Hypertension in pregnancy is divided into two categories –

• Chronic hypertension- Hypertension before 20 weeks of gestation/pregnancy.
• Pregnancy-induced hypertension (Hypertension after 20 weeks of gestation/Pregnancy).

Danger signs such as – Severe headaches, blurred vision, epigastric pain, pedal oedema convulsions and loss of consciousness are often associated with hypertension in pregnancy but are not necessarily specific to it.

Other conditions that may cause convulsions or coma include epilepsy, complicated malaria, head injury, meningitis, encephalitis, etc. Diastolic blood pressure is a good indicator of prognosis for the management of hypertensive disorders in pregnancy.

Hypertensive disorders in pregnancy are a major cause of maternal, fetal and new-born morbidity and mortality. According to the current studies around 5-8 % of pregnancy is complicated by pregnancy-induced hypertension. Pregnancy with PIH is at a greater risk of complications such as abruptio placentae, cerebrovascular events, organ failure and disseminated intravascular coagulation. Foetuses of these mothers are at greater risk of intrauterine growth retardation, prematurity, fetal distress, intrauterine death and neonatal death.

Articles Required for managing Eclampsia-

S. No.	Articles and Medicine	Quantity Required
1	Cannula 16,18 gauze	2
2	IV set	2
3	RL and NS	2
4	Mouth gag	2
5	20, 10 and 5 cc Syringes	2 each
6	Surgical Gloves	2 set
7	Injection of Magnesium sulphate 50%	20 ampules
8	Injection Calcium gluconate (10 ml 10%)	1
9	Injection Labetalol 20 mg	1
10	Tablet Labetalol 100 mg	10 tablets
11	Tablet Nifedipine 10 mg	10 tablets
12	2 % xylocaine	1
13	Folies catheter and Uro bag	2 set
14	Kee hammer	1

Management of PIH and Pre-eclampsia

Objective:

By end of this exercise, the participant will be able to perform the initial management of PIH and pre-eclampsia (mild/moderate) by providing the safest antihypertensive drugs for pregnancy.

Steps	Rationales
Perform Handwashing before starting the management
Assess the Blood pressure of the mother If BP ≥ 140/90 but ≤ 160/110, proteinuria ≥ traces to 2+	In some cases, systolic BP is below 140 mmHg but diastolic BP is raised up to 100 or more than 100 mmHg In this condition need, close observation for 4 hr and management will be the same
Look for the Danger Signs which are listed here- headache/epigastric pain/blurring of vision/Convulsion/oliguria/pulmonary edema/thrombocytopenia.	Looking for danger signs is necessary to identify the severity of the complication At a time one or more than one danger signs will be present
Provide counselling regarding no restriction on routine salt intake but avoid added salt. Give advice for the rest with limited activity.
Start anti-hypertensive if   BP is ≥ 140/90 or diastolic BP ≥ 100 mmHg. Tab Alpha methyldopa 250 – 500 mg, 6-8 hourly. OR Tab labetalol 100 mg BD OR Inj Labetalol 20 mg IV bolus OR Oral Tablet Nifedipine 10 mg (Stat repeat after 30 mins)	Protein urea may be present or may not be present. Remember Protein urea is the second Sign. Do not give Tablet Nifedipine sublingually as BP may fall down instantly and cause cardiac arrest
Maintain Diastolic BP 90 – 100 mmHg.
Ensure Close observation of BP, Protein Urea and danger signs every 30 minutes.
Refer to higher centre
Note down medication and findings on the case sheet referral sheet.

Management of Severe Eclampsia and Eclampsia/ Administration of Magnesium Sulphate (Mgso4)

Objective:

By end of this exercise, the participant will be able to perform the initial management of Severe pre-eclampsia and eclampsia by administering MgSO4.

Steps	Rationale
Wash your hands thoroughly with soap and running water and dry them before and after the procedure and wear gloves.
Assess vital Signs (BP, Pulse Rate, Reparatory Rate, Temperature and Fetal Heart Rate.	Assessment of vital and close observation is the key to successful management.
If the mother is having convulsion insert a mouth gag to prevent tongue bite and injury.	It helps to prevent tragedies.
Admit the mother to a quiet and comfortable room in a bed with padded rails on the side. Provide her left lateral Position.	Severe pre-eclampsia and eclampsia are high-risk cases, these mothers required special attention and immediate care. Separate rooms for eclampsia mothers help in managing them and also avoid the panic situation for other normal mothers
If needed Insert the oropharyngeal airway and perform suctioning to clear the airway.	Suctioning is required to avoid the aspiration of convulsion secretions.
Start Oxygen administration at 6-8 litter/minutes.	To provide artificial breathing support.
Start IV Fluid RL/NS at the rate of 60 drops/minute.	Keep the mother hydrated.
Insert Foyle’s catheter and monitor the input and output chart.	Monitoring of urine output is mandatory to assess the side effect of mgso4.
Keep ready (loading dose) 10 ampoules of 50% magnesium sulphate (MgSO4 -50%)  Prepare 2 10 ml syringes with 22 gauzes Load 5g (10 ml) of 50% magnesium sulphate solution in each syringe and load 1 ml of 2% xylocaine at last	Before loading recheck the concentration of 50% of MgSo4   22 Gauze needle is mandatory for IM injection.   At the last loading of 1 ml,2% of xylocaine is help to reduce pain at the site of IM injection as Mgso4 is very thick in concentration which may cause severe pain during IM administration.
Now carefully clean the both gluteal IM site of injection (upper outer quadrant of the buttocks) by using an alcohol swab.	If the woman is conscious, tell her that she may experience a feeling of warmth when magnesium sulphate is given Do not administer Mgso4 in deltoid muscles (upper arm muscles)
Now administered loaded (mgso4) 5g (10 ml) deep IM injection in each buttock.	10 gm loading dose is for L1 and L2 facilities. For e.g.- Subcentre/PHC/CHC.
At L3 Facility health care provider need to administer a 14gm loading dose. 10 gm IM and 4 gm 20 % MgSO4 will be given slow IV bolus over 5 mins in addition.	14 gm loading dose is only applicable for L3 facility FRU/DH/Medical College   Do not load xylocaine during IV Dose
To prepare 4gm 20% IV MgsO4 – fill a 20 ml of the syringe with 4 gm (8 ml mgso4) and 12 ml Normal saline (NS) s = 4gm 20% of mgso4. Use 22 gauzes of needle
After administering mgso4 close observation is required
After 30 minutes of administering the loading dose if still recurrent, fits persist administer maintenance dose (2 gm 20% mgso4 slow IV bolus in 5 minutes)	For making 2 gm 20% mgso4 Take a 10 ml syringe load of 2 gm mgso4 (4 ml) with 6 ml NS.
Repeat 5 gm (50 % mgso4) IM alternate buttocks every 4 hourly
After administering mgso4 cut the needle with a hub cutter and discard the used syringes in a proper waste bin.
If the mother’s gestational age is ≥24 – < 34 weeks administer Corticosteroid	Administration of corticosteroids in ≥24 – < 34 weeks of gestational age will help in the lung maturity of the fetus.
If still mothers’ condition is not well continue the management and prepare for a Caesarean section.
Record every detail carefully.
Mother should be referred to the higher facility if further treatment is not available in the facility

Notes:

1. The maintenance dose is to be administered only at CHC FRU and District Hospitals.
2. It is mandatory to monitor the following signs before giving a maintenance dose, every 4 hourlies
   • Presence of patellar jerks
   • Respiratory Rate (RR) ≥ 16/min
   • Urine output ≥ 30 ml/hour in last 4 hours
3. If Patellar jerks are absent or urine output is <30ml/hour in the last 4 hours then withhold the maintenance dose of MgSO4
4. IF RR<16/min, then withhold the maintenance dose of MgSO4 and administer an antidote of 1 gm of 10% Inj. Calcium Gluconate 10 ml slow IV over 10 minutes. For remember this may call 10%,10ml and 10 minutes.

Points to be Remember:

• Hypertension: BP ≥140/90 TWO consecutive readings 4 hours apart
• Chronic Hypertension: Hypertension before 20 weeks of pregnancy, which means the mother is having hypertension before her current pregnancy.
• Gestational Hypertension: Hypertension after 20 weeks of pregnancy, which means the mother leads hypertension after 20 weeks of gestation in her current pregnancy.
• Mild Pre-eclampsia (PE): BP 140/90 but <160/110 mmHg with proteinuria trace, 1 + or 2+
  • Start Anti-hypertensive when diastolic BP ≥ 100 mmHg
  • Tablet labetalol 100 mg BD, nifedipine 10 mg orally.
  • Maintain Diastolic BP at 90-100 mmhg.
• Severe pre-eclampsia (Severe PE):
  • BP ≥ 160/110 with proteinuria ≥ 3+.
  • Pre-eclampsia (BP> 140/90 with proteinuria) with the presence of any danger sign like headache, blurring of vision, epigastric pain, oliguria, pulmonary oedema or Thrombocytopenia.
  • Only difference between Severe pre-eclampsia and eclampsia is the convulsion which means till the convulsion does not happen is called severe pre-eclampsia and as the convulsion happens it is called eclampsia.
• Protein Urea-
  • The presence of proteinuria changes the diagnosis from pregnancy-induced hypertension to pre-eclampsia.
  • Other conditions that cause proteinuria and false positive results are possible such as urinary infection, severe anaemia, heart failure and difficult labour may all cause proteinuria.
  • Blood in the urine due to catheter injury, schistosomiasis and contamination from vaginal blood may give false positive results.
  • Random urine sampling such as the dipstick/Uri stick test for proteinuria is a useful screening tool.
  • A change from negative to positive result during pregnancy is a warning sign.
  • Vaginal secretions or amniotic fluid may contaminate urine specimens only clean-catch mid-stream specimens should be used.  Catheterization for this purpose is not justified due to the risk of urinary tract infection.
• The Management of severe pre-eclampsia is the same as eclampsia. The loading dose for Severe pre-eclampsia and Eclampsia in FRU /DH is same i.e., 14 gm

Conclusion:

In summary, hypertension during pregnancy can be hazardous for both the mother and the foetus, even though many of these women have healthy, problem-free newborns. Pregnant women with pre-existing, or chronic, high blood pressure are more prone than normal blood pressure women to experience specific pregnancy problems. On the other hand, gestational hypertension, or elevated blood pressure, is a condition that some pregnant women experience.

High blood pressure can have modest to severe effects. Low birth weight and premature delivery can result from high blood pressure, which can also damage the mother’s kidneys and other organs. In the worst situations, the mother experiences preeclampsia, also known as “toxaemia of pregnancy,” which puts the mother’s and the foetus’ lives in danger.

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