• Classification and diagnosis of hypertensive disorders of pregnancy
• Preeclampsia: features, investigations, and management
• Chronic hypertension in pregnancy
• Antihypertensive drugs safe in pregnancy
• Exam-style OB-GYN notes or a case discussion

• Classification and diagnosis of hypertensive disorders of pregnancy
• Preeclampsia: features, investigations, and management
• Chronic hypertension in pregnancy
• Antihypertensive drugs safe in pregnancy
• Exam-style OB-GYN notes or a case discussionWhich topic would you like?

Hypertension in pregnancy: management through all phases

Blood pressure definitions

1. Before conception

Goals

• Confirm whether hypertension is primary or secondary.
• Assess baseline maternal organ function.
• replace unsafe drugs before pregnancy.
• reduce the risk of superimposed preeclampsia and adverse fetal outcomes.

Preconception assessment

• Accurate BP, including home BP readings if available
• Duration and severity of hypertension
• Previous preeclampsia, fetal growth restriction, preterm birth, placental abruption, or stillbirth
• Comorbidities: chronic kidney disease, diabetes, obesity, systemic lupus erythematosus, antiphospholipid syndrome, cardiac disease
• Medication review
• Renal function: serum creatinine, electrolytes, urinalysis and urine protein quantification
• Full blood count, liver enzymes, glucose or HbA1c as indicated
• ECG, echocardiography, retinal examination, or evaluation for secondary hypertension if clinically indicated

Medicines before conception

• Labetalol
• Extended-release nifedipine
• Methyldopa, less commonly used now because it may cause fatigue or low mood

• ACE inhibitors, for example lisinopril, enalapril
• Angiotensin receptor blockers, for example losartan
• Direct renin inhibitors
• Mineralocorticoid antagonists such as spironolactone, unless a specialist has a compelling reason

Prevention of preeclampsia

• Stop smoking and alcohol
• Optimize weight, diabetes, kidney disease, and nutrition before conception
• Avoid stopping prescribed antihypertensives without medical advice

2. First trimester and early second trimester: before 20 weeks

Normal physiological change

Management

• Record baseline BP and baseline urine protein.
• Establish baseline platelet count, creatinine, and liver enzymes.
• Continue or commence pregnancy-compatible antihypertensives as needed.
• Review medication adherence and side effects.
• Begin low-dose aspirin at 12 weeks in high-risk patients.
• Plan serial fetal growth assessment later in pregnancy.

Risks with chronic hypertension

• Superimposed preeclampsia
• Placental abruption
• Fetal growth restriction
• Oligohydramnios
• Medically indicated preterm birth
• Stillbirth
• Maternal cardiac, renal, and cerebrovascular complications

3. After 20 weeks: gestational hypertension and preeclampsia surveillance

Diagnosis of preeclampsia

A. Proteinuria

• 24-hour urine protein at least 300 mg
• Protein-creatinine ratio at least 0.3
• Dipstick testing may be used where quantitative tests are unavailable, but is less reliable

B. End-organ involvement, even without proteinuria

• Platelet count below 100,000/µL
• Serum creatinine above 1.1 mg/dL or doubling from baseline in the absence of another explanation
• Liver transaminases at least twice the normal level, often with persistent right upper quadrant or epigastric pain
• Pulmonary edema
• New persistent headache not responding to usual analgesics
• Visual symptoms
• Severe BP at least 160/110 mmHg

Gestational hypertension

• About 10% to 25% of cases may progress to preeclampsia.
• Severe gestational hypertension can have risks similar to preeclampsia.
• It needs frequent review, usually including maternal BP checks, symptom assessment, urine or laboratory testing when indicated, and fetal surveillance.

4. Monitoring in the second and third trimesters

Maternal surveillance

• BP, using correct cuff size and standardized technique
• Symptoms: headache, vision changes, upper abdominal pain, nausea or vomiting, dyspnea, chest symptoms, reduced urine output
• Weight and edema, although edema alone does not diagnose preeclampsia
• Urine protein assessment when required
• Full blood count with platelet count
• Liver enzymes
• Serum creatinine and renal function

Home monitoring

• When and how to check BP
• How to contact the maternity unit
• The need to attend immediately for severe readings or warning symptoms

Fetal surveillance

• Serial ultrasound for fetal growth, usually particularly important in the third trimester for chronic hypertension
• Amniotic fluid volume assessment
• Umbilical artery Doppler when fetal growth restriction is suspected
• Non-stress testing or biophysical profile when disease is severe, medication is required, fetal growth restriction is present, or delivery risk is increased
• Daily fetal movement awareness or kick counts

5. Drug treatment during pregnancy

Maintenance treatment

1. Labetalol
2. Extended-release nifedipine
3. Methyldopa

• Labetalol may worsen asthma or bronchospasm and may not suit significant bradycardia or heart block.
• Nifedipine can cause flushing, headache, palpitations, or ankle edema.
• Methyldopa has extensive pregnancy safety experience but may cause sedation, depression, and liver-related adverse effects.

Acute severe hypertension

• IV labetalol
• IV hydralazine
• Immediate-release oral nifedipine

6. Preeclampsia with severe features

Immediate priorities

• Stabilize airway, breathing, circulation
• Repeat BP and treat severe hypertension promptly
• Check platelets, renal function, liver enzymes, coagulation if indicated
• Assess fetal status
• Give magnesium sulfate for seizure prophylaxis when preeclampsia has severe features, and for treatment of eclamptic seizures
• Give antenatal corticosteroids if preterm delivery is anticipated and gestation is appropriate
• Plan delivery based on maternal and fetal condition

Magnesium sulfate

• Loss of deep tendon reflexes
• Respiratory depression
• Reduced urine output

Eclampsia

• Protect the airway and prevent injury
• Magnesium sulfate
• Treat severe hypertension
• Stabilize mother first
• Proceed to delivery after maternal stabilization, regardless of gestational age if clinically necessary

7. Timing of delivery

8. Hypertension during labor and birth

• Check BP regularly.
• Continue maintenance antihypertensive therapy unless the clinical team changes it.
• Treat sustained severe hypertension urgently.
• Use magnesium sulfate where indicated.
• Avoid fluid overload, particularly in severe preeclampsia, because endothelial leak and reduced oncotic pressure increase pulmonary edema risk.
• Monitor urine output, respiratory status, reflexes when receiving magnesium, and fetal wellbeing.

9. Postpartum period: the risk does not end at delivery

Postpartum preeclampsia warning symptoms

• Severe headache
• Visual disturbance
• Epigastric or right upper abdominal pain
• Shortness of breath or chest pain
• Marked swelling of face/hands
• BP at least 160/110 mmHg
• Seizure
• New nausea, vomiting, or confusion

Postpartum management

• BP check soon after delivery and again during the first 1 to 2 weeks, with earlier and more frequent review after severe disease.
• Continue or adjust antihypertensive medication.
• Severe hypertension is treated urgently, as in pregnancy.
• Magnesium sulfate may be used for postpartum preeclampsia with neurologic symptoms or severe features.
• Assess renal function, platelets, liver enzymes, and symptoms if clinically indicated.
• Do not assume headache postpartum is “just stress” or a post-dural puncture headache until preeclampsia has been considered.

Breastfeeding

10. Long-term follow-up after a hypertensive pregnancy

• Chronic hypertension
• Ischemic heart disease and heart attack
• Stroke
• Chronic kidney disease
• Recurrence of preeclampsia in subsequent pregnancy

• BP review and transition to primary care
• Cardiovascular risk assessment
• Weight, diet, exercise, smoking cessation, and diabetes screening as appropriate
• Preconception counseling before the next pregnancy

Exam summary

Hypertension in Pregnancy: OB-GYN Overview

Diagnostic BP thresholds

• Hypertension: BP ≥140/90 mmHg on repeat appropriate measurements.
• Severe hypertension: systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg.
• Severe persistent hypertension is an obstetric emergency because of maternal stroke risk.

Classification

1. Chronic hypertension in pregnancy

Definition

• BP ≥140/90 before conception or before 20 weeks of gestation.
• It can be essential hypertension or secondary to renal, endocrine, vascular, or other disease.

Risks

• Superimposed preeclampsia
• Placental abruption
• Stroke, heart failure, renal impairment

• Fetal growth restriction
• Preterm birth
• Stillbirth
• Low birth weight

Antenatal care

• Establish baseline: urine protein measurement, creatinine, liver enzymes, platelet count.
• Assess for secondary causes and target-organ damage if indicated.
• Low-dose aspirin is commonly started from 12 weeks in high-risk women to reduce preeclampsia risk.
• Monitor BP regularly, with third-trimester ultrasound surveillance for fetal growth.

Treatment

• Labetalol
• Extended-release nifedipine
• Methyldopa

• ACE inhibitors, for example enalapril, lisinopril
• Angiotensin receptor blockers, for example losartan
• Direct renin inhibitors

2. Gestational hypertension

Definition

• New hypertension after 20 weeks in a previously normotensive woman.
• No proteinuria and no features of maternal end-organ involvement.

Importance

Management

• Outpatient or inpatient care depending on reliability and severity
• Home BP monitoring where appropriate
• Fetal movement monitoring
• Regular fetal growth and antenatal surveillance as indicated
• Delivery at 37 weeks is generally recommended.

3. Preeclampsia

Diagnosis

A. Proteinuria

• ≥300 mg in 24-hour urine, or
• Protein-creatinine ratio ≥0.3

B. End-organ dysfunction, even if proteinuria is absent

• Platelets <100,000/µL
• Creatinine >1.1 mg/dL or doubling from baseline
• Liver transaminases at least twice normal, often with right upper abdominal or epigastric pain
• Pulmonary edema
• Persistent severe headache
• Visual disturbance

Pathophysiology

Symptoms needing urgent assessment

• Severe headache not relieved by medication
• Blurred vision, flashing lights, or visual loss
• Right upper abdominal or epigastric pain
• Breathlessness or chest pain
• Vomiting in late pregnancy
• Reduced urine output
• Sudden swelling of face or hands
• Reduced fetal movements

4. Preeclampsia with severe features

• BP ≥160/110 mmHg
• Cerebral or visual symptoms
• Pulmonary edema
• Significant thrombocytopenia
• Impaired liver or renal function
• Severe persistent epigastric or right upper abdominal pain

Management

• Admit to hospital.
• Stabilize mother and evaluate fetus.
• Treat severe BP urgently.
• Give magnesium sulfate for prevention of seizures.
• Give corticosteroids if preterm delivery is likely and gestation permits.
• Avoid excessive IV fluid due to pulmonary edema risk.
• Plan delivery according to gestational age and maternal-fetal condition.

5. Acute severe hypertension

Definition

Management

• IV labetalol
• IV hydralazine
• Immediate-release oral nifedipine

6. Eclampsia

Definition

Management

1. Protect airway and prevent injury.
2. Place in left lateral position.
3. Give magnesium sulfate.
4. Control severe hypertension.
5. Assess and stabilize mother.
6. Deliver after stabilization. The route of delivery depends on obstetric circumstances.

7. HELLP syndrome

• H: Hemolysis
• EL: Elevated liver enzymes
• LP: Low platelet count

8. Timing of delivery

9. Intrapartum management

• Frequent BP measurement.
• Continue suitable antihypertensive medication.
• Treat severe BP immediately.
• Magnesium sulfate for severe preeclampsia/eclampsia.
• Strict fluid balance and urine-output monitoring.
• Vaginal birth is possible if mother and fetus are stable. Cesarean birth is for usual obstetric indications or urgent clinical need.

10. Postpartum hypertension

Postpartum follow-up

• BP review soon after delivery, especially within 72 hours after severe hypertension.
• Continue or adjust antihypertensives.
• Investigate headache, visual symptoms, upper abdominal pain, dyspnea, or severe BP urgently.
• Magnesium sulfate may be needed for postpartum preeclampsia with severe neurologic features.

Long-term significance

• Chronic hypertension
• Ischemic heart disease
• Stroke
• Chronic kidney disease
• Recurrent preeclampsia in a future pregnancy

High-yield exam points

• Before 20 weeks = chronic hypertension until proven otherwise.
• After 20 weeks = consider gestational hypertension or preeclampsia.
• Proteinuria is not essential for diagnosis of preeclampsia if end-organ dysfunction is present.
• BP ≥160/110 mmHg is severe and needs urgent treatment.
• Magnesium sulfate prevents/treats eclamptic seizures.
• Delivery is the definitive treatment for preeclampsia.
• Preeclampsia can occur postpartum.

Hypertension in Pregnancy: OB-GYN Short Note

Definitions

• Hypertension: BP ≥140/90 mmHg on repeat measurement.
• Severe hypertension: BP ≥160 systolic and/or ≥110 diastolic mmHg.
• Before 20 weeks: usually chronic hypertension.
• After 20 weeks: consider gestational hypertension or preeclampsia.

Classification

Preeclampsia

Diagnosis

• 24-hour urine protein ≥300 mg, or
• Protein-creatinine ratio ≥0.3.

• Platelets <100,000/µL
• Creatinine >1.1 mg/dL or doubled from baseline
• Liver transaminases at least twice normal
• Persistent right upper abdominal or epigastric pain
• Pulmonary edema
• New persistent headache or visual symptoms
• Severe BP ≥160/110 mmHg

Risk factors for preeclampsia

• Previous preeclampsia
• Chronic hypertension
• Chronic kidney disease
• Diabetes mellitus
• Obesity
• Multiple pregnancy
• First pregnancy
• Antiphospholipid syndrome or systemic lupus erythematosus
• Advanced maternal age

Assessment

Maternal

• Repeat properly measured BP
• Ask about headache, blurred vision, flashing lights, epigastric/right-upper-quadrant pain, vomiting, breathlessness, reduced urine output
• Urine protein assessment
• Complete blood count and platelets
• Liver enzymes
• Serum creatinine and renal function

Fetal

• Fetal movement assessment
• Ultrasound for growth and amniotic fluid
• Doppler studies if fetal growth restriction is suspected
• Non-stress test/CTG or biophysical profile where indicated

Management

1. Chronic hypertension

• Baseline renal function, liver enzymes, platelet count, and urine protein.
• Low-dose aspirin from about 12 weeks for preeclampsia prevention in high-risk patients.
• Monitor fetal growth in the third trimester.
• Common maintenance drugs:
  • Labetalol
  • Extended-release nifedipine
  • Methyldopa
• Avoid ACE inhibitors and angiotensin receptor blockers during pregnancy.
• Medication is generally initiated or adjusted at BP ≥140/90 mmHg in chronic hypertension.

2. Gestational hypertension without severe features

• Close BP and symptom monitoring.
• Weekly or more frequent review for evolving preeclampsia.
• Maternal labs and fetal surveillance as clinically indicated.
• Delivery is generally planned at 37 weeks.

3. Preeclampsia without severe features

• Maternal and fetal surveillance, either outpatient or inpatient depending on reliability and disease status.
• Monitor BP, symptoms, platelets, renal function, liver enzymes, and fetal growth/wellbeing.
• Delivery at 37 weeks, or at diagnosis if later.

4. Severe hypertension or preeclampsia with severe features

• Treat persistent BP ≥160/110 urgently.
• Common acute agents:
  • IV labetalol
  • IV hydralazine
  • Immediate-release oral nifedipine
• Give magnesium sulfate for seizure prophylaxis.
• Monitor fluid input and output carefully. Excess IV fluid can precipitate pulmonary edema.
• Give antenatal corticosteroids when preterm delivery is expected and gestation is appropriate.
• Deliver at 34 weeks or more if stable. Deliver earlier after maternal stabilization if there is maternal or fetal deterioration.

Indications for delivery regardless of gestation

• Eclampsia
• Uncontrolled severe hypertension
• HELLP syndrome
• Pulmonary edema
• Placental abruption
• Worsening renal failure or liver dysfunction
• Disseminated intravascular coagulation
• Persistent severe headache, visual symptoms, or epigastric pain
• Non-reassuring fetal condition

Eclampsia

1. Maintain airway and place patient in left lateral position.
2. Prevent injury and give oxygen as required.
3. Give magnesium sulfate to stop/prevent recurrent seizures.
4. Treat severe hypertension.
5. Deliver after maternal stabilization.

HELLP syndrome

• Hemolysis
• ELevated liver enzymes
• LPow platelet count

Intrapartum and postpartum care

During labor

• Frequent BP checks.
• Continue antihypertensives as appropriate.
• Treat severe BP urgently.
• Magnesium sulfate for severe preeclampsia/eclampsia.
• Strict fluid balance and urine-output monitoring.

After delivery

• Severe headache
• Visual symptoms
• Breathlessness or chest pain
• Epigastric/right upper abdominal pain
• Seizures
• BP ≥160/110 mmHg

High-yield points

• BP ≥160/110 mmHg is an obstetric emergency.
• Preeclampsia can be diagnosed without proteinuria.
• Magnesium sulfate prevents and treats eclamptic seizures.
• Delivery of the placenta is the definitive treatment for preeclampsia.
• Hypertension and preeclampsia may first occur postpartum.
• A hypertensive pregnancy increases later maternal risk of chronic hypertension, cardiovascular disease, stroke, and kidney disease.

1. Classification and diagnostic criteria
2. Chronic hypertension and preconception care
3. Gestational hypertension and preeclampsia
4. Severe preeclampsia, eclampsia, and HELLP syndrome
5. Investigations and maternal-fetal monitoring
6. Antihypertensive drugs and magnesium sulfate
7. Timing and mode of delivery
8. Intrapartum, postpartum, and long-term follow-up

• Classification and diagnosis of hypertensive disorders of pregnancy
• Preeclampsia: features, investigations, and management
• Chronic hypertension in pregnancy
• Antihypertensive drugs safe in pregnancy
• Exam-style OB-GYN notes or a case discussionWhich topic would you like?

Hypertension in pregnancy: management through all phases

Blood pressure definitions

1. Before conception

Goals

• Confirm whether hypertension is primary or secondary.
• Assess baseline maternal organ function.
• replace unsafe drugs before pregnancy.
• reduce the risk of superimposed preeclampsia and adverse fetal outcomes.

Preconception assessment

• Accurate BP, including home BP readings if available
• Duration and severity of hypertension
• Previous preeclampsia, fetal growth restriction, preterm birth, placental abruption, or stillbirth
• Comorbidities: chronic kidney disease, diabetes, obesity, systemic lupus erythematosus, antiphospholipid syndrome, cardiac disease
• Medication review
• Renal function: serum creatinine, electrolytes, urinalysis and urine protein quantification
• Full blood count, liver enzymes, glucose or HbA1c as indicated
• ECG, echocardiography, retinal examination, or evaluation for secondary hypertension if clinically indicated

Medicines before conception

• Labetalol
• Extended-release nifedipine
• Methyldopa, less commonly used now because it may cause fatigue or low mood

• ACE inhibitors, for example lisinopril, enalapril
• Angiotensin receptor blockers, for example losartan
• Direct renin inhibitors
• Mineralocorticoid antagonists such as spironolactone, unless a specialist has a compelling reason

Prevention of preeclampsia

• Stop smoking and alcohol
• Optimize weight, diabetes, kidney disease, and nutrition before conception
• Avoid stopping prescribed antihypertensives without medical advice

2. First trimester and early second trimester: before 20 weeks

Normal physiological change

Management

• Record baseline BP and baseline urine protein.
• Establish baseline platelet count, creatinine, and liver enzymes.
• Continue or commence pregnancy-compatible antihypertensives as needed.
• Review medication adherence and side effects.
• Begin low-dose aspirin at 12 weeks in high-risk patients.
• Plan serial fetal growth assessment later in pregnancy.

Risks with chronic hypertension

• Superimposed preeclampsia
• Placental abruption
• Fetal growth restriction
• Oligohydramnios
• Medically indicated preterm birth
• Stillbirth
• Maternal cardiac, renal, and cerebrovascular complications

3. After 20 weeks: gestational hypertension and preeclampsia surveillance

Diagnosis of preeclampsia

A. Proteinuria

• 24-hour urine protein at least 300 mg
• Protein-creatinine ratio at least 0.3
• Dipstick testing may be used where quantitative tests are unavailable, but is less reliable

B. End-organ involvement, even without proteinuria

• Platelet count below 100,000/µL
• Serum creatinine above 1.1 mg/dL or doubling from baseline in the absence of another explanation
• Liver transaminases at least twice the normal level, often with persistent right upper quadrant or epigastric pain
• Pulmonary edema
• New persistent headache not responding to usual analgesics
• Visual symptoms
• Severe BP at least 160/110 mmHg

Gestational hypertension

• About 10% to 25% of cases may progress to preeclampsia.
• Severe gestational hypertension can have risks similar to preeclampsia.
• It needs frequent review, usually including maternal BP checks, symptom assessment, urine or laboratory testing when indicated, and fetal surveillance.

4. Monitoring in the second and third trimesters

Maternal surveillance

• BP, using correct cuff size and standardized technique
• Symptoms: headache, vision changes, upper abdominal pain, nausea or vomiting, dyspnea, chest symptoms, reduced urine output
• Weight and edema, although edema alone does not diagnose preeclampsia
• Urine protein assessment when required
• Full blood count with platelet count
• Liver enzymes
• Serum creatinine and renal function

Home monitoring

• When and how to check BP
• How to contact the maternity unit
• The need to attend immediately for severe readings or warning symptoms

Fetal surveillance

• Serial ultrasound for fetal growth, usually particularly important in the third trimester for chronic hypertension
• Amniotic fluid volume assessment
• Umbilical artery Doppler when fetal growth restriction is suspected
• Non-stress testing or biophysical profile when disease is severe, medication is required, fetal growth restriction is present, or delivery risk is increased
• Daily fetal movement awareness or kick counts

5. Drug treatment during pregnancy

Maintenance treatment

1. Labetalol
2. Extended-release nifedipine
3. Methyldopa

• Labetalol may worsen asthma or bronchospasm and may not suit significant bradycardia or heart block.
• Nifedipine can cause flushing, headache, palpitations, or ankle edema.
• Methyldopa has extensive pregnancy safety experience but may cause sedation, depression, and liver-related adverse effects.

Acute severe hypertension

• IV labetalol
• IV hydralazine
• Immediate-release oral nifedipine

6. Preeclampsia with severe features

Immediate priorities

• Stabilize airway, breathing, circulation
• Repeat BP and treat severe hypertension promptly
• Check platelets, renal function, liver enzymes, coagulation if indicated
• Assess fetal status
• Give magnesium sulfate for seizure prophylaxis when preeclampsia has severe features, and for treatment of eclamptic seizures
• Give antenatal corticosteroids if preterm delivery is anticipated and gestation is appropriate
• Plan delivery based on maternal and fetal condition

Magnesium sulfate

• Loss of deep tendon reflexes
• Respiratory depression
• Reduced urine output

Eclampsia

• Protect the airway and prevent injury
• Magnesium sulfate
• Treat severe hypertension
• Stabilize mother first
• Proceed to delivery after maternal stabilization, regardless of gestational age if clinically necessary

7. Timing of delivery

8. Hypertension during labor and birth

• Check BP regularly.
• Continue maintenance antihypertensive therapy unless the clinical team changes it.
• Treat sustained severe hypertension urgently.
• Use magnesium sulfate where indicated.
• Avoid fluid overload, particularly in severe preeclampsia, because endothelial leak and reduced oncotic pressure increase pulmonary edema risk.
• Monitor urine output, respiratory status, reflexes when receiving magnesium, and fetal wellbeing.

9. Postpartum period: the risk does not end at delivery

Postpartum preeclampsia warning symptoms

• Severe headache
• Visual disturbance
• Epigastric or right upper abdominal pain
• Shortness of breath or chest pain
• Marked swelling of face/hands
• BP at least 160/110 mmHg
• Seizure
• New nausea, vomiting, or confusion

Postpartum management

• BP check soon after delivery and again during the first 1 to 2 weeks, with earlier and more frequent review after severe disease.
• Continue or adjust antihypertensive medication.
• Severe hypertension is treated urgently, as in pregnancy.
• Magnesium sulfate may be used for postpartum preeclampsia with neurologic symptoms or severe features.
• Assess renal function, platelets, liver enzymes, and symptoms if clinically indicated.
• Do not assume headache postpartum is “just stress” or a post-dural puncture headache until preeclampsia has been considered.

Breastfeeding

10. Long-term follow-up after a hypertensive pregnancy

• Chronic hypertension
• Ischemic heart disease and heart attack
• Stroke
• Chronic kidney disease
• Recurrence of preeclampsia in subsequent pregnancy

• BP review and transition to primary care
• Cardiovascular risk assessment
• Weight, diet, exercise, smoking cessation, and diabetes screening as appropriate
• Preconception counseling before the next pregnancy

Exam summary

Diagnostic BP thresholds

• Hypertension: BP ≥140/90 mmHg on repeat appropriate measurements.
• Severe hypertension: systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg.
• Severe persistent hypertension is an obstetric emergency because of maternal stroke risk.

Classification

1. Chronic hypertension in pregnancy

Definition

• BP ≥140/90 before conception or before 20 weeks of gestation.
• It can be essential hypertension or secondary to renal, endocrine, vascular, or other disease.

Risks

• Superimposed preeclampsia
• Placental abruption
• Stroke, heart failure, renal impairment

• Fetal growth restriction
• Preterm birth
• Stillbirth
• Low birth weight

Antenatal care

• Establish baseline: urine protein measurement, creatinine, liver enzymes, platelet count.
• Assess for secondary causes and target-organ damage if indicated.
• Low-dose aspirin is commonly started from 12 weeks in high-risk women to reduce preeclampsia risk.
• Monitor BP regularly, with third-trimester ultrasound surveillance for fetal growth.

Treatment

• Labetalol
• Extended-release nifedipine
• Methyldopa

• ACE inhibitors, for example enalapril, lisinopril
• Angiotensin receptor blockers, for example losartan
• Direct renin inhibitors

2. Gestational hypertension

Definition

• New hypertension after 20 weeks in a previously normotensive woman.
• No proteinuria and no features of maternal end-organ involvement.

Importance

Management

• Outpatient or inpatient care depending on reliability and severity
• Home BP monitoring where appropriate
• Fetal movement monitoring
• Regular fetal growth and antenatal surveillance as indicated
• Delivery at 37 weeks is generally recommended.

3. Preeclampsia

Diagnosis

A. Proteinuria

• ≥300 mg in 24-hour urine, or
• Protein-creatinine ratio ≥0.3

B. End-organ dysfunction, even if proteinuria is absent

• Platelets <100,000/µL
• Creatinine >1.1 mg/dL or doubling from baseline
• Liver transaminases at least twice normal, often with right upper abdominal or epigastric pain
• Pulmonary edema
• Persistent severe headache
• Visual disturbance

Pathophysiology

Symptoms needing urgent assessment

• Severe headache not relieved by medication
• Blurred vision, flashing lights, or visual loss
• Right upper abdominal or epigastric pain
• Breathlessness or chest pain
• Vomiting in late pregnancy
• Reduced urine output
• Sudden swelling of face or hands
• Reduced fetal movements

4. Preeclampsia with severe features

• BP ≥160/110 mmHg
• Cerebral or visual symptoms
• Pulmonary edema
• Significant thrombocytopenia
• Impaired liver or renal function
• Severe persistent epigastric or right upper abdominal pain

Management

• Admit to hospital.
• Stabilize mother and evaluate fetus.
• Treat severe BP urgently.
• Give magnesium sulfate for prevention of seizures.
• Give corticosteroids if preterm delivery is likely and gestation permits.
• Avoid excessive IV fluid due to pulmonary edema risk.
• Plan delivery according to gestational age and maternal-fetal condition.

5. Acute severe hypertension

Definition

Management

• IV labetalol
• IV hydralazine
• Immediate-release oral nifedipine

6. Eclampsia

Definition

Management

1. Protect airway and prevent injury.
2. Place in left lateral position.
3. Give magnesium sulfate.
4. Control severe hypertension.
5. Assess and stabilize mother.
6. Deliver after stabilization. The route of delivery depends on obstetric circumstances.

7. HELLP syndrome

• H: Hemolysis
• EL: Elevated liver enzymes
• LP: Low platelet count

8. Timing of delivery

9. Intrapartum management

• Frequent BP measurement.
• Continue suitable antihypertensive medication.
• Treat severe BP immediately.
• Magnesium sulfate for severe preeclampsia/eclampsia.
• Strict fluid balance and urine-output monitoring.
• Vaginal birth is possible if mother and fetus are stable. Cesarean birth is for usual obstetric indications or urgent clinical need.

10. Postpartum hypertension

Postpartum follow-up

• BP review soon after delivery, especially within 72 hours after severe hypertension.
• Continue or adjust antihypertensives.
• Investigate headache, visual symptoms, upper abdominal pain, dyspnea, or severe BP urgently.
• Magnesium sulfate may be needed for postpartum preeclampsia with severe neurologic features.

Long-term significance

• Chronic hypertension
• Ischemic heart disease
• Stroke
• Chronic kidney disease
• Recurrent preeclampsia in a future pregnancy

High-yield exam points

• Before 20 weeks = chronic hypertension until proven otherwise.
• After 20 weeks = consider gestational hypertension or preeclampsia.
• Proteinuria is not essential for diagnosis of preeclampsia if end-organ dysfunction is present.
• BP ≥160/110 mmHg is severe and needs urgent treatment.
• Magnesium sulfate prevents/treats eclamptic seizures.
• Delivery is the definitive treatment for preeclampsia.
• Preeclampsia can occur postpartum.# Hypertension in Pregnancy: OB-GYN Short Note

Definitions

• Hypertension: BP ≥140/90 mmHg on repeat measurement.
• Severe hypertension: BP ≥160 systolic and/or ≥110 diastolic mmHg.
• Before 20 weeks: usually chronic hypertension.
• After 20 weeks: consider gestational hypertension or preeclampsia.

Classification

Preeclampsia

Diagnosis

• 24-hour urine protein ≥300 mg, or
• Protein-creatinine ratio ≥0.3.

• Platelets <100,000/µL
• Creatinine >1.1 mg/dL or doubled from baseline
• Liver transaminases at least twice normal
• Persistent right upper abdominal or epigastric pain
• Pulmonary edema
• New persistent headache or visual symptoms
• Severe BP ≥160/110 mmHg

Risk factors for preeclampsia

• Previous preeclampsia
• Chronic hypertension
• Chronic kidney disease
• Diabetes mellitus
• Obesity
• Multiple pregnancy
• First pregnancy
• Antiphospholipid syndrome or systemic lupus erythematosus
• Advanced maternal age

Assessment

Maternal

• Repeat properly measured BP
• Ask about headache, blurred vision, flashing lights, epigastric/right-upper-quadrant pain, vomiting, breathlessness, reduced urine output
• Urine protein assessment
• Complete blood count and platelets
• Liver enzymes
• Serum creatinine and renal function

Fetal

• Fetal movement assessment
• Ultrasound for growth and amniotic fluid
• Doppler studies if fetal growth restriction is suspected
• Non-stress test/CTG or biophysical profile where indicated

Management

1. Chronic hypertension

• Baseline renal function, liver enzymes, platelet count, and urine protein.
• Low-dose aspirin from about 12 weeks for preeclampsia prevention in high-risk patients.
• Monitor fetal growth in the third trimester.
• Common maintenance drugs:
  • Labetalol
  • Extended-release nifedipine
  • Methyldopa
• Avoid ACE inhibitors and angiotensin receptor blockers during pregnancy.
• Medication is generally initiated or adjusted at BP ≥140/90 mmHg in chronic hypertension.

2. Gestational hypertension without severe features

• Close BP and symptom monitoring.
• Weekly or more frequent review for evolving preeclampsia.
• Maternal labs and fetal surveillance as clinically indicated.
• Delivery is generally planned at 37 weeks.

3. Preeclampsia without severe features

• Maternal and fetal surveillance, either outpatient or inpatient depending on reliability and disease status.
• Monitor BP, symptoms, platelets, renal function, liver enzymes, and fetal growth/wellbeing.
• Delivery at 37 weeks, or at diagnosis if later.

4. Severe hypertension or preeclampsia with severe features

• Treat persistent BP ≥160/110 urgently.
• Common acute agents:
  • IV labetalol
  • IV hydralazine
  • Immediate-release oral nifedipine
• Give magnesium sulfate for seizure prophylaxis.
• Monitor fluid input and output carefully. Excess IV fluid can precipitate pulmonary edema.
• Give antenatal corticosteroids when preterm delivery is expected and gestation is appropriate.
• Deliver at 34 weeks or more if stable. Deliver earlier after maternal stabilization if there is maternal or fetal deterioration.

Indications for delivery regardless of gestation

• Eclampsia
• Uncontrolled severe hypertension
• HELLP syndrome
• Pulmonary edema
• Placental abruption
• Worsening renal failure or liver dysfunction
• Disseminated intravascular coagulation
• Persistent severe headache, visual symptoms, or epigastric pain
• Non-reassuring fetal condition

Eclampsia

1. Maintain airway and place patient in left lateral position.
2. Prevent injury and give oxygen as required.
3. Give magnesium sulfate to stop/prevent recurrent seizures.
4. Treat severe hypertension.
5. Deliver after maternal stabilization.

HELLP syndrome

• Hemolysis
• ELevated liver enzymes
• LPow platelet count

Intrapartum and postpartum care

During labor

• Frequent BP checks.
• Continue antihypertensives as appropriate.
• Treat severe BP urgently.
• Magnesium sulfate for severe preeclampsia/eclampsia.
• Strict fluid balance and urine-output monitoring.

After delivery

• Severe headache
• Visual symptoms
• Breathlessness or chest pain
• Epigastric/right upper abdominal pain
• Seizures
• BP ≥160/110 mmHg

High-yield points

• BP ≥160/110 mmHg is an obstetric emergency.
• Preeclampsia can be diagnosed without proteinuria.
• Magnesium sulfate prevents and treats eclamptic seizures.
• Delivery of the placenta is the definitive treatment for preeclampsia.
• Hypertension and preeclampsia may first occur postpartum.
• A hypertensive pregnancy increases later maternal risk of chronic hypertension, cardiovascular disease, stroke, and kidney disease.This topic is broad. I can cover it as an OB-GYN exam note in these sections:

1. Classification and diagnostic criteria
2. Chronic hypertension and preconception care
3. Gestational hypertension and preeclampsia
4. Severe preeclampsia, eclampsia, and HELLP syndrome
5. Investigations and maternal-fetal monitoring
6. Antihypertensive drugs and magnesium sulfate
7. Timing and mode of delivery
8. Intrapartum, postpartum, and long-term follow-up

1. Definition and epidemiology
2. Etiology and pathophysiology
3. Classification
4. Risk factors
5. Diagnosis, investigations, and differential diagnosis
6. Maternal and fetal complications
7. Antenatal monitoring
8. Antihypertensive management, including emergency regimens
9. Anticonvulsant treatment and magnesium sulfate regimens
10. Timing and mode of delivery
11. Intrapartum and postpartum management

• Classification and diagnosis of hypertensive disorders of pregnancy
• Preeclampsia: features, investigations, and management
• Chronic hypertension in pregnancy
• Antihypertensive drugs safe in pregnancy
• Exam-style OB-GYN notes or a case discussionWhich topic would you like?

Hypertension in pregnancy: management through all phases

Blood pressure definitions

1. Before conception

Goals

• Confirm whether hypertension is primary or secondary.
• Assess baseline maternal organ function.
• replace unsafe drugs before pregnancy.
• reduce the risk of superimposed preeclampsia and adverse fetal outcomes.

Preconception assessment

• Accurate BP, including home BP readings if available
• Duration and severity of hypertension
• Previous preeclampsia, fetal growth restriction, preterm birth, placental abruption, or stillbirth
• Comorbidities: chronic kidney disease, diabetes, obesity, systemic lupus erythematosus, antiphospholipid syndrome, cardiac disease
• Medication review
• Renal function: serum creatinine, electrolytes, urinalysis and urine protein quantification
• Full blood count, liver enzymes, glucose or HbA1c as indicated
• ECG, echocardiography, retinal examination, or evaluation for secondary hypertension if clinically indicated

Medicines before conception

• Labetalol
• Extended-release nifedipine
• Methyldopa, less commonly used now because it may cause fatigue or low mood

• ACE inhibitors, for example lisinopril, enalapril
• Angiotensin receptor blockers, for example losartan
• Direct renin inhibitors
• Mineralocorticoid antagonists such as spironolactone, unless a specialist has a compelling reason

Prevention of preeclampsia

• Stop smoking and alcohol
• Optimize weight, diabetes, kidney disease, and nutrition before conception
• Avoid stopping prescribed antihypertensives without medical advice

2. First trimester and early second trimester: before 20 weeks

Normal physiological change

Management

• Record baseline BP and baseline urine protein.
• Establish baseline platelet count, creatinine, and liver enzymes.
• Continue or commence pregnancy-compatible antihypertensives as needed.
• Review medication adherence and side effects.
• Begin low-dose aspirin at 12 weeks in high-risk patients.
• Plan serial fetal growth assessment later in pregnancy.

Risks with chronic hypertension

• Superimposed preeclampsia
• Placental abruption
• Fetal growth restriction
• Oligohydramnios
• Medically indicated preterm birth
• Stillbirth
• Maternal cardiac, renal, and cerebrovascular complications

3. After 20 weeks: gestational hypertension and preeclampsia surveillance

Diagnosis of preeclampsia

A. Proteinuria

• 24-hour urine protein at least 300 mg
• Protein-creatinine ratio at least 0.3
• Dipstick testing may be used where quantitative tests are unavailable, but is less reliable

B. End-organ involvement, even without proteinuria

• Platelet count below 100,000/µL
• Serum creatinine above 1.1 mg/dL or doubling from baseline in the absence of another explanation
• Liver transaminases at least twice the normal level, often with persistent right upper quadrant or epigastric pain
• Pulmonary edema
• New persistent headache not responding to usual analgesics
• Visual symptoms
• Severe BP at least 160/110 mmHg

Gestational hypertension

• About 10% to 25% of cases may progress to preeclampsia.
• Severe gestational hypertension can have risks similar to preeclampsia.
• It needs frequent review, usually including maternal BP checks, symptom assessment, urine or laboratory testing when indicated, and fetal surveillance.

4. Monitoring in the second and third trimesters

Maternal surveillance

• BP, using correct cuff size and standardized technique
• Symptoms: headache, vision changes, upper abdominal pain, nausea or vomiting, dyspnea, chest symptoms, reduced urine output
• Weight and edema, although edema alone does not diagnose preeclampsia
• Urine protein assessment when required
• Full blood count with platelet count
• Liver enzymes
• Serum creatinine and renal function

Home monitoring

• When and how to check BP
• How to contact the maternity unit
• The need to attend immediately for severe readings or warning symptoms

Fetal surveillance

• Serial ultrasound for fetal growth, usually particularly important in the third trimester for chronic hypertension
• Amniotic fluid volume assessment
• Umbilical artery Doppler when fetal growth restriction is suspected
• Non-stress testing or biophysical profile when disease is severe, medication is required, fetal growth restriction is present, or delivery risk is increased
• Daily fetal movement awareness or kick counts

5. Drug treatment during pregnancy

Maintenance treatment

1. Labetalol
2. Extended-release nifedipine
3. Methyldopa

• Labetalol may worsen asthma or bronchospasm and may not suit significant bradycardia or heart block.
• Nifedipine can cause flushing, headache, palpitations, or ankle edema.
• Methyldopa has extensive pregnancy safety experience but may cause sedation, depression, and liver-related adverse effects.

Acute severe hypertension

• IV labetalol
• IV hydralazine
• Immediate-release oral nifedipine

6. Preeclampsia with severe features

Immediate priorities

• Stabilize airway, breathing, circulation
• Repeat BP and treat severe hypertension promptly
• Check platelets, renal function, liver enzymes, coagulation if indicated
• Assess fetal status
• Give magnesium sulfate for seizure prophylaxis when preeclampsia has severe features, and for treatment of eclamptic seizures
• Give antenatal corticosteroids if preterm delivery is anticipated and gestation is appropriate
• Plan delivery based on maternal and fetal condition

Magnesium sulfate

• Loss of deep tendon reflexes
• Respiratory depression
• Reduced urine output

Eclampsia

• Protect the airway and prevent injury
• Magnesium sulfate
• Treat severe hypertension
• Stabilize mother first
• Proceed to delivery after maternal stabilization, regardless of gestational age if clinically necessary

7. Timing of delivery

8. Hypertension during labor and birth

• Check BP regularly.
• Continue maintenance antihypertensive therapy unless the clinical team changes it.
• Treat sustained severe hypertension urgently.
• Use magnesium sulfate where indicated.
• Avoid fluid overload, particularly in severe preeclampsia, because endothelial leak and reduced oncotic pressure increase pulmonary edema risk.
• Monitor urine output, respiratory status, reflexes when receiving magnesium, and fetal wellbeing.

9. Postpartum period: the risk does not end at delivery

Postpartum preeclampsia warning symptoms

• Severe headache
• Visual disturbance
• Epigastric or right upper abdominal pain
• Shortness of breath or chest pain
• Marked swelling of face/hands
• BP at least 160/110 mmHg
• Seizure
• New nausea, vomiting, or confusion

Postpartum management

• BP check soon after delivery and again during the first 1 to 2 weeks, with earlier and more frequent review after severe disease.
• Continue or adjust antihypertensive medication.
• Severe hypertension is treated urgently, as in pregnancy.
• Magnesium sulfate may be used for postpartum preeclampsia with neurologic symptoms or severe features.
• Assess renal function, platelets, liver enzymes, and symptoms if clinically indicated.
• Do not assume headache postpartum is “just stress” or a post-dural puncture headache until preeclampsia has been considered.

Breastfeeding

10. Long-term follow-up after a hypertensive pregnancy

• Chronic hypertension
• Ischemic heart disease and heart attack
• Stroke
• Chronic kidney disease
• Recurrence of preeclampsia in subsequent pregnancy

• BP review and transition to primary care
• Cardiovascular risk assessment
• Weight, diet, exercise, smoking cessation, and diabetes screening as appropriate
• Preconception counseling before the next pregnancy

Exam summary

Diagnostic BP thresholds

• Hypertension: BP ≥140/90 mmHg on repeat appropriate measurements.
• Severe hypertension: systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg.
• Severe persistent hypertension is an obstetric emergency because of maternal stroke risk.

Classification

1. Chronic hypertension in pregnancy

Definition

• BP ≥140/90 before conception or before 20 weeks of gestation.
• It can be essential hypertension or secondary to renal, endocrine, vascular, or other disease.

Risks

• Superimposed preeclampsia
• Placental abruption
• Stroke, heart failure, renal impairment

• Fetal growth restriction
• Preterm birth
• Stillbirth
• Low birth weight

Antenatal care

• Establish baseline: urine protein measurement, creatinine, liver enzymes, platelet count.
• Assess for secondary causes and target-organ damage if indicated.
• Low-dose aspirin is commonly started from 12 weeks in high-risk women to reduce preeclampsia risk.
• Monitor BP regularly, with third-trimester ultrasound surveillance for fetal growth.

Treatment

• Labetalol
• Extended-release nifedipine
• Methyldopa

• ACE inhibitors, for example enalapril, lisinopril
• Angiotensin receptor blockers, for example losartan
• Direct renin inhibitors

2. Gestational hypertension

Definition

• New hypertension after 20 weeks in a previously normotensive woman.
• No proteinuria and no features of maternal end-organ involvement.

Importance

Management

• Outpatient or inpatient care depending on reliability and severity
• Home BP monitoring where appropriate
• Fetal movement monitoring
• Regular fetal growth and antenatal surveillance as indicated
• Delivery at 37 weeks is generally recommended.

3. Preeclampsia

Diagnosis

A. Proteinuria

• ≥300 mg in 24-hour urine, or
• Protein-creatinine ratio ≥0.3

B. End-organ dysfunction, even if proteinuria is absent

• Platelets <100,000/µL
• Creatinine >1.1 mg/dL or doubling from baseline
• Liver transaminases at least twice normal, often with right upper abdominal or epigastric pain
• Pulmonary edema
• Persistent severe headache
• Visual disturbance

Pathophysiology

Symptoms needing urgent assessment

• Severe headache not relieved by medication
• Blurred vision, flashing lights, or visual loss
• Right upper abdominal or epigastric pain
• Breathlessness or chest pain
• Vomiting in late pregnancy
• Reduced urine output
• Sudden swelling of face or hands
• Reduced fetal movements

4. Preeclampsia with severe features

• BP ≥160/110 mmHg
• Cerebral or visual symptoms
• Pulmonary edema
• Significant thrombocytopenia
• Impaired liver or renal function
• Severe persistent epigastric or right upper abdominal pain

Management

• Admit to hospital.
• Stabilize mother and evaluate fetus.
• Treat severe BP urgently.
• Give magnesium sulfate for prevention of seizures.
• Give corticosteroids if preterm delivery is likely and gestation permits.
• Avoid excessive IV fluid due to pulmonary edema risk.
• Plan delivery according to gestational age and maternal-fetal condition.

5. Acute severe hypertension

Definition

Management

• IV labetalol
• IV hydralazine
• Immediate-release oral nifedipine

6. Eclampsia

Definition

Management

1. Protect airway and prevent injury.
2. Place in left lateral position.
3. Give magnesium sulfate.
4. Control severe hypertension.
5. Assess and stabilize mother.
6. Deliver after stabilization. The route of delivery depends on obstetric circumstances.

7. HELLP syndrome

• H: Hemolysis
• EL: Elevated liver enzymes
• LP: Low platelet count

8. Timing of delivery

9. Intrapartum management

• Frequent BP measurement.
• Continue suitable antihypertensive medication.
• Treat severe BP immediately.
• Magnesium sulfate for severe preeclampsia/eclampsia.
• Strict fluid balance and urine-output monitoring.
• Vaginal birth is possible if mother and fetus are stable. Cesarean birth is for usual obstetric indications or urgent clinical need.

10. Postpartum hypertension

Postpartum follow-up

• BP review soon after delivery, especially within 72 hours after severe hypertension.
• Continue or adjust antihypertensives.
• Investigate headache, visual symptoms, upper abdominal pain, dyspnea, or severe BP urgently.
• Magnesium sulfate may be needed for postpartum preeclampsia with severe neurologic features.

Long-term significance

• Chronic hypertension
• Ischemic heart disease
• Stroke
• Chronic kidney disease
• Recurrent preeclampsia in a future pregnancy

High-yield exam points

• Before 20 weeks = chronic hypertension until proven otherwise.
• After 20 weeks = consider gestational hypertension or preeclampsia.
• Proteinuria is not essential for diagnosis of preeclampsia if end-organ dysfunction is present.
• BP ≥160/110 mmHg is severe and needs urgent treatment.
• Magnesium sulfate prevents/treats eclamptic seizures.
• Delivery is the definitive treatment for preeclampsia.
• Preeclampsia can occur postpartum.# Hypertension in Pregnancy: OB-GYN Short Note

Definitions

• Hypertension: BP ≥140/90 mmHg on repeat measurement.
• Severe hypertension: BP ≥160 systolic and/or ≥110 diastolic mmHg.
• Before 20 weeks: usually chronic hypertension.
• After 20 weeks: consider gestational hypertension or preeclampsia.

Classification

Preeclampsia

Diagnosis

• 24-hour urine protein ≥300 mg, or
• Protein-creatinine ratio ≥0.3.

• Platelets <100,000/µL
• Creatinine >1.1 mg/dL or doubled from baseline
• Liver transaminases at least twice normal
• Persistent right upper abdominal or epigastric pain
• Pulmonary edema
• New persistent headache or visual symptoms
• Severe BP ≥160/110 mmHg

Risk factors for preeclampsia

• Previous preeclampsia
• Chronic hypertension
• Chronic kidney disease
• Diabetes mellitus
• Obesity
• Multiple pregnancy
• First pregnancy
• Antiphospholipid syndrome or systemic lupus erythematosus
• Advanced maternal age

Assessment

Maternal

• Repeat properly measured BP
• Ask about headache, blurred vision, flashing lights, epigastric/right-upper-quadrant pain, vomiting, breathlessness, reduced urine output
• Urine protein assessment
• Complete blood count and platelets
• Liver enzymes
• Serum creatinine and renal function

Fetal

• Fetal movement assessment
• Ultrasound for growth and amniotic fluid
• Doppler studies if fetal growth restriction is suspected
• Non-stress test/CTG or biophysical profile where indicated

Management

1. Chronic hypertension

• Baseline renal function, liver enzymes, platelet count, and urine protein.
• Low-dose aspirin from about 12 weeks for preeclampsia prevention in high-risk patients.
• Monitor fetal growth in the third trimester.
• Common maintenance drugs:
  • Labetalol
  • Extended-release nifedipine
  • Methyldopa
• Avoid ACE inhibitors and angiotensin receptor blockers during pregnancy.
• Medication is generally initiated or adjusted at BP ≥140/90 mmHg in chronic hypertension.

2. Gestational hypertension without severe features

• Close BP and symptom monitoring.
• Weekly or more frequent review for evolving preeclampsia.
• Maternal labs and fetal surveillance as clinically indicated.
• Delivery is generally planned at 37 weeks.

3. Preeclampsia without severe features

• Maternal and fetal surveillance, either outpatient or inpatient depending on reliability and disease status.
• Monitor BP, symptoms, platelets, renal function, liver enzymes, and fetal growth/wellbeing.
• Delivery at 37 weeks, or at diagnosis if later.

4. Severe hypertension or preeclampsia with severe features

• Treat persistent BP ≥160/110 urgently.
• Common acute agents:
  • IV labetalol
  • IV hydralazine
  • Immediate-release oral nifedipine
• Give magnesium sulfate for seizure prophylaxis.
• Monitor fluid input and output carefully. Excess IV fluid can precipitate pulmonary edema.
• Give antenatal corticosteroids when preterm delivery is expected and gestation is appropriate.
• Deliver at 34 weeks or more if stable. Deliver earlier after maternal stabilization if there is maternal or fetal deterioration.

Indications for delivery regardless of gestation

• Eclampsia
• Uncontrolled severe hypertension
• HELLP syndrome
• Pulmonary edema
• Placental abruption
• Worsening renal failure or liver dysfunction
• Disseminated intravascular coagulation
• Persistent severe headache, visual symptoms, or epigastric pain
• Non-reassuring fetal condition

Eclampsia

1. Maintain airway and place patient in left lateral position.
2. Prevent injury and give oxygen as required.
3. Give magnesium sulfate to stop/prevent recurrent seizures.
4. Treat severe hypertension.
5. Deliver after maternal stabilization.

HELLP syndrome

• Hemolysis
• ELevated liver enzymes
• LPow platelet count

Intrapartum and postpartum care

During labor

• Frequent BP checks.
• Continue antihypertensives as appropriate.
• Treat severe BP urgently.
• Magnesium sulfate for severe preeclampsia/eclampsia.
• Strict fluid balance and urine-output monitoring.

After delivery

• Severe headache
• Visual symptoms
• Breathlessness or chest pain
• Epigastric/right upper abdominal pain
• Seizures
• BP ≥160/110 mmHg

High-yield points

• BP ≥160/110 mmHg is an obstetric emergency.
• Preeclampsia can be diagnosed without proteinuria.
• Magnesium sulfate prevents and treats eclamptic seizures.
• Delivery of the placenta is the definitive treatment for preeclampsia.
• Hypertension and preeclampsia may first occur postpartum.
• A hypertensive pregnancy increases later maternal risk of chronic hypertension, cardiovascular disease, stroke, and kidney disease.This topic is broad. I can cover it as an OB-GYN exam note in these sections:

1. Classification and diagnostic criteria
2. Chronic hypertension and preconception care
3. Gestational hypertension and preeclampsia
4. Severe preeclampsia, eclampsia, and HELLP syndrome
5. Investigations and maternal-fetal monitoring
6. Antihypertensive drugs and magnesium sulfate
7. Timing and mode of delivery
8. Intrapartum, postpartum, and long-term follow-up

1. Definition and epidemiology
2. Etiology and pathophysiology
3. Classification
4. Risk factors
5. Diagnosis, investigations, and differential diagnosis
6. Maternal and fetal complications
7. Antenatal monitoring
8. Antihypertensive management, including emergency regimens
9. Anticonvulsant treatment and magnesium sulfate regimens
10. Timing and mode of delivery
11. Intrapartum and postpartum management

1. Definitions and classification
2. Etiology, pathophysiology, and risk factors
3. Diagnosis, investigations, and complications
4. Antihypertensive drugs with doses and routes
5. Magnesium sulfate and eclampsia management
6. Delivery, intrapartum, and postpartum management

Hypertension in Pregnancy: Detailed OB-GYN Note

1. Definition

• Systolic BP ≥140 mmHg, and/or
• Diastolic BP ≥90 mmHg

• Systolic BP ≥160 mmHg, and/or
• Diastolic BP ≥110 mmHg

2. Normal BP changes in pregnancy

• BP usually falls in the first and second trimesters.
• The lowest BP is around 20 weeks.
• BP gradually rises toward the pre-pregnancy level in the third trimester.

3. Classification of hypertensive disorders of pregnancy

4. Etiology

A. Chronic hypertension

Primary or essential hypertension

Secondary hypertension

• Chronic kidney disease
• Renal artery stenosis
• Diabetic nephropathy
• Systemic lupus erythematosus
• Pheochromocytoma
• Primary hyperaldosteronism
• Cushing syndrome
• Thyroid disorders
• Coarctation of the aorta
• Drug-induced hypertension, for example cocaine, amphetamines, corticosteroids

B. Gestational hypertension and preeclampsia

5. Pathophysiology of preeclampsia

Stage 1: Abnormal placentation

• Trophoblast invasion is shallow or defective.
• Spiral arteries remain narrow, high-resistance vessels.
• Placental blood flow becomes inadequate.
• Placental ischemia and oxidative stress occur.

Stage 2: Maternal endothelial dysfunction

• Generalized vasoconstriction
• Hypertension
• Increased capillary permeability
• Platelet activation and consumption
• Activation of coagulation
• Reduced organ perfusion
• Endothelial injury in kidneys, liver, brain, lungs, and placenta

Organ effects

6. Risk factors

High-risk factors

• Previous preeclampsia, especially early-onset or severe preeclampsia
• Chronic hypertension
• Chronic kidney disease
• Diabetes mellitus type 1 or type 2
• Antiphospholipid syndrome
• Systemic lupus erythematosus
• Multiple pregnancy
• Previous fetal growth restriction, placental abruption, stillbirth, or preterm birth due to preeclampsia

Moderate-risk factors

• First pregnancy
• Maternal age ≥35 years
• Obesity
• Family history of preeclampsia
• Long interpregnancy interval
• Assisted reproduction or IVF
• Low socioeconomic status
• Previous adverse pregnancy outcome

7. Diagnosis

A. Proper BP measurement

• Patient seated and rested for at least 5 minutes.
• Appropriate cuff size.
• Arm supported at heart level.
• Confirm elevated readings with repeat measurement.
• In severe BP elevation, do not delay emergency treatment while waiting for repeated readings if hypertension remains persistent.

B. Diagnosis of gestational hypertension

• BP ≥140/90 mmHg after 20 weeks
• Previously normal BP
• No proteinuria
• No maternal end-organ dysfunction

C. Diagnosis of preeclampsia

Proteinuria

• 24-hour urine protein ≥300 mg
• Urine protein-creatinine ratio ≥0.3
• Dipstick protein may be used if quantitative testing is unavailable, but it is less reliable.

Preeclampsia without proteinuria

• Platelet count <100,000/µL
• Serum creatinine >1.1 mg/dL or doubled from baseline
• Liver transaminases at least twice normal
• Persistent severe right-upper-quadrant or epigastric pain
• Pulmonary edema
• Persistent headache not responding to usual treatment
• Visual disturbances

D. Severe features

• BP ≥160/110 mmHg
• Severe persistent headache
• Visual disturbance
• Altered sensorium
• Persistent epigastric/right upper abdominal pain
• Platelets <100,000/µL
• Significant transaminitis
• Renal insufficiency or oliguria
• Pulmonary edema
• Eclampsia
• HELLP syndrome

8. Investigations

Maternal investigations

• Complete blood count and platelet count
• Urine protein-creatinine ratio or 24-hour urine protein
• Liver function tests: AST, ALT, bilirubin
• Renal function tests: creatinine, urea, electrolytes
• LDH and peripheral smear if hemolysis/HELLP suspected
• Coagulation profile if bleeding, thrombocytopenia, abruption, severe liver disease, or DIC suspected
• Blood group and cross-match when delivery may be needed
• Fundus examination if severe chronic hypertension, where appropriate
• ECG/echocardiography if cardiac disease or severe chronic hypertension is suspected

Fetal assessment

• Maternal report of fetal movements
• Ultrasound for fetal growth and amniotic fluid
• Umbilical artery Doppler if fetal growth restriction is suspected
• Non-stress test/CTG
• Biophysical profile if indicated

9. Complications

Maternal complications

• Eclampsia
• Stroke/intracranial hemorrhage
• HELLP syndrome
• Acute kidney injury
• Pulmonary edema
• DIC
• Placental abruption
• Liver hematoma or rupture
• Maternal death

Fetal and neonatal complications

• Fetal growth restriction
• Oligohydramnios
• Fetal hypoxia
• Prematurity
• Low birth weight
• Stillbirth
• Neonatal intensive-care admission
• Complications of iatrogenic preterm birth

10. General management principles

• Gestational age
• Severity of hypertension
• Presence or absence of preeclampsia
• Maternal symptoms and laboratory findings
• Fetal status
• Availability of tertiary obstetric and neonatal care

Immediate actions in suspected severe preeclampsia/eclampsia

1. Admit to hospital, preferably a high-dependency obstetric unit.
2. Place in left lateral position.
3. Assess airway, breathing, circulation.
4. Establish IV access and send blood tests.
5. Measure BP frequently.
6. Insert urinary catheter in severe disease and monitor hourly urine output.
7. Assess fetal wellbeing after maternal stabilization.
8. Treat persistent severe hypertension promptly.
9. Administer magnesium sulfate when indicated.
10. Decide timing of delivery after stabilizing the mother.

11. Antihypertensive management

Treatment goals

• Systolic BP: 140-150 mmHg
• Diastolic BP: 90-100 mmHg

A. Oral maintenance therapy

Drugs generally avoided in pregnancy

• ACE inhibitors: lisinopril, enalapril, ramipril
• Angiotensin receptor blockers: losartan, valsartan
• Direct renin inhibitor: aliskiren
• Mineralocorticoid antagonist: spironolactone, unless a specialist advises otherwise
• Atenolol is generally avoided because of concern for fetal growth restriction

B. Acute treatment of severe hypertension

Option 1: IV labetalol regimen

• 20 mg IV slowly over 2 minutes
• If BP remains severe after 10 minutes: 40 mg IV
• If still severe after another 10 minutes: 80 mg IV
• May give an additional 80 mg IV after 10 minutes if required
• Maximum cumulative dose commonly 220 mg

• Asthma/bronchospasm
• Marked bradycardia
• Heart block
• Decompensated heart failure

Option 2: IV hydralazine regimen

• 5-10 mg IV slowly
• Reassess BP after 20 minutes.
• Repeat 5-10 mg IV every 20 minutes if necessary.
• Common maximum cumulative dose: 20 mg

• Maternal tachycardia
• Headache
• Hypotension
• Fetal tachycardia

Option 3: Immediate-release oral nifedipine regimen

• 10 mg orally
• If still severe after 20 minutes: 20 mg orally
• If still severe after another 20 minutes: 20 mg orally
• Usual maximum in the first hour: 50 mg

If BP remains severe

• Escalate to senior obstetric, anesthesia, and medical support.
• Consider ICU/HDU care.
• Reassess for stroke, pulmonary edema, placental abruption, or worsening preeclampsia.
• Plan delivery when maternal or fetal indications exist.

12. Anticonvulsant management: magnesium sulfate

Indications

1. Prevention of seizures in preeclampsia with severe features
2. Treatment of eclampsia
3. Continued protection around delivery and postpartum in severe disease

A. IV regimen: Zuspan regimen

Loading dose

• 4-6 g magnesium sulfate IV
• Dilute and infuse over 20-30 minutes

Maintenance infusion

• 1-2 g per hour IV infusion

Duration

• 24 hours after delivery, or
• 24 hours after the last seizure, whichever is later.

B. IM plus IV regimen: Pritchard regimen

Loading dose

• 4 g IV, usually as 20% solution, given slowly over about 5 minutes
  plus
• 10 g IM total, commonly 5 g deep IM into each buttock, often with lignocaine/local anesthetic

Maintenance dose

• 5 g IM every 4 hours, given alternately in each buttock.

• Patellar reflex is present
• Respiratory rate is at least 12/minute
• Urine output is at least 25 mL/hour, or at least 100 mL over 4 hours

C. Recurrent seizure while on magnesium sulfate

• Give an additional 2 g magnesium sulfate IV slowly over 5 minutes.

• Secure airway.
• Request anesthesia and critical-care support.
• Consider another anticonvulsant, such as IV benzodiazepine, according to emergency protocol.
• Evaluate for other causes of seizures, including intracranial hemorrhage.

D. Monitoring during magnesium therapy

• Respiratory rate
• Deep tendon reflexes, especially patellar reflex
• Urine output
• Consciousness level
• Oxygen saturation
• BP and fetal status

E. Signs of magnesium toxicity

• Loss of deep tendon reflexes
• Respiratory depression
• Hypotension
• Drowsiness or reduced consciousness
• Cardiac conduction disturbances or cardiac arrest in severe toxicity

F. Antidote

• Calcium gluconate 10%, 10 mL IV slowly, equivalent to 1 g
• Stop magnesium infusion and provide airway/ventilatory support.

13. Eclampsia: emergency management

1. Call for senior obstetric, anesthesia, neonatal, and critical-care help.
2. Place the woman in the left lateral position.
3. Protect her from injury. Do not forcibly restrain or put objects in her mouth.
4. Maintain airway and give oxygen if needed.
5. Suction secretions after convulsions if required.
6. Establish IV access.
7. Give magnesium sulfate immediately.
8. Treat severe hypertension.
9. Check glucose and consider other causes if appropriate.
10. After maternal stabilization, arrange delivery. Do not perform immediate cesarean delivery during an uncontrolled convulsion.

14. HELLP syndrome

• H: Hemolysis
• EL: Elevated liver enzymes
• LP: Low platelets

• Right-upper-quadrant or epigastric pain
• Nausea, vomiting, malaise
• Hypertension may be mild or occasionally absent
• Thrombocytopenia
• Elevated AST/ALT
• Hemolysis with raised LDH

• Admit and stabilize.
• Magnesium sulfate if severe features/eclampsia risk.
• Control severe BP.
• Correct coagulopathy or thrombocytopenia as needed.
• Delivery is usually indicated after stabilization, particularly when maternal or fetal condition worsens.

15. Timing of delivery

16. Intrapartum care

• Continue antihypertensive treatment as appropriate.
• Monitor BP frequently.
• Treat severe BP promptly.
• Strict fluid balance.
• Monitor urine output.
• Continue magnesium sulfate when indicated.
• Vaginal delivery is possible and often preferred if maternal and fetal status permit.
• Cesarean delivery is performed for standard obstetric indications or where rapid delivery is necessary.

17. Postpartum management

Monitor for

• Severe headache
• Visual disturbance
• Breathlessness or pulmonary edema
• Epigastric pain
• Seizure
• BP ≥160/110 mmHg

Management

• Continue BP monitoring and antihypertensive therapy.
• Treat severe hypertension urgently.
• Continue magnesium sulfate for 24 hours after delivery or last seizure when indicated.
• Check renal function, platelets, and liver enzymes if symptoms or severe disease persist.
• Review patients with severe hypertension early after discharge, often within 72 hours.

18. Important exam points

• Hypertension: ≥140/90 mmHg
• Severe hypertension: ≥160/110 mmHg
• Before 20 weeks: usually chronic hypertension
• After 20 weeks: think gestational hypertension or preeclampsia
• Proteinuria is not required for preeclampsia if maternal end-organ dysfunction is present.
• Magnesium sulfate prevents and treats eclampsia.
• Calcium gluconate is the antidote for magnesium toxicity.
• IV labetalol, IV hydralazine, or oral immediate-release nifedipine are standard drugs for acute severe hypertension.
• Delivery is the only definitive treatment for preeclampsia.
• Hypertension and preeclampsia may occur for the first time postpartum.

Hypertension During Pregnancy: Detailed OB-GYN Note

1. Definition

• Systolic BP ≥140 mmHg and/or
• Diastolic BP ≥90 mmHg

• Systolic BP ≥160 mmHg and/or
• Diastolic BP ≥110 mmHg

2. Classification of hypertensive disorders in pregnancy

Important timing rule

• Before 20 weeks: usually chronic hypertension.
• After 20 weeks: think gestational hypertension or preeclampsia.
• This is not absolute. Rarely, early preeclampsia can occur with conditions such as molar pregnancy, antiphospholipid syndrome, or severe renal disease.

3. Etiology

A. Chronic hypertension

1. Primary or essential hypertension

• Obesity
• Family history
• Older maternal age
• Insulin resistance
• Sedentary lifestyle

2. Secondary hypertension

• Chronic kidney disease
• Renal artery stenosis
• Glomerulonephritis
• Polycystic kidney disease
• Endocrine causes: pheochromocytoma, primary hyperaldosteronism, Cushing syndrome, thyroid disease
• Connective-tissue disease, especially systemic lupus erythematosus
• Coarctation of the aorta
• Drugs: cocaine, amphetamines, corticosteroids, NSAIDs, oral contraceptives before conception

B. Gestational hypertension

• A transient pregnancy-related hypertensive response
• Early or incomplete preeclampsia
• Unmasking of a predisposition to future chronic hypertension

C. Preeclampsia

• Abnormal trophoblastic invasion of maternal spiral arteries
• Inadequate remodeling of spiral arteries
• Reduced uteroplacental perfusion and placental ischemia
• Placental release of antiangiogenic and inflammatory factors
• Widespread maternal endothelial dysfunction
• Vasospasm, capillary leak, platelet activation, and coagulation abnormalities

4. Pathophysiology of preeclampsia

Step 1: Defective placentation

• Trophoblastic invasion is incomplete.
• Spiral arteries remain narrow, high-resistance vessels.
• Placental blood flow is reduced.
• Placental ischemia and oxidative stress develop.

Step 2: Release of placental factors

• Soluble fms-like tyrosine kinase-1, or sFlt-1
• Soluble endoglin

• Vascular endothelial growth factor
• Placental growth factor

Step 3: Systemic maternal endothelial dysfunction

5. Risk factors for preeclampsia

High-risk factors

• Previous preeclampsia, especially early-onset or severe disease
• Chronic hypertension
• Chronic kidney disease
• Diabetes mellitus type 1 or type 2
• Antiphospholipid syndrome
• Systemic lupus erythematosus
• Multiple gestation
• Assisted reproduction in some settings

Moderate-risk factors

• Nulliparity
• Obesity
• Maternal age 35 years or more
• Family history of preeclampsia
• Long interval since previous pregnancy
• Previous adverse pregnancy outcome: fetal growth restriction, abruption, stillbirth
• Low socioeconomic status in some populations

6. Diagnosis

A. Diagnosis of gestational hypertension

• BP ≥140/90 mmHg after 20 weeks
• Previously normal BP
• No proteinuria
• No clinical or laboratory evidence of maternal organ dysfunction

B. Diagnosis of preeclampsia

1. Proteinuria

• 24-hour urine protein ≥300 mg
• Urine protein-creatinine ratio ≥0.3
• Dipstick proteinuria may be used where quantitative testing is unavailable, but is less reliable

2. Preeclampsia without proteinuria

• Platelet count <100,000/µL
• Serum creatinine >1.1 mg/dL or doubling of baseline creatinine
• Liver transaminases at least twice the normal upper limit
• Persistent severe right-upper-quadrant or epigastric pain
• Pulmonary edema
• New persistent headache not responding to treatment
• Visual symptoms
• Severe hypertension

7. Preeclampsia with severe features

1. BP ≥160/110 mmHg
2. Persistent severe headache or altered sensorium
3. Visual disturbance, scotoma, blurred vision
4. Persistent epigastric or right-upper-quadrant pain
5. Platelets <100,000/µL
6. Liver transaminases ≥2 times normal
7. Creatinine >1.1 mg/dL or worsening renal insufficiency
8. Pulmonary edema
9. Eclampsia
10. HELLP syndrome

8. HELLP syndrome

• H: Hemolysis
• EL: Elevated liver enzymes
• LP: Low platelet count

• Epigastric or right-upper-quadrant pain
• Nausea and vomiting
• Malaise
• Headache
• Hypertension may be mild or even absent initially

• Hemolysis: raised LDH, indirect bilirubin, fragmented red cells
• Elevated AST/ALT
• Thrombocytopenia

9. Clinical assessment

History

• Headache, especially severe or persistent
• Blurred vision, flashing lights, scotoma
• Epigastric or right-upper-quadrant pain
• Nausea and vomiting in late pregnancy
• Dyspnea or chest pain
• Reduced urine output
• Sudden swelling of face or hands
• Decreased fetal movements
• Vaginal bleeding, suggesting placental abruption
• Previous hypertension, preeclampsia, kidney disease, diabetes, autoimmune disease, medications

Examination

• Repeat BP with correct technique
• Weight and edema
• Reflexes and clonus
• Respiratory examination for pulmonary edema
• Abdominal examination for liver tenderness or uterine tenderness
• Fundal height and fetal heart rate
• Fetal growth assessment

10. Investigations

Maternal investigations

• Full blood count, especially platelet count
• Peripheral smear and LDH if hemolysis suspected
• Liver function tests: AST, ALT, bilirubin
• Renal function: serum creatinine, urea, electrolytes
• Urine protein-creatinine ratio or 24-hour urine protein
• Coagulation profile if HELLP, abruption, liver dysfunction, or DIC is suspected
• Blood group and cross-match if delivery or hemorrhage is likely

Fetal investigations

• Ultrasound for fetal growth and estimated fetal weight
• Amniotic fluid volume
• Umbilical artery Doppler if fetal growth restriction is suspected
• Cardiotocography/non-stress test
• Biophysical profile where indicated
• Daily fetal movement assessment

11. General management principles

• Gestational age
• Severity of hypertension
• Presence of preeclampsia/severe features
• Maternal clinical and laboratory status
• Fetal growth and fetal testing
• Availability of monitoring and neonatal intensive care

Immediate actions in severe disease

1. Admit to labor ward/high-dependency unit.
2. Call senior obstetrician, anesthetist, physician, and neonatologist.
3. Place the patient in the left lateral position.
4. Secure IV access, usually two large-bore cannulas in severe disease.
5. Monitor BP, pulse, respiratory rate, oxygen saturation, consciousness, reflexes, and urine output.
6. Insert urinary catheter for strict input-output monitoring when severe preeclampsia/eclampsia is present.
7. Send urgent blood tests.
8. Assess fetal wellbeing.
9. Treat severe hypertension.
10. Give magnesium sulfate if severe features or eclampsia are present.
11. Plan delivery after maternal stabilization when indicated.

Fluid management

12. Antihypertensive management

A. Goals

• Hemorrhagic stroke
• Heart failure
• Myocardial ischemia
• Placental abruption
• Renal injury

B. When to treat

Chronic hypertension

Acute severe hypertension

C. Oral maintenance antihypertensive drugs

1. Labetalol

• Start: 100 to 200 mg orally twice daily
• Titrate according to BP
• Usual maximum: 2,400 mg/day in divided doses

• Common first-line agent
• Effective and widely used

• Asthma or bronchospasm
• Bradycardia
• Heart block
• Decompensated cardiac failure

2. Extended-release nifedipine

• Start: 30 mg orally once daily
• May increase to 60 mg daily, then as required
• Maximum commonly: 120 mg/day

• Once-daily administration
• Useful when labetalol is contraindicated

• Headache
• Flushing
• Palpitations
• Peripheral edema

3. Methyldopa

• Start: 250 mg orally two or three times daily
• Titrate according to BP
• Maximum: 3 g/day in divided doses

• Long record of fetal safety

• Sedation
• Depression
• Dry mouth
• Rare hepatitis or hemolytic anemia

Drugs generally avoided during pregnancy

• ACE inhibitors: enalapril, lisinopril
• Angiotensin receptor blockers: losartan, valsartan
• Direct renin inhibitors
• Mineralocorticoid antagonists such as spironolactone, unless specialist-directed
• Sodium nitroprusside is generally avoided because prolonged infusion can cause fetal cyanide toxicity

13. Management of acute severe hypertension

Option 1: IV labetalol regimen

1. 20 mg IV slowly over 2 minutes
2. If BP remains severe after 10 minutes: 40 mg IV
3. If still severe after another 10 minutes: 80 mg IV
4. Further 80 mg doses may be used at 10-minute intervals according to protocol.

Option 2: IV hydralazine regimen

1. 5 to 10 mg IV slowly
2. Reassess after 20 minutes.
3. Repeat 5 to 10 mg IV if necessary.
4. Common maximum in an acute episode: 20 mg.

• Maternal hypotension
• Reflex tachycardia
• Headache
• Nausea
• Risk of excessive BP fall

Option 3: immediate-release oral nifedipine

1. 10 mg orally
2. If BP remains severe after 20 minutes: 20 mg orally
3. If still severe after another 20 minutes: 20 mg orally

14. Anticonvulsant management: magnesium sulfate

Indications

• Eclampsia: treatment of seizures and prevention of recurrence
• Preeclampsia with severe features: seizure prophylaxis
• Gestational hypertension with severe-range BP where severe features are present or considered likely
• Postpartum preeclampsia with severe features or neurological symptoms

A. IV regimen: Zuspan regimen

1. Loading dose:
   4 to 6 g magnesium sulfate IV, diluted and administered slowly over 15 to 20 minutes
2. Maintenance infusion:
   1 to 2 g per hour IV infusion
3. Continue for:
   • 24 hours after delivery, or
   • 24 hours after the last seizure, whichever is later.

B. Combined IV and IM regimen: Pritchard regimen

1. Loading dose:
   • 4 g IV slowly over 5 minutes, plus
   • 10 g IM, given as 5 g deep IM into each buttock, usually with local anesthetic according to protocol.
2. Maintenance dose:
   • 5 g IM every 4 hours, alternating buttocks.

• Patellar reflexes are present
• Respiratory rate is >12/minute
• Urine output is adequate, commonly >25 to 30 mL/hour

C. If seizure recurs

• Give 2 g magnesium sulfate IV slowly over about 5 minutes.

• Reassess diagnosis, airway, hypoxia, hypoglycemia, intracranial pathology, and magnesium toxicity.
• Escalate urgently to anesthetic/critical care support.
• Additional anticonvulsants such as benzodiazepines may be required under specialist supervision.

15. Monitoring during magnesium sulfate therapy

• Respiratory rate
• Oxygen saturation
• Level of consciousness
• Deep tendon reflexes, especially patellar reflex
• Urine output
• BP and pulse

Signs of magnesium toxicity

• Loss of patellar reflexes
• Flushing, somnolence, slurred speech
• Respiratory depression
• Hypotension
• Bradycardia
• Cardiac arrest in severe toxicity

Management of magnesium toxicity

1. Stop magnesium sulfate.
2. Support airway and breathing.
3. Give the antidote:

• Calcium gluconate 10%: 10 mL IV slowly over 10 minutes
  This equals 1 g calcium gluconate.

1. Seek urgent critical care/anesthetic support.

16. Management of eclampsia

Immediate management

1. Call for help.
2. Protect the patient from injury.
3. Place in left lateral position.
4. Maintain airway and suction secretions if needed.
5. Give oxygen if hypoxemic.
6. Establish IV access.
7. Check blood glucose.
8. Give magnesium sulfate.
9. Treat severe hypertension promptly.
10. Continuous maternal and fetal monitoring after stabilization.
11. Plan delivery after maternal stabilization.

Delivery

• Cervical favorability
• Gestational age
• Fetal condition
• Need for urgent birth
• Obstetric indication

17. Timing of delivery

Corticosteroids

18. Intrapartum management

• Admit severe cases to a facility capable of emergency obstetric and neonatal care.
• Monitor BP frequently.
• Continue appropriate antihypertensives.
• Treat sustained severe BP immediately.
• Magnesium sulfate in severe preeclampsia/eclampsia.
• Strict fluid balance.
• Monitor urine output.
• Avoid ergometrine in uncontrolled hypertension because it can precipitate severe BP elevation.
• Regional anesthesia may be appropriate if platelet count and coagulation status permit.

19. Postpartum management

Continue monitoring

• Monitor BP during admission.
• Early post-discharge BP review is required, especially after severe hypertension.
• Continue magnesium sulfate for 24 hours after delivery or last seizure where indicated.
• Adjust oral antihypertensive drugs.

Drugs compatible with breastfeeding

• Labetalol
• Nifedipine
• Enalapril may be used postpartum under clinician supervision, although ACE inhibitors are avoided during pregnancy

Urgent postpartum warning signs

• Severe headache
• Visual symptoms
• Upper abdominal pain
• Shortness of breath/chest pain
• Seizure
• BP ≥160/110 mmHg
• Heavy bleeding or symptoms of abruption-related complications

20. Maternal and fetal complications

Maternal

• Eclampsia
• Stroke and intracranial hemorrhage
• HELLP syndrome
• DIC
• Placental abruption
• Pulmonary edema
• Acute kidney injury
• Liver hematoma or hepatic rupture
• Maternal death

Fetal/neonatal

• Fetal growth restriction
• Oligohydramnios
• Prematurity
• Placental insufficiency
• Fetal hypoxia
• Stillbirth
• Neonatal complications due to prematurity

21. High-yield summary

• ≥140/90 mmHg: hypertension in pregnancy.
• ≥160/110 mmHg: severe hypertension requiring urgent treatment.
• Before 20 weeks: chronic hypertension until proven otherwise.
• After 20 weeks: gestational hypertension or preeclampsia.
• Preeclampsia can occur without proteinuria if end-organ dysfunction is present.
• Magnesium sulfate is first-line for prevention and treatment of eclamptic seizures.
• Labetalol, hydralazine, and immediate-release nifedipine are standard emergency drugs for severe hypertension.
• Delivery of the placenta is the definitive treatment for preeclampsia.
• Preeclampsia can occur or worsen after delivery.