1. Hypertension in pregnancy
Hypertensive disorders complicate 3.7% of all pregnancies and is a leading cause of maternal and perinatal mortality and morbidity.
Identification of patients at high risk and timely detection with proper management can prevent life threatening complications.
Diagnosis-working group report(2000)
1)Gestational hypertension-
Bp >/= 140/90 mm of hG for first time during pregnancy
No proteinuria
Bp returns to normal within 12 weeks postpartum
So final diagnosis-only post partum

2. 2)Pre-eclampsia
-minimum criteria bp>/=140/90 mm of hg after 20 weeks gestation.
Proteinuria >/= 300 mg /24 hrs
Increased certainity of pre-eclampsia
Bp>/= 160/110 mm of hg
Proteinuria 2g/24 hrs or >/=2+dipstick
S.creatinine > 1.2 mg%(unless previously elevated)
Platelets<100,000/cu.mm
Microangiopathic hemolysis
Elevated ALT/AST
Persistent headache/cerebral/visual disturbances/persistent epigastric pain.

3. 3)eclampsia-seizures that cannot be attributed to other causes in a woman with pre eclampsia
4)Superimposed preeclampsia(on chronic hypertension)
New onset proteinuria >/=300 mg/24 hrs but no proteinuria before 20 weeks.
Sudden increase in proteinuria/BP/platelet count<100,000/cumm if hypertension & proteinuria before 20 weeks
5)Chronc hypertension-BP>/=140/90 mm of hg before pregnancy or before 20 weeks gestation (excluding hydatidiform mole/acute polyhydramnios) OR
Hypertension first diagnosed after 20 weeks gestation and persistent after 12 weeks post partum.

4. HISTORY
Age –more common in young primigravidae and elderly primigravidae >35 years(increased incidence of hypertension with superimposed pre-eclampsia)
Poor socioeconomic status-poor antenatal care and poor nurtition
Residence-high altitude-increased incidence of pre-eclampsia
Race-african american women are more prone
Obstetric history-parity-primigravidae,h/o pregnancy complications like h.mole,multiple pregnancy,polyhydramnios,rh-incompatibility,gestational diabetes
Marital history-h/o new paternity
Past h/o any medical disorders-essential HT,chronic renal disease,diabetes mellitus,endocrine disorders,connective tissue disorders
Family h/o of pre-eclampsia/eclampsia in mother/siblings

5. h/o symptoms of pre-eclampsia(usually after 20th week)
h/o swelling of ankles which persists on rising from bed in the morning
Tightness of the finger ring
Swelling may extending to face,abdomen,vulva or whole body.
Ominous symptoms
Headache-occipital/frontal,disturbed sleep
Dimished output of urine
Epigastric pain/vomiting-due to hepatocellular ischemia/necrosis,edema,with stretching of glissons capsule,subcapsular hge
Blurring/dimness of vision,blindness-spasm of retinal vessels,retinal edema,retinal detachment,occipital lobe lesions(hypodensities on MRI)

6. SIGNS Abnormal weight gain-greater than 5 pounds/month or1 pound/week
Edema-common feature in 80% of normotensive pregnancies,so no longer incloded in the definition of pre-eclampsia
Mild edema-ignore
Sudden,severe widespread edema-pathological-may indicate imminent eclampsia

7. Blood pressure measurement-ideally woman should be seated for 5 minutes before measuring BP with feet supported on the ground & arm resting on a table at the level of the heart.( Each cm above/below-0.8 mm hg change in bp recording)
BP recording in LLP-spuriously reduced by mm of hg.
The same arm should be used on each occasion
Cuff should be of appropriate size (12 cm bladder width for regular patients & 15cm for more obese women)
Readings should be recorded to the nearest 2 mm of hg.
Use korotkoff phase 5(disappearance of sound)

8. To diagnose HT in pregnancy BP should be >/= 140/90 mm of hg at 2 separate readings at least 4 hrs apart.
MAP=systolic BP+2* diastolic BP 3
MAP>/=105 mm of hg or ^ in MAP by 20 mmof hg from previous is also diagnostic of HT in pregnancy
Diastolic BP tends to rise first followed by the systolic

9. P/A-the fundal height will be less than period of gestation-oligohydramnios,iugr
Abdominal wall edema may be present-FHS may be difficult to localise
Signs of IUD/abruption/preterm labour
Fundoscopic examination-retinal edema,arteriolar constriction,alteration of normal vein to arteriole diameter from 3:2 to 3:1,nicking of veins by the arterioles
Patient may present with eclampsia in the antenatal period(50%)
Eclamptic fit-premomitory stage,tonic stage,clonic stage,stage of coma. Fits usually multiple episodes at varying intervals/status epilepticus

10. Premonitory stage-unconscious,twitching of the muscles of face ,tongue and limbs,rolling f eyeballs-30 sec
Tonic stage-tonic spasm of all voluntary muscles with opisthotonus,limbs flexed,hands clenched.respiration ceases,tongue protrudes.cyanosis appears ,eyeballs are fixed-30sec
Clonic stage-voluntary muscles undergo alternate contractuion/relaxationbiting of tongue ,breathing sterterous,blood stained frothy secretions fill mouth,cyansis disappears gradually-1 to 4 min
Stage of coma-for brief period or lasyts till next convulsion,pt may be in confused state foll seizure,coma may occur without prior convulsion

11. r/o other causes of convulsions-epilepsy/,hysteria,encephalitis,meningitis,poisoning,cerebral malaria,neurocysticercosis,intracranial tumours
o/e-temp raised,^ pulse,resp rate,BP
Disoriention-cerebral haemorrhage
Urine output-markedly decreased,haematuria with jaundice(HELLP syndrome),anuria-b/l renal cortical necrosis
Injuries-tongue bite,due to fall
RS-basal crepitations- pulmonary edema(aspiration),signs of hypostatic/infective pneumonia,pulmonary embolism(cyanosis,resp distress)
Shock-acute LVF-due to anoxia ,muscular exhaustion
Generalised bleeding tendency-DIC
Blindness

12. Tests of prediction
Based on the abnormal vascular responsivity/sympathetic overactivity in women destined to develop HT later in pregnancy.
ROLL OVER TEST weeks
Positive predictive value-33%
Positive roll over test indicates abnormal angiotensin 2 sensitivity
Angiotensin 2 infusion test

13. Early prenatal detection
Increased prenatal visits during 3rd trimester
If overt hypertension(>140/90mm 0f hg)-admit the patient and evaluate the severity of pih
Pts with new onset diastolic BP of mm of hg or wt gain>2 pounds/week should come for return visit in 3-4 days
Once admitted-daily scrutiny for symptoms/signs of imminent eclampsia
Daily wt chart
4th hrly BP chart
Clinical evaluation of fetal size,amniotic fluid volume