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hypertensive disorders of pregnancy.pptx
1. Karunav
Final Year MBBS Student
Punjab Institute of Medical Sciences, Jalandhar
Hypertensive Disorders of
Pregnancy
(karunav4301@gmail.com)
2. Hypertensive disorders of Pregnancy
(Topics to be covered)
• Epidemiology
• Definitions
• Diagnostic criteria
• Risk Factors
• Etiology
• Pathogenesis
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3. Epidemiology of Hypertensive Disorders in
Pregnancy
‣ They constitute one of the leading causes of maternal and perinatal
mortality worldwide.
‣ Highest incidence is present in primigravidae patients and patients in the
age group of 18-22 years.
‣ It has been estimated that preeclampsia complicates 2–8% of pregnancies
globally.
‣ Associated with maternal complications: APH, PPH, Hepatic Failure,
RF
‣ Associated with fetal complications: FGR, Preterm birth, perinatal
death.
‣ Hypertensive disorders of pregnancy contribute to 9% of maternal deaths
in Asia.
Source: ACOG Practice Bulletin Vol. 135 No.6, June 2020
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5. Gestational Hypertension
It is the case of hypertension which is diagnosed after 20 weeks of
gestation in a previously normotensive female but is not associated
with proteinuria and/ or end organ damage.
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6. PreEclampsia
It is defined as the new onset hypertension (BP 140/90 mmHg) which is
diagnosed after 20 weeks of gestation in a previously normotensive
female and is associated with proteinuria and/or end organ damage.
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7. Eclampsia
It is defined by new-onset tonic-clonic, focal, or multifocal seizures in
the absence of other causative conditions (such as epilepsy, cerebral
arterial ischemia) which presents as a convulsive complication of
hypertensive disorders of pregnancy.
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8. Chronic Hypertension
It is defined as case of hypertension which is diagnosed before 20 weeks of
gestation and persists longer than 12 weeks after delivery.
Causes:
1. Primary hypertension: Essential hypertension
2.Secondary hypertension: renal disease, coarctation of aorta, SLE
etc.
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10. Diagnosis of Hypertension in pregnancy
• Absolute criteria: A systolic blood pressure of 140 mm Hg and diastolic blood
pressure of 90mm Hg.
• Relative criteria: A rise in 30 mm Hg in systolic and 15mm Hg in diastolic blood
pressure in previously known BP.
• Mean arterial pressure criteria: A rise of over 20mm Hg in the MAP or MAP
>105mm Hg (25th percentile). Though the SBP/DBP is <140/90 in this case. (delta
hypertension).
Source: DC Dutta’s textbook of obstetrics-10/e-pg210
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11. Arm Circumference Cuff Size
Upto 33cm Standard size
(13x23cm)
33-41cm Large size
(33x15cm)
>41cm Thigh cuff
(18x36)
Assessment of Blood Pressure
• Instrument: Mercury BP apparatus are preferable than
automated blood pressure monitors.
• appropriate size cuff:
Source: Action on preeclampsia community (APEC); www.apec.org.uk
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Patient position: woman should be seated or lying at 45° angle, with
arm at level of the heart.
White Coat effect: blood pressure should be measured after rest of
5-10 mins.
13. Blood Pressure
1. BP >=140 / 90 mm Hg on two occasions at least 4 hours apart.
2. BP >=160 /110 mm Hg on two occasions at least 15-30 mins
apart.
Source: ACOG Practice Bulletin Vol. 135 No.6, June 2020
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POG: >20 weeks
patient have a previously normal BP
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14. Proteinuria
1. 24hr urine protein: >/=300 mg/dL
2. Protein/creatinine ratio of >/= 0.3 mg/dL
3. Dipstick reading of 2+
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Source: ACOG Practice Bulletin Vol. 135 No.6, June 2020
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15. Other Criteria
(in absence of proteinuria)
1. Thrombocytopenia: Platelet count < 1,00,000/mm3
2. Renal insufficiency: Serum creatinine concentrations >1.1 mg/dL or a
doubling of the serum creatinine concentration in the absence of
other renal disease.
3. Impaired liver function: Elevated blood concentrations of liver
transaminases to twice normal concentration.
4. Pulmonary edema
5. New-onset headache unresponsive to medication and not accounted
for any alternative diagnosis.
6. visual symptoms
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Source: ACOG Practice Bulletin Vol. 135 No.6, June 2020
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16. Risk Factors for PreEclampsia
1. Nulliparity
2. Multifetal gestations
3. Preeclampsia in a previous
pregnancy
4. Chronic hypertension
5. Pregestational diabetes
6. Gestational diabetes
7. Thrombophilia
8. SLE
9. Prepregnancy BMI >30
10. Antiphospholipid antibody
syndrome
11.Maternal age 35 years or older
12.Kidney disease
13.Assisted reproductive technology
14.Obstructive sleep apnea
Source: ACOG Practice Bulletin Vol. 135 No.6, June 2020
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23. NORMAL PREGNANCY:
There is endovascular trophoblast invasion
into the spiral arterioles.
Ist trimester: up to decidual segments
IInd trimester: up to myometrial segments
LOW RESISTANCE LOW
PRESSURE HIGH FLOW SYSTEM
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24. PREECLAMPSIA:
There is failure of second invasion of
trophoblast which reduces the blood
supply to fetoplacental unit.
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26. Endothelial dysfunction
• Due to abnormal invasion, there is state of chronic hypoxia of the placenta.
• This causes the ER to activate apoptotic pathways, increasing the
oxidative stress and causes release of angiotensin-II, Endoglin and uric
acid.
• There is release of inflammatory mediators like TNF alpha, IL-6 etc.
• This increased systemic inflammatory response causes endothelial
damage.
• There is overproduction of antiangiogenic proteins like fms-like tyrosine
kinase and endoglin which bind to placental growth factor & VEGF and
causes endothelial dysfunction.
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