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The normal systolic blood pressure is less than 140 mm Hg and the diastolic blood pressure is less than 90 mm Hg.
Hypertension during pregnancy is defined as a diastolic blood pressure of 90 mm Hg or more and/or a systolic blood pressure of 140 mm Hg or more.
A diastolic blood pressure of 90 mm Hg or more and a systolic blood pressure of 140 mm Hg or more during pregnancy is abnormal.
During pregnancy an abnormally high blood pressure is often accompanied by proteinuria.
Proteinuria is defined as an excessive amount of protein in the urine. Normally the urine contains no protein or only a trace of protein. Therefore, a trace of protein in the urine is not regarded as abnormal.
Proteinuria during pregnancy is diagnosed when 1+ or more protein as measured with a reagent strip (e.g. Albustix, Labstix, Uristix, Multistix, Lenstrip, etc).
Proteinuria during pregnancy may also be caused by:
Patients with proteinuria must be asked to collect a second sample, as a midstream specimen of urine (MSU). The correct method of collecting an MSU must be carefully explained to the patient. The amount of proteinuria present in the MSU must be recorded in the notes. The further management will be dictated by the amount of proteinuria in the MSU.
1+ or more protein in the urine is abnormal.
Pre-eclampsia presents with hypertension and proteinuria which develop in the second half of pregnancy (20 weeks or more). Pre-eclampsia may present during pregnancy, labour or the puerperium.
Pre-eclampsia is also called gestational (pregnancy induced) proteinuric hypertension.
In contrast to pre-eclampsia, gestational hypertension is not accompanied by proteinuria but also presents in the second half of pregnancy. Should proteinuria develop in a patient with gestational hypertension, the diagnosis must be changed to pre-eclampsia.
Pre-eclampsia presents with hypertension and proteinuria in the second half of pregnancy.
Chronic hypertension is hypertension, with or without proteinuria, that presents during the first half of pregnancy. There is usually a history of hypertension before the start of the pregnancy.
This is hypertension presenting during the first half of pregnancy that is complicated by the appearance of proteinuria during the second half of pregnancy. In other words it is chronic hypertension that is complicated by the development of pre-eclampsia.
Eclampsia is a serious complication of pre-eclampsia that presents with convulsions during pregnancy, labour or the first 7 days of the puerperium. Convulsions can also be the result of other causes, e.g. epilepsy, but the possibility of eclampsia must be carefully ruled out whenever convulsions occur.
Pre-eclampsia is the hypertensive disorder of pregnancy which occurs most commonly and also causes most problems for the mother and fetus.
Gestational proteinuric hypertension and chronic hypertension with superimposed pre-eclampsia will be discussed under the heading ‘pre-eclampsia’ because the management is similar.
In the Western Cape of South Africa 5–6% of all pregnant women develop pre-eclampsia.
Yes, it is one of the most important causes of maternal death in most parts of southern Africa.
The most important complications of pre-eclampsia are also important causes of maternal death during pregnancy:
The risk of intracerebral haemorrhage is especially high if the diastolic blood pressure is 110 mm Hg or more and/or a systolic blood pressure of 160 mm Hg or more.
No, eclampsia can occur at a much lower blood pressure, especially in young patients.
Pre-eclampsia is an important cause of perinatal death because:
Pre-eclampsia may result in intra-uterine growth restriction, fetal distress, preterm delivery and intra-uterine death.
The severity of pre-eclampsia can be graded by:
Patients with pre-eclampsia can be divided into 4 grades of severity:
Pre-eclampsia. A diastolic blood pressure of 90 to 109 mm Hg and proteinuria, and/or a systolic blood pressure of 140 to 159 mm Hg, plus proteinuria.
Imminent eclampsia. These patients have symptoms and/or signs that indicate that they are at extremely high risk of developing eclampsia at any moment. The diagnosis does not depend on the degree of hypertension or the amount of proteinuria present.
If there is any doubt about the grade of pre-eclampsia, the patient should always be placed in the more severe grade.
Patients who improve on bed rest should be kept in the grade of pre-eclampsia which they were given at the initial evaluation. Further management should be in accordance with this grade.
The symptoms are:
The signs are:
The diagnosis of imminent eclampsia is made even if only one of the symptoms or signs is present, irrespective of the blood pressure or the amount of proteinuria.
In the Western Cape of South Africa the incidence of eclampsia is 1 per 1000 pregnancies.
They must be told about the symptoms of imminent eclampsia, and advised to contact the clinic or hospital immediately, if these symptoms appear.
In the second half of pregnancy, the following must be carefully watched for:
Patients with an obstetric history of pre-eclampsia that developed late in the second or early in the third trimester, must receive 75 mg aspirin (a quarter Disprin) daily from a gestational age of 14 weeks. This will reduce the risk that pre-eclampsia may develop.
All patients with pre-eclampsia must be admitted to hospital, irrespective of the level of the blood pressure.
The management of patients with severe pre-eclampsia and imminent eclampsia is the same and consists of stabilising the patient, followed by referral to a level 2 or 3 hospital.
The two greatest dangers, which are a threat to the patient’s life, are eclampsia and an intracerebral haemorrhage.
The main aims of management are to:
The initial management of severe pre-eclampsia and imminent eclampsia is aimed at the prevention of eclampsia and intracerebral haemorrhage.
The steps in the management of severe pre-eclampsia are:
An intravenous infusion is started (Balsol or Ringer’s lactate) and magnesium sulphate is administered as follows:
A total of 14 g of magnesium sulphate is, therefore, given.
After the magnesium sulphate has been administered, a Foley’s catheter is inserted into the patient’s bladder, to monitor the urinary output.
After giving the magnesium sulphate the blood pressure must be measured again. Magnesium sulphate may cause a slight drop in blood pressure. If the diastolic blood pressure is still 110 mg Hg or more and/or the systolic blood pressure 160 mm Hg or more, oral nifedipine (Adalat) or dihydralazine (Nepresol) is given as follows:
If dihydralazine was used, an ampoule of dihydralazine (25 mg) should be mixed with 20 ml of sterile water. Bolus doses of 2 ml (2.5 mg) are then given slowly intravenously at 20 minute intervals until the diastolic blood pressure drops below 110 mm Hg.
Nifedipine 10 mg capsules must always be given orally in pregnancy and not given sublingually (under the tongue). The 10 mg capsules must not be confused with Adalat XL tablets which are slowly dissolved and not suitable for rapidly lowering the blood pressure.
When the blood pressure is controlled, the patient is transferred to a level 2 or 3 hospital.
Patients with severe pre-eclampsia or imminent eclampsia must always be stabilised before they are transferred.
The management of eclampsia is as follows:
Prevent aspiration of the stomach contents by:
Stop the convulsion and prevent further convulsions by putting up an intravenous infusion of Balsol or Ringer’s lactate and giving magnesium sulphate.
After the magnesium sulphate has been given, insert a Foley’s catheter to monitor the urinary output.
If the diastolic blood pressure is 110 mm Hg or more and/or the systolic blood pressure 160 mm Hg or more, it must be reduced with dihydralazine (Nepresol). Oral nifedipine can be used if the patient is fully conscious after the convulsion.
The patient must now be urgently transferred to a level 2 or 3 hospital.
Eclampsia is a life-threatening condition for both the mother and the fetus. Immediate management is, therefore, needed.
If the patient convulses again, after the convulsions had initially been controlled by the total loading dose of 14 g of magnesium sulphate, a further 2 g of magnesium sulphate should be administered intravenously. This dose can be repeated once more in the unlikely event of the patient having yet a further convulsion.
A patient with a slightly elevated blood pressure (a diastolic blood pressure of 90 to 95 mm Hg), which develops in the second half of pregnancy, in the absence of proteinuria, may be managed in a level 1 hospital or clinic. If the home circumstances are poor, she must be admitted to hospital, for bedrest. Where the home circumstances are good, the patient is allowed bedrest at home, under the following conditions:
Patients with a diastolic blood pressure of 100 mm Hg or more and/or a systolic blood pressure of 160 mm Hg or more must be admitted to hospital and alpha methyldopa (Aldomet) must be prescribed. Once the diastolic blood pressure has dropped below 100 mm Hg and the systolic blood pressure to below 160 mm Hg, they are managed as indicated above.
Fetal movements must be counted and recorded twice daily. If available the patient should be referred for a Doppler measurement of the blood flow in the umbilical artery to determine placental function.
If the blood pressure remains well controlled, no proteinuria develops and the fetal condition remains good, the pregnancy must be allowed to continue until 40 weeks when induction of labour must be done.
These patients have hypertension in the first half of pregnancy, or are known to have had hypertension before the start of pregnancy. They do not have superimposed pre-eclampsia.
A good prognosis can be expected if:
Therefore, these women can be managed at a level 1 hospital. However, women with chronic hypertension should be referred to a level 2 or 3 hospital for further management if:
Yes, she must be put onto alpha methyldopa (Aldomet) 500 mg 8 hourly. Other antihypertensives (i.e. diuretics, beta blockers and ACE inhibitors) must be stopped.
The management is the same as that for gestational hypertension.
A 21 year old primigravid patient has attended the antenatal clinic and her pregnancy progresses normally to 33 weeks. At the next visit at 35 weeks, the patient complains that her hands and feet have started to swell over the past week. On examination, you notice that her face is also slightly swollen. Her blood pressure is 120/80, which is the same as at her previous visit, and she has no proteinuria. She reports that her fetus moves frequently.
Because she is a primigravida and has developed generalised oedema over the past week.
She should rest a lot. She also should be seen at the antenatal clinic again in a week when she must be carefully examined for a rise in blood pressure or the presence of proteinuria.
She should be told about the symptoms of imminent eclampsia, i.e. headache, flashes of light before the eyes, and upper abdominal pain. She should also be asked to count and record fetal movements twice a day. If any of the above-mentioned symptoms are experienced, or if fetal movements decrease, she must immediately report to the clinic or hospital.
The patient has pregnancy-induced hypertension. If the home conditions are satisfactory, she can be managed with bedrest at home. The hypertension must be controlled with alpha methyldopa (Aldomet). She must be seen twice a week, and carefully monitored, to detect a rise in the blood pressure and the possible development of proteinuria. If the blood pressure rises and/or proteinuria develops, she must be referred to hospital for admission. If the home conditions are poor, she should be admitted to hospital for bed rest.
At an antenatal clinic you see a patient who is 39 weeks pregnant. Up until now she has had a normal pregnancy. On examination, you find that her diastolic blood pressure is 95 mm Hg and that she has 2+ proteinuria.
She should be transferred to hospital as all patients with 2+ proteinuria must be hospitalised.
Increased tendon reflexes are a sign of imminent eclampsia. The diagnosis must be made, irrespective of the degree of hypertension or the amount of proteinuria. To prevent the development of eclampsia, the patient must be given magnesium sulphate.
The patient has severe pre-eclampsia. Therefore, the immediate danger to her life is the development of eclampsia or an intracerebral haemorrhage.
Her clinical condition must first be stabilised. An intravenous infusion should be started and a loading dose of 14 g magnesium sulphate must be given. This should prevent the development of eclampsia. A Foley’s catheter must be inserted in her bladder.
No. Sometimes with severe pre-eclampsia, the diastolic blood pressure will drop to below 110 mm Hg after a loading dose of magnesium sulphate has been given. In that case, no further management is needed for the hypertension. However, if the patient’s blood pressure does not drop after administering the magnesium sulphate, 10 mg (one capsule) oral nifedipine (Adalat) or intramuscular dihydralazine (Nepresol) 6.25 mg should be given.
While working at a level 1 hospital you admit a patient with a diastolic blood pressure of 120 mm Hg and 3+ proteinuria. She is 32 weeks pregnant. On further questioning and examination she has no symptoms or signs of imminent eclampsia.
The patient has severe pre-eclampsia. Therefore, the immediate danger to her life is the development of eclampsia or an intracerebral haemorrhage.
Her clinical condition must first be stabilised. An intravenous infusion should be started and a loading dose of 14 g magnesium sulphate must be given. This should prevent the development of eclampsia.
No. Sometimes, the diastolic blood pressure will drop to below 110 mm Hg after a loading dose of magnesium sulphate has been given. In that case, no further management is needed for the hypertension. However, if the patient’s blood pressure does not drop after administering the magnesium sulphate, intramuscular dihydralazine (Nepresol) 6.25 mg or 10 mg (one capsule) oral nifedipine (Adalat) should be given.
No. The patient should be transferred to a level 2 or 3 hospital, for further management. Both severe pre-eclampsia and the gestational age (32 weeks) at which the complications developed are reasons for management at least in a level 2 hospital.
A 37 year old, gravida 4, para 3 patient books for antenatal care. She has chronic hypertension and is managed with a diuretic. By dates and examination she is 14 weeks pregnant.
Yes. The diuretic should be stopped, as these drugs are not completely safe during pregnancy. Instead, the patient should be treated with alpha methyldopa (Aldomet).
Normal renal function, no superimposed pre-eclampsia and good control of the blood pressure during pregnancy.
The patient will develop proteinuria and/or a rise in blood pressure during the second half of pregnancy.
Because the risk of complications increases. As a result a preterm delivery may be necessary. The patient should, therefore, be transferred to a level 2 or 3 hospital if superimposed pre-eclampsia develops.
A postpartum sterilisation. Postpartum sterilisation should be discussed with the patient during the pregnancy. Postpartum sterilisation is particularly important as the patient is a 37 year old multipara with chronic hypertension.