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1. Hypertensive disorders in pregnancy,
labour and postpartum period.
Preeclampsia and eclampsia.
Kazan State Medical University
Ganeeva Albina V.
Teaching and research assistant of the
department of obstetrics and gynecology

3. Classification of hypertensive disorders in pregnancy
1. Pre-existing hypertension (AH) – AH diagnosed either before pregnancy, or during
the first 20 weeks of gestation. It can be primary or secondary etiology.
2. Gestational arterial hypertension - arterial hypertension, established after 20th
week of pregnancy, and that is not accompanied by significant proteinuria.
3. Preeclampsia (PE) - arterial hypertension, established after 20th week of pregnancy,
that is accompanied by significant proteinuria. PE can be also developed at the
background of Pre-existing hypertension.
Significant proteinuria is defined as 0.3 g / L protein loss in daily urine.

5. Maternal mortality structure in the Russian Federation in 2016
Hypertensive disorders in pregnancy take the leading positions among the reasons of
maternal and perinatal death.

6. 10% of pregnancies are complicated by Arterial Hypertension (АН),
2-5% - by Preeclampsia (РЕ), up to 12% in some countries in Africa.

7. Preeclampsia (PE) is a complication of the second half of pregnancy which is
characterized by combination of symptoms: Proteinuria( of >0,3 g/l in daily urine) +
Arterial Hypertension + sometimes - edema.
PE never occurs:
• Out of pregnancy
• In animals
• Before the 20 weeks of gestational age
DURING PREGNANCY PREECLAMPSIA ONLY PROGRESSES, IT CANNOT BE CURED!
IT REGRESSES:
• After delivery (placental expulsion)

8. PE Pathogenesis is based on the incomplete trophoblast invasion to the spiral arteries of
uterus.
Physiological pregnancy
PATHOGENESIS OF PREECLAMPSIA
The causes of PE development are multiple, varied and not clearly understood.
Transformation of the muscular layer in spiral arteries
Trophoblast cells migration to the spiral artery walls

9. Post-fertilization events

10. PREECLAMPSIA
Spiral arteries retain the morphology of non-
pregnant vessels
Suppression of trophoblast migration
PATHOGENESIS OF PREECLAMPSIA

11. • Suppression of trophoblast migration;
• no transformation of the muscular layer in spiral arteries; they retain the
morphology of non-pregnant vessels;
• spiral artery spasm;
• decrease in intervillous blood flow;
• disturbance of placental microcirculation
• hypoxia developing as a result (ischemia of placenta)
PATHOGENESIS OF PREECLAMPSIA

12. In its turn, hypoxia of uteroplacental complex leads to overproduction of proinflamatory
cytokines by placenta, that attack endothelium.
• endothelial lesion and disorder of endothelial thromboresistant and vasoactive
properties;
• generalized vascular spasm;
• hypovolemia;
• disorder of rheological and clotting properties of the blood (hypercogulation);

13. • non-decrease in total peripheral vascular resistance; in physiological pregnancy
it decreases;
• reduced cardiac output;
• decrease in blood flow and glomerular filtration in kidneys;
• generalized compensatory arterial hypertension;
• tissue hypoperfusion;
• multiple organ failure

14. Prediction: Factors that increase the risk of preeclampsia
• Anamnestic factors:
1. low-socioeconomic standing (moderate risk)
2. first pregnancy (moderate risk)
3. mother's age 40 years or more (moderate risk)
4. new partner (husband) (moderate risk)
5. PE in previous pregnancies (high risk)
6. family history of PE (moderate risk)
7. IVF-induced pregnancy (moderate risk)
8. some ethnic groups (like negroid race, for instance) (moderate risk)

15. Factors that increase the risk of preeclampsia
• Extragenital pathology:
1. Obesity (moderate risk)
2. Chronic renal disease (moderate risk)
3. Chronic arterial hypertension (moderate risk)
4. Diabetes mellitus (moderate risk)
5. Thrombophilia (moderate risk)
6. Autoimmune diseases (moderate risk)

16. Factors that increase the risk of preeclampsia
• The course of pregnancy:
1. Systolic blood pressure of more than 130 mm Hg or diastolic blood pressure of more
than 80 mm Hg (moderate risk)
2. Excessive weight gain (moderate risk)
3. Infections during pregnancy (moderate risk)
4. Methamphetamine, cocaine use (moderate risk)
5. Multiple pregnancy (moderate risk)

17. The screening for PE, conducted before the end of the 1st trimester (11-13 weeks
6 days), includes:
* assessment of maternal risk factors;
* measurement of average blood pressure ;
* determination of Placental growth factor (PIGF) in serum;
* measurement of the Pulsatory index of the Uterine arteries (the smallest value
of the two is taken into account).
International Federation of Gynecology and Obstetrics (FIGO) initiative
on pre-eclampsia:
а pragmatic guide for first-trimester screening and prevention (2019)

18. A calculator of the individual risk of PE is freely available on the website
https://fetalmedicine.org/research/assess/preeclampsia
International Federation of Gynecology and Obstetrics (FIGO) initiative on
pre-eclampsia:
а pragmatic guide for first-trimester screening and prevention (2019)

19. Preeclampsia prophylaxis
1. The risk of developing PE should be considered high if the result is ≥1 in 100. Low-dose
Aspirine (150 mg a day) is used in the group of high risk starting from the 12th week
of gestational age, up to labour, 36 weeks of gestation or manifestation of PE.
2. Calcium supplementation(≥1000 mg a day) is used in patients with its deficit in diet.

20. CLINICAL FEATURES OF PREECLAMPSIA.
Arterial hypertension - a condition
characterized by high blood pressure.
Сriteria for hypertension during pregnancy:
Systolic BP ≥140 mm Hg or/and diastolic BP≥90
mm Hg, defined as the average of at least two
measurements оn the same hand.

21. Proteinuria is a sign developing in pregnancy;
Ideally proteinuria should be determined by protein content in daily urine.
Proteinuria is considered abnormal when it reaches or exceeds 0.3 g/day or 0.3 g/l in
samples obtained at an interval of 6 hours.
To assess the true level of proteinuria, it is
necessary to exclude the infection of the urinary
system.

22. Edemais a common symptom of preeclampsia but not its diagnostic criteria.
Edema is general, excessive accumulation of fluid in tissues after 12-hour rest in
bed.
Edema develops secondary to disturbance of capillary permeability and escape
of fluid from the blood stream to the interstitial space as a result of renal glomerular
lesion with increased permeability of the basal membrane of their capillaries, and
due to decreased oncotic pressure (with underlying hypoalbuminuria).
In physiological pregnancy moderate swelling is noted in 50 – 80% of women.

23. It is classified in the following way:
• invisible edema (abnormal weight gain by 500 g and more within
a week, positive ring symptom, nocturia, decrease in diuresis below
900–1000 ml while fluid intake is 1400–1500 ml);
• visible edema divided into stages:
– stage I: edema of upper and lower extremities;
– stage II: edema of upper and lower extremities, abdominal wall;
– stage III: edema of upper and lower extremities, abdominal wall
and face;
– stage IV: anasarca.

24. Classification.
1. Moderate PE
The criteria of moderate PE:
Severe AH (Systolic BP ≥140 mm hg, up to 159 mm hg or/and Dyastolic BP ≥ 90 mm hg, up
to 109 mm hg ) + Proteinuria >0,3 g/l in daily urine
2. Severe PE
The criteria of severe PE:
Severe AH (Systolic BP ≥160 mm hg or/and Dyastolic BP ≥ 110 mm hg) +(or) Proteinuria >5
g/l in daily urine or 3 g/l in each of 2 portions of urine ( interval - 6 hours)
OR
Hypertension + Evidence of other maternal organ dysfunction or Uteroplacental
dysfunction

25. Additional criteria for severe PE indicating multiple organ
failure:
1. HELLP (ELLP) syndrome;
2. persistent headaches, vomiting, or other cerebral or visual disturbances;
3. impaired renal function (oliguria <500 ml / day, increased creatinine);
4. acute lung damage / acute respiratory distress syndrome, pulmonary edema;
5. swelling of the optic disc;
6. impaired liver function (increased enzymes AlAT, AsAT, LDH);
7. epigastric pain / right upper quadrant of the abdomen (overstretching of the liver
capsule, intestinal ischemia due to circulatory disorders);
8. thrombocytopenia and / or its progression;
9. suddenly appearing, growing swelling on the hands, feet or face;
10. confirmation of fetal suffering (RRP syndrome, oligohydramnios, negative non-stress test).
In the presence of symptoms of a critical condition the presence of proteinuria is not necessary for the diagnosis of severe
preeclampsia

26. Classification
PE can be subclassified into:
1.Early‐onset PE (with delivery at <34+0 weeks of gestation);
2.Late‐onset PE (with delivery at ≥34+0 weeks of gestation).
Early‐onset PE is associated with a much higher risk of short‐ and long‐term maternal
and perinatal morbidity and mortality.
Obstetricians managing women with preterm PE are faced with the challenge of
balancing the need to achieve fetal maturation in utero with the risks to the mother
and fetus of continuing the pregnancy longer.

27. Early complications of preeclampsia
1. Eclampsia;
2. Edema, hemorrhage and retinal detachment;
3. Acute fatty hepatosis;
4. HELLP syndrome (hematoma or rupture of the liver);
5. Acute renal failure;
6. Pulmonary edema;
7. Stroke;
8. Myocardial infarction
9. Placental abruption;
10.Antenatal fetal death.

28. Delayed complications of Preeclampsia (in mother)
• Increased body mass index (BMI)
• Chronic hypertension
• Myocardial infarction
• Diabetes mellitus
• Renal failure
• Stroke

29. • Eclampsia is a соnvulsion attack against the background of preeclampsia in the
absence of other causes.
• Eclampsia can develop against the background of preeclampsia of any severity,
and it is not a manifestation of the maximum severity of preeclampsia.
• In 30% of cases, eclampsia develops suddenly in the absence of the previous
signs of preeclampsia.
• Headache, pain in the abdomen or disturbance of vision the main symptoms that
predict the development of eclampsia.
Eclampsia

30. Classification of Eclampsia
• Eclampsia during pregnancy and
childbirth
• Eclampsia in the postpartum
period:
 early postpartum period (24
hours)
 late postpartum period(28 days)
Up to 44% of cases of eclampsia occur in the postpartum period, especially after full-term
pregnancy.
Downtown Abbey

31. Attack of convulsion is the main manifestation of eclampsia, which leads to the loss of
consciousness. Attack develops consequently,
in 4 stages:
I stage lasts for 20–30 s and is accompanied with fibrillar twitching of the mimic muscles, sometimes of
the upper extremities, the look is fixed at one point;
II stage lasts till 30 s and is characterized by the expressed tonic convulsions, which spread from the head
on the trunk and extremities, head throw to the back, opistotonus can be observed. Respiration stops,
pulse is not palpated, pupils are widened, occlusion of the tongue can occur;
III stage lasts up to 2 min — clonic convulsions, which also spread from up downwards, cyanosis develops,
saliva with admixture of blood discharges from the mouth (as the result of the tongue’s bite);
IV stage — begins with deep interrupted inhalation, respiration gradually restores, however, the patient is
in coma.

32. TREATMENT TACTICS IN PREECLAMPSIA AND ECLAMPSIA
1. With moderate PE: careful monitoring of the condition of the pregnant woman and
the fetus with symptomatic treatment. In the absence of negative dynamics,
pregnancy can be prolonged. Delivery is indicated when the condition of the mother
and fetus worsens.
2. In severe PE – frequently* prolongation of pregnancy is impossible. Labour should be
induced after stabilization of the mother’s condition and, if needed (25-34 weeks of
gestation), after the prophylaxis of the fetal Respiratory distress syndrome.
Vaginal delivery is preferable.
* At the gestational age of 25-34 weeks, in the absence of negative dynamics we can
make the attempt for prolongation of pregnancy even in severe PE.

33. Basic preeclampsia treatment
• Delivery (the most effective treatment for PE)
• Antihypertensive therapy
• Anticonvulsant therapy with magnesium sulfate
(in severe PE or eclampsia)

34. Criteria for initiating antihypertensive therapy in PE:
Blood pressure > or = 140/90 mm Hg
The target level of blood pressure (taking into account both the safety of the mother and
the need of the fetus) is:
• Systolic blood pressure of 135 mm Hg
• Diastolic blood pressure 85 mm Hg

35. Antihypertensive therapy
1. Central α2-agonists of Methyldopa tab. 500 mg - 2000 mg per day, in 2-3 doses. The
first-line drug, the most studied, possibly impaired liver function in the mother, depression,
sedation, orthostatic hypotension are noted in 22% of women
2. Calcium antagonist - Nifedipine tab. prolonged action - 20 mg, the average daily dose of
40-90 mg in 1-2 doses, depending on the form of release, the maximum daily dose of 120
mg.
3. Labetalol - combined both alpha- and beta- adrenergic receptor blocker.
If indicated, Metoprolol, Verapamil, Amlodipine also can be used.

36. MgSO4 dosage regimen
Only intravenously, always using a device for continuous administration (infusomat,
pump).
Loading dose – 4 g of dry matter for 10-15 minutes;
Maintenance dose - 1-2 g of dry matter per hour.
The introduction of Nagnesium sulfate should be carried out before and against the
background of delivery, and should continue at least 24 hours after delivery or 24
hours after the last episode of seizures
Magnesium sulfate is not actually a hypotensive drug.
In severe PE, its introduction is necessary for the prevention of convulsive syndrome

39. • Team approach with the participation of obstetrician-gynecologists,
resuscitation anesthetists, therapists and neonatologists.
• Before delivery, it is necessary to stabilize the condition of the woman.
• With a gestational age of <32 weeks a cesarean section preferable
• After 34 weeks - vaginal delivery with cephalic presentation.
• Anticonvulsant, antihypertensive therapy should be carried out throughout the
entire period of delivery.
• preeclampsia and its complicated forms represent the highest risk of massive
bleeding in obstetrics.
Delivery

40. Indications for urgent delivery (hours):
1. persistent headache and visual manifestations
2. persistent epigastric pain, nausea, or vomiting
3. progressive deterioration in liver and / or kidney function
4. eclampsia
5. arterial hypertension not amenable to medical correction
6. platelet count less than 50 * 10⁹ / l and its progressive decrease
7. violation of the fetus, recorded according to CTG, ultrasound,
8. Severe oligohydramnion

41. Indications for emergency delivery (minutes):
1. Bleeding from the birth canal, suspected placental abruption
2. Acute fetal hypoxia

42. Offer Enalapril to treat hypertension in women during the postnatal period, with
appropriate monitoring of maternal renal function and maternal serum
potassium.
Antihypertensive treatment during the postnatal
period, including the period of breastfeeding
For women with hypertension in the postnatal period, if blood pressure is not
controlled with a single medicine, consider a combination of nifedipine (or
amlodipine) and enalapril.
If this combination is not tolerated or is ineffective,consider either:
• adding atenolol or labetalol to the combination treatment or
• swapping 1 of the medicines already being used for atenolol or labetalol.

43. HELLP SYNDROME
HELLP syndrome is a complex of symptoms including
• hemolysis;
• elevated liver enzymes;
• low platelet count.
the atypical PE form
It is noted in 0.3% of all pregnancies. In case of severe PE and eclampsia it
develops in 4–12% of cases; it is characterized by high maternal (up to 25%) and
perinatal mortality.

44. Clinical features include a rapid, aggressive progression of signs.
Initial manifestations are not specific: headache, weakness, vomiting, and abdominal pain
localized mostly in the right subcostal area.
Later there appear blood-tinged vomiting, hemorrhages at the sites of injections,
progressive jaundice and hepatic failure, convulsions, marked coma.
Rupture of liver with hemorrhage into the abdominal cavity is not a rare occasion.
HELLP syndrome can be manifested as total placental abruption followed by massive
coagulopathic hemorrhage and rapid development of hepatorenal failure.

45. Laboratory findings indicative of HELLP syndrome:
•elevated aminotransferase activity (AST >200 IU/l, ALT >70 IU/l, Lactate dehydrogenase
>600 IU/l;
• thrombocytopenia (<100×109/l);
• decrease in antithrombin III below 70%;
• intravascular hemolysis and elevated bilirubin concentration;
• increased prothrombin time and APTT;
• decrease in fibrinogen concentration below the levels necessary in pregnancy;
• increased nitrogenous waste content in the blood;
• blood glucose fall to the extent of hypoglycemia.

46. For today there are no methods of conservative treatment of this
complication.
Similar to PE, the only treatment method is delivery.

47. Thank you