Hypertensive Disorders in Pregnancy.

2. Hypertension in PregnancyHypertension in Pregnancy
ClassificationClassification
 Chronic hypertension
 Gestational hypertension (only during pregnancy)
 Preeclampsia Superimposed upon chronic
hypertension or Renal Disease
 Preeclampsia - eclampsia
 Transient hypertension (only after pregnancy)

3. Chronic HypertensionChronic Hypertension
Defined as hypertension
diagnosed
 Before pregnancy
 Before the 20th week of gestation
 During pregnancy and not resolved
postpartum

4. Gestational HypertensionGestational Hypertension
Gestational Hypertension:
– Systolic >140
– Diastolic>90
– No Proteinurea
– 25% Develop Pre-eclampsia

5. Gestational HypertensionGestational Hypertension
Diagnosis of gestational hypertension:
 Detected for first time after midpregnancy
 No proteinuria
 Only until a more specific diagnosis can be assigned
postpartum
If preeclampsia does not develop and
 BP returns to normal by 12 weeks postpartum, diagnosis is
transient hypertension.
 BP remains high postpartum, diagnosis is chronic
hypertension.
 Proteinurea develops Preeclampsia is diagnosed (25%
incidence)

6. Hypertension in PregnancyHypertension in Pregnancy
Complicates 7-10% of pregnancies
– 70% Preeclampsia-eclampsia
– 30% Chronic hypertension
Eclampsia 0.05% incidence
20% of Maternal Deaths
Cause of 10% of Preterm birth
Etiology unknown

7. Hypertension in PregnancyHypertension in Pregnancy
Young female 3 fold increased risk
Africans 2 fold increased risk
Multifetal pregnancies
– Twins
– Triplets
Hypertension
Renal Disease
Collagen Vascular Disease

8. ** INCIDENCE: 5-10% 0f all pregnancies . 20% recurrence
This is the third most important cause of maternal mortality
worldwide
** DEFINITION OF HYPEWRTENSION:
 D.B.P. > 90 mmHg or
 S.B.P. > 140 mmHg or
 Rise in D.B.P. of at least 15 mmHg (physiological changes) or
 Rise in S.B.P. of at least 30 mmHg
** PROTIENUREA:
Proteinurea is defined as urinary excretion
0.3 g protein or greater in a 24-hour
30 mg/dl (+1 or greater on urine dip specimen)
** OEDEMA: 90% pregnancy. progressive
abandoned
+/-

9. •Enlarged placenta e.g………….
•Pre-existing hypertension, renal
•Pre-existing vascular disease
•P0 >>>> multip
•Family history
•New husband

10. Symptoms of Pre-eclampsiaSymptoms of Pre-eclampsia
 Visual disturbances typical of preeclampsia are
scintillations and scotomata. These disturbances
are presumed to be due to cerebral vasospasm.
 Headache is of new onset and may be described as
frontal, throbbing, or similar to a migraine
headache. However, no classic headache of
preeclampsia exists.
 Epigastric pain is due to hepatic swelling and
inflammation, with stretch of the liver capsule.
Pain may be of sudden onset, it may be constant,
and it may be moderate-to-severe in intensity.

11. Symptoms of preeclampsiaSymptoms of preeclampsia
 While mild lower extremity edema is common in
normal pregnancy, rapidly increasing or
nondependent edema may be a signal of
developing preeclampsia. However, this signal
theory remains controversial and recently has been
removed from most criteria for the diagnosis of
preeclampsia.
 Rapid weight gain is a result of edema due to
capillary leak as well as renal sodium and fluid
retention.

12. Physical Findings inPhysical Findings in
PreeclampsiaPreeclampsia
Blood Pressure
Proteinurea
Retinal vasospasm or Retinal edema
Right upper quadrant (RUQ) abdominal
tenderness stems from liver swelling and
capsular stretch

13. Physical findings inPhysical findings in
PreeclampsiaPreeclampsia
– Brisk, or hyperactive, reflexes are common
during pregnancy, but clonus is a sign of
neuromuscular irritability that raises concern.
– Among pregnant women, 30% have some
lower extremity edema as part of their normal
pregnancy. However, a sudden change in
dependent edema, edema in nondependent areas
such as the face and hands, or rapid weight gain
suggests a pathologic process and warrants
further evaluation

14. •Why screening
•Accuracy. Uterine artery doppler at 24 weeks, notching on both
uterine arteries identifies 80% who will develop PET,,, 5% false
positive

15. Methods Used to Prevent Hypertensive Disorders of Pregnancy
Proper prenatal care
Low-salt diet
Diuretics
Antihypertensive drugs
Nutritional supplementation
Magnesium (365 mg/d)
Zinc (20 mg/d)
Calcium (1500–200 mg/d)
Fish oil
Antithrombotic agents Low-dose aspirin (50–150 mg/d)
Dipyridamole (225–300 mg/d)
Subcutaneous heparin (15,000 IU/d)

16.  HELLP SYNDROME
 ABRUPTIO PLACENTAE
 PULMONARY OEDEMA
 ACUTE RENAL FAILURE
 CEREBRAL HAEMORRHAGE
 VISUAL DISTURBANCES & BLINDNESS
 HEPATIC RUPTURE
 ELECTROLYTIC IMBALANCE
 POSTPARTUM COLLAPSE
SERIOUS COMPLICATIONS: -

17. CURE / PREVENT PROGRESSION -
– CLOSE MONITORING
REDUCE BLOOD PRESSURE -TATRGET- 140/90
PROMOTE FOETAL MATURITY
PROLONG PREGNANCY (34 - 36 WEEKS)
– TO ACHIEVE FOETAL MATURITY  TERMINATION
DELIVERY-DELIVERY- BEST DAY, BEST WAY & BEST PLACE
PREVENT / MANAGE COMPLICATIONS
OBJECTIVES OF MANAGEMENT
HYPERTENSION DURING PREGNANCY

18. ** Definite treatment is delivery (ending the pregnancy).
But,
Mother vs. Fetus

19. ** Mild pre-eclampsia:
diastolic /90-95 & proteinurea trace-1+
** Moderate pre-eclampsia
** Severe pre-eclampsia
** Does the treatment improve the condition?
Then why. Adv/disadv

20. CONTROL OF ACUTE SEVERE HYPERTENSION
• There is no consensus on the optimum acute treatment.
• The important objective is to reduce the blood pressure to safe levels.
(but not too low!).
• Parenteral hydralazine is used most commonly but oral nifedipine should be
considered .
The combined a- and (B- blocking agent labetalol is commonly
used.
The potent vasodilator and calcium channel blocker nifedipine is a
useful second-line treatment. Its major drawback is severe
headache.
Angiotensin-converting enzyme (ACE) inhibitors have deleterious fetal
effects and their use is not recommended. If a woman with
chronic hypertension becomes pregnant on an ACE inhibitor,
change to another anti-hypertensioe agent is advised.
LONGER-TERM CONTROL OF SEVERE HYPERTENSION

21. • There is still insufficient trial evidence to determine whether the benefits
outweigh any disadvantages.
• If it is to be used, the suggested indications are: ,-DBP >_100 mmHg
-pregnancy <_34 weeks
*fetal and maternal state otherwise good.
• Methyldopa remains the drug of first choice.
The combined a- and (B- blocking agent labetalol is commonly
used.
The potent vasodilator and calcium channel blocker nifedipine is a
useful second-line treatment. Its major drawback is severe
headache.
Angiotensin-converting enzyme (ACE) inhibitors have deleterious fetal
effects and their use is not recommended. If a woman with
chronic hypertension becomes pregnant on an ACE inhibitor,
change to another anti-hypertensioe agent is advised.
LONGER-TERM CONTROL OF SEVERE HYPERTENSION

22. Timing of delivery
• The most common grounds for delivery are:
 progressive fetal compromise,
(i.e. when the baby is safer delivered).
 unacceptable risk to maternal health,
e.g. uncontrollable BP, impending renal failure or heart
failure, HELLP syndrome, DIC, eclampsia .

23. The mode of delivery (caesarean section versus vaginal)
depends on:
-The seriousness of the situation
-The gestational age
-The degree of fetal/maternal compromise.
• Epidural analgesia is the method of choice for labour
(as long as a coagulation defect has been excluded).
• Appropriate facilities for the care of the newborn available