obstetrics & gynecology,

1. Hypertensive disorders in
pregnancy
ANUM FATIMA
08-226
Batch E

2. Hypertensive disorders are the
most common and yet serious
conditions seen in obstetrics

3. Classification
Pre-
eclampsia
Eclampsia
Preeclampsia
superimposed
on chronic
hypertension
Chronic
hypertension
with pregnancy
Gestational
hypertension

4. Blood Pressure ≥ 140/90mmHg on two
or more occasions
- in a previously normotensive patient
- after 20 weeks gestation
- without proteinuria
- returning to normal 12 weeks after
delivery
Almost half of these develop
preeclampsia syndrome
GESTATIONAL HYPERTENSION

5. GESTATIONAL HYPERTENSION
GESTATION ≥ 20 WEEKS
SUSTAINED HYPERTENSION ( ≥
140/90)
No proteinuria

6. DEFINITION
SYMPTOMS
EXAMINATION
GESTATIONAL HYPERTENSION
Sustained B.P
No proteinuria
NONE
Unremarkable

7. Preeclampsia
◦ It is defined as hypertension of at least
140/90mm Hg recorded on two separate
occasions at least 4 hours apart and in
the presence of at least 300mg protein in
a 24 hour collection of urine, arising after
the 20th week of gestation in a previously
normotensive woman and resolving
completely by the 6th postpartum week.

8. (
RISK FACTORS for PREECLAMPSIA
DEMOGRAPHIC
OBSTETRICS
MEDICAL
NULLIPARA
(Age extremes <20yrs ,
>35yrs )
1. Multiple gestation
2. Molar pregnancy
3. Non-immune hydrops
1. Diabetes mellitus
2. Chronic HTN
3. Renal disease
4. SLE

9. MILD PREECLAMPSIA
GESTATION ≥ 20 WEEKS
SUSTAINED HYPERTENSION (≥ 140/90)
Proteinuria (≥300mg /24 hr)

10. NONE
SYMPTOMS
EXAMINATION
PATHO -
PYSIOLOGY
MILD PREECLAMPSIA
NONE
NONE
Diffuse Vasospasm
Capillary injury

11. MILD PREECLAMPSIA
LABORATORY
FINDINGS
MANAGEMENT
PROTEINPROTEINURIA
URIA
Proteinuria (1-2+)
Hemoconcentration
< 36 wks Conservative
>36 wks MgSO4 and
Delivery

12. GESTATIONAL HYPERTENSION
GESTATION ≥ 20 WEEKS
SUSTAINED HYPERTENSION (≥ 140/90)
NO PROTEINURIA
MILD PREECLAMPSIA
SUSTAINED HYPERTENSION ( ≥
140/90)
Proteinuria ( ≥ 300mg /24 hr)
GESTATION ≥ 20 WEEKS

13. BLOOD
PRESSURE
PROTEINURIA
SYMPTOMS
CRITERIA: SEVERE PREECLEMPSIA
≥ 160/110
≥ 5grams
1. Headache
2. Epigastric pain
3. Visual changes

14. CRITERIA: SEVERE
PREECLEMPSIA
LABORATORY
FINDINGS
SIGNS
DIC
Elevated Liver
enzymes
1. Pulmonary edema
2. Oliguria
3. cyanosis

15. new onset of seizures or unexplained coma
during pregnancy in patients with pre-existing
preeclampsia and without pre-existing
neurological disorder.
ECLAMPSIA

16. rebra
ECLAMPSIA
SYMPTOMS
PATHO -
PYSIOLOGY
RISK FACTORS Same as Preeclampsia
Cerebral vasospasm ,
ischemia and edema
Generalized tonic-
clonic
SEIZURES

17. ECLAMPSIA
LABORATORY
FINDINGS
MANAGEMENT
Proteinuria
Hemoconcentration
DIC
Elevated Liver
enzymes
1. Stop convulsions with MgSO4
2. Prompt delivery at any
gestational age
3. Lower diastolic B.P 90-
100mm/Hg

18. MANAGEMENT
IV MgSO4 – To prevent convulsions ( continue
24 hrs post-partum )
LOWER B.P ( hydralazine or labetalol)
INDUCE LABOR (IV oxytocin and amniotomy
)

19. Blood pressure ≥ 140/90 before 20 weeks of
gestation
OR
persistence of hypertension beyond 12 weeks
after delivery.
CHRONIC
HYPERTENSION

20. CHRONIC HYPERTENSION
GESTATION < 20 WEEKS OR Prepragnancy
SUSTAINED HYPERTENSION
(≥140/90)
+/- PROTEINURIA

21. CHRONIC HTN PREGNANCY
PROGNOSIS
GOOD
PROGNOSIS
POOR
PROGNOSIS
WORST
PROGNOSIS
B.P 140/90 to 179/109
No end organ damage
KIDNEYS: Renal disease
EYES : Retinopathy
HEART : Left Ventricular
Hypertrophy (B.P
>180/90)
Uncontrolled HTN
Chronic HTN
+Superimposed PIH

22. D
MANAGEMENT OF CHRONIC HYPERTENSION
If antihypertensive meds needed
- Methyl dopa is drug of choice (or labetalol)
Serial ultrasounds (increase risk of IUGR >30
weeks )
Induce labor at term
DC antihypertensive meds
(if B.P <100 mm Hg diastolic)
Serial B.P and urine protein
(watch for superimposed preeclampsia)

23. SUPERIMPOSED PREECLAMPSIA
(on Chronic Hypertension)
 New-onset proteinuria > 300 mg/24 hrs in
hypertensive women but no proteinuria
before 20 wks gestation
 A sudden increase in proteinuria or blood
pressure or platelet count < 100,000/ cu
mm in women with hypertension and
proteinuria before 20 wks gestation.
23

24. CHRONIC HTN SUPERIMPOSED PIH
CHRONIC HYPERTENSION
Worsening BLOOD
PRESSURE
Worsening proteinuria

25. MANAGEMENT of Chronic HTN and
superimposed PIH
IV MgSO4 – To prevent convulsions ( continue
24 hrs post-partum )
LOWER B.P - Diastolic 90-100 mm Hg(
hydralazine or labetalol)
INDUCE LABOR (IV oxytocin and amniotomy
)

26. HELLP Syndrome
 HTN patients with
hemolysis (H), elevated
liver enzymes (EL), low
platelet count (LP)
 4-12% of pt. with severe
preeclampsia and
eclampsia develop
HELLP syndrome

27. PATHOPHYSIOLOGY
 Complex disease
 Appears to be triggered by the
placenta
◦ Can occur in molar pregnancies where
fetus absent
◦ Can also occur in abdominal pregnancy
(pregnancy not in uterus)

28. TWO – STAGE MODEL FOR
PREECLAMPSIA
Stage 1:
reduced
placental
perfusion
Abnormal
implantation
Stage 2 :
maternal
syndrome
-hypertension
-proteinuria
-endothelial
dysfunction

29. NORMAL
PREGNANCY
PREECLAMPSIA

30. Impair/ inadequate trophoblast invasion to the spiral arteries
Spiral arteries retain their charecteristic (narrow, tortuous, high
resistance)
Reduce blood supply to placenta
Result in placental hypoperfusion
As a compensation
High BP in maternal

31. Stage 1:
reduced
placental
perfusion
Abnormal
implantation
Stage 2 :
maternal
syndrome
-hypertension
-proteinuria
-endothelial
dysfunction
WHAT CAUSES MATERNAL
SYNDROME ?????
WHAT GETS INTO MATERNAL
CIRCULATION ???

32. ANTI-ANGIOGENIC
FACTORS
ANGIOGENIC
FACTORS
Vascular endothelial
growth (VEGF)
including placental
growth factor
Transforming growth
factor- beta (TGF-B)
Look after maternal
endothelium
Soluble endoglin (sEng)
Soluble FMS-like
tyrosine kinase-1 (sFlt-1)
Released from
diseased placenta

33. ↓PGI2
↑TXA2
Vasoconstriction
Platelet aggregation
↑Vasopressor
response
↑uterine activity
Inflammatory mediators

34. Coagulation disturbance
Activated endothelial cells promote
coagulation and increase vasopressor
sensitivity
Widespread coagulation occur (DIC)
Fibrin deposition in kidney & placenta
HPT & placental insufficiency

35. Cardiovascular
• Generalized vasospasm
• Increased peripheral resistance
• Reduced central venous/
pulmonary pressure
Hematological
• Platelet activation and depletion
• Coagulopathy
• Decreased plasma volume
• Increased blood viscosity
• Proteinuria
• Decreased glomerular filtration
rate
• Decreased urate excretion
Renal
Hepatic
• Periportal necrosis
• Subscapular
hematoma
• Cerebral oedema
• Cerebral haemorrhages
Central Nervous System
Organ Specific Changes associated with
Pre-eclampsia

36. 36

37. RISK FACTORS
Maternal related
 History of Preeclampsia in previous
pregnancy
 Advanced maternal age
 Family history of Preeclampsia
 History of placental abruption, IUGR,
fetal death
 Obesity, BMI>35 doubles the risk
 Hypertension
 Diabetes
 Thrombotic vascular diseases

38.  Multiple gestation
 Molar pregnancy
 Smoking

39.  Large placenta
 Prolonged pregnancy
 Placental hydrops
 Chromosomal abnormality
Fetal/placental factors

40.  Hemoglobin and hematocrit
platelet count : decreased, if < 1 lakh
coagulation profile
 LFTs : indicated in all patients
 RFTs : raised (S.urea creatinine is decreased in Norm
pregnancy)
 Urine Routine : proteinuria
OBSTETRIC MANAGEMENT
1. Maternal
evaluation

41. 2. Fetal evaluation:
 Daily fetal movement count
 Ultrasound
 Doppler ultrasound for fetal blood flow

42. 3. Treatment of Hypertension:
Antihypertensive drugs used in
pregnancy are
-methyldopa
-hydralazine
-labetalol

43. 4. Seizure
Prophylaxis
• Routinely used in severe
PE
• Magnesium sulphate:
most commonly used
• Initiated with onset of
labor till 24h postpsrtum
• For caesarean, started
2hrs before the section
till 12hrs postpartum

44. it can be given either IV or IM.
IV has good prognosis.
Loading dose for IV is 4g. i.e. 8
ml diluted in 12ml normal saline.
This 20 ml is given in 20
minutes.
Maintenance dose is 20 g i.e.
40ml diluted in 60ml
normal saline and given at rate
of 1g/hr.
Recommended regime for MgSO4

45. IM is also used.
Loading dose is as IV.
Maintenance dose is 5g
every 4 hrs in alternate
buttocks for 24hrs.
Mgso4 acts on NM junction
and inhibit entry of Ca++
ions thus inhibiting
excitability of neurons.

46. Side effects of MgSO4
Maternal :
flushing
perspiration
headache,
muscle weakness
pulmonary oedema
Neonatal:
lethargy
hypotonia
respiratory depression

47. Management of MgSO4 Toxicity
Calcium gluconate is antagonist for MgSO4.
it is usually given as 10 ml of 10% Calcium
gluconate in 10 minutes

48. The only definitive
treatment
Preeclamptic patients
divided into 3 categories
A- Preeclampsia features
fully subside
B- partial control, but BP
maintains a steady high
level
C- persistently increasing
BP to severe level or
addition of other features
5. Delivery

49. Management:
A: can wait till
spontaneous onset of labor
don’t exceed Expected
Date of Delivery
B: >37wk terminate without
delay
<37wk, expectant
management at least
till 34wks
C: terminate irrespective of
POG
start seizure prophylaxis
and steroids if<34wks

50. Delivery in Eclampsia
Unless contraindicated: Eclamptic women should
undergo normal vaginal delivery
Indications for caesarean section -
Fetal distress
Placental abruption
Unfavourable cervix
Failed induction of labour
Recurrent seizures

51. Investigations
 Laboratory:
◦ Urine: 24 hour urine, Proteinuria.
◦ Kidney functions: serum creatinine, urea,
creatinine clearance and uric acid.
◦ Liver functions: bilirubin, Enzymes
◦ Blood: CBC, HCt , Hemolysis and Platelet
count (Thrombocytopenia).
◦ Coagulation Profile: Bleeding and clotting
time

52. Complications
1. Maternal:
a. Convulsions and coma (eclampsia).
b. Cerebral haemorrhage.
c. Renal failure.
d. Heart failure.
e. Liver failure.
f. Disseminated intravascular coagulation.
g. Abruptio placentae.
h. Residual chronic hypertension in about 1/3 of
cases.
i. Recurrent pre-eclampsia in next pregnancies.
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53. Complications
2.Foetal:
a. Intrauterine growth retardation
(IUGR).
b. Intrauterine foetal death.
c. Prematurity and its complications.
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54. PREVENTION
• Regular Antenatal checkup:
rapid gain in weight
rising blood pressure
edema
proteinuria/deranged liver or renal profile
• Low dose Aspirin in High risk group: ↑PGs
and↓TXA2
• Calcium supplementation: no effects
unless women are calcium deficient
• Antioxidants- Vitamin C and E
• Nutritional supplementation: zinc,
magnesium, fish oil, low salt diet

55. Differential Diagnosis
 meningitis
 encephalitis
 space occupying lesion
 electrolyte disturbance
 vasculitis
 amniotic fluid embolism
 medications
 organ failure
 stroke

56. Thank you