Hypertensive disorders in Pregnancy

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Hypertensive disorders in Pregnancy

  1. 1. HYPERTENSION IN PREGNANCY Associate Professor Dr Hanifullah Khan
  2. 2. Objectives <ul><li>Understand definitions </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Presentations of the disease </li></ul><ul><li>Important signs and symptoms </li></ul>
  3. 3. INTRODUCTION
  4. 4. Introduction <ul><li>H/T in pregnancy – leading cause of maternal & fetal morbidity </li></ul><ul><li>The most frequent cause of iatrogenic prematurity </li></ul><ul><li>PE & eclampsia – delivery is the only effective tx </li></ul>
  5. 5. Definitions – H/T <ul><li>H/T – </li></ul><ul><ul><li>a DBP of 90mmHg or more, taken on 2 occasions > 4 hrs apart OR </li></ul></ul><ul><ul><li>A single DBP of > 110mmHg </li></ul></ul><ul><li>Can occur either in – </li></ul><ul><ul><li>Women who already have H/T (1 0 or 2 0 ) </li></ul></ul><ul><ul><li>Manifest in 2 nd half of pregnancy </li></ul></ul>
  6. 6. Pregnancy HT & Chronic HT <ul><li>May be difficult to differentiate </li></ul><ul><li>Both have high risk of complications </li></ul><ul><li>Chr HT – </li></ul><ul><ul><li>Diagnosed prepregnancy </li></ul></ul><ul><ul><li>high BP early in pregnancy </li></ul></ul>
  7. 7. Definitions - PE <ul><li>A multisystem disorder characterized by HT + proteinuria </li></ul><ul><ul><li>Proteinuria - > 300mg urine pr / 24 hrs </li></ul></ul><ul><li>Occurs > 20 wks gestation </li></ul><ul><li>Resolves postnatally </li></ul><ul><li>Complications of PE – eclampsia, HELLP synd </li></ul>
  8. 8. Definition - Eclampsia <ul><li>The occurrence of tonic-clonic convulsions in a woman with PE </li></ul><ul><ul><li>Pregnancy </li></ul></ul><ul><ul><li>Any gestation </li></ul></ul><ul><ul><li>No neurological disease </li></ul></ul>
  9. 9. <ul><li>Gestational hypertension. </li></ul><ul><li>Preeclampsia (mild, severe). </li></ul><ul><li>Eclampsia. </li></ul><ul><li>Superimposed preeclampsia upon chronic hypertension. </li></ul><ul><li>Chronic hypertension with pregnancy. </li></ul>Classification
  10. 11. Incidence <ul><li>PE – 2-8% of all pregnancies </li></ul><ul><ul><li>Risk in 1 st pregnancy – 4.1% </li></ul></ul><ul><ul><li>Risk in later pregnancies – 1.7% </li></ul></ul><ul><ul><li>Risk in woman with PE in 1 st pregnancies – 14.7% </li></ul></ul><ul><ul><li>Risk in woman with PE in previous 2 pregnancies – 31.9% </li></ul></ul>
  11. 12. Summary <ul><li>Gestational hypertension: </li></ul><ul><ul><li>Hypertension for first time after 20 w, without proteinuria. BP returns to normal before 12 weeks postpartum. </li></ul></ul><ul><li>Chronic hypertension with pregnancy : </li></ul><ul><ul><li>Hypertension antedates pregnancy and detected before 20 w, & lasts more than 12 weeks postpartum. </li></ul></ul>
  12. 13. PATHOPHYSIOLOGY
  13. 14. Basic understanding <ul><li>Complex disease </li></ul><ul><li>Appears to be triggered by the placenta </li></ul><ul><ul><li>Can occur in molar pregnancies where fetus absent </li></ul></ul>
  14. 15. Trophoblast <ul><li>In normal conditions – </li></ul><ul><ul><li>Trophoblast invades myometrium </li></ul></ul><ul><ul><li>Spiral arteries converted to low pressure system </li></ul></ul><ul><li>This process is inhibited in PE </li></ul><ul><li>Immunological process also involved </li></ul><ul><li>Thus HT & PE is caused by abnormal placentation </li></ul>
  15. 16. Other factors <ul><li>Abn placentation -> placental insufficiency & IUGR </li></ul><ul><ul><li>Development of PE requires further changes </li></ul></ul><ul><li>↑ Inflammatory activity </li></ul><ul><ul><li>Widespread vascular endothelial damage </li></ul></ul><ul><ul><li>Capillary leak, vasoconstriction, intravascular haemolysis, platelet activation </li></ul></ul><ul><ul><li>↑ Immune status - ↑ leucocytes </li></ul></ul>
  16. 17. Pathology <ul><li>Primarily a disorder of placental dysfunction </li></ul><ul><ul><li>leading to a syndrome of endothelial dysfunction with associated vasospasm </li></ul></ul><ul><li>Evidence of placental insufficiency with associated abnormalities </li></ul><ul><ul><li>diffuse placental thrombosis, an inflammatory placental decidual vasculopathy, and/or abnormal trophoblastic invasion of the endometrium </li></ul></ul><ul><li>This supports abnormal placental development or placental damage from diffuse microthrombosis as being central to the development of this disorder </li></ul>
  17. 18. <ul><li>Pathopyhsiology </li></ul><ul><li>Placental factors </li></ul><ul><li>Immune complex deposition in kidney & placenta </li></ul><ul><li>Impair/ inadequate trophoblast invasion to the spiral arteries </li></ul><ul><li>Spiral arteries retain their charecteristic (narrow, tortuous, high resistance) </li></ul><ul><li>Reduce blood supply to placenta </li></ul><ul><li>Result in placental hypoperfusion </li></ul><ul><li>As a compensation </li></ul><ul><li>High BP in maternal </li></ul>
  18. 19. 2. Altered vascular reactivity <ul><li>PG12 angiotensin II </li></ul><ul><li>vasoconstrict </li></ul><ul><li>HPT and reduce placenta blood flow </li></ul>
  19. 20. 3. Coagulation disturbance <ul><li>Activated endothelial cells promote coagulation and increase vasopressor sensitivity </li></ul><ul><li>Widespread coagulation occur (DIC) </li></ul><ul><li>Fibrin deposition in kidney & placenta </li></ul><ul><li>HPT & placental insufficiency </li></ul>
  20. 21. Summary The development of PE is mediated through the degree of placental pathology & the maternal inflammatory response
  21. 22. PREECLAMPSIA & ECLAMPSIA
  22. 23. <ul><li>Is the most common medical disorder complicating pregnancy </li></ul><ul><li>Is the most common hypertensive disorder in pregnancy </li></ul><ul><li>More common in primigravidas and elderly multipara </li></ul>Occurrence
  23. 24. <ul><li>Chronic hypertension. </li></ul><ul><li>Chronic nephritis. </li></ul><ul><li>Past history . </li></ul><ul><li>Family history. </li></ul><ul><li>Obesity. </li></ul><ul><li>Multiple pregnancy. </li></ul>Epidemiology
  24. 25. Maternal personal risk factors for preeclampsia <ul><li>First pregnancy </li></ul><ul><li>Multigravida pregnant by a different partner </li></ul><ul><li>Age younger than 18 years or older than 35 years </li></ul><ul><li>History of preeclampsia </li></ul><ul><li>Multiple pregnancy </li></ul><ul><li>Family history of preeclampsia in a first-degree relative </li></ul><ul><li>Obesity </li></ul><ul><li>Preexisting diabetes </li></ul><ul><li>Chronic hypertension </li></ul><ul><li>Renal disease </li></ul><ul><li>Smoking </li></ul>
  25. 26. Multisystem Features Of Preeclampsia Hypertension Proteinuria Eclampsia HELLP syndrome Intra-uterine growth restriction Multi-organ disease Cerebral vessels Fetus Liver Systemic blood vessels Kidneys
  26. 27. Diagnosis Of PE <ul><li>Hypertension + Proteinuria </li></ul><ul><li>= </li></ul><ul><li>Two facets of a complex pathophysiological process </li></ul>
  27. 28. Peripheral oedema <ul><li>Not a useful diagnostic criterion </li></ul><ul><ul><li>Common in pregnancy </li></ul></ul><ul><ul><li>PE can occur without oedema </li></ul></ul>
  28. 29. <ul><li>Headache. </li></ul><ul><li>Blurring of vision. </li></ul><ul><li>Nausea and vomiting. </li></ul><ul><li>Epigastric pain (distension of the liver capsule) </li></ul><ul><li>Oliguria or anuria </li></ul>Symptoms – non-specific
  29. 30. <ul><ul><ul><ul><li>The frequency and intensity of the signs and symptoms. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>The more the severity of PE, the more likely the need to terminate pregnancy </li></ul></ul></ul></ul>Severity of PE
  30. 31. <ul><li>Eclamptic fit stages ( 4 stages): </li></ul><ul><ul><li>Premonitory stage (1/2 minute): </li></ul></ul><ul><ul><ul><li>Eye rolled up </li></ul></ul></ul><ul><ul><ul><li>Twitches of the face and hands. </li></ul></ul></ul><ul><ul><li>Tonic stage (1/2 minute): </li></ul></ul><ul><ul><ul><li>Generalized tonic spasm with opisthotonus. </li></ul></ul></ul><ul><ul><ul><li>Cyanosis. </li></ul></ul></ul><ul><ul><ul><li>Tongue may be bitten between the clenched teeth. </li></ul></ul></ul>Diagnosis of Eclampsia
  31. 32. EVALUATION
  32. 33. Evaluation of Hypertension in Pregnancy <ul><li>History </li></ul><ul><ul><ul><li>ID and Complaint </li></ul></ul></ul><ul><ul><ul><li>HPI (S/S of Preeclampsia) </li></ul></ul></ul><ul><ul><ul><li>Past Medical Hx, Past Family Hx </li></ul></ul></ul><ul><ul><ul><li>Past Obstetrical Hx, Past Gyne Hx </li></ul></ul></ul><ul><ul><ul><li>Social Hx </li></ul></ul></ul><ul><ul><ul><li>Medications, Allergies </li></ul></ul></ul><ul><ul><ul><li>Prenatal serology, blood work </li></ul></ul></ul><ul><ul><ul><li>Assess for Hypertension in Pregnancy risk factors </li></ul></ul></ul><ul><li>Physical </li></ul><ul><ul><ul><li>BP (essential) </li></ul></ul></ul><ul><ul><ul><li>Oedema </li></ul></ul></ul><ul><ul><ul><li>Hyperreflexia </li></ul></ul></ul><ul><ul><ul><li>Clonus </li></ul></ul></ul><ul><ul><ul><li>Fondoscopy </li></ul></ul></ul><ul><ul><ul><li>Urine dipstick test </li></ul></ul></ul><ul><ul><ul><li>Cardiovascular </li></ul></ul></ul><ul><ul><ul><li>Respiratory </li></ul></ul></ul><ul><ul><ul><li>Abdominal = Epigastric pain, RUQ pain </li></ul></ul></ul>
  33. 34. Cardiovascular <ul><li>Generalized vasospasm </li></ul><ul><li>Increased peripheral resistance </li></ul><ul><li>Reduced central venous/ pulmonary pressure </li></ul>Hematological <ul><li>Platelet activation and depletion </li></ul><ul><li>Coagulopathy </li></ul><ul><li>Decreased plasma volume </li></ul><ul><li>Increased blood viscosity </li></ul><ul><li>Proteinuria </li></ul><ul><li>Decreased glomerular filtration rate </li></ul><ul><li>Decreased urate excretion </li></ul>Renal Hepatic <ul><li>Periportal necrosis </li></ul><ul><li>Subscapular hematoma </li></ul><ul><li>Cerebral oedema </li></ul><ul><li>Cerebral haemorrhages </li></ul>Central Nervous System Organ Specific Changes associated with Pre-eclampsia
  34. 35. Clinical presentation Symptoms Signs <ul><li>Headache (frontal/ occipital) </li></ul><ul><li>Visual disturbance </li></ul><ul><li>Nausea & vomiting </li></ul><ul><li>Epigastric and right upper abdominal pain </li></ul><ul><li>Oliguria / anuria </li></ul><ul><li>Maybe asymptomatic </li></ul><ul><li>Rapid rise in BP </li></ul><ul><li>Papilloedema </li></ul><ul><li>Fluid retention (non-dependent edema) </li></ul><ul><li>Hyperreflexia </li></ul><ul><li>Clonus </li></ul><ul><li>Uterus and fetus may feel small for gestational age </li></ul>
  35. 36. Investigations <ul><li>Urine - 24 hour urine, Proteinuria. </li></ul><ul><li>Kidney functions - serum creatinine, urea, creatinine clearance and uric acid. </li></ul><ul><li>Liver functions - bilirubin, Enzymes (SGPT and SGOT). </li></ul><ul><li>Blood - CBC, HCt , Hemolysis and Platelet count (Thrombocytopenia). </li></ul><ul><li>Coagulation Profile - Bleeding and clotting time </li></ul>
  36. 37. Differential Diagnosis: <ul><li>A. Hypertension With Pregnancy . </li></ul><ul><li>B. Proteinuria With Pregnancy . </li></ul><ul><li>C. Edema With Pregnancy : </li></ul>
  37. 38. Differential Diagnosis Convulsions <ul><li>Convulsions With Pregnancy : </li></ul><ul><li>Eclampsia. </li></ul><ul><li>Epilepsy. </li></ul><ul><li>Hysteria. </li></ul><ul><li>Meningitis and Encephalitis. </li></ul><ul><li>Tetanus. </li></ul><ul><li>Tetany. </li></ul><ul><li>Brain tumors. </li></ul><ul><li>Uremic convulsions </li></ul>
  38. 39. Differential Diagnosis <ul><li>HELLP Syndrome : </li></ul><ul><li>Acute fatty liver in pregnancy. </li></ul><ul><li>Hepatitis. </li></ul><ul><li>Thrombocytopenia purpura. </li></ul><ul><li>Hemolytic Uremic syndrome. </li></ul>
  39. 40. Treatment <ul><li>PREVENTION. </li></ul><ul><li>Antepartum </li></ul><ul><ul><ul><li>Proper antenatal care </li></ul></ul></ul><ul><ul><ul><li>Expectant treatment. </li></ul></ul></ul><ul><ul><ul><li>Control hypertension. </li></ul></ul></ul><ul><ul><ul><li>Treatment of eclampsia . </li></ul></ul></ul><ul><ul><ul><li>Prevention and control of convulsions. </li></ul></ul></ul><ul><ul><ul><li>Termination of pregnancy . </li></ul></ul></ul><ul><li>Intrapartum care. </li></ul><ul><li>Postpartum care. </li></ul>
  40. 41. Control of Convulsions: <ul><li>Magnesium Sulfate (MgSO4): </li></ul><ul><ul><ul><li>It is the drug of choice. </li></ul></ul></ul><ul><ul><ul><li>Mechanism: </li></ul></ul></ul><ul><ul><ul><ul><li>CNS depression. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Mild VD. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Mild diuresis. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Inhibits platelet aggregation. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Increase PGI2 synthesis. </li></ul></ul></ul></ul>
  41. 42. Prognosis: <ul><li>BP usually normalize after placental delivery . </li></ul><ul><li>Hypertension may persist. </li></ul><ul><li>Postpartum eclampsia carries the worst prognosis. </li></ul><ul><li>Maternal mortality is about 2% in severe preeclampsia and 10% in eclampsia. </li></ul><ul><li>Perinatal mortality rate is about 5% in mild cases, 25% in severe cases and 30% in eclampsia. </li></ul>
  42. 43. CONCLUSIONS
  43. 44. Summary <ul><li>Hypertension diagnosed prior to 20 weeks' gestation, is generally due to preexisting chronic hypertension rather than pregnancy induce hypertension </li></ul><ul><li>Pre- eclampsia may be diagnose by a combination of fetal and maternal features, including IUGR, hematological or biochemical abnormalities as well as clinical symptom and signs </li></ul>
  44. 45. Maternal deaths <ul><li>Confidential Enquiry into Maternal and Child Health UK (2003-2005) </li></ul><ul><ul><li>18 deaths from PE & eclampsia </li></ul></ul><ul><ul><li>10 deaths caused by IC haemorrhage </li></ul></ul><ul><ul><ul><li>Due to uncontrolled BP </li></ul></ul></ul>
  45. 46. References <ul><li>Obstetrics by Ten Teachers 18 th Edition </li></ul><ul><li>Obstetrics illustrated 6 th Edition </li></ul><ul><li>Lecture Notes Obstetrics and gynaecology 3 rd Edition </li></ul><ul><li>http://emedicine.medscape.com/article/261435-overview </li></ul>

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