Classification of hypertension with pregnancy
1- Gestational hypertension
2- Preeclampsia (mild, severe)
3- Eclampsia
introduction 4- Chronic hypertension
🔻 Hypertensive disease occurs in approximately 12–22% of pregnancies, and it is directly
5- Superimposed preeclampsia
🔻
responsible for maternal deaths.
Although the rate of eclampsia appears to have fallen, hypertension in pregnancy remains one Gestational Hypertension (Pregnancy Induced
🔻One-third of severe maternal morbidity was a consequence of hypertensive conditions.
of the leading causes of maternal death. Hypertension)
• Hypertension detected for the first time after 20 weeks’
gestation, in the absence of proteinuria
Definition ofHypertension in Pregnancy • Hypertension defined as systolic blood pressure ≥ 140 mm Hg or
Hypertension with pregnancy is defined as a systolic blood pressure ≥ 140 mmHg or diastolic diastolic blood pressure ≥ 90 mm Hg
blood pressure ≥ 90 mmHg (on two occasions more than 6 hours apart) or a single diastolic • Resolves within three months after the birth
blood pressure ≥ 110 mmHg.
Pre-eclampsia and eclampsia
• Hypertension and proteinuria detected for the first time after 20
In the past, hypertension has been defined as an elevation of more than 30 mm Hg systolic or weeks’ gestation
more than 15 mm Hg diastolic above the patient’s baseline blood pressure; however, this • Hypertension defined as above
definition has not proved to be a good prognostic indicator of out-come. • Proteinuria defined as ≥ 300 mg/day or ≥ 30 mg/mmol in a single
specimen or ≥ 1+ on dipstick
Measurement of BP(SOGC) • Eclampsia is the occurrence of seizures superimposed on the
BP should be measured with the woman in the sitting position or in left lateral syndrome of pre-eclampsia
recumbent position with the arm at the level of the heart.
Chronic hypertension
An appropriately sized cuff (i.e., length of 1.5 times the circumference of the arm) • Hypertension known to be present before pregnancy or
should be used. detected before 20 weeks’ gestation “Essential” hypertension if
there is no underlying cause“Secondary” hypertension if
associated with underlying disease
Pre-eclampsia superimposed on chronic hypertension
• Onset of new signs or symptoms of pre-eclampsia after 20
weeks gestation in a woman with chronic hypertension.
Prevention of preeclampsia
The ability to prevent preeclampsia is limited by lack of knowledge of its underlying cause.
Prevention has focused on identifying women at higher risk , followed by close clinical and laboratory
Factors associated with an increased risk of pre-eclampsia: Pathophysiology
monitoring to recognize the disease process in its early stages. These women can then be selected for
more intensive monitoring or delivery. • First pregnancy •Preeclampsia is a syndrome with both maternal and fetal manifestations.
However ,there are few interventions that could reduce the risk of preeclampsia in high risk cases. • Pre-eclampsia in a previous pregnancy •The pathologic changes in this disorder are primarily ischemic in nature and
🔻Preventing Preeclampsia and its Complications in Women at Low Risk • ≥10 years since previous pregnancy affect the placenta, kidney, liver and brain.
• ≥40 years of age •Preeclampsia is a systemic syndrome , and several of its non-hypertensive
• Body mass index ≥ 35 at booking in complications may be life-threatening even when blood pressure elevations
1.Calcium supplementation (of at least 1g/d, orally) is recommended for women with low dietary intake of • Family history of pre-eclampsia (especially motheror sister) are quite mild.
calcium (< 600 mg/d).
• Diastolic blood pressure ≥ 80 mm Hg at booking in
2. The following are recommended for other established beneficial effects in pregnancy: abstention from
• Proteinuria at booking in •There is evidence that trophoblastic invasion of uterine spiral arteries is
alcohol
use of a folate-containing multivitamin. • Multiple pregnancy incomplete in women in whom preeclampsia eventually develops , with the
3.The following are not recommended: dietary salt restriction during pregnancy, • Underlying medical condition: vessels remaining thick walled and muscular.
calorie restriction during pregnancy for overweight women, vitamins C and E (based on current evidence), -Chronic hypertension •Failure of the spiral arteries to remodel is postulated as the morphologic
or thiazide diuretics. -Renal diseaseDiabetes basis for decreased placental perfusion in preeclampsia , which may
🔻Preventing Preeclampsia and its Complications in Women at Increased Risk -Presence of antiphospholipid antibodies ultimately lead to early placental hypoxia
1. Low-dose aspirin and calcium supplementation (of at least 1 g/d) are recommended for women with low
calcium intake,
-Low-dose aspirin (75–100 mg/d ) should be
administered at bedtime, starting pre-pregnancy or
from diagnosis of pregnancy but before 16 weeks’ gestation, and continuing until delivery.
2. The following may be useful:
avoidance of interpregnancy weight gain, increased rest at home in the third trimester, and reduction of
workload or stress.
🔻
Diagnostic Criteria
🔹 PREECLAMPSIA
Blood pressure:
140 mm Hg or higher systolic or 90 mm Hg or higher diastolic after 20
Expectant management of preeclampsia
refers to attempted pregnancy prolongation following a period of observation, assessment, stabilization (usually of
maternal BP), and, if gestational age is less than 34 weeks.
Diagnosis
The correct diagnosis is important when counseling patients 🔹
weeks of gestation in a woman with previously normal blood pressure
Proteinuria:
0.3 g or more of protein in a 24-hour urine collection (usually
Following stabilization, appropriate candidates for expectant management remain undelivered while maternal and fetal regarding future pregnancies.
•The period during gestation when hypertension is first corresponds with 1+ or greater on a urine dipstick test)
well-being are closely monitored. monitored.
Place of Care
1. In-patient care should be provided for women with severe hypertension or severe preeclampsia, women who are
documented is helpful in determining the correct diagnosis:
🔻
🔹 Severe preeclampsia
Blood pressure:
noncompliant, and women who do not have ready access to medical care. 160 mm Hg or higher systolic or 110 mm Hg or higher diastolic on two
🔹
2. A component of care through hospital day units or home care can be considered for women with non-severe occasions in a woman on bed rest.
preeclampsia or non-severe (pre-existing or gestational) hypertension. Proteinuria:
5 g or more of protein in a 24-hour urine collection or 3+ or greater
🔻 For Non-Severe Hypertension (BP of 140–159/90–109 mmHg)
Management of BP is much debated. Any antihypertensive therapy will decrease the risk of transient, severe
on urine dipstick testing of two random urine samples collected at
least four hours apart
hypertension without a clear difference in other maternal or perinatal outcomes, such as stroke, perinatal death, or
preterm delivery Other features:
-Hospitalization: Yes oliguria (less than 500 mL ofurine in 24 hours)
- Antihypertensive drugs: NO unless Bp is 150/100 to 159/109 mmHg). cerebral or visual disturbances
Labetalol, Methyldopa and calcium channel blockers (nifedipine). pulmonary edema or cyanosis epigastric or right upper quadrant pain
- Maternal care: impaired liver function
Measure the blood pressure at least 4 times per day , blood test twice weekly . Thrombocytopenia
- Fetal care: intrauterine growth restriction
Fetal biometry done every 3 weeks, NST/twice/week.
Treatment
🔹 Management according to gestational age:
For women < 37 weeks (conservative) if: BP<150/100mmhg, 24 hours proteins collection < 5gm, normal fetal well
Delivery remains the ultimate treatment for preeclampsia. Clinical Presentation:
being, normal maternal investigations. Maternal and fetal risks must be weighed in determining the timing of delivery. Complications of pre-eclampsia:
The clinical presentation of preeclampsia may be insidious or fulminant.
For women ≥ 37 weeks’ gestation: delivery of the fetus should be considered.
-Active management is indicated if clear indications for delivery exist . Some'women may be asymptomatic at the time they are found to have hypertension and proteinuria; Others may
present with symptoms of severe preeclampsia
🔻
-Other cases are managed expectantly.
Severe preeclampsia Indications for Delivery in Preeclampsia: From 4 to'14 percent of women with preeclampsia present with superimposed HELLP syndrome.
Hospitalization: yes
Prevention of eclamptic seizures by MgSO4 is recommended for first-line treatment of preeclampsia. 🔻Fetal indications: Diagnostic Evaluation
History
-Phenytoin and benzodiazepines should not be used for eclampsia prophylaxis or treatment, unless there is a
contraindication to MgSO4 or it is ineffective.
-Severe intrauterine growth restriction
-Non reassuring fetal Surveillance
🔹 As part of the initial prenatal assessment, pregnant women should be questioned about potential risk factors for
preeclampsia.
Initial antihypertensive therapy: -Oligohydramnios
labetalol (oral or intravenous) nifedipine capsules, or hydralazine. (oral or intravenous)
🔻 Maternal indications:
preeclampsia They should be asked about their obstetric history, specifically the occurrence of hypertension or preeclampsia
🔹• < 24 weeks: TOP is highly recommended due: to poor fetal outcome and high risk for mother.
Management according to Gestational age
Gestational age of 38 weeks or greater
Platelet count below 100 X 103 per mm3
🔹
during previous pregnancies.
A thorough medical history should be obtained to identify medical conditions that increase the risk for
preeclampsia, including diabetes mellitus, hypertension, vascular and connective tissue disease, nephropathy, and
management
🔹
• 24- 34 wks :( expectant management). Progressive deterioration of hepatic function antiphospholipid antibody syndrome.
TOP
-Severe hypertension develops refractory to treatment. Progressive deterioration of renal function During prenatal visits after 20 weeks of gestation, pregnant women should be asked about specific symptoms,
-Maternal or fetal complications. including visual disturbances, persistent headaches, epigastric or right upper quadrant pain, and increased edema.
Suspected placental abruption
-34 weeks is reached.
• > 34 weeks: Persistent severe headache or visual changes PHYSICAL EXAMINATION:
Top is highly recommended. Persistent severe epigastric pain, nausea, or vomiting Blood pressure should be measured at each prenatal visit. Increases above the patient's baseline (greater than 30 mm Hg
systolic or 15 mm Hg diastolic) are no longer considered to be criteria for the diagnosis of preeclampsia. However, such
Eclampsia
Severe preeclampsia and mode of delivery:
-Vaginal delivery should be considered unless a Caesarean section is required for the usual obstetric indications. 🔹
increases warrant close observation.
Fundal height
should be measured at each prenatal visit because size less than dates may indicate intrauterine growth retardation or
-Recommend operative birth in the second stage of labour for women with severe hypertension whose hypertension has
not responded to initial treatment. oligohydramnios.
-Antihypertensive treatment should be continued throughout labor and delivery to maintain systolic BP at <160 mmHg
and diastolic BP at < 110 mmHg.
🔹
These conditions may become apparent long before diagnostic criteria for preeclampsia are met
Increasing maternal facial edema and rapid weight gain
also should be noted because fluid retention often is associated with preeclampsia. Although these symptoms (e.g., facial
-The third stage of labor should be actively managed.
edema, rapid weight gain) are not unique to preeclampsia, it is wise to follow affected patients for hypertension and
proteinuria. Edema involving the lower extremities frequently occurs during normal pregnancy and therefore is of less
Mode of Delivery concern.
🔹 1. For women with any HDP, vaginal delivery should be considered unless a Caesarean section is required for the
🔹
usual obstetric indications.
2. If vaginal delivery is planned and the cervix is unfavourable, then cervical ripening should be used to increase the Laboratory Evaluation
🔹3. Antihypertensive treatment should be continued
chance of a successful vaginal delivery.
throughout labor and delivery to maintain SBP at
# A baseline laboratory evaluation should be performed early in pregnancy in women who are at high risk for
preeclampsia.
🔹
< 160 mmHg and DBP at < 110 mmHg.
4. The third stage of labor should be actively managed with oxytocin 5 units IV or 10 units IM, particularly in the
presence of thrombocytopenia or coagulopathy. # Once the diagnosis of preeclampsia has been made, an expanded set of laboratory tests should be performed.
🔹5. Ergometrine should not be given in any form. In women who have preeclampsia with no suspected progression, all laboratory tests should be conducted weekly.
🔹
Antihypertensive drug therapy 🔻If progression of preeclampsia is suspected, the tests should be repeated more frequently.
Women at high risk for preeclampsia: Prediction of pre-eclampsia
🔹
Hydralazine, dose 5-10 mg I.V or I.M ( maximal effect at 20 minutes , duration of action 6 to 8 hours).
•Hemoglobin level
Labetalol ( alfa and beta adrenergic blocker), administered in I.V bolus injections of 20 mg or 40 mg or as a continuous
•Hematocrit
intravenous infusion of 1 mg /kg as needed .It should be avoided in women with asthma and in those with congestive heart
•Platelet count Urine
🔹
failure.
•protein collection (12 or 24 hour)
Nifedipine acts rapidly ,causing significant reduction in arterial blood pressure within 10 to 20 minutes of oral
administration .Start with 10 mg orally and repeat in 30 minutes if necessary.
•Serum creatinine level
•Serum uric acid level
🔹Sodium nitroprusside , in rare cases , may be indicated for acute hypertensive emergency after failure of hydralazine, 🔻 Women developing hypertension after 20 weeks of gestation:
nifedipine, and labetalol.
Same tests as in women at high risk plus:
🔻Corticosteroids for Acceleration of Fetal Pulmonary Maturity Serum transaminase levels
📍HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets) Antenatal corticosteroid therapy should be considered for all women who present with preeclampsia before 34 weeks’ Serum albumin level
syndrome: gestation. Lactic acid dehydrogenase level
is a life-threatening pregnancy complication usually considered to be Peripheral blood smear
a variant of preeclampsia. Both conditions usually occur during the
later stages of pregnancy, or soon after childbirth.
🔹
Therapies for HELLP Syndrome Coagulation profile
🔻
1. Prophylactic transfusion of platelets is not recommended, even prior to Caesarean section, when platelet count is >
50x109/L and there is no excessive bleeding or platelet dysfunction.
In women who have already been diagnosed with preeclampsia:
🔹
🔹 2. Platelet transfusion should be strongly considered prior to vaginal delivery when platelet count is < 20 109/L.
4. Corticosteriods may be considered for women with a
•antepartum testing with a nonstress test, a biophysical profile, or both should be performed on a weekly basis starting
at the time of diagnosis.
🔹
platelet count < 50 x109 L.
5. There is insufficient evidence to make a recommendation regarding the usefulness of plasma exchange or
plasmapheresis. •If intrauterine growth retardation or oligohydramnios is suspected, the tests should be performed at least twice weekly,
and delivery should be contemplated if there are any signs of fetal compromise.
•Uterine artery Doppler velocimetry may be useful among hypertensive pregnant women to support a placental origin
for hypertension, proteinuria, and/or adverse conditions.
•Umbilical artery Doppler velocimetry may be useful to support a placental origin for intrauterine fetal growth
restriction.
by fatema okoff
1- Gestational hypertension
2- Preeclampsia (mild, severe)
3- Eclampsia
introduction 4- Chronic hypertension
🔻 Hypertensive disease occurs in approximately 12–22% of pregnancies, and it is directly
5- Superimposed preeclampsia
🔻
responsible for maternal deaths.
Although the rate of eclampsia appears to have fallen, hypertension in pregnancy remains one Gestational Hypertension (Pregnancy Induced
🔻One-third of severe maternal morbidity was a consequence of hypertensive conditions.
of the leading causes of maternal death. Hypertension)
• Hypertension detected for the first time after 20 weeks’
gestation, in the absence of proteinuria
Definition ofHypertension in Pregnancy • Hypertension defined as systolic blood pressure ≥ 140 mm Hg or
Hypertension with pregnancy is defined as a systolic blood pressure ≥ 140 mmHg or diastolic diastolic blood pressure ≥ 90 mm Hg
blood pressure ≥ 90 mmHg (on two occasions more than 6 hours apart) or a single diastolic • Resolves within three months after the birth
blood pressure ≥ 110 mmHg.
Pre-eclampsia and eclampsia
• Hypertension and proteinuria detected for the first time after 20
In the past, hypertension has been defined as an elevation of more than 30 mm Hg systolic or weeks’ gestation
more than 15 mm Hg diastolic above the patient’s baseline blood pressure; however, this • Hypertension defined as above
definition has not proved to be a good prognostic indicator of out-come. • Proteinuria defined as ≥ 300 mg/day or ≥ 30 mg/mmol in a single
specimen or ≥ 1+ on dipstick
Measurement of BP(SOGC) • Eclampsia is the occurrence of seizures superimposed on the
BP should be measured with the woman in the sitting position or in left lateral syndrome of pre-eclampsia
recumbent position with the arm at the level of the heart.
Chronic hypertension
An appropriately sized cuff (i.e., length of 1.5 times the circumference of the arm) • Hypertension known to be present before pregnancy or
should be used. detected before 20 weeks’ gestation “Essential” hypertension if
there is no underlying cause“Secondary” hypertension if
associated with underlying disease
Pre-eclampsia superimposed on chronic hypertension
• Onset of new signs or symptoms of pre-eclampsia after 20
weeks gestation in a woman with chronic hypertension.
Prevention of preeclampsia
The ability to prevent preeclampsia is limited by lack of knowledge of its underlying cause.
Prevention has focused on identifying women at higher risk , followed by close clinical and laboratory
Factors associated with an increased risk of pre-eclampsia: Pathophysiology
monitoring to recognize the disease process in its early stages. These women can then be selected for
more intensive monitoring or delivery. • First pregnancy •Preeclampsia is a syndrome with both maternal and fetal manifestations.
However ,there are few interventions that could reduce the risk of preeclampsia in high risk cases. • Pre-eclampsia in a previous pregnancy •The pathologic changes in this disorder are primarily ischemic in nature and
🔻Preventing Preeclampsia and its Complications in Women at Low Risk • ≥10 years since previous pregnancy affect the placenta, kidney, liver and brain.
• ≥40 years of age •Preeclampsia is a systemic syndrome , and several of its non-hypertensive
• Body mass index ≥ 35 at booking in complications may be life-threatening even when blood pressure elevations
1.Calcium supplementation (of at least 1g/d, orally) is recommended for women with low dietary intake of • Family history of pre-eclampsia (especially motheror sister) are quite mild.
calcium (< 600 mg/d).
• Diastolic blood pressure ≥ 80 mm Hg at booking in
2. The following are recommended for other established beneficial effects in pregnancy: abstention from
• Proteinuria at booking in •There is evidence that trophoblastic invasion of uterine spiral arteries is
alcohol
use of a folate-containing multivitamin. • Multiple pregnancy incomplete in women in whom preeclampsia eventually develops , with the
3.The following are not recommended: dietary salt restriction during pregnancy, • Underlying medical condition: vessels remaining thick walled and muscular.
calorie restriction during pregnancy for overweight women, vitamins C and E (based on current evidence), -Chronic hypertension •Failure of the spiral arteries to remodel is postulated as the morphologic
or thiazide diuretics. -Renal diseaseDiabetes basis for decreased placental perfusion in preeclampsia , which may
🔻Preventing Preeclampsia and its Complications in Women at Increased Risk -Presence of antiphospholipid antibodies ultimately lead to early placental hypoxia
1. Low-dose aspirin and calcium supplementation (of at least 1 g/d) are recommended for women with low
calcium intake,
-Low-dose aspirin (75–100 mg/d ) should be
administered at bedtime, starting pre-pregnancy or
from diagnosis of pregnancy but before 16 weeks’ gestation, and continuing until delivery.
2. The following may be useful:
avoidance of interpregnancy weight gain, increased rest at home in the third trimester, and reduction of
workload or stress.
🔻
Diagnostic Criteria
🔹 PREECLAMPSIA
Blood pressure:
140 mm Hg or higher systolic or 90 mm Hg or higher diastolic after 20
Expectant management of preeclampsia
refers to attempted pregnancy prolongation following a period of observation, assessment, stabilization (usually of
maternal BP), and, if gestational age is less than 34 weeks.
Diagnosis
The correct diagnosis is important when counseling patients 🔹
weeks of gestation in a woman with previously normal blood pressure
Proteinuria:
0.3 g or more of protein in a 24-hour urine collection (usually
Following stabilization, appropriate candidates for expectant management remain undelivered while maternal and fetal regarding future pregnancies.
•The period during gestation when hypertension is first corresponds with 1+ or greater on a urine dipstick test)
well-being are closely monitored. monitored.
Place of Care
1. In-patient care should be provided for women with severe hypertension or severe preeclampsia, women who are
documented is helpful in determining the correct diagnosis:
🔻
🔹 Severe preeclampsia
Blood pressure:
noncompliant, and women who do not have ready access to medical care. 160 mm Hg or higher systolic or 110 mm Hg or higher diastolic on two
🔹
2. A component of care through hospital day units or home care can be considered for women with non-severe occasions in a woman on bed rest.
preeclampsia or non-severe (pre-existing or gestational) hypertension. Proteinuria:
5 g or more of protein in a 24-hour urine collection or 3+ or greater
🔻 For Non-Severe Hypertension (BP of 140–159/90–109 mmHg)
Management of BP is much debated. Any antihypertensive therapy will decrease the risk of transient, severe
on urine dipstick testing of two random urine samples collected at
least four hours apart
hypertension without a clear difference in other maternal or perinatal outcomes, such as stroke, perinatal death, or
preterm delivery Other features:
-Hospitalization: Yes oliguria (less than 500 mL ofurine in 24 hours)
- Antihypertensive drugs: NO unless Bp is 150/100 to 159/109 mmHg). cerebral or visual disturbances
Labetalol, Methyldopa and calcium channel blockers (nifedipine). pulmonary edema or cyanosis epigastric or right upper quadrant pain
- Maternal care: impaired liver function
Measure the blood pressure at least 4 times per day , blood test twice weekly . Thrombocytopenia
- Fetal care: intrauterine growth restriction
Fetal biometry done every 3 weeks, NST/twice/week.
Treatment
🔹 Management according to gestational age:
For women < 37 weeks (conservative) if: BP<150/100mmhg, 24 hours proteins collection < 5gm, normal fetal well
Delivery remains the ultimate treatment for preeclampsia. Clinical Presentation:
being, normal maternal investigations. Maternal and fetal risks must be weighed in determining the timing of delivery. Complications of pre-eclampsia:
The clinical presentation of preeclampsia may be insidious or fulminant.
For women ≥ 37 weeks’ gestation: delivery of the fetus should be considered.
-Active management is indicated if clear indications for delivery exist . Some'women may be asymptomatic at the time they are found to have hypertension and proteinuria; Others may
present with symptoms of severe preeclampsia
🔻
-Other cases are managed expectantly.
Severe preeclampsia Indications for Delivery in Preeclampsia: From 4 to'14 percent of women with preeclampsia present with superimposed HELLP syndrome.
Hospitalization: yes
Prevention of eclamptic seizures by MgSO4 is recommended for first-line treatment of preeclampsia. 🔻Fetal indications: Diagnostic Evaluation
History
-Phenytoin and benzodiazepines should not be used for eclampsia prophylaxis or treatment, unless there is a
contraindication to MgSO4 or it is ineffective.
-Severe intrauterine growth restriction
-Non reassuring fetal Surveillance
🔹 As part of the initial prenatal assessment, pregnant women should be questioned about potential risk factors for
preeclampsia.
Initial antihypertensive therapy: -Oligohydramnios
labetalol (oral or intravenous) nifedipine capsules, or hydralazine. (oral or intravenous)
🔻 Maternal indications:
preeclampsia They should be asked about their obstetric history, specifically the occurrence of hypertension or preeclampsia
🔹• < 24 weeks: TOP is highly recommended due: to poor fetal outcome and high risk for mother.
Management according to Gestational age
Gestational age of 38 weeks or greater
Platelet count below 100 X 103 per mm3
🔹
during previous pregnancies.
A thorough medical history should be obtained to identify medical conditions that increase the risk for
preeclampsia, including diabetes mellitus, hypertension, vascular and connective tissue disease, nephropathy, and
management
🔹
• 24- 34 wks :( expectant management). Progressive deterioration of hepatic function antiphospholipid antibody syndrome.
TOP
-Severe hypertension develops refractory to treatment. Progressive deterioration of renal function During prenatal visits after 20 weeks of gestation, pregnant women should be asked about specific symptoms,
-Maternal or fetal complications. including visual disturbances, persistent headaches, epigastric or right upper quadrant pain, and increased edema.
Suspected placental abruption
-34 weeks is reached.
• > 34 weeks: Persistent severe headache or visual changes PHYSICAL EXAMINATION:
Top is highly recommended. Persistent severe epigastric pain, nausea, or vomiting Blood pressure should be measured at each prenatal visit. Increases above the patient's baseline (greater than 30 mm Hg
systolic or 15 mm Hg diastolic) are no longer considered to be criteria for the diagnosis of preeclampsia. However, such
Eclampsia
Severe preeclampsia and mode of delivery:
-Vaginal delivery should be considered unless a Caesarean section is required for the usual obstetric indications. 🔹
increases warrant close observation.
Fundal height
should be measured at each prenatal visit because size less than dates may indicate intrauterine growth retardation or
-Recommend operative birth in the second stage of labour for women with severe hypertension whose hypertension has
not responded to initial treatment. oligohydramnios.
-Antihypertensive treatment should be continued throughout labor and delivery to maintain systolic BP at <160 mmHg
and diastolic BP at < 110 mmHg.
🔹
These conditions may become apparent long before diagnostic criteria for preeclampsia are met
Increasing maternal facial edema and rapid weight gain
also should be noted because fluid retention often is associated with preeclampsia. Although these symptoms (e.g., facial
-The third stage of labor should be actively managed.
edema, rapid weight gain) are not unique to preeclampsia, it is wise to follow affected patients for hypertension and
proteinuria. Edema involving the lower extremities frequently occurs during normal pregnancy and therefore is of less
Mode of Delivery concern.
🔹 1. For women with any HDP, vaginal delivery should be considered unless a Caesarean section is required for the
🔹
usual obstetric indications.
2. If vaginal delivery is planned and the cervix is unfavourable, then cervical ripening should be used to increase the Laboratory Evaluation
🔹3. Antihypertensive treatment should be continued
chance of a successful vaginal delivery.
throughout labor and delivery to maintain SBP at
# A baseline laboratory evaluation should be performed early in pregnancy in women who are at high risk for
preeclampsia.
🔹
< 160 mmHg and DBP at < 110 mmHg.
4. The third stage of labor should be actively managed with oxytocin 5 units IV or 10 units IM, particularly in the
presence of thrombocytopenia or coagulopathy. # Once the diagnosis of preeclampsia has been made, an expanded set of laboratory tests should be performed.
🔹5. Ergometrine should not be given in any form. In women who have preeclampsia with no suspected progression, all laboratory tests should be conducted weekly.
🔹
Antihypertensive drug therapy 🔻If progression of preeclampsia is suspected, the tests should be repeated more frequently.
Women at high risk for preeclampsia: Prediction of pre-eclampsia
🔹
Hydralazine, dose 5-10 mg I.V or I.M ( maximal effect at 20 minutes , duration of action 6 to 8 hours).
•Hemoglobin level
Labetalol ( alfa and beta adrenergic blocker), administered in I.V bolus injections of 20 mg or 40 mg or as a continuous
•Hematocrit
intravenous infusion of 1 mg /kg as needed .It should be avoided in women with asthma and in those with congestive heart
•Platelet count Urine
🔹
failure.
•protein collection (12 or 24 hour)
Nifedipine acts rapidly ,causing significant reduction in arterial blood pressure within 10 to 20 minutes of oral
administration .Start with 10 mg orally and repeat in 30 minutes if necessary.
•Serum creatinine level
•Serum uric acid level
🔹Sodium nitroprusside , in rare cases , may be indicated for acute hypertensive emergency after failure of hydralazine, 🔻 Women developing hypertension after 20 weeks of gestation:
nifedipine, and labetalol.
Same tests as in women at high risk plus:
🔻Corticosteroids for Acceleration of Fetal Pulmonary Maturity Serum transaminase levels
📍HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets) Antenatal corticosteroid therapy should be considered for all women who present with preeclampsia before 34 weeks’ Serum albumin level
syndrome: gestation. Lactic acid dehydrogenase level
is a life-threatening pregnancy complication usually considered to be Peripheral blood smear
a variant of preeclampsia. Both conditions usually occur during the
later stages of pregnancy, or soon after childbirth.
🔹
Therapies for HELLP Syndrome Coagulation profile
🔻
1. Prophylactic transfusion of platelets is not recommended, even prior to Caesarean section, when platelet count is >
50x109/L and there is no excessive bleeding or platelet dysfunction.
In women who have already been diagnosed with preeclampsia:
🔹
🔹 2. Platelet transfusion should be strongly considered prior to vaginal delivery when platelet count is < 20 109/L.
4. Corticosteriods may be considered for women with a
•antepartum testing with a nonstress test, a biophysical profile, or both should be performed on a weekly basis starting
at the time of diagnosis.
🔹
platelet count < 50 x109 L.
5. There is insufficient evidence to make a recommendation regarding the usefulness of plasma exchange or
plasmapheresis. •If intrauterine growth retardation or oligohydramnios is suspected, the tests should be performed at least twice weekly,
and delivery should be contemplated if there are any signs of fetal compromise.
•Uterine artery Doppler velocimetry may be useful among hypertensive pregnant women to support a placental origin
for hypertension, proteinuria, and/or adverse conditions.
•Umbilical artery Doppler velocimetry may be useful to support a placental origin for intrauterine fetal growth
restriction.
by fatema okoff
