Pregnancy: Medical

ComplicationsBy:DR.MALAK AL- HAKEEM

ASSOCIAT PROF. & CONSULTANT OBSTETRICS &GYNECOLOGY.

.1HYPERTENSIVE DISORDERS

.ACriteria for diagnosis.1Blood pressure (BP) elevation must be

sustained, and one of the following conditions must be present:

(aAbsolute BP of ≥ 140/90 mm Hg, or

(bAn increase in baseline diastolic BP of ≥15 mm Hg, or

(cAn increase in baseline systolic BP of ≥ 30 mm Hg

.2BP elevation must be confirmed on at least two

occasions at least 6 hours apart and at bed rest

.BClassification .1Mild preeclampsia. Criteria for diagnosis include:

(aBP of ≥ 140/90 mmHg or increase in diastolic BP of ≥ 15 mm Hg or increase in systolic BP of

≥ 30mmHg

(bProteinuria of 1-2+ on dipstick or ≥ 300 mg on 24 hour urine collection

(cEdema of the face or upper extremities

.2Severe Preeclampsia. Criteria for diagnosis include:

(aBP of ≥ 160/110 mm Hg

(bProteinuria of ≥ 3-4+ on dipstick or ≥ 5 g on

24-hour urine collection

(cSymptoms

(1Headaches resulting from cerebral edema

(2Visual disturbances resulting from decreased cerebral perfusion of the occipital cortex

(3Epigastric pain resulting from hepatocellular necrosis, edema, and ischemia stretching

Glisson’s capsule

(dLaboratory Findings

Mild Preeclampsia – Relative increased dias

15 mmHg, or increased syst 30 mm Hg, or absolute 140/90

Proteinuria – 1-2+ on dipstick or ≥ 300 mg/24 hrEdema of face, hands- Variable

Convulsions- NoneSymptoms- None

DIC findings - NoneHemoconcentration- MildCyanosis, Oliguria,

pulmonary edema- None

Severe Preeclampsia

Blood pressure ≥ 160/110 mm HgProteinuria – 3-4+ on dipstick or ≥ 5 g/24 hr

Edema of face, hands- VariableConvulsions- None

Symptoms- PossibleDIC findings - Possible

Hemoconcentration- MarkedCyanosis, Oliguria,

pulmonary edema- Possible

Eclampsia

Blood pressure - At least mild preeclampsia criteria

Proteinuria - At least mild preeclampsia criteria

Edema of face, hands- VariableConvulsions- Present

Symptoms- PossibleDIC findings - Possible

Hemoconcentration- MarkedCyanosis, Oliguria,

pulmonary edema- Possible

Chronic HTN

Blood pressure – Preexisting HTN or HTN

< 20 weeksProteinuria – Variable (may be none)

Edema of face, hands - None Convulsions - None

Symptoms - None DIC findings - None

Hemoconcentration - None Cyanosis, Oliguria,

pulmonary edema - None

Chronic HTN with Superimposed Preeclampsia

Blood pressure – Increased over baselineProteinuria – At least mild preeclampsia

criteria or increased over baseline

Edema of face, hands - Variable (may be none) Convulsions - None

Symptoms - Possible DIC findings - Possible

Hemoconcentration - Variable Cyanosis, Oliguria,

pulmonary edema - Variable

Transient HTN

Blood pressure – At least mild preeclampsia

criteria

Proteinuria - None

Edema of face, hands - None Convulsions - None

Symptoms - None DIC findings - None

Hemoconcentration - None Cyanosis, Oliguria,

pulmonary edema - None

(1Thrombocytopenia (<100,000/ml) resulting from vasospasm-induced macroangiopathic hemolysis

(2Elevated liver enzymes resulting from hepatocellular necrosis

.eClinical Findings (1Pulmonary edema resulting from increased capillary

membrane permeability(2Oliguria resulting from intrarenal vasospasm(3Cyanosis resulting from right heart failure

.3Eclampsia is diagnosed in the presence of unexplained convulsions with other criteria for

preeclampsia.

.aApproximately 25% occur antepartum (before labor)

.bApproximately 50% occur intrapartum (during labor)

.cApproximately 25% occur postpartum (most within first 24 hours)

.4Chronic hypertension is diagnosed with a history of preexisting hypertension either

before the onset of pregnancy or before 20 weeks’ gestation (without coexisting molar

pregnancy) and persisting past 6 weeks postpartum.

.5Chronic hypertension with superimposed preeclampsia has a worse outcome than

either chronic or pregnancy – induced hypertension

alone. Diagnosis requires all of the following criteria :

.aPresence of chronic hypertension

.bIncrease in diastolic BP of ≥ 15mm Hg or systolic

BP of ≥ 30 mm Hg

.cIncrease in proteinuria

.6Transient hypertension, which is diagnosed with the development of hypertension without

other findings of preeclampsia, is largely a retrospective diagnosis that is made after the

pregnancy is over.

.7HELLP syndrome is a subtype of preeclampsia. The five letters make

characteristics by up a mnemonic device representing the unique disease findings: Hemolysis, Elevated Liver enzymes, and

Low Platelets.

.CPreeclampsia – eclampsia spectrum.1Epidemiology of preeclampsia. Preeclampsia

occurs only in humans and only in pregnant women beyond 20 weeks’ gestation.

.aIncidence. Approximately 8% of the general obstetric population develop preeclampsia .

.bRisks factors(1Nulliparity (most common risk factors; eight times than

in multiparas)(2Age extremes (i.e., <20 years, <34 years)(3Multiple gestation(4Hydatidiform mole(5Diabetes mellitus (DM)(6Nonimmune fetal hydrops

(7Chronic hypertension

(8Preexisting renal disease

(9Small vessel disease (e.g., systemic lupus erythematosus, longstanding type 1 DM)

.2Characteristic pathology involves renal glomerular endotheliosis, which refers to

swelling of the endothelial cells of the capillary loops in the

glomerular tuft.

.3Pathogenesis involves diffuse vasospasm and capillary wall endothelial injury.

.aDiffuse vasospasm produces:(1Altered refractory state of pregnancy against the pressor

effect of renin, angiotensin II, and aldosterone

(2Systolic and diastolic hypertension(3Increased capillary permeability, which results in:

.aHemoconcentration from decreased intravascular volume, which leads to increased blood urea

nitrogen (BUN), creatinine, uric acid, hemoglobin, and hematocrit. Diuretics should be avoided,

because they may exacerbate hemoconcentration by further reducing intravascular volume.

.bEdema from loss of protein into extravascular space

.cExcessive weight gain from fluid retention.

(4Reduced systemic perfussion of the following organ systems:

.aKidneys, resulting in increased BUN, creatinine, and uric acid

.bUteroplacental unit, resulting in placental insufficiency, which may decrease placental

nutritional function and lead to intrauterine growth restriction (IUGR) as well as decrease placental

respiratory function that leads to fetal hypoxia.(5Vasoactive prostaglandins imbalance, with levels of

vasoconstricting thromboxane exceeding the vasodilating effect of prostacyclin

.bCapillary wall endothelial injury results in:(1Fibrin deposition in the capillary beds

(microangiopathic hemolytic anemia)(2Platelet destruction(3Disseminated intravascular coagulation (DIC)(4Consumptive coagulopathy

.DEvaluation of maternal – fetal status. Management is based on type and severity

of hypertensive disease as well as gestational age.

.1Indicators of a decline in maternal well – being

.aIncreasing BP (systolic and/or diastolic)

.bWorsening symptoms (i.e., headache, visual disturbances, epigastric pain)

.cIncreasing hemoconcentration (i.e., BUN, creatinine, uric acid, hemoglobin, hematocrit)

.dIncreasing proteinuria on 24-hour urine collection

.eWorsening DIC laboratory tests (e.g., decreasing platelet count, lengthening prothrombin/partial

thromboplastin times (PT/PTTs), decreasing fibrinogen)

.2Indicators of a decline in fetal well-being.aNonreactive nonstress test (NST).bPositive contraction stress test (CST).cDeclining biophysical profile (BPP).dSerial sonographic growth parameters showing

slowing or arrest of growth.eDecreasing fetal movements

.EClinical approach. Management is based on the type and severity of hypertensive

disease as well as gestational age. Options include aggressive inpatient,

conservative inpatient, and conservative outpatient.

.1Aggressive inpatient management includes:.aDiagnostic criteria

.1Mild or severe preeclampsia; ≥ 37 weeks’ gestation

.2Severe preeclampsia; <26 weeks’ gestation

.3Severe preeclampsia; 26-34 weeks’ gestation, when associated with maternal jeopardy:

(aSevere persistent headache(bPersistent visual changes(cHepatocellular injury(dThrombocytopenia or other evidence of DIC(ePulmonary edema(fAbruptio placentae

.4Severe preeclampsia; 26-34 weeks’ gestation, when associated with fetal jeopardy:

(aRepetitive severe variable decelerations(bRepetitive late decelarations(cRepetitive BPP ≥ 4(dOligohydramnios (amniotic fluid index (AFI) ≥ 4cm)(eIUGR (estimated fetal weight ≥ fifth percentile)

.5Chronic hypertension with superimposed preeclampsia at any gestational age

.6Eclampsia or HELLP syndrome at any gestational age

.bGuidelines.1Maintenance of diastolic BP between 90 and 100 mm

Hg. Further reduction of BP jeopardizes placental blood flow. Appropriate antihypertensive medications include:

(aHydralazine (direct arteriolar vasodilator), which causes baroreceptor sympathetic stimulation

(increasing heart rate (HR) and cardiac output (CO), thus preserving placental blood flow<

(bLabetalol (nonselective β-blocker), which preserves uteroplacental blood flow.

.2Prevention of convulsions with intravenous (IV) magnesium sulfate

(aAdministration of loading dose of 5g IV over 20 minutes, and maintenance infusion at 2g/hr. The

maintenance IV infusion should be given for 24 hours after delivery.

(bWatching for clinical evidence of magnesium toxicity (Box 4-1)

(cAbsence of toxicity is ensured as long as deep tendon reflexes are obtainable.

Box 4-1 Clinical Findings for Parenteral Magnesium Sulfate

Dose Effect5-8 mg/dlTherapeutic level10 mg/dlLoss of deep tendon reflexes15 mg/dl Respiratory paralysis

25 mg/dl Cardiac arrest

(dIV calcium gluconate is the antidote for magnesium toxicity.

.3Initiation of delivery. Labor can be induced anticipating vaginal delivery if the patient is stable and there are no

contraindications. Otherwise, cesarean delivery is indicated.

.2Conservative inpatient management is appropriate in the following cases:

.aMild preeclampsia that is remote from term (<37 weeks).

Guidelines include:(1Monitoring BP every 4 hours(2Performing a daily urine dipstick for protein(3Performing twice-weekly 24-hour urine

protein measurements

(4Performing weekly liver function tests and electrolyte levels

(5Initiating delivery if criteria for severe preeclampsia are met

.bSevere preeclampsia in carefully selected cases(1All of the following criteria must be met

a) Gestational age <26 weeks but <34 weeks

b) BP persistently ≥ 160/110 mmHg c) Absence of fetal jeopardy

d) Absence of maternal jeopardy

(2Guidelines include: a) Intensive maternal and fetal monitoring

in a tertiary perinatal center b) Cautious volume expansion c) Aggressive antihypertensive therapy

(e.g., hydralizine, labetalol) d) Anticonvulsant therapy (e.g. magnesium

sulfate) e) Corticosteroids to enhance fetal lung

maturity(3Initiation of delivery if maternal or fetal

deterioration occurs

.3Conservative outpatient management.aPatient selection criteria include:

1 (Transient hypertension (i.e., BP in the mildly elevated range, no proteinuria(

2 (Uncomplicated chronic hypertension ) without superimposed preeclampsia(

.bGuidelines include: 1 (Bed rest in the left lateral position 2 (Home BP monitoring 3 (Twice – weekly outpatient visits

.cInitiation of delivery if maternal or fetal deterioration occurs

.FPrevention. Large, prospective, randomized studies have shown that no prophylactic

intervention for preeclampsia improves pregnancy outcome. This includes use of aspirin

and supplemental calcium.