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Hypertensive disorders in
pregnancy
ANUM FATIMA
08-226
Batch E
Hypertensive disorders are the
most common and yet serious
conditions seen in obstetrics
Classification
Pre-eclampsia
Eclampsia
Preeclampsia superimposed
on chronic hypertension
Chronic hypertension
with pregnancy
Gestational hypertension
Blood Pressure ≥ 140/90mmHg on two
or more occasions
- in a previously normotensive patient
- after 20 weeks gestation
- without proteinuria
- returning to normal 12 weeks after
delivery
Almost half of these develop
preeclampsia syndrome
GESTATIONAL HYPERTENSION
GESTATIONAL HYPERTENSION
GESTATION ≥ 20 WEEKS
SUSTAINED HYPERTENSION ( ≥
140/90)
No proteinuria
DEFINITION
SYMPTOMS
EXAMINATION
GESTATIONAL HYPERTENSION
Sustained B.P
No proteinuria
NONE
Unremarkable
Preeclampsia
◦ It is defined as hypertension of at least
140/90mm Hg recorded on two separate
occasions at least 4 hours apart and in
the presence of at least 300mg protein in
a 24 hour collection of urine, arising after
the 20th week of gestation in a previously
normotensive woman and resolving
completely by the 6th postpartum week.
(
RISK FACTORS for PREECLAMPSIA
DEMOGRAPHIC
OBSTETRICS
MEDICAL
NULLIPARA
(Age extremes <20yrs ,
>35yrs )
1. Multiple gestation
2. Molar pregnancy
3. Non-immune hydrops
1. Diabetes mellitus
2. Chronic HTN
3. Renal disease
4. SLE
MILD PREECLAMPSIA
GESTATION ≥ 20 WEEKS
SUSTAINED HYPERTENSION (≥ 140/90)
Proteinuria (≥300mg /24 hr)
NONE
SYMPTOMS
EXAMINATION
PATHO -
PYSIOLOGY
MILD PREECLAMPSIA
NONE
NONE
Diffuse Vasospasm
Capillary injury
MILD PREECLAMPSIA
LABORATORY
FINDINGS
MANAGEMENT
PROTEINPROTEINURIA
URIAProteinuria (1-2+)
Hemoconcentration
< 36 wks Conservative
>36 wks MgSO4 and
Delivery
GESTATIONAL HYPERTENSION
GESTATION ≥ 20 WEEKS
SUSTAINED HYPERTENSION (≥ 140/90)
NO PROTEINURIA
MILD PREECLAMPSIA
SUSTAINED HYPERTENSION ( ≥
140/90)
Proteinuria ( ≥ 300mg /24 hr)
GESTATION ≥ 20 WEEKS
BLOOD
PRESSURE
PROTEINURIA
SYMPTOMS
CRITERIA: SEVERE PREECLEMPSIA
≥ 160/110
≥ 5grams
1. Headache
2. Epigastric pain
3. Visual changes
CRITERIA: SEVERE
PREECLEMPSIA
LABORATORY
FINDINGS
SIGNS
DIC
Elevated Liver
enzymes
1. Pulmonary edema
2. Oliguria
3. cyanosis
new onset of seizures or unexplained coma
during pregnancy in patients with pre-existing
preeclampsia and without pre-existing
neurological disorder.
ECLAMPSIA
rebra
ECLAMPSIA
SYMPTOMS
PATHO -
PYSIOLOGY
RISK FACTORS Same as Preeclampsia
Cerebral vasospasm ,
ischemia and edema
Generalized tonic-
clonic
SEIZURES
ECLAMPSIA
LABORATORY
FINDINGS
MANAGEMENT
Proteinuria
HemoconcentrationDIC
Elevated Liver
enzymes
1. Stop convulsions with MgSO4
2. Prompt delivery at any
gestational age
3. Lower diastolic B.P 90-
100mm/Hg
MANAGEMENT
IV MgSO4 – To prevent convulsions ( continue
24 hrs post-partum )
LOWER B.P ( hydralazine or labetalol)
INDUCE LABOR (IV oxytocin and amniotomy
)
Blood pressure ≥ 140/90 before 20 weeks of
gestation
OR
persistence of hypertension beyond 12 weeks
after delivery.
CHRONIC
HYPERTENSION
CHRONIC HYPERTENSION
GESTATION < 20 WEEKS OR Prepragnancy
SUSTAINED HYPERTENSION
(≥140/90)
+/- PROTEINURIA
CHRONIC HTN PREGNANCY
PROGNOSIS
GOOD
PROGNOSIS
POOR
PROGNOSIS
WORST
PROGNOSIS
B.P 140/90 to 179/109
No end organ damage
KIDNEYS: Renal disease
EYES : Retinopathy
HEART : Left Ventricular
Hypertrophy (B.P
>180/90)
Uncontrolled HTN
Chronic HTN
+Superimposed PIH
D
MANAGEMENT OF CHRONIC HYPERTENSION
If antihypertensive meds needed
- Methyl dopa is drug of choice (or labetalol)
Serial ultrasounds (increase risk of IUGR >30
weeks )
Induce labor at term
DC antihypertensive meds
(if B.P <100 mm Hg diastolic)
Serial B.P and urine protein
(watch for superimposed preeclampsia)
SUPERIMPOSED PREECLAMPSIA
(on Chronic Hypertension)
New-onset proteinuria > 300 mg/24 hrs in
hypertensive women but no proteinuria
before 20 wks gestation
A sudden increase in proteinuria or blood
pressure or platelet count < 100,000/ cu
mm in women with hypertension and
proteinuria before 20 wks gestation.
23
CHRONIC HTN SUPERIMPOSED PIH
CHRONIC HYPERTENSION
Worsening BLOOD
PRESSURE
Worsening proteinuria
MANAGEMENT of Chronic HTN and
superimposed PIH
IV MgSO4 – To prevent convulsions ( continue
24 hrs post-partum )
LOWER B.P - Diastolic 90-100 mm Hg(
hydralazine or labetalol)
INDUCE LABOR (IV oxytocin and amniotomy
)
HELLP Syndrome
HTN patients with hemolysis (H), elevated liver enzymes (EL), low platelet count (LP)
4-12% of pt. with severe preeclampsia and eclampsia develop HELLP syndrome
PATHOPHYSIOLOGY
Complex disease
Appears to be triggered by the
placenta
◦ Can occur in molar pregnancies where
fetus absent
◦ Can also occur in abdominal pregnancy
(pregnancy not in uterus)
TWO – STAGE MODEL FOR
PREECLAMPSIA
Stage 1:
reduced
placental
perfusion
Abnormal
implantation
Stage 2 :
maternal
syndrome
-hypertension
-proteinuria
-endothelial
dysfunction
NORMAL
PREGNANCY
PREECLAMPSIA
Impair/ inadequate trophoblast invasion to the spiral arteries
Spiral arteries retain their charecteristic (narrow, tortuous, high resistance)
Reduce blood supply to placenta
Result in placental hypoperfusion
As a compensation
High BP in maternal
Stage 1:
reduced
placental
perfusion
Abnormal
implantation
Stage 2 :
maternal
syndrome
-hypertension
-proteinuria
-endothelial
dysfunction
WHAT CAUSES MATERNAL
SYNDROME ?????
WHAT GETS INTO MATERNAL
CIRCULATION ???
ANTI-ANGIOGENIC
FACTORSANGIOGENIC
FACTORS
Vascular endothelial
growth (VEGF)
including placental
growth factor
Transforming growth
factor- beta (TGF-B)
Look after maternal
endothelium
Soluble endoglin (sEng)
Soluble FMS-like
tyrosine kinase-1 (sFlt-1)
Released from
diseased placenta
↓PGI2
↑TXA2
Vasoconstriction
Platelet aggregation
↑Vasopressor
response
↑uterine activity
Inflammatory mediators
Coagulation disturbance
Activated endothelial cells promote coagulation and increase vasopressor sensitivity
Widespread coagulation occur (DIC)
Fibrin deposition in kidney & placenta
HPT & placental insufficiency
Cardiovascular
• Generalized vasospasm
• Increased peripheral resistance
• Reduced central venous/
pulmonary pressure
Hematological
• Platelet activation and depletion
• Coagulopathy
• Decreased plasma volume
• Increased blood viscosity
• Proteinuria
• Decreased glomerular filtration
rate
• Decreased urate excretion
Renal
Hepatic
• Periportal necrosis
• Subscapular
hematoma
• Cerebral oedema
• Cerebral haemorrhages
Central Nervous System
Organ Specific Changes associated with
Pre-eclampsia
36
RISK FACTORS
Maternal related
History of Preeclampsia in previous
pregnancy
Advanced maternal age
Family history of Preeclampsia
History of placental abruption, IUGR,
fetal death
Obesity, BMI>35 doubles the risk
Hypertension
Diabetes
Thrombotic vascular diseases
Multiple gestation
Molar pregnancy
Smoking
Large placenta
Prolonged pregnancy
Placental hydrops
Chromosomal abnormality
Fetal/placental factors
Hemoglobin and hematocrit
platelet count : decreased, if < 1 lakh
coagulation profile
LFTs : indicated in all patients
RFTs : raised (S.urea creatinine is decreased in Normal
pregnancy)
Urine Routine : proteinuria
OBSTETRIC MANAGEMENT
1. Maternal
evaluation
2. Fetal evaluation:
Daily fetal movement count
Ultrasound
Doppler ultrasound for fetal blood flow
3. Treatment of Hypertension:
Antihypertensive drugs used in
pregnancy are
-methyldopa
-hydralazine
-labetalol
4. Seizure
Prophylaxis
• Routinely used in severe
PE
• Magnesium sulphate:
most commonly used
• Initiated with onset of
labor till 24h postpsrtum
• For caesarean, started
2hrs before the section
till 12hrs postpartum
it can be given either IV or IM.
IV has good prognosis.
Loading dose for IV is 4g. i.e. 8
ml diluted in 12ml normal saline.
This 20 ml is given in 20
minutes.
Maintenance dose is 20 g i.e.
40ml diluted in 60ml
normal saline and given at rate
of 1g/hr.
Recommended regime for MgSO4
IM is also used.
Loading dose is as IV.
Maintenance dose is 5g
every 4 hrs in alternate
buttocks for 24hrs.
Mgso4 acts on NM junction
and inhibit entry of Ca++
ions thus inhibiting
excitability of neurons.
Side effects of MgSO4
Maternal :
flushing
perspiration
headache,
muscle weakness
pulmonary oedema
Neonatal:
lethargy
hypotonia
respiratory depression
Management of MgSO4 Toxicity
Calcium gluconate is antagonist for MgSO4.
it is usually given as 10 ml of 10% Calcium
gluconate in 10 minutes
The only definitive
treatment
Preeclamptic patients
divided into 3 categories
A- Preeclampsia features
fully subside
B- partial control, but BP
maintains a steady high
level
C- persistently increasing
BP to severe level or
addition of other features
5. Delivery
Management:
A: can wait till
spontaneous onset of labor
don’t exceed Expected
Date of Delivery
B: >37wk terminate without
delay
<37wk, expectant
management at least
till 34wks
C: terminate irrespective of
POG
start seizure prophylaxis
and steroids if<34wks
Delivery in Eclampsia
Unless contraindicated: Eclamptic women should
undergo normal vaginal delivery
Indications for caesarean section -
Fetal distress
Placental abruption
Unfavourable cervix
Failed induction of labour
Recurrent seizures
Investigations
Laboratory:
◦ Urine: 24 hour urine, Proteinuria.
◦ Kidney functions: serum creatinine, urea,
creatinine clearance and uric acid.
◦ Liver functions: bilirubin, Enzymes
◦ Blood: CBC, HCt , Hemolysis and Platelet
count (Thrombocytopenia).
◦ Coagulation Profile: Bleeding and clotting
time
Complications
1. Maternal:
a. Convulsions and coma (eclampsia).
b. Cerebral haemorrhage.
c. Renal failure.
d. Heart failure.
e. Liver failure.
f. Disseminated intravascular coagulation.
g. Abruptio placentae.
h. Residual chronic hypertension in about 1/3 of cases.
i. Recurrent pre-eclampsia in next pregnancies.
www.freelivedoctor.com
Complications
2.Foetal:
a. Intrauterine growth retardation
(IUGR).
b. Intrauterine foetal death.
c. Prematurity and its complications.
www.freelivedoctor.com
PREVENTION
• Regular Antenatal checkup:
rapid gain in weight
rising blood pressure
edema
proteinuria/deranged liver or renal profile
• Low dose Aspirin in High risk group: ↑PGs
and↓TXA2
• Calcium supplementation: no effects
unless women are calcium deficient
• Antioxidants- Vitamin C and E
• Nutritional supplementation: zinc,
magnesium, fish oil, low salt diet
Differential Diagnosis
meningitis
encephalitis
space occupying lesion
electrolyte disturbance
vasculitis
amniotic fluid embolism
medications
organ failure
stroke
Thank you