about different hypertensive conditions associated with pregnancy

1. HYPERTENSIVE
DISORDER IN
PREGNANCY
BY;
DR.MALIHA

2. HYPERTENSION
• Hypertension is defined as changes of blood pressure recorded on at least 2-
ocassions of either:
• Diastolic BP > 90 mmHg,
• Systolic BP > 140 mmHg,
• Hypertensive diseases in pregnancy may be:
• Chronic (pre-existing) hypertension
• Pregnancy-Induced hypertension
• Pre-eclampsia
• Eclampsia
• HELLP syndrome

3. CHRONIC HYPERTENSION:
• It refers to BP of 140/90 mmHg before the start of pregnancy or before 20 weeks'
gestation.
• It is of a different etiology from pre-eclampsia, although it can predispose to the later
development of superimposed pre-eclampsia.
Causes:
• Essential hypertension (90%)
• Collagen vascular disease
• Coarctation of the aorta
• Renal disease:
Complications ;
• Maternal Risks:
• Pre-eclampsia
• Placental abruption
• Heart failure
• Intracerebral hemorrhage
•

4. FETAL COMPLICATIONS
• Placental insufficiency
• Growth restriction
• Preterm delivery
• Increased morbidity and mortality
Investigations:
• Creatinine, Urea & Electrolyte
• LFTS
• 24-hour urinary protein/creatinine clearance
• Renal scan
• Autoantibody screen
• ECG and Echocardiography
Management
• Mild Cases ie BP < 150/100
• No immediate indication to treat.
• Serial sonograms and antenatal testing
• Serial BP and urine protein assessment
• induce labour at term if the cervix is favorable.

5. SEVERE CASES:
• Start antihypertensive medication, the drug of choice being “methyldopa".
• Labetalol (a & B-blocker) and Nifedipine (calcium channel blocker) are acceptable
alternatives.
• The aim of anti-hypertensive medication is to maintain BP < 160/100 mmHg.
• Serial BP and urine protein assessment for early identification of super-imposed
preeclampsia.
• Mode of delivery:
• Await spontaneous labour
• Attempt vaginal delivery at 38 weeks' gestation
• If delivery planned before 34 weeks' mother should be given steroids for fetal lung
maturity.
• Continuous fetal monitoring is required in labour if the fetus is growth restricted.
•

6. 2. PREGNANCY-INDUCED HYPERTENSION:
• Also known as “gestational hypertension".
• It is defined as HTN arising for the first time in the second half of pregnancy and in the
absence of proteinuria.
• It is not associated with adverse pregnancy outcome and as such should be clearly
distinguished from pre-eclampsia.
• BP usually returns to pre-pregnancy limits within 6 weeks of delivery.
Diagnosis:
• No symptoms of pre-eclampsia are seen.
• Physical findings are unremarkable for pregnancy
• Laboratory tests are unremarkable and proteinuria is absent.
• The key findings are sustained elevation of BP>
Management:
• Conservative outpatient management is appropriate.
• Appropriate laboratory testing should be performed to rule out preeclampsia Delivery
should be aimed at the time of EDD
•

7. PRE-ECLAMPSIA:
• It is defined as
• HTN of at least 140/90 mmHg recorded on two separate occasions, at least 4 hours apart.
• In the presence of at least 300 mg protein in a 24-hour collection of urine
• Arising after the 20th week of gestation in a previously normotensive women.
• Resolving completely by the sixth week postpartum.
Risk Factors:
• Previous severe and early onset preeclampsia
• Extremes of age (>40 or < 18)
• Family history
• Obesity
• Primiparity
• Multiple pregnancy
• Long birth interval (>10 years)
• Fetal hydrops
•

8. • Hydatidiform mole
• Pre-existing medical conditions:
• Hypertension, Renal disease, Diabetes, Antiphospholipid antibodies,
PATHO-PHYSIOLOGY
• Trophoblast Invasion:
• Preeclampsia is clinical manifestation of failure of trophoblast invasion of the myometrial segments
of the spiral arteries.
• Due to this deficient trophoblast invasion, the small narrow caliber "Spiral Arteries which supply the
intervillous space, cannot transform into large “Sinusoidal Vessels.
• These changes don't allow the normal transformation of vascular supply to a low pressure, high-
flow system, resulting in inadequate blood flow to the placenta and fetus.

9. PATHOPHYSIOLOGY OF PRE ECLAPSIA

10. PATHOPHYSIOLOGY

11. SIGN AND SYMPTOMS

12. ORGAN-SPECIFIC CHANGES
• Cardiovascular system:
• Generalized vasospasm
• Increased peripheral resistance
• Reduced central venous pressure
• Hematological Changes
• Platelet activation and depletion
• Coagulopathy
• Decreased plasma volume
• Increased blood viscosity
• Renal Changes
• Proteinuria
• Decreased Glomerular filtration rate
• Decreased urate excretion
• Liver:Periportal necrosis, Subcapsular hematoma
• CNS: Cerebral edema, Cerebral hemorrhage

13. INVESTIGATIONS & COMPLICATIONS
• Investigations:
• Urinalysis by dipstick (quantitatively inaccurate)
• 24-hour urine collection (total protein & creatinine clearance)
• Full blood count
• Coagulation profile
• Blood chemistry (renal function, protein concentration)
• Plasma urate concentration
• Liver function
• Ultrasound assessment of:
• Fetal size,Amniotic fluid volume,Maternal and fetal well being,Dopplers U/S
•

15. Maternal Deaths: Most of the matemal deaths are due to failure to recognize a deteriorating
condition after delivery and result from multiple organ failure.
Mild preeclampsia:
• It is defined as BP <160 systolic and <110 diastolic with significant proteinuria and no maternal
complication
Signs:
• Elevation of BP, Fluid retention (non-dependent edema), Brisk reflexes, Ankle clonus, Uterus and
fetus small for gestational age
Management:
• Management is based on gestational age:
• Before 36 weeks' Gestation:
• Conservative inpatient management as long as the mother and fetus are stable.
Guidelines include:
• Monitoring BP every 4 hours
•

16. • Daily urine dipstick for protein.
• Daily fetal assessment with CTG
• Twice weekly 24-hour urine protein assessment.
• Weekly LFTs and electrolytes
• Regular U/S assessment
• Antihypertensive Drugs
• After 36 weeks' Gestation:
• Delivery is indicated: After 36 weeks' weeks gestation Or when the mother and fetus are
unstable after conservative management
• Dilute IV oxytocin is used for induction of labour.
• Continuous infusion of IV MgSO4 to prevent eclamptic seizures.

17. SEVERE PREECLAMPSIA:
• fined as BP > 160 systolic or > 110 diastolic in the presence of significant proteinuria or if maternal
complications occur.
Signs & Symptoms:
• Symptoms:
• Fontal headache, Visual disturbance, Epigastric pain, General malaise and nausea & Restlessness
• Signs:
• Agitation, Hyper-reflexia , Facial and peripheral edema, Right upper quadrant tenderness, Poor urine output
Management:
• Aggressive prompt delivery is indicated for severe preeclampsia at any gestational age.
• Administer IV MgSO4 to prevent convulsions.
• Lower BP using Labetalol or IV hydralazine.
• Methyldopa and nifedipine can be used too, but methyldopa is slow-acting (oral route) and nifedipine causes
severe headache.
• Attempt vaginal delivery with IV oxytocin infusion if mother and fetus are stable.
• However, delivery before term is usually be Caesarean section.
• If delivery is before 34 weeks, IM steroids (betamethasone) should be given to mother, for fetal lung
maturity,
•

18. ECLAPSIA

19. ECLAMPSIA:
• Eclampsia is defined as grand mal convulsions occurring in a woman with established
preeclampsia, in the absence of any other neurological or metabolic cause.
• Eclampsia is an obstetric emergency, and is a serious and life-threatening complication of
preeclampsia.
• Convulsions may occur antenatally (38%), intrapartum (18%), or postnatally within 48
hours(44%).
• Any convulsion in pregnancy should be considered to be eclamptic until proved otherwise.
Investigations:
• Test the urine for protein .
• Full blood count
• Clotting studies
• Urea/creatinin
• Liver function tests
• serum electrolytes , blood suger
Management:
• Call for help – senior obstetrician and anesthetist
• Maintain airway, breathing, and circulation
• Maintain IV line

20. Antihypertensive drugs:
• IV hydralazine : Direct relaxation of arteriolar smooth muscle
• Labetalol : Alpha- and beta-blocker
Anticonvulsant drugs:
• MgSO4 is the drug of choice.
• It acts as cerebral vasodilator and membrane stabilizer.
• IV bolus of 5 g to stop seizures, continuing maintenance infusion rate of 2 g/h.
• Overdose is associated with respiratory depression and cardiac arrest.
• Overdose can be reversed with Calcium gluconate.
Fluid Balance:
• Fluid restrict the patient to 100 ml/hour due to risk of pulmonary edema.
• Monitor renal function with the creatinine.
• If oliguria develops maintain CVP line.
• Avoid diuretics (decrease intravascular volume)
Delivery:
• It is the only definitive cure at any gestational age after stabilization of mother and the fetus.
• Vaginal delivery is not contraindicated if the cervix is favourable, and should be attempted with
IV oxytocin infusion.
•

21. • It gestation is<34 weeks steroids should be given to improve fetal lung maturity.
• Delivery is often by C-section
Indications for Urgent Delivery:
• BP persistently at 160/100 mmHg
• Elevated liver enzymes
• Low platelet count
• Eclamptic fit
• Anuria &Significant fetal distress
HELLP Syndrome:
• • It is a combination of hemolysis, elevated liver enzymes,and low platelets.
• It is seen in 5-10% of cases of severe pre-eclampsia.
Symptoms:
• Epigastric or RUQ pain (65%)
• Nausea and vomiting (35%)
Signs:
• Tenderness in Right Upper Quadrant (RUQ).
• Increased BP and other features of preeclampsia.

22. Complicatlons & Management:
Complication:
• DIC
• Placental abruption
• Fetal demise
• Ascites
• Hepatic rupture
Management:
• Prompt delivery at any gestational age is appropriate
• Use of maternal steroids may enchance postpartum normalization of liver enzymes
and platelet count.