obstetrics & gynecology,

1. HypertensiveHypertensive
Diseases inDiseases in
PregnancyPregnancy
SAYED SAADATSAYED SAADAT
ALIALI
Roll # 06-146Roll # 06-146
Batch : “K”Batch : “K”

2. IntroductionIntroduction
• Incidence: China: 9.4%, worldwide: 7-12%Incidence: China: 9.4%, worldwide: 7-12%
• The most common and yet serious conditionsThe most common and yet serious conditions
seen in obstetricsseen in obstetrics
• cause substantial morbidity and mortality in thecause substantial morbidity and mortality in the
mother and fetusmother and fetus
• Death due to cerebral hemorrhage, aspirationDeath due to cerebral hemorrhage, aspiration
pneumonia, hypoxic encephalophathy,pneumonia, hypoxic encephalophathy,
thromboembolism, hepatic rupture, renal failurethromboembolism, hepatic rupture, renal failure

3. Hypertension inHypertension in
pregnancypregnancy
DefinitionDefinition
• Diastolic BP ≥90 mmHgDiastolic BP ≥90 mmHg
• Systolic BP ≥140 mmHgSystolic BP ≥140 mmHg
• Or as an increase in the diastolic BP of ≥Or as an increase in the diastolic BP of ≥
15 mmHg or in the systolic blood pressure15 mmHg or in the systolic blood pressure
of 30 mmHg, as compared to previousof 30 mmHg, as compared to previous
pressurepressure
• The increased blood pressures be presentThe increased blood pressures be present
on at least two separate occasions, > 6hon at least two separate occasions, > 6h

4. ClassificationClassification

5. • Pregnancy-induced hypertension
Preeclampsia
Mild
Severe
Eclampsia
• Chronic hypertension preceding pregnancy
• Chronic hypertension with superimposed PIH
Superimposed preeclampsia
Superimposed eclampsia
• Gestational hypertension
Classification of HypertensiveClassification of Hypertensive
Disorders in PregnancyDisorders in Pregnancy

6. Classification (1)Classification (1)
1.1. Pregnancy-induced hypertension:Pregnancy-induced hypertension:
Hypertension associated with proteinuria andHypertension associated with proteinuria and
edema, occurring primarily in nulliparas after theedema, occurring primarily in nulliparas after the
2020thth
week or near term.week or near term.
PreeclampsiaPreeclampsia
【【 mildmild 】】
• BP ≥ 140/90mmHgBP ≥ 140/90mmHg
• Onset after 20 weeks’ gestationOnset after 20 weeks’ gestation
• Proteinuria (>300mg/24-hr urine collection)Proteinuria (>300mg/24-hr urine collection)
• Epigastric discomfortEpigastric discomfort
• ThrombocytopeniaThrombocytopenia

7. Classification (2)Classification (2)
【【 severesevere 】】
• BP ≥ 160/110 mmHgBP ≥ 160/110 mmHg
• Marked proteinuria (>1-2 g/24-hr urine collection orMarked proteinuria (>1-2 g/24-hr urine collection or
2+ or more), oliguria2+ or more), oliguria
• Cerabral or visual disturbances such as headacheCerabral or visual disturbances such as headache
and scotomataand scotomata
• Pulmonary edema or cyanosisPulmonary edema or cyanosis
• Epigastric or right upper quadrant pain (probablyEpigastric or right upper quadrant pain (probably
caused by subcapsular hepatic hemorrhage)caused by subcapsular hepatic hemorrhage)
• Evidence of hepatic dysfunction, orEvidence of hepatic dysfunction, or
thrombocytopeniathrombocytopenia

8. Classification (3)Classification (3)
EclampsiaEclampsia
• Meets the criteria of preeclampsiaMeets the criteria of preeclampsia
• Presence of convulsions, notPresence of convulsions, not
attributable to other neurologicalattributable to other neurological
disease,disease,
• Occurrence: 0.5 -4 %, with 25%Occurrence: 0.5 -4 %, with 25%
occurring in the 1occurring in the 1stst
72 hs postpartum72 hs postpartum

9. Classification (4)Classification (4)
2.2. Chronic hypertensionChronic hypertension
proceeding pregnancyproceeding pregnancy (essential(essential
or secondary to renal disease,or secondary to renal disease,
endocrine disease, or other causes)endocrine disease, or other causes)
• BP ≥ 140/90 mmHgBP ≥ 140/90 mmHg
• Present before 20 wks gestationPresent before 20 wks gestation
• Persists beyond 12 wks postpartumPersists beyond 12 wks postpartum

10. Classification (5)Classification (5)
3.3. Chronic hypertension withChronic hypertension with
superimposed preeclampsia orsuperimposed preeclampsia or
eclampsiaeclampsia
• Coexistence of preeclampsia or eclampsiaCoexistence of preeclampsia or eclampsia
with preexisting chronic hypertensionwith preexisting chronic hypertension
• Cause greatest riskCause greatest risk
• When diagnosis is obscure, it is always wiseWhen diagnosis is obscure, it is always wise
to assume that the findings representto assume that the findings represent
preeclampsia and treat accordingly.preeclampsia and treat accordingly.

11. Classification (6)Classification (6)
4.4. Gestational hypertension:Gestational hypertension:
• Finding of hypertension in late pregnancy inFinding of hypertension in late pregnancy in
the absence of other findings suggestive ofthe absence of other findings suggestive of
preeclampsiapreeclampsia
• Transient hypertension of pregnancyTransient hypertension of pregnancy
• May develop into chronic hypertension ifMay develop into chronic hypertension if
elevated BP persists beyond 12 weeks ofelevated BP persists beyond 12 weeks of
postpartumpostpartum

12. High risk factorsHigh risk factors
• NulliparousNulliparous
• <18ys or >40 ys, multiple pregnancy<18ys or >40 ys, multiple pregnancy
• Has previous gestational hypertensiveHas previous gestational hypertensive
disordersdisorders
• Chronic nephritisChronic nephritis
• DiabeticDiabetic
• MalnutritionMalnutrition
• Low social statusLow social status
• Hydatidiform moleHydatidiform mole

13. Etiology:Etiology: UNCLEARUNCLEAR
• Immune mechanism (rejection phenomenon,Immune mechanism (rejection phenomenon,
insufficient blocking Ab)insufficient blocking Ab)
• Injury of vascular endothelium----disruption ofInjury of vascular endothelium----disruption of
the equilibrium between vasoconstriction andthe equilibrium between vasoconstriction and
vasodilatationvasodilatation
• Compromised placental profusionCompromised placental profusion
• Genetic factorGenetic factor
• Dietary factors: nutrition deficiencyDietary factors: nutrition deficiency
• Insulin resistanceInsulin resistance
• Increased CNS irritabilityIncreased CNS irritability

14. PathophysiologyPathophysiology

15. Central nervous systemCentral nervous system
• Raised BP disrupt autoregulationRaised BP disrupt autoregulation
• Increased permeability due to vasospasm---Increased permeability due to vasospasm---
thrombosis of arterioles, microinfarcts, andthrombosis of arterioles, microinfarcts, and
petechial hemorrhagepetechial hemorrhage
• Cerebral edema: increased intracranial pressureCerebral edema: increased intracranial pressure
• CT scan: focal hypodensityCT scan: focal hypodensity
• Cerebral angiography: diffuse arterialCerebral angiography: diffuse arterial
vasoconstrictionvasoconstriction
• EEG: nonspecific abnormality (75% in eclampticEEG: nonspecific abnormality (75% in eclamptic
patient)patient)

16. EyesEyes
• Serous retinal detachmentSerous retinal detachment
• Cortical blindnessCortical blindness

17. Pulmonary systemPulmonary system
• Pulmonary edemaPulmonary edema
• Cardiogenic or noncardiogenicCardiogenic or noncardiogenic
• Excessive fluid retention, decreased hepaticExcessive fluid retention, decreased hepatic
synthesis of albumin, decreased plasma colloidsynthesis of albumin, decreased plasma colloid
osmotic pressure,osmotic pressure,
• Often occurs postpartumOften occurs postpartum
• Aspiration of gastric contents: the most deadlyAspiration of gastric contents: the most deadly
complications of eclamptic seizurescomplications of eclamptic seizures

18. KidneysKidneys
• Characteristic lesion of preeclampsia:Characteristic lesion of preeclampsia:
glomeruloendotheliosisglomeruloendotheliosis
• Swelling of the glomerular capillarySwelling of the glomerular capillary
endotheliumendothelium
• Decreased GFRDecreased GFR
• Fibrin split products deposit on basementFibrin split products deposit on basement
membranemembrane
• ProteinuriaProteinuria
• Increase of plasma uric acid, creatinine.Increase of plasma uric acid, creatinine.

19. LiverLiver
• The spectrum of liver disease inThe spectrum of liver disease in
preeclampsia is broadpreeclampsia is broad
• Subclinical involvementSubclinical involvement
• Rupture of the liver or hepatic infarctionRupture of the liver or hepatic infarction
• HELLP syndrome: hemolysis, elevatedHELLP syndrome: hemolysis, elevated
liver enzymes and low plateletsliver enzymes and low platelets

20. Cardiovascular systemCardiovascular system
• Generalized vasoconstriction, low-output,Generalized vasoconstriction, low-output,
high-resistance statehigh-resistance state
• Untreated preeclamptic women areUntreated preeclamptic women are
significantly volume-depletedsignificantly volume-depleted
• Capillary leakCapillary leak
• Cardiac ischemia, hemorrhage, infarction,Cardiac ischemia, hemorrhage, infarction,
heart failureheart failure
• Increased sensitivity to vasoconstrictorIncreased sensitivity to vasoconstrictor
effects of angiotensineffects of angiotensin

21. Blood (1)Blood (1)
• Volume: reduced plasma volumeVolume: reduced plasma volume
• Normal physiologic volume expansionNormal physiologic volume expansion
does not occurdoes not occur
• Generalized vasoconstriction andGeneralized vasoconstriction and
capillary leakcapillary leak

22. Blood (2): coagulationBlood (2): coagulation
• Isolated thrombocytopenia: <150,000/Isolated thrombocytopenia: <150,000/µµll
• Microangiopathic hemolytic anemiaMicroangiopathic hemolytic anemia
• DIC (5%)DIC (5%)
• HELLP syndrome: in severe preeclampsiaHELLP syndrome: in severe preeclampsia
1.1. schistocytes on the peripheral blood smearschistocytes on the peripheral blood smear
2.2. lactic dehydrogenase > 600 U/Llactic dehydrogenase > 600 U/L
3.3. total bilirubin > 1.2 mg/dltotal bilirubin > 1.2 mg/dl
4.4. aspartate aminotransferase >70 U/Laspartate aminotransferase >70 U/L
5.5. platelet count <100,000/mmplatelet count <100,000/mm33
• Misdiagnosis: hepatitis, gallbladder disease, ITPMisdiagnosis: hepatitis, gallbladder disease, ITP

23. Endocrine systemEndocrine system
• Vascular sensitivity toVascular sensitivity to
catecholamines and othercatecholamines and other
endogenous vasopressors such asendogenous vasopressors such as
antidiuretic hormone andantidiuretic hormone and
angiotensin II is increased inangiotensin II is increased in
preeclampsiapreeclampsia
• Disequilibrium of prostacyclin/Disequilibrium of prostacyclin/
thromboxane A2thromboxane A2

24. Placenta perfusionPlacenta perfusion
• 500500 µµm vs 200m vs 200 µµmm
• Acute atherosis of spiral arteries:Acute atherosis of spiral arteries:
fibrinoid necrosis of the arterial wall, thefibrinoid necrosis of the arterial wall, the
presence of lipid and lipophages and apresence of lipid and lipophages and a
mononuclear cell infiltrate around themononuclear cell infiltrate around the
damaged vessel----vessel obliteration----damaged vessel----vessel obliteration----
placental infarctionplacental infarction
• Fetus is subjected to poor intervillousFetus is subjected to poor intervillous
blood flowblood flow
• IUGR or stillbirthIUGR or stillbirth

25. Clinical findings (1)Clinical findings (1)
Symptoms and signsSymptoms and signs
1.1. HypertensionHypertension
Diastolic pressure ≥ 90 mmHg orDiastolic pressure ≥ 90 mmHg or
Systolic pressure ≥ 140 mmHg orSystolic pressure ≥ 140 mmHg or
Increase of 30/15 mmHgIncrease of 30/15 mmHg
2.2. ProteinuriaProteinuria
• >300 mg/24-hr urine collection or>300 mg/24-hr urine collection or
• + or more on dipstick of a random urine+ or more on dipstick of a random urine

26. Clinical findings (2)Clinical findings (2)
3.3. EdemaEdema
• Weight gain: 1-2 lb/wk or 5 lb/wk isWeight gain: 1-2 lb/wk or 5 lb/wk is
considered worrisomeconsidered worrisome
• Degree of edemaDegree of edema
• Preeclampsia may occur in women with noPreeclampsia may occur in women with no
edemaedema
• Most recent reports omit it from theMost recent reports omit it from the
definitiondefinition

27. Clinical findings (3)Clinical findings (3)
4.4. Differing clinical picture in preeclampsia-Differing clinical picture in preeclampsia-
eclampsia crises: patient may present witheclampsia crises: patient may present with
• Eclamptic seizuresEclamptic seizures
• Liver dysfunction and IUGRLiver dysfunction and IUGR
• Pulmonary edemaPulmonary edema
• Abruptio placentaAbruptio placenta
• Renal failureRenal failure
• Ascites and anasarcaAscites and anasarca

28. Clinical findings (4)Clinical findings (4)
Laboratory findings (1)Laboratory findings (1)
Blood test:Blood test: elevated Hb or Hct, in severe cases,elevated Hb or Hct, in severe cases,
anemia secondary to hemolysis,anemia secondary to hemolysis,
thrombocytopenia, FDP increase, decreasedthrombocytopenia, FDP increase, decreased
coagulation factorscoagulation factors
Urine analysis:Urine analysis: proteinuria and hyaline cast,proteinuria and hyaline cast,
specific gravity > 1.020specific gravity > 1.020
Liver function:Liver function: ALT and AST increase, alkalineALT and AST increase, alkaline
phosphatase increase, LDH increase, serumphosphatase increase, LDH increase, serum
albuminalbumin
Renal function:Renal function: uric acid: 6 mg/dl, serumuric acid: 6 mg/dl, serum
creatinine may be elevatedcreatinine may be elevated

29. Clinical findings (5)Clinical findings (5)
Laboratory findings (2)Laboratory findings (2)
Retinal check:Retinal check:
Other tests:Other tests: ECG, placentaECG, placenta
function, fetal maturity, cerebralfunction, fetal maturity, cerebral
angiography, etcangiography, etc

30. Differential diagnosisDifferential diagnosis
• Pregnancy complicated with chronicPregnancy complicated with chronic
nephritisnephritis
• Eclampsia should be distinguishedEclampsia should be distinguished
from epilepsy, encephalitis, brainfrom epilepsy, encephalitis, brain
tumor, anomalies and rupture oftumor, anomalies and rupture of
cerebral vessel, hypoglycemiccerebral vessel, hypoglycemic
shock, diabetic hyperosmatic comashock, diabetic hyperosmatic coma

31. ComplicationsComplications
• Preterm deliveryPreterm delivery
• Fetal risks: acute and chronicFetal risks: acute and chronic
uteroplacental insufficiencyuteroplacental insufficiency
• Intrapartum fetal distress or stillbirthIntrapartum fetal distress or stillbirth
• IUGRIUGR
• OligohydramniosOligohydramnios

32. Predictive evaluation (1)Predictive evaluation (1)
1.1. Mean arterial pressure,Mean arterial pressure,
MAPMAP= (sys. Bp + 2 x Dia. Bp) /3= (sys. Bp + 2 x Dia. Bp) /3
• MAP> 85 mmHg: suggestive ofMAP> 85 mmHg: suggestive of
eclampsiaeclampsia
• MAP > 140 mmHg: high likelihoodMAP > 140 mmHg: high likelihood
of seizure and maternal mortalityof seizure and maternal mortality
and morbidityand morbidity

33. Predictive evaluation (2)Predictive evaluation (2)
2.2. Roll over test:Roll over test: ROTROT
• Preeclamptic patients are morePreeclamptic patients are more
sensitive to angiotensin IIsensitive to angiotensin II
• Difference between Bp obtained atDifference between Bp obtained at
left recumbent position and supineleft recumbent position and supine
position (at a 5 min interval)position (at a 5 min interval)
• Positive: > 20 mmHgPositive: > 20 mmHg
3.3. Urine calcium/ creatinine <Urine calcium/ creatinine <

34. PreventionPrevention
• Calcium supplementation:Calcium supplementation: notnot
effective in low risk women but showeffective in low risk women but show
effect in high risk groupeffect in high risk group
• Aspirin (antithrombotic):Aspirin (antithrombotic): uncertainuncertain
• Good prenatal care and regularGood prenatal care and regular
visitsvisits
• Baseline test for high-risk womenBaseline test for high-risk women
• Eclampsia cannot always be prevented,Eclampsia cannot always be prevented,
it may occur suddenly and withoutit may occur suddenly and without
warning.warning.

35. TreatmentTreatment
A.A. Mild preeclampsia: bed rest & deliveryMild preeclampsia: bed rest & delivery
• Hospitalization or home regimenHospitalization or home regimen
• Bed rest (position and whyBed rest (position and why ) and daily) and daily
weighingweighing
• Daily urine dipstick measurements ofDaily urine dipstick measurements of
proteinuriaproteinuria
• Blood pressure monitoringBlood pressure monitoring
• Fetal heart rate testingFetal heart rate testing
• Periodic 24-h urine collectionPeriodic 24-h urine collection
• UltrasoundUltrasound
• Liver function, renal function, coagulationLiver function, renal function, coagulation

36. A. Mild preeclampsia: bed rest &A. Mild preeclampsia: bed rest &
deliverydelivery
• Observe for danger signals: severeObserve for danger signals: severe
headache, epigastric pain, visualheadache, epigastric pain, visual
disturbancesdisturbances
• Sedatives: debatableSedatives: debatable

37. B. Severe preeclampsia:B. Severe preeclampsia:
• Prevention of convulsion:Prevention of convulsion:
magnesium sulfate or diazepam andmagnesium sulfate or diazepam and
phenytoinphenytoin
• Control of maternal blood pressure:Control of maternal blood pressure:
antihypertensive therapyantihypertensive therapy
• Initiation of delivery:Initiation of delivery: the definitivethe definitive
mode of therapy if severe preeclampsiamode of therapy if severe preeclampsia
develops at or > 36 wk or if there isdevelops at or > 36 wk or if there is
evidence of fetal lung maturity or fetalevidence of fetal lung maturity or fetal

38. Magnesium sulfateMagnesium sulfate
MOAMOA::
 Decreases the amount ofDecreases the amount of
acetylcholine released at theacetylcholine released at the
neuromuscular junctionneuromuscular junction
 Blocks calcium entry into neuronsBlocks calcium entry into neurons
 Vasodilates the smaller-diameterVasodilates the smaller-diameter
intracranial vesselsintracranial vessels

39. Magnesium sulfateMagnesium sulfate
USESUSES::
 Prevent convulsionPrevent convulsion
 Virtually ineffective on blood pressureVirtually ineffective on blood pressure
 i.v. or i.m.i.v. or i.m.
• 5g loading dose 5-10 min, i.v.5g loading dose 5-10 min, i.v.
• 1-2g/hr constant infusion1-2g/hr constant infusion
• Total dose: 20-30 g/dlTotal dose: 20-30 g/dl

40. Toxicity:Toxicity:
• Diminished or loss of patellar reflexDiminished or loss of patellar reflex
• Diminished respirationDiminished respiration
• Muscle paralysisMuscle paralysis
• Blurred speechBlurred speech
• Cardiac arrestCardiac arrest

41. How to prevent toxicity?How to prevent toxicity?
• Frequent evaluation of patellar reflexFrequent evaluation of patellar reflex
and respirationsand respirations
• Maintenance of urine output at >25Maintenance of urine output at >25
ml/hr or 600 ml/dml/hr or 600 ml/d
• Reversal of toxicity:Reversal of toxicity:
1.1. Slow i.v . 10% calcium gluconateSlow i.v . 10% calcium gluconate
2.2. Oxygen supplementationOxygen supplementation
3.3. Cardiorespiratory supportCardiorespiratory support

42. Antihypertensive therapy:Antihypertensive therapy:
reduce the Dia. pressure to 90-110 mmHgreduce the Dia. pressure to 90-110 mmHg
IndicationIndication
• Bp> 160/110 mmHgBp> 160/110 mmHg
• Dia. Bp > 110 mmHgDia. Bp > 110 mmHg
• MAP > 140 mmHgMAP > 140 mmHg
• Chronic hypertension with previousChronic hypertension with previous
antihypertensive drugs usageantihypertensive drugs usage

43. Antihypertensive therapyAntihypertensive therapy
Medications:Medications:
• Hydrolazine: initial choiceHydrolazine: initial choice
• LabetololLabetolol
• NifedipineNifedipine
• NimlodipineNimlodipine
• MethyldopaMethyldopa
• Sodium nitroprussideSodium nitroprusside
• DiureticsDiuretics

44. DeliveryDelivery
• Indication of termination ofIndication of termination of
pregnancypregnancy
1.1. Preeclampsia close to termPreeclampsia close to term
2.2. <34 wk with decreased placental<34 wk with decreased placental
functionfunction
3.3. 2 hrs after control of seizure2 hrs after control of seizure

45. DeliveryDelivery
• Induction of laborInduction of labor
1.1.First stage: close monitor, rest and sedationFirst stage: close monitor, rest and sedation
2.2.Second stage: shorten as much as possibleSecond stage: shorten as much as possible
3.3.Third stage: postpartum hemorrhageThird stage: postpartum hemorrhage
• Cesarean sectionCesarean section
1.1.Induction of labor unsuccessfulInduction of labor unsuccessful
2.2.Induction of labor not possibleInduction of labor not possible
3.3.Maternal or fetal status is worseningMaternal or fetal status is worsening

46. EclampsiaEclampsia
• No aura preceding seizureNo aura preceding seizure
• Multiple tonic-clonic seizuresMultiple tonic-clonic seizures
• UnconsciousnessUnconsciousness
• Hyperventilation after seizureHyperventilation after seizure
• Tongue biting, broken bones, head traumaTongue biting, broken bones, head trauma
and aspiration, pulmonary edema and retinaland aspiration, pulmonary edema and retinal
detachmentdetachment

47. ManagementManagement
• Control of seizureControl of seizure
• Control of hypertensionControl of hypertension
• DeliveryDelivery
• Proper nursing careProper nursing care

48. Thank YouThank You