Hypertensive Hypertensive Diseases in Diseases in PregnancyPregnancy

SAYED SAADAT SAYED SAADAT ALIALI

Roll # 06-146Roll # 06-146 Batch : “K”Batch : “K”

IntroductionIntroduction

• Incidence: China: 9.4%, worldwide: 7-12%Incidence: China: 9.4%, worldwide: 7-12%

• The most common and yet serious conditions The most common and yet serious conditions seen in obstetricsseen in obstetrics

• cause substantial morbidity and mortality in the cause substantial morbidity and mortality in the mother and fetusmother and fetus

• Death due to cerebral hemorrhage, aspiration Death due to cerebral hemorrhage, aspiration pneumonia, hypoxic encephalophathy, pneumonia, hypoxic encephalophathy, thromboembolism, hepatic rupture, renal failurethromboembolism, hepatic rupture, renal failure

Hypertension in Hypertension in pregnancypregnancy

Definit ionDefinit ion• Diastolic BP ≥90 mmHgDiastolic BP ≥90 mmHg

• Systolic BP ≥140 mmHgSystolic BP ≥140 mmHg

• Or as an increase in the diastolic BP of ≥ Or as an increase in the diastolic BP of ≥ 15 mmHg or in the systolic blood pressure 15 mmHg or in the systolic blood pressure of 30 mmHg, as compared to previous of 30 mmHg, as compared to previous pressurepressure

• The increased blood pressures be present The increased blood pressures be present on at least two separate occasions, > 6h on at least two separate occasions, > 6h apartapart

Classif icationClassif ication

• Pregnancy-induced hypertension

Preeclampsia

Mild

Severe

Eclampsia

• Chronic hypertension preceding pregnancy

• Chronic hypertension with superimposed PIH

Superimposed preeclampsia

Superimposed eclampsia

• Gestational hypertension

Classif ication of Hypertensive Classif ication of Hypertensive Disorders in PregnancyDisorders in Pregnancy

Classif ication (1)Classif ication (1)1.1. Pregnancy-induced hypertension:Pregnancy-induced hypertension: Hypertension associated with proteinuria and Hypertension associated with proteinuria and

edema, occurring primarily in nulliparas after the edema, occurring primarily in nulliparas after the 2020 thth week or near term. week or near term.

PreeclampsiaPreeclampsia 【【 mild mild 】】• BP ≥ 140/90mmHgBP ≥ 140/90mmHg• Onset after 20 weeks’ gestationOnset after 20 weeks’ gestation• Proteinuria (>300mg/24-hr urine collection)Proteinuria (>300mg/24-hr urine collection)• Epigastric discomfort Epigastric discomfort • ThrombocytopeniaThrombocytopenia

Classif ication (2)Classif ication (2)【【 severesevere 】】• BP ≥ 160/110 mmHgBP ≥ 160/110 mmHg• Marked proteinuria (>1-2 g/24-hr urine collection or Marked proteinuria (>1-2 g/24-hr urine collection or

2+ or more), oliguria2+ or more), oliguria• Cerabral or visual disturbances such as headache Cerabral or visual disturbances such as headache

and scotomataand scotomata• Pulmonary edema or cyanosisPulmonary edema or cyanosis• Epigastric or right upper quadrant pain (probably Epigastric or right upper quadrant pain (probably

caused by subcapsular hepatic hemorrhage)caused by subcapsular hepatic hemorrhage)• Evidence of hepatic dysfunction, or Evidence of hepatic dysfunction, or

thrombocytopeniathrombocytopenia

Classif ication (3)Classif ication (3)

EclampsiaEclampsia

• Meets the criteria of preeclampsiaMeets the criteria of preeclampsia

• Presence of convulsions, not Presence of convulsions, not attributable to other neurological attributable to other neurological disease, disease,

• Occurrence: 0.5 -4 %, with 25% Occurrence: 0.5 -4 %, with 25% occurring in the 1occurring in the 1stst 72 hs postpartum 72 hs postpartum

Classif ication (4)Classif ication (4)

2.2. Chronic hypertension Chronic hypertension proceeding pregnancyproceeding pregnancy (essential (essential or secondary to renal disease, or secondary to renal disease, endocrine disease, or other causes)endocrine disease, or other causes)

• BP ≥ 140/90 mmHgBP ≥ 140/90 mmHg

• Present before 20 wks gestationPresent before 20 wks gestation

• Persists beyond 12 wks postpartumPersists beyond 12 wks postpartum

Classif ication (5)Classif ication (5)

3.3. Chronic hypertension with Chronic hypertension with superimposed preeclampsia or superimposed preeclampsia or eclampsiaeclampsia

• Coexistence of preeclampsia or eclampsia Coexistence of preeclampsia or eclampsia with preexisting chronic hypertensionwith preexisting chronic hypertension

• Cause greatest riskCause greatest risk

• When diagnosis is obscure, it is always wise When diagnosis is obscure, it is always wise to assume that the findings represent to assume that the findings represent preeclampsia and treat accordingly. preeclampsia and treat accordingly.

Classif ication (6)Classif ication (6)4.4. Gestational hypertension:Gestational hypertension:

• Finding of hypertension in late pregnancy in Finding of hypertension in late pregnancy in the absence of other findings suggestive of the absence of other findings suggestive of preeclampsiapreeclampsia

• Transient hypertension of pregnancyTransient hypertension of pregnancy

• May develop into chronic hypertension if May develop into chronic hypertension if elevated BP persists beyond 12 weeks of elevated BP persists beyond 12 weeks of postpartumpostpartum

High risk factorsHigh risk factors

• NulliparousNulliparous• <18ys or >40 ys, multiple pregnancy<18ys or >40 ys, multiple pregnancy• Has previous gestational hypertensive Has previous gestational hypertensive

disordersdisorders• Chronic nephritisChronic nephritis• DiabeticDiabetic• MalnutritionMalnutrition• Low social statusLow social status• Hydatidiform moleHydatidiform mole

Etiology:Etiology: UNCLEARUNCLEAR• Immune mechanism (rejection phenomenon, Immune mechanism (rejection phenomenon,

insufficient blocking Ab)insufficient blocking Ab)

• Injury of vascular endothelium----disruption of Injury of vascular endothelium----disruption of the equilibrium between vasoconstriction and the equilibrium between vasoconstriction and vasodilatationvasodilatation

• Compromised placental profusionCompromised placental profusion

• Genetic factorGenetic factor

• Dietary factors: nutrition deficiencyDietary factors: nutrition deficiency

• Insulin resistanceInsulin resistance

• Increased CNS irritabilityIncreased CNS irritability

PathophysiologyPathophysiology

Central nervous systemCentral nervous system• Raised BP disrupt autoregulationRaised BP disrupt autoregulation

• Increased permeability due to vasospasm---Increased permeability due to vasospasm---thrombosis of arterioles, microinfarcts, and thrombosis of arterioles, microinfarcts, and petechial hemorrhagepetechial hemorrhage

• Cerebral edema: increased intracranial pressureCerebral edema: increased intracranial pressure

• CT scan: focal hypodensityCT scan: focal hypodensity

• Cerebral angiography: diffuse arterial Cerebral angiography: diffuse arterial vasoconstrictionvasoconstriction

• EEG: nonspecific abnormality (75% in eclamptic EEG: nonspecific abnormality (75% in eclamptic patient)patient)

EyesEyes

• Serous retinal detachment Serous retinal detachment • Cortical blindnessCortical blindness

Pulmonary systemPulmonary system

• Pulmonary edemaPulmonary edema• Cardiogenic or noncardiogenicCardiogenic or noncardiogenic• Excessive fluid retention, decreased hepatic Excessive fluid retention, decreased hepatic

synthesis of albumin, decreased plasma colloid synthesis of albumin, decreased plasma colloid osmotic pressure, osmotic pressure,

• Often occurs postpartumOften occurs postpartum• Aspiration of gastric contents: the most deadly Aspiration of gastric contents: the most deadly

complications of eclamptic seizurescomplications of eclamptic seizures

KidneysKidneys

• Characteristic lesion of preeclampsia: Characteristic lesion of preeclampsia: glomeruloendotheliosisglomeruloendotheliosis

• Swelling of the glomerular capillary Swelling of the glomerular capillary endothelium endothelium

• Decreased GFRDecreased GFR

• Fibrin split products deposit on basement Fibrin split products deposit on basement membranemembrane

• ProteinuriaProteinuria

• Increase of plasma uric acid, creatinine.Increase of plasma uric acid, creatinine.

LiverLiver

• The spectrum of liver disease in The spectrum of liver disease in preeclampsia is broadpreeclampsia is broad

• Subclinical involvementSubclinical involvement

• Rupture of the liver or hepatic infarctionRupture of the liver or hepatic infarction

• HELLP syndrome: hemolysis, elevated HELLP syndrome: hemolysis, elevated liver enzymes and low plateletsliver enzymes and low platelets

Cardiovascular systemCardiovascular system

• Generalized vasoconstriction, low-output, Generalized vasoconstriction, low-output, high-resistance statehigh-resistance state

• Untreated preeclamptic women are Untreated preeclamptic women are significantly volume-depleted significantly volume-depleted

• Capillary leakCapillary leak

• Cardiac ischemia, hemorrhage, infarction, Cardiac ischemia, hemorrhage, infarction, heart failureheart failure

• Increased sensitivity to vasoconstrictor Increased sensitivity to vasoconstrictor effects of angiotensineffects of angiotensin

Blood (1)Blood (1)

• Volume: reduced plasma volume Volume: reduced plasma volume • Normal physiologic volume expansion Normal physiologic volume expansion

does not occurdoes not occur• Generalized vasoconstriction and Generalized vasoconstriction and

capillary leakcapillary leak

Blood (2): coagulationBlood (2): coagulation• Isolated thrombocytopenia: <150,000/Isolated thrombocytopenia: <150,000/µµll

• Microangiopathic hemolytic anemiaMicroangiopathic hemolytic anemia

• DIC (5%)DIC (5%)

• HELLP syndrome: in severe preeclampsiaHELLP syndrome: in severe preeclampsia

1.1. schistocytes on the peripheral blood smearschistocytes on the peripheral blood smear

2.2. lactic dehydrogenase > 600 U/Llactic dehydrogenase > 600 U/L

3.3. total bilirubin > 1.2 mg/dltotal bilirubin > 1.2 mg/dl

4.4. aspartate aminotransferase >70 U/Laspartate aminotransferase >70 U/L

5.5. platelet count <100,000/mmplatelet count <100,000/mm33

• Misdiagnosis: hepatitis, gallbladder disease, ITPMisdiagnosis: hepatitis, gallbladder disease, ITP

Endocrine systemEndocrine system

• Vascular sensitivity to Vascular sensitivity to catecholamines and other catecholamines and other endogenous vasopressors such as endogenous vasopressors such as antidiuretic hormone and antidiuretic hormone and angiotensin II is increased in angiotensin II is increased in preeclampsiapreeclampsia

• Disequilibrium of prostacyclin/ Disequilibrium of prostacyclin/ thromboxane A2 thromboxane A2

Placenta perfusionPlacenta perfusion• 500 500 µµm vs 200 m vs 200 µµmm

• Acute atherosis of spiral arteries: Acute atherosis of spiral arteries: fibrinoid necrosis of the arterial wall, the fibrinoid necrosis of the arterial wall, the presence of lipid and lipophages and a presence of lipid and lipophages and a mononuclear cell infiltrate around the mononuclear cell infiltrate around the damaged vessel----vessel obliteration---- damaged vessel----vessel obliteration---- placental infarctionplacental infarction

• Fetus is subjected to poor intervillous Fetus is subjected to poor intervillous blood flowblood flow

• IUGR or stillbirthIUGR or stillbirth

Clinical f indings (1)Clinical f indings (1)Symptoms and signsSymptoms and signs

1.1. HypertensionHypertension

Diastolic pressure ≥ 90 mmHg orDiastolic pressure ≥ 90 mmHg or

Systolic pressure ≥ 140 mmHg orSystolic pressure ≥ 140 mmHg or

Increase of 30/15 mmHgIncrease of 30/15 mmHg

2.2. ProteinuriaProteinuria

• >300 mg/24-hr urine collection or >300 mg/24-hr urine collection or

• + or more on dipstick of a random urine+ or more on dipstick of a random urine

Clinical f indings (2)Clinical f indings (2)

3.3. EdemaEdema

• Weight gain: 1-2 lb/wk or 5 lb/wk is Weight gain: 1-2 lb/wk or 5 lb/wk is considered worrisomeconsidered worrisome

• Degree of edemaDegree of edema

• Preeclampsia may occur in women with no Preeclampsia may occur in women with no edemaedema

• Most recent reports omit it from the Most recent reports omit it from the definitiondefinition

Clinical f indings (3)Clinical f indings (3)4.4. Differing clinical picture in preeclampsia-Differing clinical picture in preeclampsia-

eclampsia crises: patient may present witheclampsia crises: patient may present with

• Eclamptic seizuresEclamptic seizures

• Liver dysfunction and IUGRLiver dysfunction and IUGR

• Pulmonary edemaPulmonary edema

• Abruptio placentaAbruptio placenta

• Renal failureRenal failure

• Ascites and anasarcaAscites and anasarca

Clinical f indings (4)Clinical f indings (4)Laboratory f indings (1)Laboratory f indings (1)

Blood test:Blood test: elevated Hb or Hct, in severe cases, elevated Hb or Hct, in severe cases, anemia secondary to hemolysis, anemia secondary to hemolysis, thrombocytopenia, FDP increase, decreased thrombocytopenia, FDP increase, decreased coagulation factorscoagulation factors

Urine analysis:Urine analysis: proteinuria and hyaline cast, proteinuria and hyaline cast, specific gravity > 1.020specific gravity > 1.020

Liver function:Liver function: ALT and AST increase, alkaline ALT and AST increase, alkaline phosphatase increase, LDH increase, serum phosphatase increase, LDH increase, serum albuminalbumin

Renal function:Renal function: uric acid: 6 mg/dl, serum uric acid: 6 mg/dl, serum creatinine may be elevated creatinine may be elevated

Clinical f indings (5)Clinical f indings (5)Laboratory f indings (2)Laboratory f indings (2)

Retinal check:Retinal check:

Other tests: Other tests: ECG, placenta ECG, placenta function, fetal maturity, cerebral function, fetal maturity, cerebral angiography, etcangiography, etc

Differential diagnosisDifferential diagnosis

• Pregnancy complicated with chronic Pregnancy complicated with chronic nephritisnephritis

• Eclampsia should be distinguished Eclampsia should be distinguished from epilepsy, encephalitis, brain from epilepsy, encephalitis, brain tumor, anomalies and rupture of tumor, anomalies and rupture of cerebral vessel, hypoglycemic cerebral vessel, hypoglycemic shock, diabetic hyperosmatic comashock, diabetic hyperosmatic coma

ComplicationsComplications

• Preterm deliveryPreterm delivery

• Fetal risks: acute and chronic Fetal risks: acute and chronic uteroplacental insufficiencyuteroplacental insufficiency

• Intrapartum fetal distress or stillbirthIntrapartum fetal distress or stillbirth

• IUGR IUGR

• OligohydramniosOligohydramnios

Predictive evaluation (1)Predictive evaluation (1)

1.1. Mean arterial pressure, Mean arterial pressure, MAPMAP= (sys. Bp + 2 x Dia. Bp) /3= (sys. Bp + 2 x Dia. Bp) /3

• MAP> 85 mmHg: suggestive of MAP> 85 mmHg: suggestive of eclampsiaeclampsia

• MAP > 140 mmHg: high likelihood MAP > 140 mmHg: high likelihood of seizure and maternal mortality of seizure and maternal mortality and morbidityand morbidity

Predictive evaluation (2)Predictive evaluation (2)

2.2. Roll over test:Roll over test: ROT ROT

• Preeclamptic patients are more Preeclamptic patients are more sensitive to angiotensin IIsensitive to angiotensin II

• Difference between Bp obtained at Difference between Bp obtained at left recumbent position and supine left recumbent position and supine position (at a 5 min interval)position (at a 5 min interval)

• Positive: > 20 mmHgPositive: > 20 mmHg

3.3. Urine calcium/ creatinine < Urine calcium/ creatinine < 0.040.04

PreventionPrevention• Calcium supplementation:Calcium supplementation: not not

effective in low risk women but show effective in low risk women but show effect in high risk groupeffect in high risk group

• Aspirin (antithrombotic):Aspirin (antithrombotic): uncertainuncertain

• Good prenatal care and regular Good prenatal care and regular visitsvisits

• Baseline test for high-risk womenBaseline test for high-risk women

• Eclampsia cannot always be prevented, Eclampsia cannot always be prevented, it may occur suddenly and without it may occur suddenly and without warning. warning.

TreatmentTreatmentA.A. Mild preeclampsia: bed rest & deliveryMild preeclampsia: bed rest & delivery• Hospitalization or home regimenHospitalization or home regimen• Bed rest (posit ion and whyBed rest (posit ion and why ) and daily ) and daily

weighingweighing• Daily urine dipstick measurements of Daily urine dipstick measurements of

proteinuriaproteinuria• Blood pressure monitoringBlood pressure monitoring• Fetal heart rate testingFetal heart rate testing• Periodic 24-h urine collectionPeriodic 24-h urine collection• UltrasoundUltrasound• Liver function, renal function, coagulationLiver function, renal function, coagulation

A. Mild preeclampsia: bed rest & A. Mild preeclampsia: bed rest & deliverydelivery

• Observe for danger signals: severe Observe for danger signals: severe headache, epigastric pain, visual headache, epigastric pain, visual disturbancesdisturbances

• Sedatives: debatableSedatives: debatable

B. Severe preeclampsia:B. Severe preeclampsia:

• Prevention of convulsion:Prevention of convulsion: magnesium sulfate or diazepam and magnesium sulfate or diazepam and phenytoinphenytoin

• Control of maternal blood pressure:Control of maternal blood pressure: antihypertensive therapyantihypertensive therapy

• Init iation of delivery:Init iation of delivery: the definitive the definitive mode of therapy if severe preeclampsia mode of therapy if severe preeclampsia develops at or > 36 wk or if there is develops at or > 36 wk or if there is evidence of fetal lung maturity or fetal evidence of fetal lung maturity or fetal jeopardy.jeopardy.

Magnesium sulfateMagnesium sulfate

MOAMOA::

Decreases the amount of Decreases the amount of acetylcholine released at the acetylcholine released at the neuromuscular junctionneuromuscular junction

Blocks calcium entry into neuronsBlocks calcium entry into neurons Vasodilates the smaller-diameter Vasodilates the smaller-diameter

intracranial vessels intracranial vessels

Magnesium sulfateMagnesium sulfate

USESUSES ::

Prevent convulsionPrevent convulsion Virtually ineffective on blood pressureVirtually ineffective on blood pressure i.v. or i.m. i.v. or i.m. • 5g loading dose 5-10 min, i.v.5g loading dose 5-10 min, i.v.• 1-2g/hr constant infusion1-2g/hr constant infusion• Total dose: 20-30 g/dlTotal dose: 20-30 g/dl

Toxicity:Toxicity: • Diminished or loss of patellar reflexDiminished or loss of patellar reflex• Diminished respirationDiminished respiration• Muscle paralysisMuscle paralysis• Blurred speechBlurred speech• Cardiac arrestCardiac arrest

How to prevent toxicity?How to prevent toxicity?

• Frequent evaluation of patellar reflex Frequent evaluation of patellar reflex and respirationsand respirations

• Maintenance of urine output at >25 Maintenance of urine output at >25 ml/hr or 600 ml/d ml/hr or 600 ml/d

• Reversal of toxicity: Reversal of toxicity:

1.1. Slow i.v . 10% calcium gluconateSlow i.v . 10% calcium gluconate

2.2. Oxygen supplementationOxygen supplementation

3.3. Cardiorespiratory supportCardiorespiratory support

Antihypertensive therapy:Antihypertensive therapy: reduce the Dia. pressure to 90-110 mmHgreduce the Dia. pressure to 90-110 mmHg

IndicationIndication

• Bp> 160/110 mmHgBp> 160/110 mmHg

• Dia. Bp > 110 mmHgDia. Bp > 110 mmHg

• MAP > 140 mmHgMAP > 140 mmHg

• Chronic hypertension with previous Chronic hypertension with previous antihypertensive drugs usageantihypertensive drugs usage

Antihypertensive therapyAntihypertensive therapyMedications:Medications:

• Hydrolazine: initial choiceHydrolazine: initial choice

• LabetololLabetolol

• NifedipineNifedipine

• NimlodipineNimlodipine

• MethyldopaMethyldopa

• Sodium nitroprussideSodium nitroprusside

• DiureticsDiuretics

DeliveryDelivery• Indication of termination of Indication of termination of

pregnancypregnancy1.1. Preeclampsia close to term Preeclampsia close to term 2.2. <34 wk with decreased placental <34 wk with decreased placental

functionfunction3.3. 2 hrs after control of seizure2 hrs after control of seizure

DeliveryDelivery

• Induction of laborInduction of labor

1.1. First stage: close monitor, rest and sedationFirst stage: close monitor, rest and sedation

2.2. Second stage: shorten as much as possibleSecond stage: shorten as much as possible

3.3. Third stage: postpartum hemorrhageThird stage: postpartum hemorrhage

• Cesarean sectionCesarean section

1.1. Induction of labor unsuccessfulInduction of labor unsuccessful

2.2. Induction of labor not possibleInduction of labor not possible

3.3. Maternal or fetal status is worseningMaternal or fetal status is worsening

EclampsiaEclampsia

• No aura preceding seizureNo aura preceding seizure

• Multiple tonic-clonic seizures Multiple tonic-clonic seizures

• Unconsciousness Unconsciousness

• Hyperventilation after seizureHyperventilation after seizure

• Tongue biting, broken bones, head trauma Tongue biting, broken bones, head trauma and aspiration, pulmonary edema and retinal and aspiration, pulmonary edema and retinal detachmentdetachment

ManagementManagement

• Control of seizureControl of seizure• Control of hypertensionControl of hypertension• DeliveryDelivery• Proper nursing careProper nursing care

Thank YouThank You