Hypertensive Disorders of Pregnancy — Clinical Management Protocol
Source: OGSB, NICE, ACOG
Definitions & Classification
Gestational Hypertension (PIH): New hypertension ≥140/90 mmHg after 20 weeks in previously normotensive woman; no proteinuria or organ dysfunction.
Preeclampsia (PE): New-onset hypertension (≥140/90 mmHg) + proteinuria after 20 weeks. Severe if ≥160/110 mmHg or with organ involvement (CNS, liver, kidney, platelets, lungs).
Eclampsia: Preeclampsia + convulsions/coma.
Chronic Hypertension: Pre-existing, diagnosed <20 weeks, or persisting >12 weeks postpartum.
Chronic HTN with Superimposed PE: Worsening HTN/proteinuria with features of PE.
Diagnostic Criteria
Proteinuria: ≥300 mg/24h OR PCR ≥0.3 OR ≥1+ dipstick (if quantitative unavailable).
Mild PE: BP 140–159/90–109 mmHg + proteinuria, no severe features.
Severe PE: BP ≥160/110 mmHg, proteinuria ± organ dysfunction (thrombocytopenia, ↑LFT, renal impairment, pulmonary edema, CNS symptoms).
Eclampsia: Hypertension + proteinuria + seizures.
Chronic HTN: High BP before 20 weeks or beyond 12 weeks postpartum.
Risk Factors
Previous preeclampsia, chronic hypertension, diabetes, renal disease.
Multiple pregnancy, obesity, advanced maternal age, family history.
Management
Gestational HTN / Mild PE: Admit; monitor BP, urine protein, fetal kick counts, CBC, creatinine, electrolytes, LFT, bilirubin. Fundoscopy. USG growth every 3 weeks. No antihypertensives if BP <150/100 mmHg. Oral labetalol if 150–159/100–109 mmHg. Discharge if stable; follow-up twice weekly.
Severe Preeclampsia: Admit to CEmONC. Stabilize. Start antihypertensives (oral labetalol first line). MgSO₄ prophylaxis if DBP ≥110 mmHg or symptoms. If full regimen not possible → give loading dose + transfer. Plan delivery once mother is stabilized.
Eclampsia: Emergency → ABC. Left lateral, oxygen, IV access, catheter. MgSO₄ preferred. Antihypertensives if BP >160/110 mmHg. Strict fluid balance (max 2 L/24h, 80 ml/hr). Monitor vitals. Deliver after stabilization.
Chronic HTN: Do not reduce BP <120/80 mmHg. Antihypertensives if ≥150/100 mmHg. Safe drugs: methyldopa, labetalol, nifedipine. Deliver at 37 weeks if stable.
Antihypertensive Therapy
Oral options: Methyldopa 250 mg TDS (max 2 g/day), Labetalol 100 mg BD–TDS (max 2400 mg/day), Nifedipine 10 mg BD–TDS (max 120 mg/day).
Emergency (BP ≥160/110 mmHg): Labetalol IV 10 → 20 → 40 → 80 mg, Hydralazine 5 mg IV slowly or 12.5 mg IM q2h, Nifedipine 5 mg oral (repeat after 10 min if no response).
Magnesium Sulfate Therapy
Preferred regimen (IV/IM): Loading 4 g IV over 5–10 min + 10 g IM (5 g each buttock). Maintenance: 5 g IM q4h (alternate buttocks). Monitor: respiration >16/min, reflexes present, urine output ≥30 ml/hr. Toxicity: stop MgSO₄, give 10 ml of 10% calcium gluconate IV.
Plan for Delivery
≥37 weeks: Deliver irrespective of severity.
34 weeks: Deliver within 12 hours.
<34 weeks: Expectant management if stable – admit, steroids, MgSO₄, antihypertensives.
Contraindications: Eclampsia, pulmonary edema, DIC, renal failure, abruption, uncontrollable BP, non-reassuring fetus.
Mode: Favorable cervix → induce (ARM + oxytocin). Unfavorable → ripen (prostaglandin/Foley) or C-section.
Maternal & Fetal Complications
Maternal: Stroke, HELLP syndrome, renal failure, pulmonary edema, placental abruption, death.
Fetal: IUGR, preterm birth, stillbirth, hypoxia.
Postpartum Care
Continue monitoring BP for 72 hours after delivery and 7–10 days postpartum. Antihypertensives may be required for days–weeks. Contraception counseling: avoid estrogen-containing contraceptives until BP controlled. Long-term: increased risk of chronic hypertension, cardiovascular disease.
Prevention
Low-dose aspirin (81 mg/day) starting 12–28 weeks in high-risk women. Calcium supplementation in populations with low calcium intake.
Compiled By:
Dr. Taslima Akter
Contributors
- Prof Fawzia Hossain
- Prof Tabassum Parveen
- Dr Sumaiya Binte Asif
- Dr Rubina Akter
- Dr Taslima Akter
- Dr Ashia Akter
- Dr Nousin Jahan Pourna
- Dr Mst. Mahbuba
- Dr Shamsun Nahar
- Dr Farzana Akhter
- Dr Moriom Binte Haque
- Dr Fatema Akter
- Dr Most. Lailun Nahar Kuddus
- Dr Gouri Rani Das
- Dr Monira Haque