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Hypertensive Disorder During Pregnancy




Diastolic blood pressure


110 mmHg or higher


Trace to 1+

Persistent 2+ or more




Visual disturbances



Upper abdominal pain








Present (eclampsia)

Serum creatinine






Liver enzyme elevation



Fetal growth restriction



Pulmonary edema












Preterm labor




HELLP Syndrome, DIC





Antihypertensives in pregnancy:

  1. Alpha methyldopa
  2. Nifedipine
  3. Hydralazine
  4. Labetalol

ACE inhibitors are contraindicated.


Extra Edge: As per the latest guidelines


DOC for hypertension in pregnancy = Labetalol followed by alpha methyldopa


DOC for hypertensive crisis in pregnancy = Labetalol followed by hydralazine



Mild PIH

Severe PIH


1. Antihypertensives- Role is doubtful.

2. No proven efficacy. Generally bed rest and some diet restrictions are done.

3. Definitive management- (as discussed earlier will always be)

4. Termination of pregnancy done at 37 completed weeks of pregnancy

1. 1st step in management is seizure

2. prophylaxis-MgSO 4

3. Antihypertensives should be given to decrease BP in a controlled manner without compromising the utero- placental perfusion. Aim-Systolic BP should be between-140 to 155 mmHg and

4. Diastolic BP should be between 90 to 105 mm of Hg

5. Definitive management is -

6. termination of pregnancy at 34

7. completed weeks

1. 1st step in management- Airway management

2. Drug to control seizures- MgSO4

3. Anti hypertensives to control BP

4. Definitive management- immediate termination of pregnancy.

  1. On antihypertensives, if the BP is under control and there are no premonitory symptoms, then the pregnancy is allowed to continue till 37 weeks (keeping a close watch on maternal and fetal well-being)
  2. Thereafter, the patient should be delivered even if the BP is under control, as the risks of continuation of pregnancy far outweigh the benefits (as this is a pregnancy-induced condition and delivery is the ultimate or definitive treatment for pregnancy-induced hypertension).
  3. It is not advisable to wait beyond 37 weeks because the BP can rise and there can be complications (eclampsia, HELLP syndrome, IUFD, abruption, DIC, etc) and there are no added benefits of continuing pregnancy beyond 37 weeks.

Root of Delivery

Indications for termination of pregnancy irrespective of the weeks of gestation in case of preeclampsia are:

  1. Severe preeclampsia, with impending eclampsia
  2. Eclampsia (give MgS04 first, followed by induction of labor)
  3. HELLP syndrome.

Prediction of Preeclampsia

  1. Roll-over test: A positive test is an elevation of >20 mmHg when patient rolls over from lateral to supine position.
  2. Urinary calcium 12 mg% in 24 h has good positive and negative predictive values for diagnosis of preeclampsia.
  3. Uric acid: elevated levels of serum uric acid (More than 5.9 mg/dl at 24 weeks).
  4. Doppler ultrasound:
    1. Persistence of diastolic notch on uterine artery waveforms on color Doppler at 18-20 weeks of gestation.
    2. Measurement 01 uteroplacental vascular resistance during Doppler ultrasound evaluation of uterine artery impedance in the second trimester has been used as an early screening test for preeclampsia. The rationale for this is based on the presumption that the pathophysiology of preeclampsia includes impaired trophoblastic invasion of the spiral arteries leading to reduction in utero placental blood flow.
  5. Fibronectin: Patients with preeclampsia have elevated levels of plasma fibronectin, a glycoprotein.
  6. Fetal DNA – Identification of fetal DNA in maternal serum also predicts preeclampsia.
  7. Angiotensin sensitivity test: It is based on the fact that women destined to develop preeclampsia lose their refractoriness to angiotensin between 28-32 weeks. If a pressure response occurs with <8ng/kg/min of infused angiotensin, 90% are likely to develop preeclampsia.
  8. Mean arterial pressure in second trimester: if mean arterial pressure is ≥ 90 mmHg in second trimester chances of developing preeclampsia increase.

Impending Eclampsia

The dangerous symptoms (premonitory symptoms) that indicate impending eclampsia in case of preeclampsia are:

  1. Headache
  2. Oliguria
  3. Epigastric pain
  4. Nausea, vomiting
  5. Blurring of vision

Whenever the above symptoms develop in a case of severe preeclampsia the patient is at a risk of eclampsia; the patient should be given anticonvulsant (MgSO4) and antihypertensive medication, and the patient to be delivered irrespective of the weeks of gestation.

'"Magnesium sulfate is the drug of choice for eclampsia and also for impending eclampsia. Prophylactic magnesium sulfate decreases the risk of convulsion, abruption, and maternal mortality in this scenario.

The indications for termination of pregnancy irrespective of the weeks of gestation in a case of preeclampsia are:

  1. Severe preeclampsia, with impending eclampsia
  2. Eclampsia (give MgSO4 first, followed by induction of labor)
  3. HELLP syndrome.

Prevention of hypertension in pregnancy

  1. Low-dose aspirin
  2. Antioxidants (vitamin E, vitamin A, vitamin C, and lycopene)
  3. Calcium (2g/ day)
  4. Omega 3 fatty acids
  5. Antithrombotic agents: Low dose aspirin 60 mg daily beginning early in pregnancy in potentially high risk patients is given. It selectively reduces platelet thromboxane production.
  6. Heparin is useful in women with thrombophilia and with high risk pregnancy.

Criteria for the diagnosis of HELP syndrome

Hemolysis (H)


         Schistocytes in the blood smear

         Bilirubin >1.2 mg/dL

         Absent plasma haptoglobin


Elevated liver enzymes (EL)


         SGOT >72 IU/L

         LDH >600 IU/L


Low platelet count (PL)


         Platelets <100 x 103/mm3





Antepartum (50%)


Intrapartum (30%)


Postpartum (20%)


Mechanisms implicated in the etiology of eclamptic convulsion

  1. Cerebral edema and hemorrhage
  2. Cerebral infarction
  3. Cerebral vasospasm
  4. Metabolic abnormality
  5. Hypertensive encephalopathy

Prevention and treatment of convulsions with magnesium sulfate


Magnesium sulfate is the DOC for eclampsia and it is also the DOC for severe preeclampsia with impending eclampsia (prophylactic magnesium sulfate can prevent convulsions and it also decreases the risk of abruption MAGPIE trial).

It can be given by various protocols:

  1. Pritchard
  2. Sibai
  3. Zuspan
  4. Sardesai

Pritchard Protocol


Loading dose: (15gm)


4 g (20 mL of 20%) IV over 4 min (only in severe preeclampsia-eclampsia) immediately followed by 10 g (20 mL of 50%) IM-5 g in each buttock (15gm)


If convulsions persist after 15 min: IV 2 g (10 mL of 20%) over 2 min (if the woman is large-4 g)



5g (10mL of 50%) IM every 4 h-alternate sides

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