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

EpidemiologyHypertensive 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.

Classification

TypeDefinitionChronic HypertensionHypertension before pregnancy or before 20 weeks of gestation, and/or after 12 weeks postpartumPreeclampsia-eclampsiaPreeclampsia : hypertension and proteinuria at or beyond 20 weeks of gestation in previously normotensive womanEclampsia : preeclampsia with seizure and or coma.Chronic hypertension with superimposed preeclampsiaChronic hypertension with signs of preeclampsia or protenuria.Gestational hypertensionHypertension without proteinuria, developing after 20 weeks of gestation, during labor, or the puerperium in a previously normotensive nonproteinuric woman

Risk FactorFirst time motherHyperplacentosis such as: mola hidatidosa, multiple pregnancy, diabetes mellitus, hydrops fetalis and macrosomia.Extreme age (under 20 or above 40)Family history of preeclampsia or eclampsiaKidney diseases and hypertension before pregnancy.Obesity

Pathophysiology

The treatment of Hypertension during PregnancyBasically, the main therapy is to maintain the blood pressure within the normal range.Some therapy choices:MethyldopaPregnancy Termination-BlockerCa- Channel BlockerDiureticGlucocorticoidMgSO4

Gestational HypertensionPregnancy complicated by gestational hypertension is managed according to severity, gestational age, and the presence of preeclampsia.The therapy of gestational hypertension was intended to maintain the blood pressure within the normal range.

Treatment of Gestational HypertensionTerminationAnti-hypertensive therapyWomen with systolic >160 or diastolic >110 require anti-hypertensive therapy-BlockerLabetalol PO 200 mg every 8-12 hours. Dose and amount should be increased until blood pressure reahed the desired level.

Chronic HypertensionThe drug of choice that can be used for chronic hypertension treatment : BlockerLabetalol (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. Hydralazine2,5 mg (IV) initial dose, followed by 5 10 mg doses at 15 20 minutes interval.Maximum dose : 20 mgs

Chronic HypertensionCa Channel BlockerNifedipineInitial dose 10-30 mg (Oral) every 4-6 hoursReaches peak level ini 30 minutes after ingestion.

Treatment of Chronic HypertensionPregnancy TerminationPregnancy needs to be delivered earlier if the patient has high risk factor to develop complication and showing unstable condition.MethyldopaSite of action : Central Nervous SystemInitial 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-EclampsiaThe 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- Ca Channel Blocker- MgSO4-Glucocorticoid

Treatment of Pre-Eclampsia (Termination)Main TherapyTermination 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 Survival rate 10%, should be done considering the maternal complication

Treatment of Pre-EclampsiaCriteria to interrupt expectant manager and deliver:Blood pressure persistently 160/100 or greater despite treatmentUrine output

Treatment of Pre-Eclampsia (-Blocker & Ca-Channel Blocker)-BlockerLabetalolHydralazine

Ca-Channel BlockerNifedipine

Treatment of Pre-Eclampsia (MgSO4)Magnesium Sulphate administered for seizure preventionLoading dose: 30ml of 20% magnesium sulfate in 100 ml of normal saline over 15-20 minutesMaintenance 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 should be 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

EclampsiaTreatment of Eclamptic Seizure:Place the patient in lateral decubitusSuction oral secretionOxygen mask at 8-10 L/minuteElevate bedside railsPulse OximetryOnce 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/hourIf BP >150/100, give IV bolus Labetalol 20 mg initially, 40 mg and 80 mg in 15 minutes interval.

EclampsiaThe 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 200-400 mg every 12 hours should be administered.

EclampsiaEclampsia may occur ante, intra and post partum. Treatment of postpartum care, magnesium sulfate should be administered following 24 hours post-partum

ComplicationsLack of blood flow to the placenta, can lead to Fetal complications include intrauterine growth restrictionlow birth weightpreterm birth, that can lead to breathing problems for the babyintrauterine fetal deathPlacental abruptionHELLP syndrome Cardiovascular disease

Other complicationsintracerebral hemorrhagepulmonary edemadue to capillary leak, myocardial dysfunction, excess IV fluid administrationacute renal failuredue to vasospasm, acute tubular necrosis [ATN], or renal cortical necrosis, proteinuria greater than 4-5 g/dhepatic swelling with or without liver dysfunctionhepatic infarction/rupture and subcapsular hematoma which may lead to massive internal hemorrhage and shockconsumptive coagulopathy - associated with placental abruption