Discussion about hypertensive disorders of pregnancy

1. Hypertensive disorders of
pregnancy
PIH & PRE-ECLAMPSIA

2. Introduction
• Hypertension is one of the most common
cause of antenatal obstetric complications
• One-third of women with PIH develop pre-
eclamsia—leadingcause of maternal death
• Pre-eclampsia frequently accompaniedby
FGR, causing pernatal morbidity and mortality

3. Degrees of hypertension
• Mild: diastolic blood pressure 90-99 mmHg,
systolic B.P 140-149 mmHg
• Moderate: diastolic B.P 100-109 mmHg,
systolic B.P 150-159 mmHg
• Severe: diastolic B.P > or equal to 110
mmHg,systolic B.P > or equal to 160 mmHg

4. Classification of hypertension in
pregnancy
• Non-proteinuric pregnancy induced
hypertension/gestational hypertension
• Pre-eclampsia
• Chronic hypertension

5. Gestational hypertension:
• Arises first time in 2nd half of pregnancy
• Absence of proteinuria
• In mild to moderate cases not associated with
adverse pregnancy outcomes
• Upto 1/3rd of women will progress to pre-
eclampsia.

6. • Pre-eclampsia is defined as HTN of at least
140/90 mmHg recorded on at least 2 separate
occasionsand at least 4 hours apart and in the
presence of atleast 300 mg protein in a 24
hour collection of urine, arising de novo after
the 20th week of pregnancy in a previously
normotensive woman and resolving
completely by the sixth postpartum week.

7. Chronic hypertension:
• Confirmed hypertension in first half of
pregnancy
• Secondary causes should be excluded
• Can predispose to superimposed pre-
eclampsia

8. PRE-ECLAMPSIA

9. Risk factors for pre-eclampsia
• First pregnancy
• Multiparous with a previous Hx of pre-eclampsia
• Pre-eclampsia in any prev. pregnancy
• 10 yrs or more since last baby
• Age 40 years or more
• BMI 35 or more
• Family history of pre-eclampsia( in mother or
sister)

10. • Booking diastolicbp of 80 mmHg or more
• Booking proteinuria (of 1+ or more on more
than one occasion or quantified at > or = to
0.3g/24hr)
• Multiple pregnancy
• Pre-existing htn/renal disease/ diabetes
• Antiphospholipd antibodies

11. Pathophysiology of pre-eclampsia
• Two stage process
• In first stage, patchy trophoblastic invasion leads
to thick muscular spiral arteries. This causes high
flow low impedance uteroplacental circulation,
causing uteroplacental ischemia
• In 2nd stage, ischemua results in oxidative and
inflammatory stress leading to endothelial
dysfunction, vasospasm and activation if
coagulation system.

12. Phsiological changeof spiralarteries by invading trophoblasts

13. Aetiology of pre-eclampsia

14. Organ involvement in pre-eclampsia
CVS
• Marked peripheral vasoconstriction
• Raised intravascular pressure
• Loss of endothelial cell integrity
• Increased vascular permeability
• Generalised edema

15. Renal system:
• Glomeruloendotheliosis
• Impaired glomerular filtration
• Selective liss of albumin and transferrin
causing proteinuria
• Reduction in pladma oncotic pressure
• Increased edema

16. Haematological system:
• Increased platelet adherence
• Increased fibrin deposition due to vascular
damage
• Thrombocytopenia

17. The liver:
• HELLP syndrome (hemolysis, elevated liver
enzymes, low platelets
• Severe form of pre-eclampsia, incidence 2-4%
• Associated with high fetal loss(upto60%)
• Symptoms of epigastic pain/nausea/vomitting
• Management- stabilize mother, correct
coagulationdefecits, assess fetus for delivery

18. Neurological system:
• Eclampsia

19. Clinical presentation
• Frontal headache
• Visual disturbance
• Epigastric pain
• Rapidly progressive edema
• Epigastric tenderness(liver involvement)
• Hypereflexia and clonus

20. Management of pre-eclampsia
• Definitive cure is to deliver the baby and
placenta
• Aim is to stabilize maternal bp and prevent
seizures and cerebral bleeding

21. Principles of management
• Early recognition of the symptomless
syndrome
• Awareness of serious nature of condition in its
severest form
• Adherence to agreed guidelines for admission,
investigation and use of
antihypertensive/anticonvulsant therapy.
• Well timed delivery
• Postnatal follow up and counselling

22. Pathophysiology
Degree of
hypertension
Mild hypertension
(140/90-149/99)
Moderate
hypertension(150/10
0-159/109)
Severe
hypertension(160/11
0 or higher)
Admit to hospital Yes Yes Yes
Treat No With oral labetalol as
first line to keep
diastolicbp btw 80-
100
Systolicbp < 150
With oral labetalol as
first line to keep
diastolicbp btw 80-
100
Systolicbp < 150
Measure blood
pressure
At least 4 times a day At least 4 times a day More than 4 times a
day, depending on
clinicalsituation
Test for proteinuria Do not repeat
quantificationof
proteinuria
Do not repeat
quantificationof
proteinuria
Do not repeat
quantificationof
proteinuria
Blood tests Monitortwice a week:
CBC,RFTs, LFTs,
electrolytes
Monitor3 times a
week:
CBC,RFTs, LFTs,
electrolytes
Monitor3 times a
week:
CBC,RFTs, LFTs,
electrolytes

23. Investigations for fetomaternal
monitoring
Maternal monitoring:
• CBC ( look for dec platelet count and rising
hematocrit)
• If platelets normal no need for additional
clotting studies
• RFTS including uric acid
• LFTS

24. Fetal monitoring:
USG assessment of:
• Fetal size
• AFI
• Fetal doppler
• CTG

25. Treatment of hypertension
• Labetalol first drug of choice
• Methyl dopa– centrally acting, causes sedation
and depression
• Nefedipine– calcium channel blocker
These drugs can be administered orally
Incase of IV administration
• Labetalol
• Hydralazine

26. • Mgso4 is NOT an antihypertensive but a
membrane stabilizer
• Used for the prevention and treatment of
eclamptic seizures, also prevents recurrent
attacks
• Dose is loading dose of 4g given diluted IV, F/B
maintenance dose of 1g/hr for next 24 hours
• Monitor for signs of Mg toxicity , reflexes, urine
output, respiratory rate
• Ca gluconate antidote for Mg toxicity

27. Additional/Important points
• Iatrogenic preterm delivery often required
Dexa cover should be given as protocol if preter
• In case of C-section high risk for
thromboembolism- need prophylactic S/C
heparin with compression stockings.
• Epidual anesthesia in normal labour if clotting
normal

28. • Avoid ergometrine in 3rd stage
• Postnatal monitoring for blood pressure and
proteinuria

29. Thank You