Hypertensive Disorders in Pregnancy

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Hypertensive Disorders in Pregnancy

• Azza Alyamani
• Prof. of Obstetrics Gynecology

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• Classification
• Women who are pregnant and hypertensive
• must be divided into
• chronic hypertension.
• pregnancy induced hypertension (PIH)
• or gestational hypertension.
• those with PIH further subdivided
• proteinuric PIH
  (preeclampsia)minority
• non-proteinuric PIH majority

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• Therefore
• women with hypertension in pregnancy are
  classified as having
• 1. preeclampsia (proteinuric hypertension).
• 2. non proteinuric hypertension.
• 3. chronic hypertension
• primary (essential)
  hypertension. 95.
• secondary hypertension.5.
• ..renal dis.
• ..adrenal dis.
• ..hyperthyroidism.
• The aetiology and management of the three
  conditions are different .
  

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• Incidence
• Worldwide , maternal mortality from
  hypertensive
• disease accounts for
• 100.000 deaths
  per year.
• preeclampsia occurs in 5 .
• non proteinuric PIH 15.
• it accounts to 15 20 of maternal
  mortality in
• the developed cuonteris.

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• Definition
• pregnancy induced hypertension (PIH) is
• Hypertension that occurs after 20 weeks
  gestation and unrelated to other pathology.
• protienuria is the excretion of 300mg or more
  of protein in 24 hours urine.
• hypertension and protienuria define
  preeclampsia.

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• Preeclampsia
• is a multisystem disorder involving the
  placenta , liver , kidneys , blood , neurological
  and
• cardiovascular systems.
• both maternal and fetal morbidity /
  mortality are more likely to occur with early
  onset disease as
• placental abruption ,acute renal failure
  ,cerebral Hge ,DIC and IUGR ,prematurity as
  delivery is
• the only cure.
• therefore , ANC is directed towards
  identifying women with hypertension and
  protienuria.

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• severity ranges from
• a mild disorder (transient hypertension
  in the later part of the pregnancy) to
• a life-threatening disorder with seizure
  HELLP syndrome, fetal hypoxia, and
  growth retardation.
• more severe disease 0.5 per 1000
  deliveries

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• Chronic Hypertension
• is the presence of persistent hypertension of
  whatever cause , before 20 weeks gestation
• or
• persistent hypertension beyond 6 weeks
• postpartum.
• sustained bl. p of 140/90 mmHg or gt on two
  occasions 6 hours apart is considered
• hypertensive.

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• Aetiology
• Pregnancy induced hypertension (PIH)
• Preeclampsia
• is unknown , believed to be involved
• immune maladaptation.
• placental ischemia.
• oxidative stress.
• genetic predisposition.

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Genetic Predisposition
Faulty interplay bet. invading trophoblast and
decidua
Decreased bl. supply to feto-placental unit
Release of circulating factors
Endothelial cell alteration
IUGR
Hypertension
Proteinuria
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• Management
• Screening for preeclampsia
• Risk Factors
• 1. ve family history in the first degree
  relative
• increase the risk of PET 4 8 fold.
• 2. primiparety
• 3. medical disorders as
• history of PET.
• chronic hypertension.
• diabetes.
• obesity.
• antiphospholipid syndrome.
• molar pregnancy.
• multiple pregnancy.
• hydrops fetalis.

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• Screening and assessment for chronic
• hypertension
• Women who is found to be hypertensive before
  pregnancy can be advised about
• 1. weight loss.
• 2. restrict salt and alcohol intake.
• 3. change her antihypertensive agents ,
  diuretics ,
• angiotensin-converting enzyme (ACE)
  inhibitors
• and ß blockers to other alternatives.

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• Diagnosis
• Screening tests
• to predict PET and superimposed preeclampsia
• on chronic hypertension.
• (1) US
• it is quick ,non-invasive and inexpensive .
• Uterine artery Doppler
• analysis of its waveform is an early
  predictor of
• poor placental perfusion and development of
  PET ,
• there is resistance circulation with notch.
• Its predictive value is greater at 24 weeks
  or more.

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Uterine art. Doppler in PET

• diastolic
  notch

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• (2) Biochemical tests
• in preeclampsia
• HB , and Hematocrit concentrations.
• CBC with platelets count.
• serum uric acid .
• endothelial activation markers are
  increased.
• urinary excretion of Ca and
  microalbuminuria

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• in severe chronic hypertension
• urine analysis.
• 24h urine for protein , creatinine
  clearance,
• catecholamine metabolites and free
  cortisol.
• bl. Urea and electrolytes as Na k.
• Lupus anticoagulant and
  anticardiolipin in APS.
• serum lipids.
• in addition
• (3) fundoscopy.
• (4) ECG ECHO.
• (5) X ray chest.

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Symptoms Signs

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• Criteria of severe preeclampsia
• blood pressure gt 160 mmHg systolic
  or
• gt 110 mm Hg diastolic
• Proteinuria gt 3 g in 24 hours
  
• Persistent and severe cerebral or
  visual disturbances (headache,
  blurred vision)
• Persistent and severe epigastric pain
  or right upper quadrant pain.
• Pulmonary edema or cyanosis.
• Oliguria ( lt 500 ml urine / 24 hour).
• Eclampsia ( grand mal seizures).
• HELLP syndrome.

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• Maternal and fetal assessment
• the GA at which woman present with
  hypertension
• is an important factor in establishing risk .
• Late onset hypertension after 37weeks rarely
  result in serious maternal or fetal
  complications.
• Superimposed pre eclampsia on chronic
  hypertension is diagnosed by identifying
  proteinuria, raised uric acid levels or failing
  platelets count .
• chronic hypertension is associated with
  preeclampsia
• in 20 and abruptio placenta in 2.

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• Uterine artery Doppler velocity waveforms
• is used to assess risk .
• bl.pressure and urine analysis are checked
• every 2 weeks.
• sudden and profound rise should alert the
• clinician to the possibility of
  PET.
• high uric acid and low platelet count
• may pre date proteinuria by some
• weeks.

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• Management
• Pre eclamptic Toxaemia
• A) PET remote from term
• Early onset PET is associated with
• a. placental insufficiency
• resulting in IUGR and fetal death. Therefore
  
• Fetal Wellbeing must be carefully
  considered.
• 1. monitoring of fetal movements.
• 2. serial symphesis -fundal height .
• 3. serial US to confirm fetal
  growth ,AF
• volume and Umbilical A. Doppler
• waveform .

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• b. involvement of other organ systems
• resulting in increased maternal morbidity
• and mortality.
• 1.serial platelets count
• as platelets are consumed due to
  endothelial
• activation.
  Thrompocytopenia
• lt100.000/ml. delivery should be
  considered.
• 2.increased HB and haematocrit values
  indicate
• hypovolaemia.
• 3.clotting abnormalities indicate DIC.
• .

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• 4.raised uric acid
• a measure of fine renal tubular
  function is used
• to assess severity of the disease.
• raised urea and creatinine
• indicate late renal involvement .
• 5.severe proteinuria
• gt 3g /24 hours urine resulting in
  fall of
• circulating albumin and increasing
  the risk of
• pulmonary edema.

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• 5.HELLP syndrome
• it is severe variant of PET,
  Haemolysis ,
• Elevated Liver enzymes and Low
  Platelets .
• PET can cause subcapsular hematoma,
  liver
• rupture and hepatic infarction which
  result in
• raised liver transaminases as AST
  indicating
• hepatocellular damage and
• liver involvement
• and the need to consider delivery.

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• Delivery
• should be considered once fetal lung maturity
  is likely ( at 32 weeks gestation) ,especially if
  either
• multi-organ involvement or fetal compromise is
• proved.
• Corticosteroids are given to enhance fetal
  lung maturity. Steroid therapy may enhance
  recovery from HEELP syndrome.
• Delivery before term is usually by CS .such
  patients are risk of thromboembolism and should
  be given prophylactic SC heparin and stockings.

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• Indications of termination of pregnancy
• in PET
• 1. uncontrollable hypertension.
• 2. deteriorating liver or renal
  function.
• 3. progressive fall in platelets.
• 4. neurological complications as
  cerebral Hge.
• 5. deteriorating fetal condition as
  non-reactive
• CTG.

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• B) PET near term
• Lat onset preeclampsia rarely results in
• serious morbidity to mother or fetus .
• Drug therapy should be considered
• a) antihypertensive
• the aim is to lower the bl.
  pressure and
• lower the risk of maternal
  cerebrovacular
• accident without uterine
  bl. flow and
• compromising the fetus.

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• 1. Labetolol
• a ß blockers .
• can be given IV and orally.
• safe during pregnancy.
• 2. Methyldopa
• centrally acting agent.
• very safe during pregnancy.
• only given orally .
• takes 24 h for its effect.
• 3. Nifedipine
• is Ca channel blocker .
• with rapid onset of action.
• cause severe headache.

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• NB
• Diuretics ,Angiotensin-converting enzyme
  (ACE)
• inhibitors and ß-blockers are
  contraindicated .
• b) Low dose aspirin
• results in significant reduction in
  preeclampsia
• associated fetal death and preterm
  delivery.
• c) for prophylaxis
• Ca , fish oil , antioxidants , vit. C
  , vit. E

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• Management of severe fulminating preeclampsia
  and impending eclampsia
• 1. IV antihypertensive
• Hydralazine / labetolol
• IV infusion titration rapidly against
  changes in
• the blood pressure .
• 2. Anticonvulsant therapy
• Magnesium Sulfate
• it is the anticonvulsant of choice
  as ttt. of
• eclampsia and also as prophylaxis
  which
• reduce the risk of fits to half.
• Diazepam and phenytoin can be
  used but
• less effective .

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• mode of action
• anticonvulsant.
• muscle relaxant.
• vasodilator.
• reduce the intracerebral
  ischaemia.
• dose
• 2 g IV as a loading dose
  then
• 1-2 g / h as maintenance
  infusion.
• toxicity is detected by
• absence of the patellar
  reflexes.
• respiratory arrest .
• may be cardiac arrest.
• antidote is
• 10 ml of 10 Ca gluconate.

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• 3. Fluid management
• a Folly's catheter should be inserted
  and fluid
• balance recorded.
• oliguria without a rising serum
  urea or
• creatinine is a manifestation of
  severe PET
• and not renal failure.
• however , if creatinine or
  potassium rises ,
• haemodialysis is necessary.
• diuretics should only be given if
  there are
• signs of pulmonary edema.
  

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• Postpartum Care
• in severe PET and eclampsia, a severe
  type of
• of eclamptic fits occur postpartum ,
  intensive
• monitoring is required for 48 h. after
  delivery.
• bl. Pressure is frequently at its
  highest levels
• 3 -4 days after delivery . Therefore ,
• antihypertensive therapy is need to be
• continued after discharge home.

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• a postnatal care visit 6 -8 w. is
  mandatory for
• measuring bl.p , urine analysis ,
  RFT, LFT and
• predisposing factors as thrompophilia
  or APS
• should be excluded.
• in women with severe chronic
  hypertension
• must be carefully monitored for at
  least 48h
• after delivery as they are at
  increased risk of
• renal failure , pulmonary edema and
• hypertensive encephalopathy.

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• Thank you