HYPERTENSIVE

DISORDER IN
PREGNANCY ( HDP )
PERINATAL CARE MANUAL 4TH EDITION 2021 AND
KELANTAN OBSTETRIC SHARED CARE GUIDELINE 1ST EDITION
2020

DR WAN FAIZAH BINTI MOHAMED

O&G HRPZ 2
INTRODUCTION

• High mortality – common cause of direct maternal death worldwide

• Prevalence of HDP worldwide : 5-10%.
• Malaysian data: NOR 2018-2020: 3.10%
• Gestational hypertension was highest prevalence of 58.6%
• Fetal complications: Prematurity, IUGR, IUD
• Maternal complications: Abruptio placenta, APO, intracranial hemorrhage, DIVC
• Mortality commonly associated with intracranial hemorrhage from poorly
controlled hypertension
INTRODUCTION
OUTLINE OF PRESENTATION

• Definition of HDP
• Classification of HDP
• Risk factors of Pre-eclampsia
• Prevention of Pre-eclampsia
• Severity of HDP
• Management of HDP
DEFINITION OF HDP (PERINATAL CARE
MANUAL)
DEFINITION OF HDP

Perinatal Care Manual 4th edition:

SBP ≥ 140 and or DBP ≥ 90 of at least 2 occasions 4-6 hours apart

Kelantan Obstetric Shared Care Guideline:

SBP ≥ 140 and or DBP ≥ 90 of at least 2 occasions after period of rest
CLASSIFICATION OF HDP

• Gestational hypertension
• Pre-eclampsia
• Chronic hypertension
• Chronic hypertension with superimposed pre-eclampsia

ISSHP 2013
Classifications definition
Gestational hypertension New onset hypertension after 20 weeks of gestation in a previously normotensive
women
CLASSIFICATIONS
Pre-eclampsia (PE ) OF HDP
New onset hypertension after 20 weeks of gestation in a previously normotensive
women and coexistence of ≥ 1 of the following new onset conditions
i. Significant proteinuria
ii. Renal impairment: serum creatinine ≥ 90 micromol/L or ≥ 2x normal value
iii. Liver transaminase : AST/ALT value > 40 iu/L or ≥ 2x normal with or without
RUQ pain
iv. Hematological complications : platelet count < 150,000 , DIVC or Hemolysis
v. Neurological complications : eclampsia, altered mental status, severe headache,
acute blindness or blurring of vision
vi. APO
vii. Placenta insufficiency: IUGR , abnormal umbilical artery doppler ,or abruptio
placenta
Chronic hypertension Hypertension diagnosed prior to pregnancy
Or new onset hypertension before 20 weeks of gestation
Or hypertension newly diagnosed in pregnancy however persist beyond 6 weeks
postpartum
Chronic hypertension with Underlying chronic hypertension with new onset of
superimposed PE i. Uncontrolled hypertension or
ii. Significant proteinuria / presence of end organ involvement
iii.Sudden increase in a proteinuria in a patient with known proteinuria
 SIGNIFICANT PROTEINURIA

• 24 hour urine protein: ≥ 300 mg in 24 hour or

• Spot urine protein/creatinine index: urine PCI ≥ 30 mg/dL
• If urine dipstix +1 ( 30 mg/) need to perform urine PCI to confirm diagnosis of Pre-
eclampsia
• If negative urinalysis for proteinuria, further test is not required at that time
• Proteinuria is not a requirement for diagnosis of Pre-eclampsia ( 25% of cases of Pre-
eclampsia is nonproteinuric)
• Massive proteinuria (5gm/ 24 hrs ) is associated more severe adverse perinatal outcomes

ISSHP 2018
RISK FACTORS OF PRE-ECLAMPSIA

MAJOR RISK FACTORS MODERATE RISK FACTORS

• Chronic Hypertension • Primigravida
• Hypertensive disease in previous • Birth interval > 10 yrs
pregnancy • Multiple pregnancies
• Chronic renal disease • Family history of pre-
• Autoimmune disease ( SLE, APS) eclampsia
• Type 1 or 2 Diabetes mellitus • Age ≥40 yrs

• ART • BMI ≥30 kg/m²

PRE-PREGNANCY CARE (PPC)
• Refer FMS for Assessment of disease controlled , complications of diseases and
counselling
• Chronic hypertension: Screen for secondary causes of young hypertension: RAS,
autoimmune disease and renal disease
• Optimization of treatment for disease complications
• To review safety of medications: are associated with congenital fetal anomaly . To
change to another antihypertensive in pregnancy
• Pregnancy care plan : early booking, explain role of Pre-eclampsia prophylaxis
PREVENTION OF PRE-ECLAMPSIA

• Aspirin and Calcium has been shown to prevent onset or progression of severe Pre
eclampsia in a women with high risk of Pre-eclampsia
• Recommended for Aspirin 150 mg OD taken at night started at 12-16 weeks gestation
until 36 weeks gestation for significant benefit. It can be continued until delivery
• However it is still beneficial if started at < 28 weeks gestation
( PCM : < 20 weeks )
• Can be replaced with oral Cardiprin 100 mg OD if contraindicated for Aspirin
• Also recommended for oral Calcium carbonate 1 g BD or Calcium lactate 600 mg
TDS from 20 weeks of gestation until delivery( calcium carbonate is preferred due to
better absorption)
ACOG 2020
MANAGEMENT OF HDP: AT BOOKING / DIAGNOSIS OF HDP

• Assessment of severity and complications:

• History and clinical examination: To exclude end organ involvement
• Blood for baseline PE profile: FBC, RP, LFT, uric acid , urine albumin
• Dating scan – to confirm date and fetal viability
• Start PE prophylaxis for high risk patients
• Chronic hypertension :
 ECG KIV for ECHO if evidence of LVH
 To review antihypertensive
SEVERITY OF HDP( KELANTAN OBSTETRIC SHARED
CARE)
Severity Criteria
Mild SBP 140-149 and or DBP 90-99 mmHg without proteinuria

Moderate SBP 150-159 and or DBP 100-109 mmHg

Severe Severe Pre-eclampsia : SBP ≥ 160 and or DBP ≥ 110 mmHg with presence of ≥ 1
severe features of Pre-eclampsia
.Neurological symptoms: severe headache ,eclampsia
.Visual symptoms: exudate, hemorrhage, loss of vision
.Severe persistant epigastric or upper quadrant pain
.APO
.Significant proteinuria
.Oliguria
.Transaminitis ( AST/ ALT > 2x normal )
. Derranged RP: Sr creatinine >1.2 mg/dL
.Thrombocytopenia
.Placental insufficiency: IUGR, abruptio placenta
SEVERITY OF HDP (PERINATAL CARE MANUAL)
ANTENATAL FOLLOW-UP OF HDP

MATERNAL SURVEILLANCE FETAL SURVEILLANCE

• Individualized BP monitoring according
to severity • SFH measurement
• Weight measurement • FKC
• Urine protein measurement , 24 hours • Monthly TAS for fetal growth starting at
urine protein / urine PCI if indicated 28 weeks gestation
• PE profile every trimester
• Education and advise mother to come
immediately if having symptoms and
signs of severe PE .
NICE 2019 (UPDATED)
• Offer pharmacological treatment if BP
remains above 140/90 mmHg
• Aim for BP of 135/85 mmHg or less
• Consider reducing or withhold
antihypertensive if BP ≤ 110/70
BP MONITORING AND TARGET BP

PERINATAL CARE MANUAL KELANTAN OBSTETRIC SHARED

CARE MANUAL
• Target BP: 140-149 / 90-99 mmHg • Start antihypertensive when BP
• To consider reducing antihypertensive if persistent ≥ 140/90 mmHg
BP <140/90 • Target BP: 110-140 mmHg / 80-85
mmHg
• Avoid BP < 110/80 mmHg. Consider
reducing antihypertensive if BP < 110/80
MANAGEMENT OF MILD-MODERATE HDP:
PERINATAL CARE MANUAL
MILD HDP MODERATE HDP/ PRE-ECLAMPSIA
• Manage at health clinic by MO, weekly BP
monitoring • Refer FMS / O&G at
• First assessment by FMS at 20 weeks and
diagnosis
at 32-34 weeks
• Option of antihypertensive • Refer for admission if
• <20 weeks: T methyldopa evidence of proteinuria
• >20 weeks: T methyldopa, T labetolol, T
• Biweekly PE profile
nifedipine
• For FMS review once patient started on • Delivery plan by O&G at 36
antihypertensive
weeks
• Refer for delivery plan by O&G at 36
weeks
MANAGEMENT OF MILD-MODERATE HDP:
KELANTAN OBSTETRIC SHARED CARE
GUIDELINE
• Refer FMS for GH / PE on medications
• Plan delivery at 38 weeks if on antihypertensive
• Plan delivery at 40 weeks if not on antihypertensive
ANTIHYPERTENSIVE IN MILD TO
MODERATE HYPERTENSION
MANAGEMENT OF SEVERE HDP /SEVERE PRE-ECLAMPSIA

Principals of management of severe HDP

1. Blood pressure stabilization: T Nifedipine, IV labetolol, IV
Hydralazine bolus/infusion
2. Prophylaxis against eclampsia : IM / IV MgSO4
3. Assessment of maternal and fetal complications
4. Timely delivery
MANAGEMENT OF SEVERE HDP

• Discussion with FMS and referral to O&G specialist for admission

• Stabilization of BP prior to transfer: T Nifedipine 10 mg stat . May consider
parenteral antihypertensive if uncontrolled BP
• Loading dose of IM or IV MgSO4 5 g each buttock prior to transfer.
• IM dexamethasone first dose 12 mg stat if pregnancy at 24-36 weeks gestation
• May request for Obstetrics Emergency Retrieval Team ( OERT ) if available
PARENTERAL ANTIHYPERTENSIVE: IV
LABETOLOL
PARENTERAL ANTIHYPERTENSIVE : IV
LABETOLOL
IV Labetolol bolus
• IV labetalol 10mg (2mls) over 1 minute and repeat at 15 minute intervals
(Maximum dose: 200mg (40mls).
• Effective dose: 20-150mg/hr (4-30mls/hr)
IV Labetolol Infusion Syringe Pump
• 200mg or 40mls Labetolol in 50mls syringe
• Start at 20mg/H = 4mls/H
• Increase at every 30 minutes of 4mls/H. i.e: 4mls/8mls/12mls/16mls
• Stop infusion if rate exceeds 160mg/hr (32mls/hr) or infusion > 4H and inform
specialist
**Hydralazine should be considered if BP is uncontrolled after infusion of IV
Labetolol at maximum rate of 160mg/hr(32ml/hr)
IV HYDRALAZINE BOLUS FOR RAPID CONTROL

• Dilute 20mg Hydralazine in 20mls Normal saline, to give 5mls=5mg Hydralazine

• Give IV Hydralazine 5mg over 5-10 minutes
• Repeat every 20 minutes only if DBP remained ≥110mmHg (1-10mg/hr infusion is
preferred).
• Repeated dose up-to 3 doses of IV Hydralazine every 20 minutes (Total max: 15mls=15mg)
*** If SBP≥180 mmHg or in situation when rapid BP controlled is desired 3rd bolus dose of
IV Hydralazine may be given at the discretion of managing specialist.
*May continue with oral maintenance dose once DBP reach ≤100mmHg.
IV HYDRALAZINE INFUSION
Syringe Pump.
• Dilute 40mg hydralazine in 40mls normal saline ie. 1mg/ml
• Start at 5mls/H= 5mg/H
• Increase every 20 minutes by 1ml/H=1mg/H
• Maximum dose of 10mls/H or 10mg/H - need for alternative anti-hypertensive agent
(second line) if BP still not controlled.
• Duration of infusion: 2-3 hour
Infusion Pump.
• Dilute 40mg hydralazine in 100mls normal saline = 0.4mg in 1mls
• 60 drop/H=3mls/H=1.2mg/H
• Start at 240 drop/H = 12mls/H or 4.8mg/H
• Titrate every 15-20 minutes at 60 drop/H=3ml/H or 1.2mg/H
• Maximum: 25mls/H=10mg/H or 500 drop/H
• Duration of infusion : 8 hour
PROPHYLAXIS FOR ECLAMPSIA
IV
DELIVERY

 Definitive management of severe HDP is delivery of fetus.

 Mode of delivery dependent on gestational age, fetal and maternal condition
Gestational age Delivery
≥ 37 weeks Delivery indicated.

34- 36+6 weeks Delivery indicated

Consider IM dexamethasone 12 mg bd x 2 doses.
May proceed with delivery without completion of IM dexamethasone

< 34 weeks For delivery if uncontrolled BP or developed complications of severe

PE: e.g : HELLP syndrome, APO, abruptio placenta
For completion of Antenatal corticosteroid prior to delivery
NICU backup
POSTPARTUM MANAGEMENT OF HDP

• To notify health clinic on discharge.

• EOD BP monitoring , urine protein and signs and symptoms of severe PE
• TCA 2/52 for MO review or earlier
• Continue BP monitoring until 6/52 postpartum
• To continue antihypertensive and tail down gradually aim BP <140/90.
• To diagnose chronic hypertension if BP ≥ 140/90 at 6/52 postpartum