1-Gestational hypertension 2-PET 3-Eclampsia 4-Chronic hypertension 5-PET superimposed on chronic hypertension

1. HYPERTENSIVE DISORDERS
IN PREGNANCY
DR. SALWA NEYAZI
CONSULTANT OBSTETRICIAN GYNECOLOGIST
PEDIATRIC & ADOLESCENT GYNECOLOGIST

2. TYPES OF HYPERTENSIVE DISEASE IN
PREGNANCY
1-Gestational hypertension
2-PET
3-Eclampsia
4-Chronic hypertension
5-PET superimposed on chronic hypertension

3. 1-Gestational hypertension
BP ≥ 140/90 mm Hg for the first time during pregnancy
No proteinuria
BP returns to N < 12 Wk postpartum
Final Dx made only postpartum
May have other signs of PET eg. Headache, epigastric
discomfort or thrombocytopenia

4. PET
Minimum criteria
BP ≥ 140/90 mm Hg after 20 Wk gestation
Proteinuria ≥ 300 mg/24 hrs or ≥ 1+ dipstick
Increased certainty of PET
BP ≥ 160/110 mm Hg
Proteinuria ≥ 2 gm/24 hrs or ≥ 2+ dipstick
Serum creatinine > 1.2 mg/dl unless known to be
previously elevated
Platelets < 100 000/mm³

5. Increased certainty of PET
Microangiopathic hemolysis (increased LDH)
Elevated ALT or AST
Persistant headache or other cerebral/ visual
disturbance
Persistant epigastric pain
ECLAMPSIA
Seizures that can not be attributed to other causes in
a woman with PET. 1% of Pt with PET develop EC

6. CHRONIC HYPERTENSION
BP ≥ 140/90 mm Hg before pregnancy or Dx before 20
Wk gestation
HPT first Dx after 20 Wk gestation & persistant after 12
Wk postpartum
PET SUPERIMPOSED ON CHRONIC HYPERTENSION
New onset proteinuria ≥ 300 mg/24 hrs in hypertensive
women but no proteinuria before 20 Wk gestation
A sudden increase in proteinuria or BP or
Plt count < 100 000/ mm³in women with HPT &
proteinuria before 20 Wk gestation

7. INCIDENCE & RISK FACTORS
PET occurs in 6-8% of all live birth
RISK FACTORS
Extremes of reproductive age
15 < & >35 Y
Nulliparity
Black race
Hx of PET in a 1st degree
female relative
Hx of PET in prior pregnancy
DM
Chronic renal disease
Ch HPT
Multiple pregnancy  twins 13
vs 6%
Hydatidiform mole
Nonimmune hydrops fetalis
Obesity  4.3%  BMI < 19.8
kg/m²
 13.3%  BMI ≥ 35
kg/m²
Smoking  ↓ risk of HPT

8. PATHOGENESIS
Endothelial cell injury ↓ ↓ prostacyclin & ↑ thromboxaneA2
Rejection phenomenon (inadequate matenal Ab response)
Compromised placental perfusion
Altered vascular reactivity  ↑sensitivity to vaspressin EPN,
NEPN & angiotensin
↓ GFR with retention of salt & water
↓ intravascular volume
↑ CNS irritability
DIC
Uterine muscle stretch & ischemia
Dietary factors
Genetic factors

9. PATHOGENESIS
Summary of current hypothesis:
Immunological disturbance  abnormal placental
implantation ↓ placental perfusion  production of
substances that activate or injure endothelial cells of the
blood vessels  multiple organ system involvement

10. PATHOPHYSIOLOGY
MULTIPLE ORGAN SYSTEM
INVOLVMENT

11. 1- CNS
Similar to hypertensive encephalopathy
Petechial Hg
Gross hemorrhages due to ruptured arteries
Thrombosis of the arterioles
Microinfarcts
Fibrinoid necrosis in the walls of blood vessels
Cerebral edema  confusion, blurred vision / coma
Brain stem herniation is a serious complication of cerebral
edema  death
MECHANISM  cerebral hyperperfusion ,vasospasm
&forced dilation

12. 1- CNS
CT Scan  ½ of the pt focal hypodensities in the white
matter / post half of the cerebral hemisphere &
occasionally in the grey matter may represent
petechial Hg
Severe cases IV Hg or subarachnoid Hg
MRI  Abnormalities in the cortical & subcortical white
matter of the occipital & parietal areas
EEG nonspecific changes

13. 2-PULMONARY SYSTEM
Pulmonary edema
May occur with sever PET OR EC
Usually postpartum
May be due to excessive fluid administration with
crystalloids + ↓ plasma colloid pressure due to
proteinuria
↑ in Pt with ch HPT & hypertensive cardiac disease
Aspiration of gastric content with EC

14. 3-CVS
Plasma volume is reduced, the cause is unknown
theories:
1-Generalized vasoconstriction with ↑ vascular
permeability  Advocate the use of vasodilators
2-1ry hypovolemia  hypoperfusion of the uterus
release of pressor substances  HPT
 Advocate the use of volume expanders & avoidance
of diuretics

15. 3-CVS
High systemic vascular resistance & hyperdynamic
ventricular function avoid aggressive fluid
adminstration
Loss of the normal refractoriness to angiotensin II

16. 4-BLOOD
Hemoconcentration
Thrombocytopenia < 150 000  15-20% of PT
Fibrinogen ↑
Thrombin time ↑ in 1/3 of the Ptwith EC
FDP ↑  20% of the Pt
DIC  5%
Microangiopathic hemolytic anemia 5%
HEELP hemolytic anemia, ↑↑ liver enzymes, low Plt
-LDH > 600 U/L
-T bilirubin >1.2 mg/dl
-AST > 70U/L
-Plt < 100 000/mm³
Found in 10% of the Pt with severe PET

17. 5-KIDNEY
Characteristic lesion glomeruloendotheliosis  swelling
of the gromelular capillary endothelium  ↓↓GFR
↓↓ creatinine clearance/ ↑↑plasma creatinine
↑↑ uric acid
Proteinuria
Renal tubular necrosis &renal failure
6-Eyes
Visual disturbances  due to retinal artery vasospasm
Retinal detachment
Cortical blindness occipital lobe ischemia infarction or
edema lasting hrs –up to 8 days

18. 7-Liver
Minimal involvement with fibrin deposition
Periportal hemorrhagic necrosis ↑↑ serum liver
enzymes
Bleeding from these lesions  Subcapsular hematoma
 hepatic rupture
Hepatic infarction
HEELP SYNDROME

19. 8-Endocrine & metabolic changes
↓↓ plasma renin, angiotensin II & aldosterone to the
normal prepregnancy values
Vasopressin levels are N
Atrial natriuretic peptide ↑↑
Volume expansion in PET ↑ ANP  ↑ COP &↓
periephal vascular resistance
Expansion of the extracellular fluid volume (edema)
Proteinuria ↓↓ plasma oncotic pressure displacement
of intravascular fluid to interstitium

20. 9-Uteroplacental perfusion
Vasospasm  compromised placental perfusion ↑↑
perinatal morbidity & mortality
Doppler velocimetry (systolic /diastolic velocity ratio of
umbilical& uterine arteries )20% N
15% N Umbilical / Abnormal uterine
40% Both Abnormal
Histological changes in placental bed
Defective trophoblastic invasion of spiral arteries /
decidual vessels but not myometrial vessels are invaded
by trophoblast
Charecteristic lipid rich lesions in the uteroplacental
arteries

21. PREVENTION
Calcium supplementation??
Fish oil ineffective
Low dose aspirin selective supression of throboxane
synthesis by the plt & sparing endothelial prostacyclin
production Not effective in preventing PET
Antioxidants Vit C & E supplementation  significant
reduction in PET

22. SYMPTOMS & SIGNS
↑ BP
Proteinuria
Edema of the face & hands ( but it has been dropped of
the definition due to poor predictive value)
Headache
Visual disturbance
Epigastric pain
Exaggerated reflexes

23. Fetal & maternal risks
Fetal
IUGR
Oligohydramnios
Placental infarcts
Placental abruption
Prematurity
Uteroplacental
insufficiency
Perinatal death
Maternal
CNS seizures & stroke
DIC
↑↑ CS
Renal failure
Hepatic failure or rupture
Death

24. CLASSIFICATION OF PET
SEVERE PET
Systolic BP >160 mmHg or diastolic >110 mmHg on two
occasions at least 6 hrs apart
Proteinuria ≥ 5 g/24 hrs
Oliguria < 500 cc /24 hrs
Cerebral or visual symptoms
Epigastric or Rt upper quadrant pain
Pulmonary edema or cyanosis
Low PLt
↑↑ liver enzymes
IUGR
MILD PET  any PET that is not considered severe

25. MANEGEMENT OF PET &
EC

26. Manegement
OBJECTIVES
Terminaton of pregnancy with the least possible trauma
to the mother & fetus
Birth of an infant who subsequently thrives
Complete restoration of health to the mother
1- Hospitalization
Women with new onset BP ≥ 140/90
Worsening BP
Development of proteinuria in addition to existing BP

27. INITIAL HOSPITAL MANAGEMENT
Observe for headache , visual disturbance, epigastric
pain & rapid wt gain
Wt daily
Analysis for proteinuria every 2 days / daily
BP in sitting position every 4 hrs except during sleep
Blood investigations  Hct, Plt, S creatinine, liver
enzymes
Frequent evaluation of fetal size & AF
Reduced physical activity but not absolute bed rest
N diet & fluid intake

28. FURTHER MANAGEMENT
Depends on:
Severity of PET
Duration of gestation
Condition of the Cx
Complete resolution of the signs & symptoms does not
occur till after delivery
Lines of management
Termination of pregnancy
Antihypertensive therapy
Anticonvulsant therapy
Home health care if BP improved within few days Pt
can be managed as outpatient Home BP & urine
protein monitoring . Instruction to come to hospital if she
has waning symptoms . Rest at home

29. Termination of pregnancy
Indications
Term pregnancy with mild or severe PET
Severe PET regardless of the gestational age
Warning signs  headache , visual disturbance, epigastric
pain, oliguria
Eclampsia Pt must be stabilized & delivered immediately
Preterm with mild PET  Assess fetal wellbeing by NST,
BPP, Doppler
Methods of termination
IOL with prostaglandines to ripen the Cx followed by IV
oxytocin
Elective CS  Severe PET with unfavorable Cx

30. Antihypertensive therapy
Mild PET
There is no benefit of antihypertensive therapy
Reduction in the maternal BP with labetalol or nifedipine
IUGR
ACI contraindicated  IUGR, boney malformations,
limb contracture, PDA, pulmonary hypoplasia, RDS,
hypotension &death
Severe PET
Antihypertensive therapy is used to control BP untill the Pt
delivers or in preterm for 48 hrs to allow time for
glucocorticoid administration for fetal lung maturity then
delivery

31. Antihypertensive therapy for severe PET & EC
Hydralazine
 IV infusion or IV 5-10 mg bolus at 15-20 min interval
 when diastolic BP ≥100-110 mm Hg or systolic BP ≥
160 mmHg
Nifedipine 10 mg po repeated in 30 min
Labetalol 10 mg IV / 20 mg after 10 min/ 40mg after
10min/80 mg (not to exceed 220 mg)
Nitroprusside used only in PT not responding to other
drugs
Diuretics not recommended because intravascular
volume depletion already exists in PET

32. Fluid therapy
Hyperosmotic agents not recommended because
intravascular influx of fluid subsequent escape of
fluid to vital organs pulmonary edema & cerebral
edema
LR 60-120 ml/hr Excessive fluid administration
pulmonary edema & cerebral edema

33. PREVENTION /CONTROL OF CONVULSIONS
Magnesium sulfate IV infusion  4 gm loading dose in 100
ml of IV fluid over 20 min  2 gm /hr maintenance
Measure serum MG level at 4-6hrs maintain at 4-7 mEq /L
D/C 24 hrs after delivery25% of seiz occur post partum
Avoid toxicity by :
-monitoring patellar reflexes
-respiratory rate
-urine output
Antidote calcium gluconate 1gm IV
MgS ↓ myometrial contractility
Compared to phenytoin or diazepam 50% ↓ in maternal
mortality ,67% ↓ in convulsions
Infants were less likely to be admitted to NICU/ intubation

34. Prognosis
Maternal death rare due to cerebral Hg, aspiration
pneumonia, hypoxic encephalopathy, thromboembolism,
hepatic rupture, renal failure, ansthesia
Recurrence  25-33% primipara
 70% multipara
PG, PET before 30 wk 40%
HEELP 5%

35. CHRONIC HYPERTENSION
in pregnancy

36. CHRONIC HYPERTENSION
Incidence of ch HPT 0.5-4%
80% essential HPT
20% due to renal disease
Symptoms & signs
↑risk in  Age > 30, obese, multipara, DM, renal
disease, black race, family Hx
Difficult to deffirentiate HPT with superimposed PET from
HPT with renal disease both have proteinuria

37. INVESTIGATIONS
Chest x ray  cardiomegaly
ECG  Lt vent hypertrophy
↑ serum creatinine, ↓ creatinine clearance & proteinuria
5-10%
MATERNAL COMPLICATIONS
Superimposed PET in 1/3 of Pt
↑ risk of abruptio placentae 0.4-10% DIC, acute tubular
& cortical necrosis
If renal function is well creatinine < 1.5 mg/dl
pregnancy does not change the coarse of renal
disease
If renal function is affected prior to pregnancy
deterioration of renal function occur more rapid in
pregnancy

38. FETAL COMPLICATIONS
Prematurity 25-30%
IUGR 10-15%
Stillbirth & fetal distress due to abruptio placentae or ch
intrauterine asphyxia

39. TREATMENT
No benefit of treating mild CH HPT ( 140-179/90-109)
in pregnancy  should be monitered for worsening HPT or
superimposed PET
Pt with severe CH HPT should have their BP controlled
before pregnancy & continue Rx in pregnancy
α Methyle Dopa
Calcium channel blockers
B blockers can be used but  IUGR
Labetalol

40. Obstetric management
Serial U/S for fetal growth. BPP, NST34wk
Follow up every 2 wks till 30 then weekly
Warn the mother about symptoms of superimposed PET
Investigations Renal function test,uric a , calcium ,LFT,
24hrs urine for creatinine clearance & protein, CBC,
Urinalysis, ECG.GTT
Early U/S for dating of preg
Not allowed to continue past 40wks
IOL at40 wks
Regular diet no salt restriction
IOL for superimposed PET,IUGR, fetal distress,
worsening renal function