DAY 4
📅 Nov 13 (Wed)
💊 Hypertensive Disorders in Pregnancy
DME 211: PIH, Pre-eclampsia, Eclampsia & HELLP
- PIH: Classification & Risk Factors
- Pre-eclampsia: Pathophysiology, Features, Management
- Eclampsia: Emergency Management with MgSO₄
- HELLP Syndrome: Recognition & Treatment
🩸 REMEMBER: PIH = BP ≥140/90 mmHg after 20 weeks! Pre-eclampsia = PIH + PROTEINURIA!
🚨 KEY POINT: Eclampsia = SEIZURES! MgSO₄ is the drug of choice - NOT diazepam!
"High BP in pregnancy is a silent killer. Measure, monitor, manage!"
"Be sober, be vigilant." - 1 Peter 5:8
1. HYPERTENSIVE DISORDERS IN PREGNANCY - DEFINITION
Definition: New onset hypertension (BP ≥140/90 mmHg) diagnosed after 20 weeks gestation in a previously normotensive woman.
Incidence: 10% of pregnancies in Uganda
Importance: 3RD LEADING CAUSE OF MATERNAL DEATH! Causes 15-20% of maternal mortality.
⚠️ DIPLOMA LEVEL EXAM TIP: Hypertensive disorders are EXAM FAVORITES! Focus on: 1) BP thresholds, 2) Proteinuria, 3) MgSO₄ regime, 4) HELLP criteria!
📊 CLASSIFICATION (WHO/FIGO):
- Gestational Hypertension (PIH): BP ≥140/90 after 20 weeks WITHOUT proteinuria
- Pre-eclampsia: PIH WITH proteinuria (≥2+ on dipstick)
- Severe Pre-eclampsia: BP ≥160/110 OR severe symptoms
- Eclampsia: Pre-eclampsia + CONVULSIONS
- HELLP Syndrome: Hemolysis, Elevated Liver enzymes, Low Platelets
- Chronic Hypertension: BP ≥140/90 before 20 weeks
- Superimposed Pre-eclampsia: Chronic HTN + proteinuria
🧠 MNEMONIC: HYPERTENSION TYPES
Gestational HTN - No protein
Pre-eclampsia - Plus protein
Severe Pre-eclampsia - Sky-high BP
Eclampsia - Everything + fits
HELLP - Labs are Bad
Gestational HTN - No protein
Pre-eclampsia - Plus protein
Severe Pre-eclampsia - Sky-high BP
Eclampsia - Everything + fits
HELLP - Labs are Bad
2. RISK FACTORS - THE "PRE-ECLAMPSIA" LIST
🔴 HIGH RISK FACTORS:
Primigravida (especially <18 or >35 years)
Revious history of pre-eclampsia
Extremes of age
-
Existing medical conditions (HTN, diabetes, kidney disease)
Chronic hypertension
Lupus or connective tissue disease
Antiphospholipid syndrome
Multiple pregnancy
Pregnancy >10 years since last
Strong family history
IVT conception
Abnormally high BMI (>30)
Primigravida (especially <18 or >35 years)
Revious history of pre-eclampsia
Extremes of age
-
Existing medical conditions (HTN, diabetes, kidney disease)
Chronic hypertension
Lupus or connective tissue disease
Antiphospholipid syndrome
Multiple pregnancy
Pregnancy >10 years since last
Strong family history
IVT conception
Abnormally high BMI (>30)
UGANDA CONTEXT: Teenage pregnancy and grand multiparity are major risk factors! Always check BP at EVERY ANC visit - at least 4 times during pregnancy.
3. PATHOPHYSIOLOGY - THE "SPIRAL ARTERY" STORY
Key Concept: Abnormal placental implantation → poor trophoblastic invasion → spiral arteries remain constricted → placental ischemia.
The Cascade:
- Placental ischemia releases toxins into maternal circulation
- Endothelial dysfunction → vasoconstriction → high BP
- Increased capillary permeability → proteinuria, edema
- Platelet activation → coagulopathy, thrombocytopenia
- Liver dysfunction → HELLP syndrome
- Cerebral edema → seizures (eclampsia)
⚠️ CRITICAL CONCEPT: The only CURE is delivery of placenta! All management is symptomatic until safe delivery.
4. CLINICAL FEATURES OF PRE-ECLAMPSIA
📋 Mild Pre-eclampsia (BP 140/90 - 159/109):
🧠 MNEMONIC: "PRE-ECLAMPSIA" SIGNS
Proteinuria (≥2+ on dipstick)
Reflexes increased (hyperreflexia)
Elevated BP (≥140/90)
-
Edgema (face, hands, feet)
Clotting factors decreased (DIC risk)
Liver enzymes elevated (HELLP)
Abdominal pain (RUQ/epigastric)
Mild headache
Platelets low
Sudden weight gain (>2kg/week)
Increased uric acid
Ankle clonus (≥3 beats)
Proteinuria (≥2+ on dipstick)
Reflexes increased (hyperreflexia)
Elevated BP (≥140/90)
-
Edgema (face, hands, feet)
Clotting factors decreased (DIC risk)
Liver enzymes elevated (HELLP)
Abdominal pain (RUQ/epigastric)
Mild headache
Platelets low
Sudden weight gain (>2kg/week)
Increased uric acid
Ankle clonus (≥3 beats)
🔴 Severe Pre-eclampsia (BP ≥160/110 OR any danger sign):
- Severe headache (frontal, throbbing)
- Visual disturbances (blurred vision, flashing lights, blindness)
- Epigastric/RUQ pain (liver capsule stretching)
- Vomiting
- Oliguria (<400ml/24hrs)
- Sudden swelling (face, hands)
- Papilledema
- Decreased fetal movements
🚨 DANGER SIGNS - REFER IMMEDIATELY!
BP ≥160/110 + Headache/Visual changes/Abdominal pain = IMMINENT ECLAMPSIA! Don't wait for seizures!
BP ≥160/110 + Headache/Visual changes/Abdominal pain = IMMINENT ECLAMPSIA! Don't wait for seizures!
🩺 Diagnostic Criteria (Must have ALL):
- BP ≥140/90 mmHg on two occasions, 4 hours apart
- Proteinuria ≥300mg/24hrs OR ≥2+ on dipstick
- Occurring after 20 weeks gestation
- Resolves postpartum
💡 EXAM TIP: The DEFINITION QUESTION always appears! Memorize the BP numbers and proteinuria threshold!
5. MANAGEMENT OF MILD PRE-ECLAMPSIA
Outpatient Management (If stable):
🏠 MNEMONIC: "MONITOR" PLAN
Monitor BP twice weekly
Older (≥37 weeks) → consider induction
No heavy work, rest in left lateral
Increase ANC visits (weekly)
Teach warning signs (headache, visual, RUQ pain)
Organize daily fetal kick count
Refer if BP >150/100 or any danger sign
&
Protein urinalysis at each visit
Lab tests: FBC, LFTs, uric acid
Avoid NSAIDs (use paracetamol only)
Normal diet, restrict salt moderately
Monitor BP twice weekly
Older (≥37 weeks) → consider induction
No heavy work, rest in left lateral
Increase ANC visits (weekly)
Teach warning signs (headache, visual, RUQ pain)
Organize daily fetal kick count
Refer if BP >150/100 or any danger sign
&
Protein urinalysis at each visit
Lab tests: FBC, LFTs, uric acid
Avoid NSAIDs (use paracetamol only)
Normal diet, restrict salt moderately
Inpatient Management (If BP >150/100 or risk factors):
- Bed rest in left lateral position
- Antihypertensives: Start if BP ≥150/100
- Methyldopa: 250mg TDS (first line, safe)
- Nifedipine: 10mg TDS (if methyldopa fails)
- Hydralazine: 20mg BD
- Daily monitoring: BP, urine protein, FHS
- Delivery plan: Induce at 37-38 weeks
6. SEVERE PRE-ECLAMPSIA - EMERGENCY!
🚨 THIS IS AN EMERGENCY! BP ≥160/110 = danger zone! Risk of stroke, placental abruption, HELLP, eclampsia!
Immediate Management:
🚨 EMERGENCY MNEMONIC: "SALUTE"
Stabilize: 2 IV lines (all severe cases)
Antihypertensives: URGENT BP control
&
Labetalol 20mg IV slow (repeat every 10min, max 300mg)
Urgent: If no labetalol → Nifedipine 10mg SL
Target BP: 140-150/90-100 (don't drop too fast!)
Emergency delivery plan: Delivery within 24-48 hours
Stabilize: 2 IV lines (all severe cases)
Antihypertensives: URGENT BP control
&
Labetalol 20mg IV slow (repeat every 10min, max 300mg)
Urgent: If no labetalol → Nifedipine 10mg SL
Target BP: 140-150/90-100 (don't drop too fast!)
Emergency delivery plan: Delivery within 24-48 hours
🎯 BP Control Protocol:
- Aim: Reduce diastolic to 90-100 mmHg (not lower!)
- Over 30-60 minutes (not faster - risk to fetus)
- After stabilization: Start MgSO₄ protocol
- Delivery: Definitive treatment - plan CS or induction
7. ECLAMPSIA - THE FITTING MOTHER
🔴 Definition:
Seizures (fits) in a woman with pre-eclampsia that cannot be attributed to other causes.
50% occur POSTPARTUM - up to 7 days after delivery!
📋 Clinical Features Before Seizure:
- Severe headache
- Visual disturbances (flashing lights)
- Hyperreflexia with clonus
- Epigastric pain
- Sudden swelling
- Oliguria
🧠 MNEMONIC: ECLAMPSIA WARNING - "HEADS UP"
Headache (severe, frontal)
Edema (sudden, facial)
Abdominal pain (RUQ)
Decreased urine output
Sees flashing lights (visual)
Unusual irritability/restlessness
Proteinuria increased
! = Seizure imminent!
Headache (severe, frontal)
Edema (sudden, facial)
Abdominal pain (RUQ)
Decreased urine output
Sees flashing lights (visual)
Unusual irritability/restlessness
Proteinuria increased
! = Seizure imminent!
⚠️ EXAM CRITICAL: 50% of eclampsia seizures occur POSTPARTUM! Monitor mothers for at least 48 hours after delivery!
🚨 EMERGENCY MANAGEMENT OF ECLAMPSIA:
- CALL FOR HELP! (obstetrician, anesthetist, neonatologist)
- Protect airway: Turn to left lateral, suction secretions
- Prevent injury: Pad bedrails, don't restrain
- Give OXYGEN: 6-8L/min via mask
- Control BP: Labetalol IV as above
- MgSO₄ PROTOCOL: THE MOST IMPORTANT STEP!
8. MAGNESIUM SULPHATE (MgSO₄) PROTOCOL
💉 Loading Dose:
- 14g total:
- 4g IV: 20ml of 20% MgSO₄ over 5 minutes
- 10g IM: 5g in each buttock (10ml of 50% in each)
💊 Maintenance Dose:
- 5g IM every 4 hours (in alternate buttock)
- OR 1g/hour IV infusion (if available)
- Continue for 24 hours after last seizure or delivery
🎯 MNEMONIC: MgSO₄ DOSE
"4 by IV, 10 by IM, 5 every 4 hours until the storm is over!"
"4 by IV, 10 by IM, 5 every 4 hours until the storm is over!"
⚠️ TOXICITY MONITORING:
- Respiratory rate: Must be >16/min
- Patella reflex: Must be present
- Urinary output: Must be >100ml/4hrs
- Antidote: 10ml of 10% Calcium Gluconate IV slowly
💡 EXAM ALERT: Always check 3 things before each dose: Respiratory rate, reflexes, urine output! Missing these = toxicity risk!
9. HELLP SYNDROME
🔴 Definition:
A severe form of pre-eclampsia involving:
- Hemolysis (blood cells break down)
- Elevated Liver enzymes (AST, ALT >70)
- Low Platelets (<100,000/μL)
📋 Clinical Features:
- Nausea and vomiting (90%)
- Epigastric/Right Upper Quadrant pain (90%)
- General malaise
- Headache
- Edema (non-dependent)
- Hypertension may be MILD!
- Bleeding tendencies
⚠️ EXAM CRITICAL: BP may be NORMAL or only mildly elevated! Don't rely on BP alone! Check labs if RUQ pain with nausea!
🧪 Diagnostic Criteria (All 3 must be present):
| Component | Diagnostic Value |
|---|---|
| Hemolysis | Abnormal smear, LDH >600, Bilirubin >1.2 |
| Elevated Liver Enzymes | AST >70 IU/L, ALT >70 IU/L |
| Low Platelets | Platelet count <100,000/μL |
🚨 Management:
- IMGSO₄ protocol (as for eclampsia)
- Blood products: Platelet transfusion if <50,000
- Corticosteroids: Dexamethasone 6mg IV/6hrs for 4 doses
- Delivery: Within 48 hours (definitive treatment)
- Monitor: Coagulation profile, LFTs daily
💡 EXAM FOCUS: HELLP = LAB DIAGNOSIS! Always ask for "platelet count, liver enzymes, hemolysis markers" if RUQ pain in pregnancy!
10. CHRONIC HYPERTENSION vs GESTATIONAL
| Feature | Chronic HTN | Gestational HTN |
|---|---|---|
| Onset | Before 20 weeks or >12 weeks postpartum | After 20 weeks |
| Proteinuria | Absent initially | May develop |
| BP after delivery | Persists | Resolves within 12 weeks |
| Management | Long-term antihypertensives | Delivery = cure |
LIKELY EXAM QUESTIONS FOR DAY 4
1. FILL-IN-THE-BLANK (2 marks)
The diagnostic criteria for pre-eclampsia include BP ≥_____/_____ mmHg with proteinuria of ≥_____ on dipstick.
ANSWER: 140/90, 2+
2. MULTIPLE CHOICE (3 marks)
A 28-year-old primigravida at 36 weeks has BP 160/110, visual disturbances, and RUQ pain. The immediate drug of choice for seizure prevention is:A) Diazepam
B) Phenytoin
C) Magnesium Sulphate ⭐ CORRECT
D) Calcium gluconate
EXPLANATION: MgSO₄ is the drug of choice for eclampsia prevention and treatment. Diazepam is NOT recommended!
3. SHORT ANSWER (5 marks)
List five signs of severe pre-eclampsia.
ANSWER GUIDE: Any 5 of: BP≥160/110, severe headache, visual disturbances, RUQ pain, oliguria, hyperreflexia with clonus, papilledema, decreased fetal movements. Each = 1 mark.
4. PRACTICAL SCENARIO (10 marks)
A woman at 35 weeks gestation is brought fitting to the health centre. She has a history of headache and swelling. Outline the IMMEDIATE management of eclampsia.
ANSWER:
1. Call for help and protect airway
2. Turn to left lateral, give oxygen 6-8L/min
3. Prevent injury (pad bedrails)
4. Control BP: Labetalol 20mg IV slow
5. MgSO₄ protocol: 4g IV + 10g IM
6. Continue 5g IM every 4 hours for 24h
7. Monitor RR, reflexes, urine output
8. Prepare for delivery within 24-48 hours
MARKING: Each step = 1-2 marks. Must include MgSO₄ dose and monitoring!
1. Call for help and protect airway
2. Turn to left lateral, give oxygen 6-8L/min
3. Prevent injury (pad bedrails)
4. Control BP: Labetalol 20mg IV slow
5. MgSO₄ protocol: 4g IV + 10g IM
6. Continue 5g IM every 4 hours for 24h
7. Monitor RR, reflexes, urine output
8. Prepare for delivery within 24-48 hours
MARKING: Each step = 1-2 marks. Must include MgSO₄ dose and monitoring!
5. TRUE/FALSE (2 marks each)
a) HELLP syndrome always presents with severe hypertension.b) The antidote for MgSO₄ toxicity is 10% calcium gluconate.
c) Eclampsia can occur up to 7 days postpartum.
ANSWERS:
a) FALSE - BP can be normal or mildly elevated
b) TRUE - 10ml IV slowly
c) TRUE - 50% occur postpartum
a) FALSE - BP can be normal or mildly elevated
b) TRUE - 10ml IV slowly
c) TRUE - 50% occur postpartum
6. LIST QUESTION (8 marks)
List and explain the three components of the HELLP syndrome.
ANSWER:
1. Hemolysis: RBC destruction → anemia, jaundice
2. Elevated Liver Enzymes: AST/ALT >70 IU/L → RUQ pain
3. Low Platelets: <100,000/μL → bleeding risk
MARKING: Each component = 2 marks (name + explanation)
1. Hemolysis: RBC destruction → anemia, jaundice
2. Elevated Liver Enzymes: AST/ALT >70 IU/L → RUQ pain
3. Low Platelets: <100,000/μL → bleeding risk
MARKING: Each component = 2 marks (name + explanation)
📊 STATISTICS: Hypertensive disorders appear in 98% of UHPAB midwifery exams! MgSO₄ protocol is tested in 85% of exams. Memorize the doses!