This document discusses hypertension in pregnancy and preeclampsia. It begins by outlining normal blood pressure changes during pregnancy, then defines pregnancy-induced hypertension and chronic hypertension. It distinguishes between gestational hypertension, preeclampsia, and eclampsia. Preeclampsia is defined as new onset hypertension and proteinuria after 20 weeks of gestation. Risk factors, incidence rates, causes, pathophysiology, complications, classification, diagnosis, and management of preeclampsia are then summarized. Indications for delivery are outlined for both mild and severe preeclampsia cases based on maternal and fetal stability and gestational age.

1. Androu Waheeb

2. Blood Pressure in normal
pregnancy
 6/52: 5-10 (sbp) /10-15 (dbp) mmHg
 26/52: nadir
 after 26/52:
 Less than pre-pregnancy

3. Hypertension in Pregnancy
Hypertension in
Pregnancy
>140 or 90 mmHg
2 consecutive times 6 hours apart
Pregnant patient
Pregnancy Induced Chronic Hypertension
Hypertension
>20/52 <20/52
Gestational Preeclampsia Eclampsia
Hypertension
-ve protrinuria + proteinuria (≥300mg/24 or 1+) + unexplained grand mal seizures
+/- nondependant edema (face &
hands)

4. Preeclampsia - Definition
 Presence of
Hypertension
• SBP ≥ 140 or DBP ≥ 90
• 2 readings 6 hours apart
• > 20/52 gestation
Proteinuria
• ≥ 1+ Urine dipstick (not sensitive)
• ≥ 300 mg / 24
Nondependent Edema
• Hand
• Face
• Not sensitive or specific

5. Preeclampsia – Incidence
30
25
2000 (per 1000 F)
20
1994 (per 1000 F)
15
1987 to 2004 (PE:MM per
10
100,000 births)
5 2008 (MMR per 100,000
births)
0
UK US South Saudi Bahrain World
(EURO (AMRO Africa Arabia
A) A) (AFRO
E)

6. Preeclampsia – Cause of Death
(2006)

7. Preeclampsia - Pathophysiology
 Systemic Inflammatory Response
 Endothelial Activation
 Maternal symptoms
 Generalized transudative edema
  intravascular depletion
  symptoms of ischemia, necrosis, hemorrhage
 Vascular damage
  imbalance of prostacyclin (VD) & thromboxane (VC)
 Generalized arteriolar Constriction (Vasospasm)

8. Preeclampsia – Pathology (1)
 Vascular Theory
 Poorly perfused placenta
 Abnormal placentation
 Maternal microvascular disease
 ‘Relative’: due to hyperplacentosis
  placental ischemia
  release of factors by placenta
  cascade
  damage maternal vascular endothelium

9. Preeclampsia – Pathology (2)
 Alloimmune Theory
 Sperm exposure
  mucous alloimmunization
  cascade (≈ classical inflammatory response)
  inhibition of placentation

10. Preeclampsia – Risk Factors
• Nulliparous • Chronic HTN • African American
• Previous preeclampsia • Chronic Renal Disease • Obesity
• Multiple Gestation • Collagen Vascular • 35 < Age < 20
• Abnormal Disease • New paternity
Placentation • Pregestational DM • Cohabiliation < 1 year
Immunogenic Disease Maternal
Related Related Related
• Relatives
• Mother-in-Law
Family
History

11. Preeclampsia - Complications
Maternal Fetal
CNS
• Seizures
Preterm Delivery
• Cerebral Edema
• Cerebral Hemorrhage
• Strokes (thrombosis)
Hepatic Stillbirth (IUFD)
• Hepatic Failure Intrapartum Fetal Distress
• Hepatic Rupture
• Subcapsular Hemorrhage
Heamatological
• DIC
Placental Abruption
• HELLP
Renal Uteroplacental Insufficency
• Renal Failure • Hypoxic Neurological Injury
• Oliguria
• Proteinuria >> Hypoproteinemia (Glomerular Injury) • IUGR
• Oligohydraminos
Lungs
• Pulmonary Edema

12. Preeclampsia - Classification
Mild Severe
Maternal Criteria Fetal Criteria
Oligohyd Abnormal
Clincal Criteria Labs IUGR -raminos Doppler
RUQ Oligo- Protein-
Pulmonary
HTN NS Edema Pain uria uria HELLP
(≤500ml) (≥5mg)
Hyperreflexia
Headache
Disturbances
Visual
SBP ≥ 160
DBP ≥110

13. Preeclampsia - Diagnosis
 Upon antenatal visits
 First visit
 Identify risk (Hx, PEx)
 BP + Urine protein test
 Following visits
 28/52 : Monthly BP + Urine protein test
 After 28/52 : More frequent BP + Urine protein tests
 2nd trimester : Uterine Artery Doppler (not sensitive)

14. Preeclampsia - Management
• Fetal: 2qw
• Close monitoring • CTG
• US
Admission
required Severity • US Doppler: Umbilical + Cerebral
Assessment • Liquor Assessment
• Bloods
IV Line • Infusions Stabilize
Patient
• Monitoring urine • Fluid Restriction (80ml/h)
output and ease of • Decision based on severity +
Urinary gestational age
Catheter 24h urine collection Therapy • Mother is concern
• Maternal
• PEx
• BP :15m, 30, 4qh
• 24/24 Urinary Collection • Decision on date required
Severity • 2qw: FBC, Coag. Delivery
Assessment Profile, LFT, serum(Cr), Uric
Acid

15. Preeclampsia – Treatment
 Curative Therapy: Delivery
 Balance maternal and fetal status
Severe Follow-Up
Mild Preeclampsia Seizure
Preeclampsia (44% PP  1/12)
•Expectant • Admission • A,B,C • Reassess.
•Admission • MgSO4 • Ox Stat Discharge when
•Betamethasone • Intrapartum • Oxygen stable  6/52
•MgSo4 4g.2g/h • Postpartum • MgSO4 4g.2g/h • MgSO4 1d
•RCOG: 1g/h 24h postpartum/post
• 2g bolus
last seizure
• IV Labetalol / IV • Left Lateral
Hydralizine / • PO Labetalol /
Position
Nifedipine PO Methyldopa /
• Prepare for Nifedipine:
• Decide on delivery CHTN
delivery
• Low dose Aspirin
/ LMWH
• Monitor HELLP
(LP:
corticosteroids)

16. Preeclampsia – Therapy (2)
 MgSO4  Antihypertensive
 Monitor  Monitor
 Ox Stat  BP
 Respiratory Rate  ≥ 130/80
 Replace Ca Gluconate 1g
 Only improves morbidity
infusion
 Deep tendon reflexes
 Urine Output  Aspirin
 Halt if less than 20 ml/h
 Inhibits thromboxane A2
 Recurrent Seizures synthesis
 MgSO4: 2g bolus (RCOG:   re-altering
increase infusion to 2g/h) TXA2/Prostacyclin balance

17. Preeclampsia – Delivery Indications
 Mild Preeclampsia  Severe Preeclampsia
 Expectant (Betamethasone +
 Expectant MgSO4)
 Stable  GA 24-32/52
 Deliver
 Preterm  GA > 32/52
 Deliver  Patient presenting with
 Uncontrollable BP
 Term  Symptoms
 Unstable preterm  Headache, RUQ, Visual
 Hyperreflexia
 Fetal compromise  Complications
 GR/OH/abnormal  HELLP or LP
 Renal Failure
Umbilical Doppler
 Hepatic Injury
Induced delivery  Pulmonary Edema
(PG, Oxytocin, Amniotomy) unless  DIC
obstetric indication

18. Androu Waheeb