Hypertension in Pregnancy

Hypertensive disorders of pregnancy affect 10% of all pregnant women all over the world. Gestational Hypertension is diagnosed when blood pressure is exceeds 140mm Hg systolic or 90 mm Diastolic after 20 weeks of pregnancy in previously normotensive woman. If it is associated with proteinuria( protein loss in urine) in dipstick 1+ persistent it is called Preeclampsia.Preeclamsia can be associated with headache, visual disturbance,convulsions, epigastric pain etc.When preeclampsia is associated with convulsions, it is called Eclampsia.

Effects of high blood pressure - impaired liver function, renal insufficiency, pulmonary edema(fluid in lung), heart failure, cerebral & visual symptoms like headache, seizure, blurring of vision, abruption, fetal growth restriction, sudden intra uterine death of fetus etc.

Investigations- CBC, LFT, RFT, LDH, BT,CT, PT INR ,Urinary protein, USG upper abdomen and for Fetal well being.

Management- In mild hypertensionDaily blood pressure monitoring and evaluation of laboratory parameters is at least once a week. Frequency can be modified based on subsequent clinical findings. Women are instructed to report symptoms of severe preeclampsia (severe headache, visual symptoms, epigastric pain, shortness of breath). The development of new sign or symptoms of severe preeclampsia or severe hypertension or evidence of fetal growth restriction require immediate hospitalization. In additions increased concentration of liver enzymes or thrombocytopenia require hospitalization. Fetal evaluation includes daily kick count, ultrasound to determine fetal growth.

Medical therapy- Corticosteroids, Magnesium sulfate prophylaxis and antihypertensive medications.

• corticosteroids for fetal lung maturity if pregnancy is less than 34 weeks.
• Antihypertensive drug- start antihypertensive if BP levels persistently at or above 140mmHg systolic or 90mmHg diastolic or both. Tablet Labetalol 100 mg is first line medicine in hypertension in pregnancy.
• Magnesium sulfate (MgSO4) in case of sever preeclampsia or eclampsia.

When to deliver?

Best practice indicates hospitalization and delivery of patient of preeclampsia without severe feature if one or more of the followings:

• 37 weeks or more of gestation

• Suspected abruption 

• 34 weeks or more plus any of the following -Progressive labor or rupture of membrane, USG estimate of fetal weight less than 5th percentile Oligohydroamnios ( AFI<5).

Delivery is recommended when gestation is 34weeks or more in severe preeclampsia and immediately with any of maternal complication irrespective of the period of gestation.

Post partum monitoring :All of these women should receive postnatal counseling regarding further management. BP should be monitored regularly. If women have persistent postpartum hypertension BP of ≥ 150/100 mm Hg, on at least two occasions 4-6hrs apart, Antihypertensive therapy is suggested. If the blood pressure is stable and well-controlled, and there are no other features of severe disease women may be discharged. For the 1st week after blood pressure should be checked at least every other day, and then weekly. The antihypertensive medication can be reduced and then stopped when target blood pressures are achieved. If blood pressure not return to normal by 12 weeks postpartum it is called as chronic hypertension.

Prevention-regular exercise, calcium supplementation if women are calcium deficient. antioxidants like vitamin C, D , E  are tried for prevention.

So all pregnant women should have monitored their blood pressure regularly at each and every antenatal visit. Because high blood pressure is the leading cause of maternal and perinatal morbidity and mortality . The majority of which are avoidable through the provision of timely and effective care to the women presenting with these complications.