Hypertensive disorders in pregnancy
-
Upload
bismoy-mondal -
Category
Education
-
view
903 -
download
2
Transcript of Hypertensive disorders in pregnancy
![Page 1: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/1.jpg)
Hypertensive
Disorders in
PregnancyBy
Agnibho Mondal
Bismoy Mondal
Atrayo Law
Debtanu Banerjee
Debjit Ghosh
![Page 2: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/2.jpg)
Incidence
Hypertensive disorders are among the most
significant & still now unresolving problem
complicating almost one in ten pregnancies
Responsible for 16% of Maternal Mortatlity in
developing countries
Commonest cause of iatrogenic prematurity
accounting 15% of all premature births & 20%
of very LBW births
![Page 3: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/3.jpg)
Hypertension in Pregnancy
Systolic B.P. > 140 mmHg
and/or
Diastolic B.P. > 90 mmHg
Documented on two occasions
At least 6 hours apart
Not more than 7 days apart
Other Criteria (Not part of definition currently)
SBP increased by 30mmHg
DBP increased by 15mmHg
Mean Arterial Pressure increased by 20mmHg
![Page 4: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/4.jpg)
Classification
Hypertension in Pregnancy
Gestational Hypertension
Preeclamsia-Eclampsia
Chronic Hypertension
Preeclamsia superimposed on Chronic Hypertension
![Page 5: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/5.jpg)
Normal Blood Pressure changes in
Pregnancy
![Page 6: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/6.jpg)
What is Significant Proteinuria in
Pregnancy
Total protein in 24 hours urine >
300mg
Protein : Creatinine ratio in random
sample > 0.1
![Page 7: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/7.jpg)
Gestational Hypertension
New onset of hypertension after 20
weeks of gestation without
proteinuria, followed by return of
B.P. to normal within 12 weeks post-
partum.
![Page 8: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/8.jpg)
Preeclamsia
New onset of hypertension after 20
weeks of gestation along with properly
documented proteinuria, followed by
return of B.P. to normal within 12
weeks post-partum.
Preeclamsia Gestational Hypertension Proteinuria
![Page 9: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/9.jpg)
Eclampsia
Generalized tonic-clonic seizure in a
patient with Preeclampsia not attributed
to any other cause.
Eclampsia Preeclampsia
Seizure/
Convulsion/
Coma
![Page 10: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/10.jpg)
Chronic Hypertension in Pregnancy
Hypertension before pregnancy /
Diagnosed before 20 weeks of pregnancy
not due to gestational trophoblastic
disease.
Hypertension diagnosed after 20 weeks but
persistent after 12 weeks postpartum
![Page 11: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/11.jpg)
Chronic HTN & Pregnancy :
Etiology :
1. Essential HTN (Most Common)
2. Secondary HTN :
1. Genetic: Glucocorticoid remediable aldosteronism,
Liddle Syndrome
2. Renal : Parenchymal, Renovascular
3. Endocrine : Primary hyperaldosteronism, cushing
syndrome, Pheochromocytoma
4. Vascular : Aortic coarctation, Estrogen use
5. Others
![Page 12: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/12.jpg)
Superimposed Preeclampsia On
Chronic Hypertension
New onset proteinuria in hypertensive
women but no proteinuria before 20 weeks'
gestation
A sudden increase in proteinuria or blood
pressure or platelet count < 100,000/L in
women with hypertension and proteinuria
before 20 weeks' gestation
![Page 13: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/13.jpg)
Risk Factors
Genetic
Age & parity
Partner factors
Pregnancy Factors
Underlying Medical Conditions
Others
Risk Factors
![Page 14: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/14.jpg)
Risk Factors: Cont.
Genetic
Genetic Predisposition
Family History
Race & Ethnicity
More Common in black & Asians
Pregnancy by ovum donation
Age &Parity
Teenage pregnancy
Age>35 yrs
Long interval between
pregnancy
Nulliparity
Partner Factors
Change of partner
Limited sperm exposure
Pregnancy by donor
insemination
Partner fathered an eclampticpregnancy
![Page 15: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/15.jpg)
Risk Factors: Cont.
Pregnancy Factors
Multiple pregnancy
Hydatiform mole
Hydrops fetalis
Fetal chromosomal anomaly
(trisomy 13)
Underlying Medical Diseae
Chronic hypertension
Diabetes mellitus
Renal Disease
Cardiovascular disease
Hyperthyroidism
Sickle cell disease
Others
Obessity
Psychological stress & strain
Previous history of preeclamsia
![Page 16: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/16.jpg)
PATHOPHYSIOLOGY:
![Page 17: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/17.jpg)
![Page 18: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/18.jpg)
2 stage model for
preeclampsia
Stage 2
Maternal syndrome
(HTN, proteinuria,
Endothelial dysfunction)
Stage1
Reduced placental implantation ???
![Page 19: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/19.jpg)
Reduced placental
implantation –Stage-1
PREDISPOSING FACTORS:
Abnormal implantation
Association with microvascular diseases (diabetes,
hypertension etc.)
Association with large placentas (hydrops, multiple
gestation, hydatidiform mole)
![Page 20: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/20.jpg)
![Page 21: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/21.jpg)
![Page 22: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/22.jpg)
Net effect
Replacement of endothelial lining & muscular arterial wall by fibrinoid formation
Distended tortuous spiral arteries
Low resistence, low pressure high flow system
![Page 23: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/23.jpg)
uterine artery DOPPLER
In preeclamptic mother:
Showing early diastolic NOTCH
Decreased EDF
(due to high resistance)
In normal mother
![Page 24: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/24.jpg)
ETIOLOGICAL FACTORS
Placental hypoxia
Immunological factors
Placental enzymes
Genetic factors (MTHFR, F5,)
Oxidative stress
???????????????????
![Page 25: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/25.jpg)
What causes maternal
syndrome
Stage 2
Maternal syndrome
(HTN, proteinuria,
Endothelial dysfunction)
Stage1
Reduced placental implantation ???
What gets into maternal circulation??????
![Page 26: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/26.jpg)
Maternal Syndrome
stage-II
not just hypertension and
proteinuria
But also involves different end
organs
![Page 27: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/27.jpg)
Physiology of maintain
uteroplacental flow in Normal
pregnancy
Placenta releases angiotensinase
destruction of angiotensin-II(a potent
vasoconstrictor) BP stabilized
Vascular synthesis of PGI-2 and NO in
excess vasodilation BP stabilized &
uteroplacental flow maintains
Release of VEGF restores
uteroplacental flow
![Page 28: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/28.jpg)
Normal balance of agonist &
anta-gonistic factors:
1.vasodialator &
vasoconstrictor
2. angiogenic and
antiangiogenic factors
![Page 29: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/29.jpg)
1.vasodialator & vasoconstrictor
vasodialator
NO
PGI-2
vasoconstrictor
Angiotensin-II
Endothelin-I
placenta
Syncytiotrophoblast
& endothelium
![Page 30: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/30.jpg)
2. angiogenic and
antiangiogenic factors
Angiogenicfactor
•VEGF
•TFG-beta•PlGF
Antiangiogenicfactor
• sFlt-1
• sEng
![Page 31: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/31.jpg)
![Page 32: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/32.jpg)
![Page 33: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/33.jpg)
Pathophysiology for different
organ damage:
![Page 34: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/34.jpg)
Basic mechanism of different organ
damage:
Increased vasoconstriction
Decreased organ perfusion :
Increased endothelial dysfunction – capillary
leak, oedema, Pulmonary oedema, proteinuria.
Activation of coagulation: DIC, low platelets
Haemoconcentration
![Page 35: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/35.jpg)
![Page 36: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/36.jpg)
Pathophysiology of different
organ damage:
![Page 37: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/37.jpg)
Organ damage
utero-placenta IUGR
Hematological Epistaxis, DIC like features, hemoconcentration
CNS Cerebral edema, cerebral hge seizures
Heart Subendothelial hge , focal necrosis & hge,
cardiomyopathy, heart failure
Lungs Pulmonary edema, hemorrhagic brochopneumonia
Kidneys glomerular endotheliosis, oliguria
liver Subcapsular hge, ischaemiaperiportal necrosis, HELLP
![Page 38: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/38.jpg)
CVS involvement:
• ↑afterload↑ed peripheral
resistance
• ↓preload ↓ed pregnancy induced
hypervolumia
•Pulmonary leak edemaalveolar endothelial
damage & ↓ed plasma oncotic pr
•hemoconcentration & ↑edhematocrit
↓ed blood volume than normal pregnancy(16%
vs 50%):
Heart failure
↓cardiac output
![Page 39: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/39.jpg)
Hematological system
Thrombocytopenia & other PL
abnormality:
• ↑ed PL activation & degranulation,
• ↓ed life span.
• Corelates well wth disease severity.
Intravascular hemolysis
• endothelial damage & altered fluidity of erythrocyte membrane d/t change in serum lipid content →↑ed LDH, spherocytosis, reticulocytosis
• microangiopathic hemolysis
↑ed coagulation & fibrinolysis
• Feature like DIC
• Release of thromboplastin
• ↓fibrinogen
• AT-III
• plasminogen
![Page 40: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/40.jpg)
Renal system involvement:
↓ed renal perfusion :(d/t ↓ed blood volume & ↑ed
afferent arteriolar pr.)
↓ed GFR : d/t
glomerular capillary endotheliosis
Endothelial dysfunction + mesangial swelling + BM
disruption
(but podocyte disruption minimal)
Oliguria
↑ed creatinine level
↑ed uric acid
![Page 41: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/41.jpg)
Hepatic involvement:
Periportalhemorrhage
hematoma formation
Rupture
epigastric pain
![Page 42: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/42.jpg)
Brain involvement:
Acute severe HTN
cerebrovascular overregulation
Vasospasm
Parenchymal ischemia
Cytotoxic edema
sudden ↑↑SBP
exceeds normal range of cerebrovascular autoregulation
Forced vasodilation + hyperperfusion
Vasogenic edema
![Page 43: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/43.jpg)
Lungs involvement:
High SBP
↑ed arteriolar pr
↑ed extravasation of blood into alveoli + rupture of arteriole
Pulmonary edema, hemorrhagic brochopneumonia
![Page 44: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/44.jpg)
Diagnosis
of HDP
![Page 45: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/45.jpg)
Diagnosing Preeclampsia-Eclampsia:
• Blood pressure ≥ 140/90 mm of Hg (at
or after 20 weeks of gestation) on 2
occasions at least 6 hours apart during
bed rest. (≥ 160/90 mm of Hg is
severe disease)
• accompanied by one or more of:
o significant proteinuria
-urinary dipstick 2+
-random urinary
protein/creatinine
ratio ≥ 30 mg/mmol
-24 hour urine excretion ≥300
mg/24 hrs
o renal involvement
-serum creatinine ≥ 90 mmol/L
or
-oliguria (<400 ml in 24 hrs)
o haematological involvement
-platelet count<1 lakh
o liver involvement
-raised AST, ALT (>70 IU/l)
-severe upper abdominal pain
o neurological involvement
-severe headache
-persistent visual disturbances
-hyperreflexia with sustained
clonus
-convulsions (eclampsia)
-stroke
o pulmonary oedema
o fetal growth restriction
o placental abruption
![Page 46: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/46.jpg)
HELLP Syndrome:
-Hemolysis:
● LDH > 600 U per L
● Abnormal PBS showing schistocytes,
burr cells.
● Serum bilirubin ≥ 1.2 mg/dL
-Elevated Liver enzymes:
● AST and ALT >70 IU/l
-Low Platelet count:
● <1 lakh/cubic mm
![Page 47: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/47.jpg)
History -special points• Patient Particulars: Age young or >35 yrs, nulliparity, low SES -
risk factors• Chief Complaints: Swelling of legs or other parts of body (face,
abdominal wall, vulva, or whole body and tightness of the ring on the finger.) Severe disease -Headache, visual changes, nausea, vomiting, abdominal or epigastric pain, and oliguria, insomnia, vaginal bleeding, seizures.
• Present Obstetric History: Onset, Duration, Severity of Htn/Proteinuria and H/o drug intake
• Past Obstetric History: H/o any hypertensive disorder of pregnancy with week of onset. Also note the interval since last pregnancy, gestational age at delivery. Any foetal complications.
• Past History: of pre-existing hypertension, renal disease, diabetes, thrombophilia, or thyroid disorder.
• Family History: of Htn, Preeclampsia, Diabetes, CVD
![Page 48: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/48.jpg)
Physical Examination:● Obesity/BMI>35 kg/m2
● Weight (serial measurements): Gain in wt at the rate of >1 lb a week or
>5 lbs a month in the later months of pregnancy may be the earliest sign
of preeclampsia.
● Oedema (all sites): has to be pathological, meaning visible pitting edema
demonstratable over the ankles after 12 hrs bed rest.
● Pulse (in all 4 limbs)
● B.P.:
○ right arm, sitting/supine, arm at level of heart, cuff length=1.5
times of arm circumference, diastolic BP is the disappearance of
Korotkoff sounds (phase V)
○ taken on 2 occasions at least 6 hrs apart for confirmation of
diagnosis.
● CVS examination: auscultation for heart rate, rhythm, splitting of S2,
murmurs.
● Ophthalmic examination: retinal haemorrage, nicking of veins,
arteriole/vein ratio 3:1 from 3:2, papilloedema
● Deep tendon reflexes: hyperreflexia/presence of clonus
![Page 49: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/49.jpg)
How to Measure Blood
Pressure
Sitting Position
Patient Relaxed
Arm well supported
Measured in right arm
Cuff at heart level
Proper cuff size (80% of
arm circumference)
Slow deflation of bladder
(2mmHg/s)
From start of Korotkoff I to
end of Korotkoff V
![Page 50: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/50.jpg)
Obstetric Examination:
Nothing special is found except features of IUGR, oligohydramnios in some cases.
![Page 51: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/51.jpg)
Maternal Investigations:
Tests may be abnormal even when BP elevation is minimal.
• Urine dipstick testing for proteinuria
o Quantitation by laboratory methods if ≥ 2+ on dipstick testing
o Urinary ACR(albumin-creatinine ratio) to detect significant
proteinuria (≥30mg/mmol)
o 24 hour urine collection is not necessary in routine clinical management
• Routine Blood Examination: TLC, DLC, Peripheral Smear, BT, CT, Hb%
• Serum Urea, creatinine, electrolytes including lactate dehydrogenase (LDH)
and uric acid.
• Liver function tests (LFT) -AST, ALT >70 IU/l
• Skiagram of chest –PA view, Pulmonary Capillary Wedge Pressure (PCWP),
Brain Natriuretic Peptide (BNP) for detection of pulmpnary oedema
![Page 52: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/52.jpg)
Foetal Investigations:
• Cardiotocograph (CTG)
• Ultrasound scan (USS) assessment of:
o fetal growth
o amniotic fluid volume (AFV)
o umbilical artery flow (Doppler)
![Page 53: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/53.jpg)
Differential Diagnosis Pre-existing hypertension,
New/gestational hypertension
Pre-eclampsia
Eclampsia
Exacerbation of underlying renal disease/Superimposed pre-eclampsia-eclampsia
SLE
ΔΔ ECLAMPSIA
-Epilepsy,
-Intracranial haemorrhage/thrombosis,
-meningitis,
-cerebral malaria,
-amniotic fluid embolism can mimic eclampsia.
![Page 54: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/54.jpg)
There are several indicators used to
assess the severity of
PIH
Blood pressure
Proteinuria
Other associated abnormalities
![Page 55: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/55.jpg)
N.B: Grades of proteinuria (in g/L): Trace=0.1, 1+=0.3, 2+=1, 3+=3,
4+=10
Pregnancy induced
Hypertension
Gestational HTN
● BP ≥ 140/90mmHg
●No evidence of underlying cause of HTN
●No associated symptoms
●Comes to normal within 6 wks of delivery
Pre-eclampsia
Non Severe Severe
Eclampsia
PreEclamsia
+
Convulsion
±
Coma
N.B: Pre-eclampsia is principally a
syndrome of signs and when symptoms
appear it is usually late.
Assessment of the severity of pre-
eclampsia is given in the next slide.
![Page 56: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/56.jpg)
ABNORMALITIES NONSEVERE (mild) SEVERE
Blood pressure ≥140/90mmHg but
<160/110mmHg
≥160/110mmHg
Proteinuria ≤2+ ≥3+
Oliguria Absent <400ml/day
Headache Absent Present
Visual disturbances Absent Present
Platelet count Normal Thrombocytopenia
(100,000/mm3)
HELLP syndrome Absent May be present
ALT,AST >70 IU/L
LDH>600 IU/L
Bilirubin >1.2g/L
Serum transaminases(AST,ALT) Normal (<40 IU/L) Elevated
Epigastric pain Absent Present
Fetal growth restriction Absent Obvious
Pulmonary oedema Absent present
![Page 57: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/57.jpg)
IMMEDIATE REMOTE
MATERNALFETAL
● IUGR
● IUD
● Asphyxia
●Prematurity
During Pregnancy During Labour During
puerperium●Eclampsia(2%) (more in acute cases)
●Accidental hemorrhage
●Oliguria
●Diminished vision
●HELLP Syndrome
●Cerebral hemorrhage
●ARDS
● Eclampsia
● Postpartum
hemorrhage
●Eclampsia(
in < 48hrs
of delivery)●Shock
●Sepsis
●Residual hypertension
●Recurrent pre-
eclampsia●Chronic Renal Disease
• Abruptio placentae
![Page 58: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/58.jpg)
MATERNAL FETAL
●Asphyxia
●Prematurity
●Hypoxia & IUD
Injuries Systemic
●Tongue bite
●Injuries due
to fall
●Bed sore
●PULMONARY: edema,
pneumonia, ARDS,
embolism
●CARDIAC: acute left
ventricular failure
●RENAL: renal failure
●HEPATIC: necrosis,
subcapsular hematoma
●CNS: cerebral
hemorrhage,
edema(vasogenic)
Vision
●Diminished
vision due to
retinal
detachment or
occipital lobe
ischemia
Hematology
●Low platelet
count
●Disseminated
Intravascular
Coagulation
Postpartum
●Shock
●Sepsis
●Psychosis
![Page 59: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/59.jpg)
HELLP Syndrome
This is an acronym for Hemolysis (H), Elevated Liver
enzymes (EL), and Low Platelet count (LP).
It is a rare multisystem disorder that complicates
pregnancy with lab evidences of micro-angiopathic
hemolysis, hepatic dysfunctioning &
thrombocytopenia.
It is a complication mostly associated with Pre-
eclampsia but can also be diagnosed (rarely though) in
the absence of these disorders.
![Page 60: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/60.jpg)
HEMOLYSIS
(due to passage of
RBCs through partially
obstructed vessel)
s)HEPATIC
DYSFUNCTION(due to
intravascular fibrin
deposition & sinosoidal
obst.)
Decreased Liver blood
flow
HELLP
Syndrome
THROMBO-CYTOPENIA
(due to platelet
aggregation & dipositionin the sites of endothhelial
damage)
![Page 61: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/61.jpg)
Diagnosis
Hemolysis (Hallmark
of the triad)
Elevated Liver
Enzymes
Low Platelet Count
LDH>600IU/L Liver Enzymes (<100,000/cu.mm)
Low serum
haptoglobin
High serum bilirubin
(>1.2 mg/dl)
High ALT & AST
(>70 IU/L)
Abnormal PBS
(Schistocytes, burr
cells)
Later-low Hb%
• ●Epigastric /Right Upper Quadrant pain
• ●Nausea, Vomiting1. Clinical Features:
2. Lab Investigation:
![Page 62: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/62.jpg)
Usual Time of Onset
Relation to delivery Percentage
Antepartum 72
Post_partum 28
≤48 hours 80
>48 hours 20
Gestational Age(Weeks)
21-27 10
28-36 70
>37 20
![Page 63: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/63.jpg)
Treatment
![Page 64: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/64.jpg)
Can we predict whether a pregnancy would be complicated with Hypertensive disorders?
Endothelial Dysfunction/Oxidant Stress
Feto-Placental unit Endocrine Dysfunction
Renal Dysfuntion Misc
Placental Perfusion/ Vascular Resistance related Tests
Uterine Artery Doppler Velocimetry
AT- III
ANPFree fetal DNA
Adapted from Conde-Agudelo and associates (2009)
Indirectly, YES…
![Page 65: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/65.jpg)
How effective are they???
• is most promising, but currently, none of them is completely suitable for clinical use.
• As a result of these trials, some methods to prevent Preeclampsia have been theorized…
Uterine Artery Doppler Velocimetry (abnormal flow resistance/ diastolic notch in 2nd/ 3rd
trimester)
![Page 66: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/66.jpg)
Trials of different preventive methods and their outcomes
Sibai et al. Lancet 365:785-99, 2005.
![Page 67: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/67.jpg)
The efficacy of the preventive methods is questionable too…
The investigative procedures are cumbersome, time-consuming and expensive…
![Page 68: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/68.jpg)
MANAGEMENT OF
PREECLAMPSIA & PIHAfter early diagnosis, further management
depends on …
Severity of disease
Fetal maturity
Condition of cervix
![Page 69: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/69.jpg)
What is EXPECTANT MANAGEMENT?
NO
YES
Neither forced nor restricted
![Page 70: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/70.jpg)
Treatment proper
![Page 71: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/71.jpg)
For mild - controlled disease :
Thereafter induction may be done at term depending on cervical condition
Can be managed expectantly till term at home/hospital and continued till term.
71
![Page 72: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/72.jpg)
Hospitalisation???
• Gestational HTN : only if severe HTN
• Preeclampsia : If diastolic pressure≥ 100mm of Hg OR, there is proteinuria OR, there is fetal compromise.37 completed weeks of gestation.
![Page 73: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/73.jpg)
When should we use antihypertensive to control the BP???
• Acute management of severe hypertension (BP > 160/110: to
prevent stroke)
which may require parenteral therapy.
![Page 74: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/74.jpg)
What are the options???
Acute
Hydralazine inj.: now available
LabetalolInjection
Nifedipinecapsule/Tablet
Long term
Methyl Dopa250 mg Tab.
Labetalol Tablet 100 mg
Nifedipine5,10,20 mg
![Page 75: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/75.jpg)
But wait…can antihypertensives be used in expectant management???
• In non-severe Pregnancy hypertension – No clear
Evidence of benefit other than to reduce
The Frequency of Episodes of Severe
hypertension
• May Adversely Effect Fetal Growth velocity
![Page 76: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/76.jpg)
For severe-uncontrolled disease:
LUCS OR In case of very severe uncontrolled disease elective LUCSmay be done without induction
Preinduction
Cervical ripening with prostaglandin/osmotic dilators followed by induction
Termination is considered
76
If failed
![Page 77: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/77.jpg)
For early onset severe preeclampsia:
• Controversy regarding termination in early onset disease
• But there is no beneficial role for mother, as well as perinatal mortality is also high instead of conservative management
• So…
77
termination is seriously considered
![Page 78: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/78.jpg)
Fetalconsiderations
Prematurity
Stillbirth
Newborn asphyxia
Maternal considerations
– Worsening of disease
Complications
![Page 79: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/79.jpg)
DELIVERY CARE
• For any HDP, vaginal delivery should be considered unless a CS is required for the usual obstetric indications.
• Antihypertensives : continued throughout labour to maintain BP < 160/110 mmHg .
• 3rd Stage : actively managed with oxytocin 5 units IV or 10 units IM, particularly in the presence of thrombocytopenia or coagulopathy. (I-A)
• Ergometrine should NOT be given
![Page 80: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/80.jpg)
Management of Eclampsia :
Prompt delivery of fetus to achieve cure
Avoidance of diuretics & hyper osmotic agents
Limitation of I.V fluid
Intermittent antihypertensive to control BP judiciously
Control of convulsion by MgSO4 (IM/IV route)
Protection & supporting care during convulsionProtection in a railed cot
Protection of airway & prevention of tongue bite
Correction of hypoxia & acidosis
Managed in Eclampsia room.
80
![Page 81: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/81.jpg)
to control convulsion
“It is the most effective drug to control even recurrent seizures without any central nervous system depression to mother & fetus”
81
Magnesium sulphate
![Page 82: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/82.jpg)
Dosages
→Paralysing agent & Intubation
→Amobarbital 250mg I.V over 3 min
In case of uncontrolled recurrent seizure (10-15%) : →additional 2-4g of 20% solution IV @ <1g/min
→4gm of 20% solution IV slowly(@ <1g/min) + 10g of 50% solution deep IM in upper & outer quadrant of buttock by a wide bore needle then 5g
of 50% solution IM 4hrly similarly
IM regime (Pritchard protocol):1955
→4 gm loading in 100ml of IVF over 15-20 min followed by 2-3g/hr in 100 ml IVF as maintenance
I.V regime (Sibai protocol):1990
IM doses are as active as IV doses in controlling seizures
82
![Page 83: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/83.jpg)
Some more about Magnesium• Duration : 24 hrs from last convulsion or from delivery which one is
longer.(This is called Magnesium sulphate prophylaxis in severe preeclampsia.)
• Features of toxicity:i> Impaired breathing(@8-10meq/L)ii>Arrythmia and Asystole ( @10-13 mEq/L)iii>Decreased/absent deep tendon reflex
(Hyporeflexia at 4 mEq/L, loss of patellar reflex at 7-10 mEq/L)iv> Shock (>13 mEq/L)
• For a maintenance dose following must be present -
Serum Mg level 4-7meq/l(twice daily)
Having Patellar reflex
Urine output >30ml/hr
RR>12/min
83
![Page 84: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/84.jpg)
WHAT If magnesium toxicity is suspected???
Administration of 10mL of 10% calcium gluconate (1 g in total) as a slow intravenous push.
Serum magnesium level obtained.
Magnesium infusion should be discontinued, supplemental oxygen administered,
![Page 85: Hypertensive disorders in pregnancy](https://reader038.fdocuments.us/reader038/viewer/2022110310/55a3fc881a28ab7a538b4835/html5/thumbnails/85.jpg)
Thank You!!!