maternity ward
 Follow vital signs every 4 hours
 CBC, every other day
 Liver enzymes, and creatinine twice weekly
 Fetal kick count daily
 Fetal surveillance twice weekly
 Administer Dexamethasone 6 mg IM every 12 hours for
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2 days or Betamethasone 12 mg daily for 2 days

 Plan for delivery …
30
Gestation > 28 to <34 weeks
 Indications for delivery are:
 Failure to control hypertension with two antihypertensive
drugs with a maximum dose in 48 hours
 Persistent maternal severity symptoms (severe headache,
visual changes and abdominal and/or epigastric pain with
elevated liver enzymes)
 HEELP Syndrome
 Eclampsia
 Pulmonary edema or left ventricular failure
 IUFD and DIC
 Severe renal dysfunction

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 Gestation 34 to 37 weeks

31

 In women with severe pre-eclampsia and a viable

fetus, expectant management may be recommended
and can be closely monitored
 if absence of
 unontrolled maternal hypertension
 Worsening maternal status and
 Fetal distress
 For women with pre-eclampsia at term (37 weeks):
 regardless of severity features, giving birth is
recommended
HDP
 Preeclampsia without severity feature
32

Gestational age less than 37 weeks

 Twice weekly outpatient follow-up is preferred
 Monitor blood pressure, fetal condition, CBC, liver and
renal function tests twice weekly
 Counsel about the danger signs
 Encourage the woman to eat a normal diet
 Orient on fetal movement counting (kick chart) daily
 Do not give anticonvulsant or antihypertensive
 Delivery at 37 completed weeks.

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 Management of Eclampsia

33
General measures
 Set up IV line & maintain intravascular volume &
replace ongoing losses
 Position the patient on her side (left lateral) & in
Trendelenburg (head down) Aspirate (suction) the
mouth & throat as necessary & ensure open airway
 Give oxygen by mask at 6 liters per minute.
 Avoid tongue bite by placing an airway or padded
tongue blade
 Place an indwelling catheter to monitor urine output.

HDP
 General measures …
34
 Observe vital signs, FHB & reflexes frequently &
auscultate the lung bases hourly for crepitation

 If the pulmonary edema occurs, withhold fluids &

administer a diuretic such as furosemide 40 mg IV
stat.

 The patient has to be kept in a quiet room, but an

attendant must be always present beside the patient.

 Administration of broad-spectrum IV antibiotics is

HDP recommended.
 Fluid balance

35
 Keeping strict input & output record is essential and determine
serum electrolyte

 For unconscious patient, 5% DW & ringer's Lactate are infused

for maintenance of nutrition & fluid balance during 24 hrs.

 Replace extra fluid loss through vomiting, diarrhea, sweating or

blood loss

 Nothing by mouth is allowed (if unconscious); when the patient

becomes conscious & can drink, oral feeding of fluid is started.

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36 Delivery

 In sever preeclampsia delivery should occur

within 24h and
 Delivery should take place within 12 hours of
onset of convulsions
 Delivery should take place as soon as the
woman's condition has stabilized, regardless
of the gestational age

HDP
37 Summary
 Management of hypertensive disorders of
pregnancy
 Magnesium sulphate preparation and
administration
 Signs of magnesium sulphate toxicity and manage
 Delivery / expectant management for selected
cases

HDP
38 Reference

 William Obstetrics 25th Edition

 Obstetrics Management Protocol for Hospitals, Ministry of Health,
Ethiopia 2021
 World continuous Education and Ethiopian Ministry of Health e-learning
platform
 Up-to-date 21.6

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39

Thank you

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