CLASSIFICATION OF HYPERTENSIVE DISORDERS IN PREGNANCY …€¦ · ACOG (2013) •Preeclampsia ......
Transcript of CLASSIFICATION OF HYPERTENSIVE DISORDERS IN PREGNANCY …€¦ · ACOG (2013) •Preeclampsia ......
CLASSIFICATION OF HYPERTENSIVE DISORDERS
IN PREGNANCY
Wilhelm Steyn
BUENOS AIRES 1992
PREECLAMPSIA
OR PRE-ECLAMPSIA?
THE CLASSIFICATION
Only diastolic blood pressure
Korotkoff IV
ASSHP NHBPEP
BUT…
Hypertension and proteinuria, the two diagnostic criteria for preeclampsia, constitute a very small part of the pathophysiology of the syndrome
SOME CONSIDERATIONS
• Inaccuracies in detecting true proteinuria
• Pathophysiology of pre-eclampsia – maternal liver, kidneys, brain, coagulation
– placental blood flow
Endothelial function / Inflammation
Place
ntation
Place
ntation
Normal
Abnormal
Normal
Abnormal
Normal
Abnormal
No Pre-eclampsia No IUGR
Pre-eclampsia (Late) No IUGR
No Pre-eclampsia IUGR
Pre-eclampsia (Early) IUGR
Pre-eclampsia IUGR
Back to ISSHP 2001
• ASSHP / NHBPEP – Chronic hypertension
– Gestational hypertension
– Pre-eclampsia
– Superimposed Pre-eclampsia
• ASSHP definite symptoms and signs
• NHBPEP highly suggestive
ISSHP 2001
Systolic blood pressure
Proteinuria??
Symptoms and signs
<20 week’s gestation not pre-eclampsia
Symptoms and signs pre-eclampsia
>20 week’s gestation surveillance
NICE
2013
ACOG (2013)
• Preeclampsia – eclampsia
• Chronic hypertension
• Chronic hypertension with superimposed preeclampsia
• Gestational hypertension
ACOG Pre-eclampsia
• Platelets < 100000/microliter • Impaired liver function • New renal insufficiency • Pulmonary edema • Visual disturbances
NOT IUGR
ISSHP 2014
NO CONSENSUS
PROTEINURIA??
WHY CHANGE?
• Inaccuracies in the measurement of proteinuria
• Mercury sphygmomanometry
• Potential for severe maternal complications in de novo hypertension without proteinuria
• White coat hypertension
• Biomarkers, particularly angiogenic factors
• Number of scholarly guidelines
REVISED CLASSIFICATION (2013)
Chronic hypertension
Gestational hypertension
Pre-eclampsia (de novo / superimposed)
White coat hypertension
HYPERTENSION
• 140/90 mm Hg
• Mercury sphygmomanometry gold standard – Aneroid - may be inaccurate
– Automated device
• Minimum of two BP measurements to diagnose hypertension
• Remain elevated after overnight rest in hospital or in a day assessment unit.
CHRONIC HYPERTENSION
• Pre-pregnancy / First trimester
– ESSENTIAL
– SECONDARY
Pre-eclampsia / Gestational hypertension
• New hypertension after 20 weeks’ gestation
• If the earlier blood pressure is unknown ??
–Pre-eclampsia
–Hypertension
UNCLASSIFIED
PRE-ECLAMPSIA
• Hypertension plus one of
1. Proteinuria
2. Other maternal organ dysfunction
3. Uteroplacental dysfunction NOT SEVERE
NOT EARLY/LATE
PRE-ECLAMPSIA
• 1. Proteinuria
– spot urine protein/creatinine >30 mg/mmol [0.3 mg/mg]
– >300 mg/day or at least 1 g/L
– ‘2 + ’ on dipstick testing
PRE-ECLAMPSIA
• 2. Other maternal organ dysfunction: – Renal insufficiency (creatinine >90 umol/L)
– Liver involvement
• elevated transaminases – at least twice upper limit of normal
• ± right upper quadrant or epigastric abdominal pain
PRE-ECLAMPSIA
• 2. Other maternal organ dysfunction: – Neurological complications (examples include
eclampsia, altered mental status, blindness, stroke, or more commonly hyperreflexia when accompanied by clonus, severe headaches when accompanied by hyperreflexia, persistent visual scotomata)
– Haematological complications (thrombocytopenia – platelet count below 150,000/dL, DIC, haemolysis)
PRE-ECLAMPSIA
• 3. Uteroplacental dysfunction • Foetal growth restriction
Gestational hypertension
• De novo hypertension after 20 weeks gestation
• No abnormality defining pre-eclampsia
• Usually benign
• 25% Pre-eclampsia – Before 32 weeks
HYPERTENSION WITHOUT PROTEINURIA
• Laboratory investigations required
• Referral of patients local decision making strategies
Superimposed pre-eclampsia
• Commonly have impaired renal function and/or proteinuria
• Diagnosed when another feature develops – new onset liver dysfunction – thrombocytopenia – neurological features
• Diagnostic test such as serum / urine angiogenic or inflammatory factors
WHITE-COAT HYPERTENSION
• 25%
• Normal 24 h ABPM in the first half of pregnancy
• Regular home blood pressure assessments
• No antihypertensives before 160–170/110 mmHg.
• Limited studies on outcome
– 50% gestational hypertension / pre-eclampsia??
– risk of pre-eclampsia doubled
REVISED CLASSIFICATION (2013)
Chronic hypertension
Gestational hypertension
Pre-eclampsia (de novo / superimposed)
White coat hypertension