1. Hypertension Disorders in Pregnancy
Irina Halfacree, October 2011

2. The patient DJ, 21 year old woman G1 P0 40/40 weeks
Referral from Community Midwife for raised BP – 160/98
Presents to ADAU

3. Previous Obstetric History
Booking BP – 12/40 weeks
BMI 23
Dating scan – 12/40 weeks
Anomaly scan – weeks
Family History – patient’s mother – chronic hypertension, chronic kidney disease
Smoker – 10/day
Previous admissions to ADAU and Labour ward triage with raised BP and proteinurea

4. History and Examination
No visual symptoms
No nausea or vomiting
No headache
No swelling of hands or face
Normal reflexes, no clonus
Abdominal examination: no tenderness, SFH appropriate for stage of pregnancy, plenty of fetal movements
Normal maternal pulse
No fever

5. Differential diagnosis
Essential hypertension
Pregnancy-induced Hypertension
Preeclampsia
Eclampsia
HELLP
BUT normal BP at 12/40 weeks
BUT it doesn’t explain the proteinurea
Raised BP: systolic >140 or diastolic >90
Significant proteinurea:
2+ on dipstick
PCR >30
Protein >300mg in 24h urine
BUT patient asymptomatic
BUT platelets and liver enzymes normal
More than 300mg in 24 hour urine collection
Or PCR > 30 mg/mmol

6. Pathogenesis of preeclampsia
Summary of the pathogenesis of preeclampsia Immune factors (such as AT1-AA), oxidative stress, NK cell abnormalities, and other factors may cause placental dysfunction, which in turn leads to the release of anti-angiogenic factors (such as sFlt1 and sEng) and other inflammatory mediators to induce hypertension, proteinuria, and other complications of preeclampsia.
Wang A et al. Physiology 2009;24:
©2009 by American Physiological Society

7. Investigations 1 Serial BP measurements: BP 138/84 → 145/86
Urine dipstick: ++ protein
Urine Protein/ Creatinine ratio (PCR): 79 ↑(normal <30)
Urinary protein: 0.19 ↑ (normal <0.10)
Platelets: 265 (normal)
Serum uric acid: 0.32 ↑
ultrasound fetal growth and amniotic fluid volume assessment
• umbilical artery doppler velocimetry

8. Investigations 2
CTG monitoring: normal (accelerations present with fetal movement, fetal movements present, no decelerations)
Ultrasound scan for fetal growth and amniotic fluid volume assessment:
Abdominal circumference (AC) > 50th centile – normal
Amniotic fluid index (AFI) – normal
Cephalic presentation, anterior placenta
Umbilical artery doppler velocimetry – end diastolic flow (EDF) – normal
ultrasound fetal growth and amniotic fluid volume assessment
• umbilical artery doppler velocimetry

9. Management Plan
Induction of labour (IOL): term pregnancy, cephalic presentation, progressing preeclampsia
No fetal distress and normal growth so no need for emergency caesarean section
Antihypertensive treatment: Labetalol 200mg TDS

10. Follow-up
At 40+1 /40 on (IOL) – increasing hypertension, increasing proteinurea, still asymptomatic
At 40+3 /40 – spontaneous vaginal delivery of baby boy, birth weight kg, Apgar score 9+9
1 day post-delivery BP ↓ to 124/77 so Labetalol ↓ 200mgBD
Re-check BP 2 weeks post-delivery

11. Family history
Patient’s mother obstetric history year old, P4, 2 fathers (2+2)
1st pregnancy: normal pregnancy, BW 6lb
2nd pregnancy: hypertension in last week before delivery, BW 6lb
3rd pregnancy: hypertension in last trimester and after delivery, BW 7lb
4th pregnancy: hypertension at 13 weeks (BP 200/110), 37/40 weeks, BW 5lb
Diagnosed with chronic kidney disease, on antihypertensive medication

12. Risk factors for pre-eclampsia
First pregnancy √
First pregnancy with new partner
Young mother
Older mother (age 40 years or older)
pregnancy interval of more than 10 years
family history of pre-eclampsia (mother, sister) √
multiple pregnancy
BMI of 35 kg/m2 or more
gestational age at presentation
previous history of pre-eclampsia or gestational hypertension
pre-existing vascular disease
pre-existing kidney disease

13. References
RCOG Green Top Guidelines: The management of severe pre-eclampsia/eclampsia, 2010
NICE clinical guideline 107, Hypertension in pregnancy - The management of hypertensive disorders during pregnancy, August 2010
Impey L, Child T, Obstetrics & Gynaecology, Wiley – Blackwell, 2004
Pre-eclampsia Ante-natal Day Assessment Unit protocol
Wang A et al. Physiology 2009;24: , Pathogenesis of Preeclampsia

14. Questions True / False In normal pregnancy:
Heart rate increases by 30%
Stroke volume decreases by 10%
Haemoglobin falls by 1g due to haemodilution
Blood pressure is unchanged

15. Questions True / False Pregnancy induced hypertension:
Is more common in primigravid women
Associated with proteinuria
Increased risk in smokers
Occurs more frequently before 28 weeks gestation

16. Questions True / False Pre-eclampsia is associated with:
A fall in plasma uric acid concentration
Intrauterine growth restriction
Disseminated intravascular coagulation
Reduced blood flow to placental bed