Obstetric hypertention

1. HYPERTENSION IN PREGNANCY
Systolic and diastolic BP both decline early in the
first trimester, reaching a nadir by 24–28 weeks;
then they gradually rise toward term but never
return quite to prepregnancy baseline.
Diastolic falls more than systolic, as much as 15 mm
Hg.
Arterial BP is never normally elevated in pregnancy.

2. Hypertensive disease complicates 8% to 11% of all
pregnancies. It is the leading cause of maternal
morbidity in developed countries (followed by
obstetric hemorrhage and thromboembolism) and
accounts for 15% of maternal deaths in the United
States

3. GESTATIONAL HYPERTENSION
Pregnancy >20 wk
Sustained HTN
No proteinuria
Preeclampsia should always be ruled out?

4. Management
Conservative outpatient management with close observation
since 30% of patients will develop preeclampsia. Appropriate
lab testing should be performed to rule out preeclampsia,
e.g., urine protein, hemoconcentration assessment. Deliver
by 40 weeks.

5. PREECLAMPSIA
Pregnancy >20 wk
Sustained HTN (>140/90 mm Hg)
Proteinuria (≥300 mg/24 h)

6. Pathophysiology involves diffuse
vasospasm caused by (1) loss of the
normal pregnancy-related refractoriness to
vasoactive substances such as angiotensin
and (2) relative or absolute changes in the
following prostaglandin substances

7. Increases in the vasoconstrictor
thromboxane
Decreases in the potent vasodilator
prostacyclin

9. Severe preeclampsia(preeclampsia with
severe features)
Criteria for severe preeclampsia (Table 8-5) include:
 BP greater than 160 mm Hg systolic or 110 mm Hg
diastolic on two occasions at least 6 hours apart
 proteinuria greater than 5 g/24 hours (or 3 to 4+
protein on dipstick on two occasions)
signs/symptoms of severe preeclampsia.

10. Signs and symptoms of severe
preeclampsia include:
altered consciousness
headache
visual changes
epigastric or RUQ pain
significantly impaired liver function (greater than two times normal)
oliguria (< 400 mL in 24 hour)
pulmonary edema
significant thrombocytopenia (< 100,000/mm3).

11. HELLP Syndrome
The disorder is characterized by:-
rapidly deteriorating liver function
 thrombocytopenia

13. ECLAMPSIA

14. Of note, eclampsia may also occur without
proteinuria.
Complications of eclampsia include:-
 cerebral hemorrhage
aspiration pneumonia
hypoxic encephalopathy
thromboembolic events.

15. CLINICAL MANIFESTATIONS
Seizures in the eclamptic patient are tonic—clonic in
nature and may or may not be preceded by an aura.
These seizures may develop:-
before labor (25%)
 during labor (50%)
 after delivery (25%)
Most postpartum seizures occur within the first 48 hours
after delivery, but will occasionally occur as late as
several weeks after delivery

16. TREATMENT
Treatment strategies for eclamptic patients
include:-
seizure management
BP control
prophylaxis against further convulsions

17. Hypertension management can usually be
achieved using hydralazine to lower the
BP. For seizure control and prophylaxis,
eclamptic patients are treated with
magnesium sulfate (MgSO4).