• Incidence: 3-7%
• Leading cause of maternal mortality: eclampsia, CVA, pulmonary
• Perinatal mortality: preterm, SGA
• Pre-eclampsia (PET): pregnancy specific syndrome
• Heterogenous conditions:can be chronic HT/renal disease

A) Gestational HT/ proteinuria:

• Gestational HT
• Gestational proteinuria,
• Gestational proteinuric hypertension (PET)

B) Chronic hypertension/ renal disease:

• Chronic HT,
• Chronic renal disease,
• Chronic HT with superimposed pre-eclampsia

C) Unclassified:

• Presents > 20 weeks, or insufficient information

Total incidence: 2.9%

A) Gestational HT/ proteinuria

• Gestational HT (54.7%)
• Gestational proteinuria (2.3%)
• Gestational proteinuric hypertension (24.6%)

B) Chronic hypertension:

• Chronic HT (5.6%)
• Chronic HT with superimposed PET (1.9%)

C) Unclassified: 10%

Maternal

• Eclampsia (0.5%)
• CVA
• Deranged renal and liver function
• Coagulopathy:DIC
• Pulmonary oedema
• Placental abruption
• HELLP (hemolysis, liver, low platelet)

Fetal

• IUGR
• Fetal hypoxia
• Fetal distress
• IUD

• Decreased perfusion to virtually all organs
• Endothelial dysfunction: vasospasm, and microthrombi
• Reduced vasodilator prostacyclin, increased vasoconstrictive thromboxane
• Circulatory factors: lipid peroxides, cytokines, syncytotrophoblast microvillous membranes
• Reduced uteroplacental blood flow.
• Lack of endovascular invasion cytotrophoblastic invasion in maternal spiral arteries
• Immunological mediated, vascular disease, increased trophoblast

• Primigraivida
• Age
• Past obs: PET
• Pre-existing maternal diseases: DM, HT, renal disease, anticardiolipin antibody syndrome
• Obstetric conditions: multiple pregnancy, hydatiform mole, hydrops.

• Classical triad: HT, proteinuria, oedema.
• Classical : PET then eclampsia
• Asymptomatic if mild (regular A/N visit)
• Presentation is variable
• Atypical presentation: PET without preceding proteinuria; eclampsia without preceding features of PET

• BP>= 140/90mmHg for two consecutive readings 4 hrs apart with rest
• Or one reading of DBP >=110mmHg
• Some: increase of DBP by 15 or 25mmHg
• Sitting, appropriate cuff, heart level
• K4: muffling, not to zero, conventional, but less agreement
• K5: disappearance of sound , more identified and agreement, but may at or near zero, conventional Mx not base on K5
• Mercury sphygmomanometry: errors, white coat HT
• Automated: reduce errors, measures K5.

• Dipstick, false positive and negative, MSU
• 24 hr urine protein>=300mg/day
• Heavy proteinuria >=1g/day

If BP normal and no proteinuria before 20 wks,

(a) HT and proteinuria afterwards => PET;

(b) HT alone => gestational HT

HT + symptoms / abnormal liver / thrombocytopenia / hyperuricemaia / IUGR => PET

If HT/proteinuria develops before 20 wks => ? Chronic HT/ renal disease

Need to rule out secondary causes: renal (GN, polycystic kidneys), CVS (renal artery stenosis, COA), endocrine (DM, phaecochromocytoma), autoimmune (SLE)

• The definitive treatment of pre-eclampsia is delivery( not just control of HT, a multi-system disorder)
• The timing is a balance between severity of pre-eclampsia and risk of prematurity

Mild non-proteinuric hypertension

• Day case reduces inpatient stay, convenient
• Monitoring of maternal and fetal well being: S/S, LRFT, urate, kick chart, +/- USG
• Progressive disorder
• Bed rest: no evidence to improve outcome
• AntiHT therapy: controversial
• Induction before 40 wks

• Symptoms: headache, visual disturbance, epigastric or RUQ pain, nausea and vomiting
• Signs: BP>=160/110, proteinuria (3 or 4 + or >3g/d), gross and rapidly progressive oedema, brisk jerks or clonus, oliguria (<30ml/h)
• Lab: thrombocytopenia, impaired LFT, RFT, clotting profile

• Early delivery: Induction or C/S
• Conservative if extreme prematurity, improve neonatal outcome, close monitoring of maternal well being.
• Steroid: dexamethasone to promote fetal lung maturity.
• Control of BP: decrease risk of cerebral hemorrhage (>= 160/110 mmHg), but avoid sudden lowering of BP=> fetal distress. Keep DBP between 90 and 100
• Antihypertensive therapy- IV hydrallazine or oral therapy (methyldopa)
• Prophylactic anticonvulsant is controversial. Choice: Magnesium sulphate

• Epidural> GA, pain relief, exclude coagulopathy
• CFHM, BP, proteinuria, jerks, convulsion
• Avoid prolong labour
• Low threshold of C/S
• Postpartum: convulsion, pulmonary oedema
• At least 24 hrs after delivery or last fit
• Appropriate fluid management, diuretics

• Occurrence of convulsion in pregnancy unless known epilepsy or cause.
• Can occur up to 10 days
• 1.8% mortality
• Tonic-clonic type followed by coma

• Acute: prevention of injury and aspiration
• Control of convulsion and prevent recurrence +/- control of HT
• Stabilisation of woman
• Expeditious delivery

• Collaborative trial:magnesium sulphate is superior to diazepam
• However, low therapeutic-toxic range
• Toxicity: respiratory depression and cardiac arrest
• Monitor: patellar reflex, urine output( >30ml/h), respiratory rate (>12/min), +/- magnesium level(4-8mg/dl)

• Recurrence of PET: 1 in 10, 1 in 4 (if eclampsia)
• Long term risk of CVD if recurrent PE or HT in pueperium.
• If BP normal, no contraindication to OC'

• Low dose aspirin increases prostacyclin to thromboxane ratio. A RCT (CLASP)*- not for routine prophylaxis,may be beneficial for high risk cases with previous adverse fetal outcome
• Calcium supplementation: no value
• Fish oil reduces formation of thromboxane: no reduction in PET.

• Prognosis depends on superimposed PET(17%), renal function (nephropathy), and progression of underlying disorder(e.g. SLE)
• Are antihypertensive agents (she has been taking) safe in pregnancy?
• BP may fall slightly in second trimester

• Sudden raised BP
• Increased or development of proteinuria
• Progressive increasing urate level
• IUGR
• Features of multi-system disorders

• Reduces the rsik of severe HT but not risk of superimposed PE.
• Consider if BP>=150/100 mmHg
• Methyldopa: central action, widely use, safe in pregnancy, well tolerated, S.E: dizziness, postural hypotension, nightmare, depression, abnormal LFT
• Labetolol: combined alpha and beta blocker, vasodilatation, effective and safe in pregnancy
• Hydrallazine: vasodilator, increase HR and CO, tachyphylaxis
• Nifedipine: new, calcium channel blocker, appears safe, SE: headache, tachycardia.
• No short term effects on breastfeeding infants: Methyldopa, hydralazine, calcium channel blockers
• Avoid propanolol (IUGR, neonatal depression), ACE inhibitors (fetal death, neonatal renal failure)

• Maternal and perinatal mortality
• PET is a multi-system disorder
• PET is progressive
• Early detection
• Approach to HT: establishment of diagnosis, differentiate between different causes, and assessment of severity of HT
• Definitive treatment is delivery

• Eclampsia: anticonvulsant (MgSO4)
• CVA: antihypertensive:IV hydrallazine; oral methyldopa
• Abnormal LRFT, coagulopathy, HELLP: delivery
• Placental abruption: delivery
• Pulmonary oedema: fluid restriction, diuretics
• IUGR/ hypoxia: foetal monitoring/ delivery