Hypertensive Disorders in Pregnancy

Description

General measures

Medicine treatment

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O10.0/O11/O14.0-2/O14.9/O16

DESCRIPTION

Hypertensive disorders are one of the most common direct causes of maternal mortality and are responsible for significant perinatal and maternal morbidity. These disorders include chronic hypertension, pre-eclampsia, eclampsia and HELLP Syndrome. Early detection and timely intervention is essential to prevent maternal and perinatal complications.

GENERAL MEASURES

• Bed rest, preferably in hospital.
• Lifestyle adjustment and diet.
• Monitor BP, urine output, renal and liver function tests, platelet count, proteinuria, and fetal condition.
• Consider delivery when risks to mother outweigh risks of prematurity to baby.

MEDICINE TREATMENT

Treatment

Antihypertensives

Medicine treatment will be dictated by blood pressure response.
Monitor progress until a stable result is achieved.
In general, diuretics are contra-indicated for hypertension in pregnant women.
When needed, combine drugs using lower doses when BP >160/100 mmHg, before increasing single medication doses to a maximum.
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• Methyldopa, oral, 250 mg 8 hourly as a starting dose.
  • Increase to a maximum of 750 mg 8 hourly, according to response.

AND/OR

• Long-acting calcium channel blocker, e.g.:
• Amlodipine, oral, 5 mg daily.
  • Increase to 10 mg daily.

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Preeclampsia

Preeclampsia is defined as hypertension with significant proteinuria developing for the first time after 20 weeks’ gestation, and can also be superimposed on chronic hypertension - evidenced by the new onset (after 20 weeks’ gestation) of persistent proteinuria in a woman who had an initial diagnosis of chronic hypertension.

Pre-eclampsia without severe features:

A diastolic BP of 90-109 mmHg and/or systolic BP of 140-159 mmHg; but no symptoms or organ dysfunction.

Maternal features of severe disease:

• Acute severe hypertension (diastolic BP ≥ 110 mmHg and/or systolic ≥160 mmHg).
• Thrombocytopenia (platelet <100 000/μL).
• Impaired liver function (ALT or AST >40 IU/L).
• Severe persistent right upper quadrant or epigastric pain.
• HELLP syndrome (platelets <100 000 and AST >70 U/L and LDH >600 U/L).
• Serum creatinine ≥120 micromol/L.
• Pulmonary oedema.
• New-onset severe headache unresponsive to medication.
• Visual disturbances.

Hypertensive emergency O10.0/9

SBP ≥160 mmHg and/or DBP ≥110 mmHg. Admit to a high-care setting for close monitoring.

• Nifedipine, oral, 10 mg.
  • Repeat after 30 minutes if needed, until systolic blood pressure <160 mmHg and diastolic blood pressure <110 mmHg.
  • Swallow whole. Do not chew, bite or give sublingually.

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If unable to take oral or inadequate response:

• Labetalol, IV infusion, 2 mg/minute to a total of 1–2 mg/kg.
  • Reconstitute solution as follows:
    • Discard 40 mL of sodium chloride 0.9% from a 200 mL container.
    • Add 2 vials (2 x 100 mg) of labetalol (5 mg/mL) to the remaining 160 mL of sodium chloride 0.9% to create a solution of 1 mg/mL.
    • Start at 40 mL/hour to a maximum of 160 mL/hour.
    • Titrate against BP – aim for BP of 140/100 mmHg.
  • Once hypertensive crisis has resolved, switch to an oral preparation.

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Delivery

• Oxytocin, IM, 10 units as a single bolus after delivery of the baby.

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Ergot-containing medicines are contraindicated in hypertensive women, including pre-eclampsia, following delivery of the baby.
Pre-eclamptic and eclamptic women are often hypovolaemic, particularly when the haematocrit exceeds 40%, but are also susceptible to pulmonary oedema. Consequently, hypotension is a risk during anaesthesia. Careful infusion of IV fluids is important. Limit blood-loss at Caesarean section.

See: Preeclampsia, Eclampsia, Chronic hypertension, and Gestational hypertension

Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2025-9 Review_Version 2.0_26 March 2026

Chapter 6 Obstetrics_6.4 Hypertensive Disorders in Pregnancy