1. Hypertension in pregnancy can manifest as gestational hypertension, preeclampsia, or eclampsia. Preeclampsia is defined as new onset hypertension and proteinuria after 20 weeks of gestation. 2. The pathophysiology of preeclampsia involves abnormal placentation leading to placental ischemia and endothelial dysfunction. This causes widespread effects including vasoconstriction and signs/symptoms affecting multiple organ systems. 3. Diagnosis of preeclampsia is based on new hypertension and proteinuria developing after 20 weeks of gestation. Evaluation of patients involves assessment of signs/symptoms and laboratory/imaging tests to determine severity and monitor for complications affecting maternal/fetal health.

1. HYPERTENSION IN PREGNANCY Associate Professor Dr Hanifullah Khan

2. Objectives Understand definitions Pathophysiology Presentations of the disease Important signs and symptoms

3. INTRODUCTION

4. Introduction H/T in pregnancy – leading cause of maternal & fetal morbidity The most frequent cause of iatrogenic prematurity PE & eclampsia – delivery is the only effective tx

5. Definitions – H/T H/T – a DBP of 90mmHg or more, taken on 2 occasions > 4 hrs apart OR A single DBP of > 110mmHg Can occur either in – Women who already have H/T (1 0 or 2 0 ) Manifest in 2 nd half of pregnancy

6. Pregnancy HT & Chronic HT May be difficult to differentiate Both have high risk of complications Chr HT – Diagnosed prepregnancy high BP early in pregnancy

7. Definitions - PE A multisystem disorder characterized by HT + proteinuria Proteinuria - > 300mg urine pr / 24 hrs Occurs > 20 wks gestation Resolves postnatally Complications of PE – eclampsia, HELLP synd

8. Definition - Eclampsia The occurrence of tonic-clonic convulsions in a woman with PE Pregnancy Any gestation No neurological disease

9. Gestational hypertension. Preeclampsia (mild, severe). Eclampsia. Superimposed preeclampsia upon chronic hypertension. Chronic hypertension with pregnancy. Classification

11. Incidence PE – 2-8% of all pregnancies Risk in 1 st pregnancy – 4.1% Risk in later pregnancies – 1.7% Risk in woman with PE in 1 st pregnancies – 14.7% Risk in woman with PE in previous 2 pregnancies – 31.9%

12. Summary Gestational hypertension: Hypertension for first time after 20 w, without proteinuria. BP returns to normal before 12 weeks postpartum. Chronic hypertension with pregnancy : Hypertension antedates pregnancy and detected before 20 w, & lasts more than 12 weeks postpartum.

13. PATHOPHYSIOLOGY

14. Basic understanding Complex disease Appears to be triggered by the placenta Can occur in molar pregnancies where fetus absent

15. Trophoblast In normal conditions – Trophoblast invades myometrium Spiral arteries converted to low pressure system This process is inhibited in PE Immunological process also involved Thus HT & PE is caused by abnormal placentation

16. Other factors Abn placentation -> placental insufficiency & IUGR Development of PE requires further changes ↑ Inflammatory activity Widespread vascular endothelial damage Capillary leak, vasoconstriction, intravascular haemolysis, platelet activation ↑ Immune status - ↑ leucocytes

17. Pathology Primarily a disorder of placental dysfunction leading to a syndrome of endothelial dysfunction with associated vasospasm Evidence of placental insufficiency with associated abnormalities diffuse placental thrombosis, an inflammatory placental decidual vasculopathy, and/or abnormal trophoblastic invasion of the endometrium This supports abnormal placental development or placental damage from diffuse microthrombosis as being central to the development of this disorder

18. Pathopyhsiology Placental factors Immune complex deposition in kidney & placenta 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

19. 2. Altered vascular reactivity PG12 angiotensin II vasoconstrict HPT and reduce placenta blood flow

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

21. Summary The development of PE is mediated through the degree of placental pathology & the maternal inflammatory response

22. PREECLAMPSIA & ECLAMPSIA

23. Is the most common medical disorder complicating pregnancy Is the most common hypertensive disorder in pregnancy More common in primigravidas and elderly multipara Occurrence

24. Chronic hypertension. Chronic nephritis. Past history . Family history. Obesity. Multiple pregnancy. Epidemiology

25. Maternal personal risk factors for preeclampsia First pregnancy Multigravida pregnant by a different partner Age younger than 18 years or older than 35 years History of preeclampsia Multiple pregnancy Family history of preeclampsia in a first-degree relative Obesity Preexisting diabetes Chronic hypertension Renal disease Smoking

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

27. Diagnosis Of PE Hypertension + Proteinuria = Two facets of a complex pathophysiological process

28. Peripheral oedema Not a useful diagnostic criterion Common in pregnancy PE can occur without oedema

29. Headache. Blurring of vision. Nausea and vomiting. Epigastric pain (distension of the liver capsule) Oliguria or anuria Symptoms – non-specific

30. The frequency and intensity of the signs and symptoms. The more the severity of PE, the more likely the need to terminate pregnancy Severity of PE

31. Eclamptic fit stages ( 4 stages): Premonitory stage (1/2 minute): Eye rolled up Twitches of the face and hands. Tonic stage (1/2 minute): Generalized tonic spasm with opisthotonus. Cyanosis. Tongue may be bitten between the clenched teeth. Diagnosis of Eclampsia

32. EVALUATION

33. Evaluation of Hypertension in Pregnancy History ID and Complaint HPI (S/S of Preeclampsia) Past Medical Hx, Past Family Hx Past Obstetrical Hx, Past Gyne Hx Social Hx Medications, Allergies Prenatal serology, blood work Assess for Hypertension in Pregnancy risk factors Physical BP (essential) Oedema Hyperreflexia Clonus Fondoscopy Urine dipstick test Cardiovascular Respiratory Abdominal = Epigastric pain, RUQ pain

34. 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

35. Clinical presentation Symptoms Signs Headache (frontal/ occipital) Visual disturbance Nausea & vomiting Epigastric and right upper abdominal pain Oliguria / anuria Maybe asymptomatic Rapid rise in BP Papilloedema Fluid retention (non-dependent edema) Hyperreflexia Clonus Uterus and fetus may feel small for gestational age

36. Investigations Urine - 24 hour urine, Proteinuria. Kidney functions - serum creatinine, urea, creatinine clearance and uric acid. Liver functions - bilirubin, Enzymes (SGPT and SGOT). Blood - CBC, HCt , Hemolysis and Platelet count (Thrombocytopenia). Coagulation Profile - Bleeding and clotting time

37. Differential Diagnosis: A. Hypertension With Pregnancy . B. Proteinuria With Pregnancy . C. Edema With Pregnancy :

38. Differential Diagnosis Convulsions Convulsions With Pregnancy : Eclampsia. Epilepsy. Hysteria. Meningitis and Encephalitis. Tetanus. Tetany. Brain tumors. Uremic convulsions

39. Differential Diagnosis HELLP Syndrome : Acute fatty liver in pregnancy. Hepatitis. Thrombocytopenia purpura. Hemolytic Uremic syndrome.

40. Treatment PREVENTION. Antepartum Proper antenatal care Expectant treatment. Control hypertension. Treatment of eclampsia . Prevention and control of convulsions. Termination of pregnancy . Intrapartum care. Postpartum care.

41. Control of Convulsions: Magnesium Sulfate (MgSO4): It is the drug of choice. Mechanism: CNS depression. Mild VD. Mild diuresis. Inhibits platelet aggregation. Increase PGI2 synthesis.

42. Prognosis: BP usually normalize after placental delivery . Hypertension may persist. Postpartum eclampsia carries the worst prognosis. Maternal mortality is about 2% in severe preeclampsia and 10% in eclampsia. Perinatal mortality rate is about 5% in mild cases, 25% in severe cases and 30% in eclampsia.

43. CONCLUSIONS

44. Summary Hypertension diagnosed prior to 20 weeks' gestation, is generally due to preexisting chronic hypertension rather than pregnancy induce hypertension 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

45. Maternal deaths Confidential Enquiry into Maternal and Child Health UK (2003-2005) 18 deaths from PE & eclampsia 10 deaths caused by IC haemorrhage Due to uncontrolled BP

46. References Obstetrics by Ten Teachers 18 th Edition Obstetrics illustrated 6 th Edition Lecture Notes Obstetrics and gynaecology 3 rd Edition http://emedicine.medscape.com/article/261435-overview