Based on the case, this is a high risk pregnancy with multiple risk factors for preeclampsia: 1. Obesity 2. Previous preeclampsia 3. Chronic hypertension Given the history of preeclampsia in the previous pregnancy requiring early delivery, close monitoring is needed in this pregnancy. Some key points: - Monitor blood pressure closely and watch for signs of worsening preeclampsia like increasing proteinuria - Consider earlier delivery between 34-37 weeks given previous preterm delivery for preeclampsia - Ensure magnesium sulfate is available in case of eclampsia during delivery - Optimize diabetes and blood pressure control to reduce risks - Counsel on signs and symptoms of

1. HYPERTENSIVE DISORDER
IN PREGNANCY

2. Hypertensive disorders in pregnancy remains a common cause of direct maternal death
worldwide. The mortality is related to intracranial hemorrhage from poorly controlled
hypertension. Furthermore, pre-eclampsia is frequently accompanied by FGR, which is
associated with perinatal morbidity and mortality.
In Malaysia, it is the third most common cause of death (Confidential Enquiry into Maternal
Deaths; CEMD 2019)
Goals:
 To ensure optimal treatment of preeclampsia
To attain clinical judgemet in prolonging the pregnancy long enough for fetal
maturity while preventing complications from preeclampsia
 To effectively prevent and manage eclampsia

3. Source: Confidential Enquiries into
Maternal Deaths 2019

4. Source: CPG Management of Hypertension 5th Edition
DEFINITION
Hypertension in pregnancy SBP ≥140 mmHg and/or DBP ≥90mmHg
Proteinuria
* reflects advanced disease and is
associated with poorer prognosis
≥300mg protein in 24H urine sample, or a spot urine protein-creatinine
ratio ≥30mg/mmol, or urine dipstick ≥2+ (approximated ≥300mg/day proteinuria)
20 weeks
gestation
3 months
postpartum
Gestational Hypertension
Chronic Hypertension
Preeclampsia
+ proteinuria
de novo
superimposed
on chronic HPT
Eclampsia
+ fits

5. Source: International Society for the Study of Hypertension in Pregnancy (IS
CLASSIFICATION OF HPT IN PREGNANCY
Gestational HPT
HPT detected after 20wks gestation
25% can progress into PE, more so if present before 34 weeks
Chronic HPT
• HPT diagnosed prior to 20wks gestation
• HPT during preconception
• De novo HPT in late gestation that fails to resolve 3 months
postpartum
Isolated office
hypertension
Elevated BP of 140/90 mmHg only in the clinic with normal BP
demonstrated by ambulatory BP monitoring (ABPM) either awake or
during sleep
Women in this group should not be considered low risk as they may progress to
gestational hypertension (50%) or PE (8%)

6. Source: International Society for the Study of Hypertension in Pregnancy (IS
CLASSIFICATION OF HPT IN PREGNANCY
Preeclampsia (PE) ≥1 of the following:
De Novo
• Significant proteinuria
• Renal insufficiency: Cr≥90 or oliguria
• Liver disease: raised AST/ALT +/- severe RUQ pain/epigastric pain
• CNS problems: convulsions (eclampsia), hyperreflexia with clonus or
severe headaches, persistant visual disturbances (scotoma)
• Haematological problems: thrombocytopenia, coagulopathy,
haemolysis
• Fetal growth restriction
* followed by normalisation of BP by 3 months postpartum
Superimposed on Chronic
HPT
• De novo proteinuria after 20 weeks
• Worsening proteinuria in pre-existing proteinuria
• A sudden increase in the severity of HPT
• Appearance of features of PE

7. In normal pregnancies
PATHOPHYSIOLOGY OF PREECLAMPSIA
In cases of PIH/ Pre-
eclampsia
• Complete or partial failure of
throphoblastic invasion
• Retain pre-pregnancy characteristics: relatively
narrow bore, high resistance and low
capacitance
• Results in impaired perfusion of the
fetoplacental unit
• Hypoperfused placenta releases circulating
factor(s) wich causes vascular endothelial cell
activation, affecting multiple organ systems
• Maternal blood flow to placenta increases
from 50ml/min in the 1st trimester to 500-
750ml/min at term
• Achieved by anatomical convesion of the
maternal spiral arteries by trophoblast
• Trophoblast cells invade the spiral arteries
within 12 weeks of pregnancy and replace
the smooth muscle of the wall, converting
them to wide bore, low resistance, large
capacitance vessels.
• This process is normally complete by 20 wks

9. a)The maternal surface shows an ill-
defined area (arrows) which coincided
with the infarction hematoma.
b)Cut sections of the placenta show a
large round hemorrhagic lesion
surrounded by infarcted placental
tissues.
These lesions are significantly
associated with intrauterine fetal
death and growth restriction

13. ROLE OF PRIMARY CARE
Source: CPG Management of Hypertension 5th Edition
1. Preconception counseling and adjustment of treatment in women with chronic hypertension
Change in anti-hypertensives. Drugs of choice are Methyldopa and Labetolol.
Anti-HPT drugs contraindicated in pregancy:
• Atenolol → FGR
• ARBs, ACEIs and thiazide diuretics → Foetal anomaly
Women in reproductive age on the abovementioned drugs must be on effective contraception
The treatment of HPT in pregnancy is solely for maternal safety particularly the prevention of ICB.
It does NOT reduce the risk of development of preeclampsia or perinatal mortality, nor improve fetal growth.

14. Contraindicated
in asthma
Source: CPG Management of Hypertension 5th Edition

15. ROLE OF PRIMARY CARE
Source: CPG Management of Hypertension 5th Edition
2. Recognition of women risk of preeclampsia for commencement of prophylaxis
Moderate Risk
•Primigravida
•Age >40 years
•Pregnancy interval >10 years
•BMI of >35kg/m2 at first visit
•Family history of PE
•Multiple pregnancy
High Risk
•Hypertensive disease during previous
pregnancy
•Chronic kidney disease
•Autoimmune disease such as Systemic Lupus
Erythematosus (SLE) or anti- phospholipid
syndrome(APS)
•Type 1 or type 2 diabetes mellitus, and
chronic hypertension.

16. ROLE OF PRIMARY CARE
Source: CPG Management of Hypertension 5th Edition
3. Prophylactic therapy
a. Aspirin
Women with ≥2 moderate or >1 high risk factor should be started on low dose aspirin from 12 weeks up to
16 weeks of gestation until delivery. Dosage should be 100-150mg and taken ON in order to significantly
reduce the incidence of PE
b. Calcium
Low dose calcium supplement (generally 500-1000mg daily) commenced before 20 weeks gestation
reduces the r isk of PE
There is no proven role of vitamin D, nor other supplememnts in reducing the risk of PE. Combined
vitamin C and E should be avoided because they significantly increase the incidence of low birth weight
without any prevention effect against PE.

17. ROLE OF PRIMARY CARE
Source: CPG Management of Hypertension 5th Edition
4. Fetal anomaly screening
Women with chronic HPT have about 20-30% increased risk for fetal congenital cardiac anomaly. They
should be referred to Maternal-Fetal Medicine (MFM) specialist in the tertiary centre for nuchal
translucency (NT) scan at 12-14wks followed by detailed scan at 18-22wks of gestation. If a cardiac
abnomality is detected, cardiology referral is recommended.
5. Prevention of eclampsia and other complications of PE
Education on the signs and symptoms of preeclampsia for early diagnosis and referral for further
management may prevent progression into eclampsia

18. SEVERE PRECLAMPSIA
Source: CPG Management of Hypertension 5th Edition
Definition: (acc to the American College of Obstetricians and Gynaecologists)
a. SBP ≥160/ DBP ≥110 mmHg on two occasions at least 4 hrs apart while resting
b. Thrombocytopenia - Plt count <100
c. Abnormal liver enzymes (elevated AST/ALT), severe persistant RUQ/epigastric pain
unresponsive to treament
d. Pulmonary oedema
e. New onset of cerebral or visual disturbances
Principle of management include:
1) Control of BP (mangement of acute hypertensive crisis:
• IV Hydralazine, IV Labetolol or oral Nifedipine may be used to lower the BP.
• BP should be reduced within 30-60 minutes to reduce the risk of maternal stroke
• Diuretics are generally contraindicated as it reduces plasma volume → IUGR and may
increase perinatal mortality. Only used in the treatment of acute pulmonary oedema
2) Monitoring of maternal or fetal complications
3) Seizure prophylaxis
4) Timely delivery

20. IV Labetolol Protocol
IV Labetolol 10mg STAT (2cc-PURE) over 1
minute and repeat at 5 minute intervals
(max dose: 200mg (40cc)
Infusion syringe pump:
200mg IV Labetolol (40cc) in 50cc syringe and
start at 4cc/hr, and increase by 4cc at 30 minutes.
Stop infusion if rate exceeds 150mg/hr (30cc/hr)
and inform specialist
1 vial = 5cc = 25mg
Effective dose: 20-150mg/hr (4-30cc/hr)
IV Hydralazine Protocol
Loading dose:
1 vial = 5cc = 20mg
Maximum dose: 10cc/hr
Dilution: 5cc Hydralazine + 20cc NS
• Start at 4cc/hr for 5 mins
• To check BP after 5 mins
• Then cont with maintenance dose
Maintenance dose:
• 1cc/hr
• check BP after 15 min
• icrease by 1cc/hr every 30 mins to titrate till DBP
100mmHg
• Maintain IV Hydralazine once DBP 90-100mmHg
• Titrate down once DBP <90mmHg
Antidote: IV Atropine 600mcg (bolus)

21. IV MgSO4 is the drug of choice for prevention of eclampsia and to abort an eclamptic fit.
It also provides fetal neuroprotection following the preterm birth with a significant reduction in the
incidence of cerebral palsy.
Alternative is IV Diazepam but it is inferior in
efficacy.
1.Start MgSO4, and continue for 24 hrs
following delivery or initiation
(whichever comes later).
2.Consider delivery once decision for
MgSO4 has been made.
Anticonvulsants in PE and Eclampsia
Source: Handbook of Obstetric Emergencies
by Dr Gunasegaran Rajan

22. IV MgSO4 Protocol
1) The Loading Dose
IV MgSO4 4g Slow Bolus
Source: Handbook of Obstetric Emergencies by Dr Gunasegaran Rajan
8cc MgSO4 + 12cc NS in 20cc syringe
run on IV infusion pump 80cc/hr to infuse
20cc in 15 mins
In case of eclampsia;
If fit persist >15minutes, add 2g MgSO4
4cc MgSO4 + 16cc NS in 20cc syringe
(infused at 80cc/hr)

23. Source: Handbook of Obstetric Emergencies by Dr Gunasegaran Rajan
IV MgSO4 Protocol
2) The Maintainence Dose
IV MgSO4 1g/hr
2cc MgSO4 + 48cc NS in 50cc syringe
run on IV infusion pump 50cc/hr for 24 hrs after the last fit or 24 hrs after delivery, whichever
comes later

24. MgSO4 Toxicity
1. Monitoring toxicity (hourly)
• ECG - prolonged PR interval, wide QRS complex
• Deep tendon reflexes must be present
• Urine output >30ml/hr (0.5cc/kg/hr)
• RR between 12 to 16/minute
• SPO2 >95%
• GCS E4V5M6
Source: Handbook of Obstetric Emergencies by Dr Gunasegaran Rajan
2. Antidote
1g Calcium Gluconate (10cc of 10% solution) given slow IV bolus over 10 minutes

25. Source: NICE guidelines 2020 hypertension in pregnancy and management
Fetal assessment
Example of Umilical Artery Doppler Wave Forms
A) Normal umbilical artery Doppler flow waveform
B) Absent
C) Reversed end-diastolic Doppler flow in umbilical artery
• Offer fetal heart auscultation at every antenatal appointment
• Carry out USG assessment of the fetus at diagnosis and, if normal, repeat every 2 weekly
• Carry out CTG at diagnosis and then only if clinically indicated; reduced FM/ PV bleed/
abdominal pain/ deterioration of maternal indication
USG assessment 2 weekly for non-PE women with previous:
• Severe PE
• PE requiring delivery <34 wks
• PE with SGA (<10th centile)
• IUD
• Placental abruptio

27. Source: NICE guidelines 2020 hypertension in pregnancy and management
Timing of birth
Weeks of
pregnancy
Timing of birth
<34 wks
34-36 wks
>37 wks
Continue surveillance unless there are indications for planned early birth. Offer IV
MgSO4 and IV Dexamethasone as per guidelines on preterm labour and birth
Continue surveillance unless there are indications for planned early birth.
When considering the option for planned early brith, take into account the woman/s
and baby’s condition, risk factors and availability of neonatal unit beds. Consider IV
Dexamethasone as per guidelines on preterm labour and birth
Initiate birth within 24-48 hrs
Indications for planned early birth:
• Inability to control maternal BP, despite using ≥3 antiHPT in appropriate doses
• Maternal SPO2 <90%
• Progressive deterioration in liver function, rel function, hemolysis or platelet count
• Ongoing neurological features; intractable headache, repeated visual scotoma, eclampsia
• Placental abruptio
• Reversed end-diastolic flow in the umbilical artery doppler velocimetry, a non-reassuring
CTG, or stillbirth

28. ECLAMPSIA OBSTETRIC
EMERGENCY
ACTIVATE RED ALERT
Place patient in left lateral position (recovery position)
Secure airway
Administer oxygen
• Give MgSO4 as per protocol
• IV access x2
• Commence antiHPT as per protocol
• Cont IV MgSO4 infusion as per protocol
• Auscultate heart and lungs
• Palpate abdomen, reflexes, assess fetal
condition
• VE and catheterize after BP stablised
• Decide mode of delivery
• Refer to anaethesia for ICU management
Blood Ix: FBC, LFT, RP, uric acid, coag profile, GXM
7 Principles of Managing Eclampsia

29. POSTPARTUM CARE
Source: CPG Management of Hypertension 5th Edition
• Postpartum, BP should be regularly checked at local clinics
• The dose of antihypertensives should be tailed down gradually
• On average, anti-HPT agents are required for longer in women with PE (~2wks) than those
with gestational hypertension (~1wk)
• Chronic HPT is diagnosed when HPT persists after 3 months postpartum.
LONG TERM FOLLOW-UP
• Evidence suggests 13% of women with PE will have underlying essential HPT that was not suspected
antenatally.
• There is increased risk of ischaemic heart disease, thrmboembolism and stroke following PE
• Long-term follow-up ot pts with a history of hypertension in pregnancy is advisable

30. Contraception Methods
The progestogen only pill, progestogen implants, copper intrauterine devices and levonorgestrel intrauterine systems can
be safely prescribed to women with well controlled hypertension

31. Case based Discussion
 Mrs.S/46y/M/G3P2 @37w1d
-Electively admitted for ELLSCS + B/L salphingectomy
Otherwise No ssx of labor/IE sx
Good FM
ANC
1.Maternal Obesity
BMI latest 40.6
ECHO EF 63%,NAD
2.GDM on treatment
MGTT x1: 5.6/4.8
HBA1c: 5.2%
Latest BSP:normal
On T.MTF 1g BD
s/c Insulatard 16u ON
3. HPT cx pregnancy
-diagnosed since 2nd pregnancy
-EMLSCS for PE with abnormal CTG @34w3d (Bp 182/118mmHg), protein +1
Bp postpartum:remains high, hence discharge with T.Labetalol
-Bp throughout this pregnancy range : 122-187/72-144
-latest PE profile(15/5/22): Normal
on T.Metyldopa 1g TDS, T.Nifedipine 10mg TDS
4.U/L 1 previous scar in 2020 at 34w3d for
EMLSCS for Pen with abnormal CTG
5.H/o admission at 33w5d
DX: Uncontrolled HPT in Pregnancy
-PE profile: Normal

32. O/E:alert, pink
Bp:140/74
Hr:76
T:37
PA:soft, non tender
Uterus at term size
Singleton,cephalic 4/5
EFW:2.6-2.8kg
No scar tenderness
TAS: singleton,cephalic, FH seen shwon to mother
Placenta :posterior upper segment
parameters: 34w5d-37w 5d
EFW: 2668 g
AFI 11
Subsequently admitted to ward 10 for op cm
Noted PE profile taken during admission deranged
Treated as
HELLP Syndrome
Plan
1.KNBM
2. Started on IV Mgso4 4g/slow bolus, followed by 1g/hr
3.T/o OICW
FBC 8/6/22
TWC 9.9
HB 12.1
PLT 99
Rp
Urea 7.2
Na 134
K 3.4
Creat 92
LFT
Uric acid 599
AST 41
LDH 265
ALT 41
Albumin 26
Coag
INR 0.90
Ufeme
Protein trace
Ketone negative

33.  Patient proceeded with Op at 0832H-0947H(8/6/22)
 Intraop: Uneventful, EBL 300cc
 Patient was T/O to OICW to continue Mgso4 1g/hr with Mgso4 toxicity charting/24Hr post
delivery
 At OICW,
Dx: 2Hr Post Op(1140H)
-noted Bp: 187/119mmHg
otherwise No IE ssx
Physical examination:Unremarkable
-Given IM Hydralazine 6.25mg
BP range:173-186/104-119
• Case D/W Dr.Marinah
• -to start IV Hydralazine infusion
Dx: 4hr Post Op(1400H)
-noted Bp was: 175/103mmHg
-started on T.nifedipine 10mg stat and TDS
-increased IVI Hydralazine to 4mg/Hr and titrated accordingly
Bp:Normotensive (131/76mmHg)at 1650H subsequently off IVI Hydralazine
At 1745H, noted Bp 162/100mmHg
-started on IVI hydralazine
• On 9/6/2022 at 0100H,
-noted BP: 129/78mmHg  off IVI Hydralazine
Continue T.Nifedipine
 Patient completed IVI Mgs04 at 1130H(9/6/2022)

34. FBC 7/6 8/6
PRE OP
8/6
POST OP
9/6 10/6 11/6 12/6 13/6
TWC 9.2 9.9 17.7 22 17.6 19.3 16 11
HB 13 12.1 13.6 11.4 10.2 8.8 6.8 8.2
PLT 119 99 140 167 181 238 238 227
RP 7/6 8/6
PRE OP
8/6
POST OP
9/6 10/6 11/6 12/6 13/6
UREA 7.2 7.2 7.5 8.8 9.8 6.9 4.09
NA 136 134 131 127 132 134 134
K 4 3.4 3.9 4.7 4.1 4 3.8
CREAT 93 92 81 96 106 91 68
URIC ACID 599 548

35. LFT/CE 7/6 8/6
PRE OP
8/6
POST OP
9/6 10/6 11/6
T PROT 58 64 64.7 62 68.1
ALB 26 26.5 27.7 27.9 30.4
GLOB 32 38 38 34 38
A/G 0.8 0.7 0.7 0.8 0.8
T BIL 17.6 21 13.6 12.2 11.2
ALP 161 186 170 161 157
AST 45 41 56 36
ALT 43 41 55 58 49 43
CK 53
LDH 265
COAG 7/6 8/6
POST OP
12/6
PT 12.2 12.6 12.2
INR 0.9 0.9 0.9
APTT 31.7 31.1 29.3
UFEME 7/6 8/6
POST OP
12/6
PROTEIN TRACE 2+ TRACE

36. REFERENCES :
1. Clinical Practice Guidelines - Management of Hypertension (5th Edition) 2018
MOH/P/PAK/391.18 (GU)
2. ISSHP guidelines in hypertension disorder in pregnancy
3. Handbook of Obstetric Emergencies by Dr Gunasegaran Rajan, Muniswaran Ganeshan,
Tang Boon Nee, Thaneemalai Jeganathan
4. Obstetrics by Ten Teachers 19th Edition