Hypertensive disorders in pregnancy are conditions where blood pressure (BP) is ≥140/90 mmHg after 20 weeks of gestation, with or without proteinuria and organ dysfunction.
Classification of Hypertensive Disorders in Pregnancy
- Chronic Hypertension
- Gestational Hypertension
- Preeclampsia
- Eclampsia
- Chronic Hypertension with Superimposed Preeclampsia
1. Chronic Hypertension
- BP ≥140/90 mmHg before pregnancy or before 20 weeks gestation.
- No proteinuria or organ dysfunction.
- Persists beyond 12 weeks postpartum.
Management:
- Monitor BP regularly.
- Antihypertensives:
- Labetalol (First-line).
- Methyldopa (Safe in pregnancy).
- Nifedipine (CCB).
- Avoid ACE inhibitors & ARBs (cause fetal renal defects).
2. Gestational Hypertension
- New onset BP ≥140/90 mmHg after 20 weeks gestation.
- No proteinuria or organ dysfunction.
- Resolves within 12 weeks postpartum.
Management:
- Monitor BP & fetal growth.
- If BP >160/110 mmHg, start antihypertensive therapy.
3. Preeclampsia
- Hypertension (BP ≥140/90 mmHg) after 20 weeks gestation with proteinuria (≥300 mg/24 hours) OR signs of organ dysfunction.
Risk Factors for Preeclampsia:
- Primigravida
- Multiple pregnancy
- Chronic hypertension, diabetes, kidney disease
- Obesity, advanced maternal age (>35 years)
Severe Preeclampsia (Signs of End-Organ Damage):
- BP ≥160/110 mmHg
- Severe proteinuria (>5 g/24 hrs, or dipstick ≥3+).
- Oliguria (<500 mL/day).
- Neurological Symptoms: Headache, visual disturbances.
- Pulmonary Edema or Cyanosis.
- Hepatic Dysfunction (Elevated AST/ALT).
- Thrombocytopenia (<100,000 platelets).
- HELLP Syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets).
Management of Preeclampsia:
- BP Control:
- Labetalol (First-line).
- Nifedipine (Oral for moderate cases).
- Hydralazine (IV for acute severe hypertension).
- Seizure Prophylaxis:
- Magnesium sulfate (MgSO₄) loading dose 4g IV, followed by 1g/hr infusion.
- Delivery:
- ≥37 weeks: Induce labor.
- <34 weeks: Corticosteroids for fetal lung maturity.
4. Eclampsia
- Severe preeclampsia with new-onset seizures.
Clinical Features of Eclampsia:
- Generalized tonic-clonic seizures.
- Severe headache, visual disturbances.
- Hyperreflexia.
Management of Eclampsia:
- Seizure Control:
- Magnesium sulfate (MgSO₄) IV/IM (Loading dose: 4-6g IV, maintenance 1-2g/hr).
- Monitor for toxicity (Loss of deep tendon reflexes, respiratory depression).
- BP Control:
- Labetalol or Hydralazine IV.
- Immediate Delivery:
- Stabilize mother, then proceed to vaginal/cesarean delivery.
5. Chronic Hypertension with Superimposed Preeclampsia
- Preexisting hypertension that worsens after 20 weeks with new-onset proteinuria or organ dysfunction.
- Increased risk of maternal & fetal complications.
- Managed as severe preeclampsia.
Complications of Hypertensive Disorders in Pregnancy
Maternal Complications:
- Eclampsia (Seizures, Stroke).
- HELLP Syndrome.
- Disseminated Intravascular Coagulation (DIC).
- Placental Abruption.
- Pulmonary Edema, Multi-organ failure.
Fetal Complications:
- Intrauterine growth restriction (IUGR).
- Preterm birth.
- Intrauterine fetal demise (IUFD).
- Neonatal respiratory distress syndrome.
Summary Table: Hypertensive Disorders in Pregnancy
|
Condition |
BP |
Proteinuria |
Onset |
Management |
|
Chronic HTN |
≥140/90 (before 20 wks) |
Absent |
Before pregnancy/early pregnancy |
Antihypertensives (Labetalol, Methyldopa) |
|
Gestational HTN |
≥140/90 (after 20 wks) |
Absent |
After 20 weeks |
Monitor BP, deliver at term |
|
Preeclampsia |
≥140/90 (after 20 wks) |
Present (≥300 mg/24 hr) |
After 20 weeks |
BP control, MgSO₄, delivery |
|
Eclampsia |
≥140/90 |
Present |
Seizures |
MgSO₄, BP control, delivery |
|
Superimposed Preeclampsia |
Pre-existing HTN + worsening |
New-onset proteinuria |
After 20 weeks |
Treat as severe preeclampsia |
