Health and medicine

1. DEFINITIONS AND ETIOLOGY
By
DR .SHEIK ABDUL CADER

2.  DEFINITION :
 BP more than or equal to 140/90 mmHg on two
occasions atleast 4 hours apart.
 It could be that only if either: SPB more than or
equal to 140 mmHg or
 DBP more than or equal to 90 mmHg or
 Both.
 BP more than or equal to 160/110 mmHg on 2
occasions within 15 minutes apart.
 It is to facilitate early administration of
antihypertensive drugs (within 30-60 mins). In
this case we do not wait for 4 hours.

3.  Assessment of BP:
 No tea or coffee within 30 minutes of assessment.
 After 5 minutes of rest.
 Correct position :
 Sitting or semi reclining with back support.
 Feet on ground, legs not crossed, arm supported at
heartlevel ,measure BP in left arm..
 If patient cannot sit measure in left lateral
position.
 Gold standard equipment used is
sphygmomanometer. Nowadays can use
automated devices

4.  Earlier, if the SBP was increased by 30 mmHg and
DBP was increased by 15 mmHg at midpregancy
level (because of max physiological decrease in BP)
 Dx: PIH.
 This criteria is no longer used. However
surviellance is required for chances of eclamptic
seizures.
 ACOG classification:
 Cat 1 : Preeclampsia-eclampsia syndrome.
 Cat II: Gestational HTN.
 Cat III: Chronic HTN in pregnancy.
 Cat IV: Chronic HTN with superimposed
 pre eclampsia.

5.  Screening of hypertension :
 In all pregnant women.
 Done in each antenatal visit.
 Done by two methods :
 BP measuring.
 Proteinuria with Dipstick method
 By measuring BP : BP >/= 140/90 on 2 occassions
4 hours apart : HTN ( check for proteinuria).
 Chronic hypertension: < 20 weeks of gestation.
Her BP will not come back to normal even after 12
weeks post delivery.

6.  if POG> 20 weeks: PIH.
 Check for proteinuria. If proteinuria >/= +1 : Do 24
hour protein excretion.
 If 24 hour protein excretion is >/= 300 mg or urine
protein creatitinine ratio >/= 0.3: Pre eclampsia
 If proteinuria is traces or negative: Look for signs of
end organ damage.
 If end organ damage is present: Pre eclampsia
 If end organ damage is absent: Gestational HTN.

7.  PIH :
Increase in BP after 20 weeks of gestation and BP
falls back to normal within 12 weeks of delivery.
Before pregnancy BP is normal.
 PIH:
 Not associated with proteinuria or no signs of
end
organ damage : Gestational hypertension
 Associated with proteinuria or presence of signs
of end organ damage : Pre-eclampsia

8.  Proteinuria:
 Screening test used for it : Dipstick method
 If more than or equal to +1, then do one following :
 • urine protein creatinine ratio more than or equal
to 0.3
 • Gold standard: 24 hours urinary protein excretion
more than or equal to 0.3gm or 300mg.
 Type: Non selective proteinuria
 Not associated with red casts or nephritis or
nephrotic syndrome.
 Only granular casts are seen (fine or coarse).
 if red cell casts or nephrotic syndrome: Chronic
HTN with underlying renal disease present.

9.  Signs of end organ damage:
 Any one of the following.
 Platelet count < 1 lakh.
 Liver enzymes raised to a times its normal
value +
 epigastric pain.
 • Serum creatinine more than or equal to 1.1
mg/dl or doubling of baseline.
 Pulmonary edema.
 Visual symptoms/headache

10. PRE ECLAMPSIA CLASSIFICATION
 Pre-Eclampsia
 • Early onset : 20-34 weeks
 • Preterm or late onset : >/= 34 weeks till 37
weeks
 • Term onset : > 37 weeks
 Based on the severity:
 • without severe features: mild preeclampsia.
 • with severe features: Severe preeclampsia.

11.  PE without severe feature
 • BP >140/90
 • Headache not present
 • Epigastric pain not present
 • Visual symptom not present
 • Convulsions not present
 • Signs of end organ damage not present

 PE with severe feature
 • BP >160/90
 • Headache present(not relieved by analgesics)
 • Epigastric pain present
 • Visual symptom present
 • Convulsions present
 • Signs of end organ damage present

12.  ACOG has removed 3 criterias for diagnosis of PE
with severe features
 1. oliguria.
 2. IUGR.
 3. Proteinuria quantification
 These can be findings but not diagnostic.
 If pregnant woman with gestational hypertension
(G HTN) develops proteinuria :Dx: Pre-eclampsia
 If pregnant woman with gestational hypertension
(G HTN) BP >/=160/110 but no proteinuria and
with any other severe features
 Dx: Treated as PE with severe features

13.  Gestational HTN is a provisional diagnosis and
this Dx is revised after delivery.
 Although the pathological changes which are seen
with Pre Eclampsia are not seen in GHTN, but 25-
50% of these patients progress to Pre Eclampsia.
Hence maternal and fetal monitoring is
mandatory
 Eclampsia. (E):
 Occurence of new onset generalised tonic clonic
seizures or coma in a patient with pre-eclampsia. It
is the most/severe form of PE spectrum.

14.  ECLAMPSIA CAN BE
 • Antepartum (m/c & worst prognosis),
 • Intrapartum or
 • Postpartum (within 48 hours after delivery).
Postpartum seizures (> 48 hours after delivery):
First rule outother causes of seizures.
 Chronic hypertension
 A female with hypertension has conceived,
Increase in BP seen even in < 20 weeks of
pregnancy and does not return back to normal by
12 weeks of delivery.

15.  Chronic hypertension with superimposed PE:
 A female with chronic PE: conceives, suddenly at 20
 weeks of gestation develops any of the following:
 1. BP becomes uncontrollable.
 2. New onset proteinuria.
 3. Signs of EOD.
 After 12 weeks of delivery
 BP still increased,Revised diagnosis to c/chronic HTN
 BP resolves . Revise diagnosis to Transient HTN
 of pregnancy

16.  Delta HTN : MAP rises suddenly in a pregnant women,
although being at normal levels. BP is normal throughout
the pregnancy and it reaches high normal values in later
stage pregnancy , can be associated with convulsions
 PRE EXISTING HTN
 Essential HTN
 Chronic HTN
Renal Artery Stenosis
Pheochromocytoma
 Acute on chronic HTN
 Platelets: 100,000
 Creatinine: >11
 New onset Proteinuna
 Liver Transaminases >2 times