HYPERTENSIVE DISORDER HYPERTENSIVE DISORDER IN PREGNANCYIN PREGNANCY

AHMED ABDULWAHABAHMED ABDULWAHAB

ASSISTANT PROFESSORASSISTANT PROFESSOR

AND CONSULUTANT OB/GYAND CONSULUTANT OB/GY

the hypertensive disorders are major the hypertensive disorders are major contributor to maternal and perinatal contributor to maternal and perinatal morbidity and mortality.morbidity and mortality.

CLASSIFICATION AND DIFINTION.CLASSIFICATION AND DIFINTION. Blood pressure reading depends on Blood pressure reading depends on

maternal position and gestational age, it is maternal position and gestational age, it is lower in left lateral position and higher in lower in left lateral position and higher in sitting position, arterial B/P normally decline sitting position, arterial B/P normally decline in 1in 1stst ,and 2 ,and 2ndnd trimester and rise to trimester and rise to

Cont.Cont. Pre pregnant level in the 3Pre pregnant level in the 3rdrd trimester. trimester. The diagnosis of hypertension is made when The diagnosis of hypertension is made when

the systolic B/P is equal or greater than the systolic B/P is equal or greater than 140mmHg or diastolic of greater or equal 140mmHg or diastolic of greater or equal 90mmHg. 90mmHg.

CLASSIFICATION.CLASSIFICATION.1.1. Preeclampsia/ eclampsia Preeclampsia/ eclampsia 2.2. Chronic hypertension. If the hypertension is Chronic hypertension. If the hypertension is

known prior to pregnancy or develops known prior to pregnancy or develops

Cont,Cont, Prior to 20 weeks gestation and persist 12 Prior to 20 weeks gestation and persist 12

weeks post partum.weeks post partum. Mostly essential hypertension but small Mostly essential hypertension but small

percentage will have secondary percentage will have secondary hypertension due to renal vascular or hypertension due to renal vascular or endocrinological causes. endocrinological causes.

3-Chronic hypertension with superimposed 3-Chronic hypertension with superimposed preeclampsia.preeclampsia.

It is diagnosed when the patient is known to It is diagnosed when the patient is known to have hypertension and the process is have hypertension and the process is aggravated by pregnancy and usually aggravated by pregnancy and usually carries a worse prognosis , it is suspected carries a worse prognosis , it is suspected by new develop of proteinuria or sudden by new develop of proteinuria or sudden significant increases in B/P or proteinuria significant increases in B/P or proteinuria after the 20 weeks of pregnancy.after the 20 weeks of pregnancy.

4- gestational hypertension.4- gestational hypertension. When hypertension appears for the first time When hypertension appears for the first time

after 20 weeks of pregnancy or within 48 to after 20 weeks of pregnancy or within 48 to 72 hours after delivery without proteinuria 72 hours after delivery without proteinuria and disappearsand disappears by 12 weeks postpartum.by 12 weeks postpartum.

PREECLAMSIA.PREECLAMSIA. It is a syndrome unique to pregnant human, It is a syndrome unique to pregnant human,

characterized by the new onset of characterized by the new onset of hypertension and proteinuria and or edema hypertension and proteinuria and or edema in the second half of gestation.in the second half of gestation.

It may arise earlier after 14 weeks and then It may arise earlier after 14 weeks and then we should suspect hydatidiform mole or we should suspect hydatidiform mole or multiple pregnancy.multiple pregnancy.

Etiology.Etiology. It is the disease of theories.It is the disease of theories. Genetics , immunologic, Genetics , immunologic,

nutritional ,endocrinologic,nutritional ,endocrinologic, and infection all and infection all have been proposed as a causes.have been proposed as a causes.

Because the condition disappears after Because the condition disappears after delivery, most attention has directed on the delivery, most attention has directed on the placenta, membranes and the fetus,placenta, membranes and the fetus,

Uteroplacental ischemia may be central to Uteroplacental ischemia may be central to the development of the disease. And the the development of the disease. And the ischemia may result in production and ischemia may result in production and release of toxins that enter the circulation release of toxins that enter the circulation and causes wide spreadand causes wide spread endothelial endothelial dysfunction that causes imbalance in dysfunction that causes imbalance in vasoconstrictors prostaglandin thromboxane vasoconstrictors prostaglandin thromboxane A2 and vasodilator prostacyclin E2 A2 and vasodilator prostacyclin E2 production.production.

PATHOPHYSIOLOGY.PATHOPHYSIOLOGY. The underlying pathophysiological The underlying pathophysiological

abnormality is generalized vasospasm .abnormality is generalized vasospasm . Renal blood flow and GFR in preeclampsia Renal blood flow and GFR in preeclampsia

are significantly lower than in normal are significantly lower than in normal pregnancy this vasoconstriction will cause pregnancy this vasoconstriction will cause the damage to the glomerular membranes the damage to the glomerular membranes and increase the permeability to proteins and increase the permeability to proteins that leads to proteinuriathat leads to proteinuria

PATHOLOGY.PATHOLOGY. 1- lack of decidualization of the myometrial 1- lack of decidualization of the myometrial

segment of the spiral arteries .segment of the spiral arteries . In normal pregnancy the second wave In normal pregnancy the second wave

trophoblast invade the muscular and elastic trophoblast invade the muscular and elastic layer of the spiral artery by fibrinoid and layer of the spiral artery by fibrinoid and fibrous tissue that becoming unresponsive fibrous tissue that becoming unresponsive to vasoconstrictors substances, this is to vasoconstrictors substances, this is limited in preeclamppsialimited in preeclamppsia

The typical renal lesion in preeclampsia is The typical renal lesion in preeclampsia is glomerular capillary endotheliosis .glomerular capillary endotheliosis .

Hemorrhage and necrosis will occur in many Hemorrhage and necrosis will occur in many organs secondary to arteriolar organs secondary to arteriolar vasoconstriction such as liver, brain, and vasoconstriction such as liver, brain, and retina.retina.

Clinical and laboratory manifestation. Clinical and laboratory manifestation. Most can be explained on the basis of the Most can be explained on the basis of the

endothelial dysfunction and vasospasm.endothelial dysfunction and vasospasm. Weight gain and edema.Weight gain and edema. It occurs early and reflect an expansion of It occurs early and reflect an expansion of

the extra vascular fluid compartment, and the extra vascular fluid compartment, and haematocrit may also increased reflecting haematocrit may also increased reflecting hypovolemia and hemoconcentration .hypovolemia and hemoconcentration .

Elevation of blood pressure. Elevation of blood pressure. Particularly the diastolic B/P, which may Particularly the diastolic B/P, which may

occur days or weeks after the onset of occur days or weeks after the onset of pathological fluid retention. pathological fluid retention.

Protienuria .Protienuria . May occur days or weeks after the onset May occur days or weeks after the onset

of hypertension, or manifest during labor of hypertension, or manifest during labor or even postpartum.or even postpartum.

Renal function test.Renal function test. Increase in serum uric acid is the earliest Increase in serum uric acid is the earliest

change, decrease in creatinine clearance change, decrease in creatinine clearance with increase in blood urea and creatinine with increase in blood urea and creatinine condition may progress to frank oligouria condition may progress to frank oligouria and renal failure. and renal failure.

Coagulation system.Coagulation system. Thrombocytopenia is the most common Thrombocytopenia is the most common

abnormality , DIC may occur and abnormality , DIC may occur and represent severe preeclampsia .represent severe preeclampsia .

Liver function.Liver function. Focal hemorrhage and infraction leading Focal hemorrhage and infraction leading

to upper quadrant and epigastric pain and to upper quadrant and epigastric pain and elevated liver enzymes and increase level elevated liver enzymes and increase level of bilirubin in significant haemolysis .of bilirubin in significant haemolysis .

Hepatic rupture is rare .Hepatic rupture is rare .

Placental function.Placental function. Vasospasm will lead to infraction and Vasospasm will lead to infraction and

decrease uteroplacental perfusion that will decrease uteroplacental perfusion that will cause intrauterine growth restriction IUGR, cause intrauterine growth restriction IUGR, oligohydramnios , fetal heart abnormalities oligohydramnios , fetal heart abnormalities and retroplacental hemorrhage or and retroplacental hemorrhage or abruption.abruption.

Central nervous system.Central nervous system. Visual disturbance, blurred vision , Visual disturbance, blurred vision ,

increase reflexes irritability or hypereflexia. increase reflexes irritability or hypereflexia.

Evaluation and management.Evaluation and management. Delivery is the only definitive cure for Delivery is the only definitive cure for

preeclampsia BUT the question is which preeclampsia BUT the question is which is more good for the mother and the baby? is more good for the mother and the baby? So delivery is indicated when the presence So delivery is indicated when the presence of the fetus inside the uterus is attended of the fetus inside the uterus is attended by certain risks that outweigh pre maturity by certain risks that outweigh pre maturity complications, or the maternal condition is complications, or the maternal condition is not responding to appropriate not responding to appropriate management regardless of fetal maturity.management regardless of fetal maturity.

Initial maternal assessment will involve .Initial maternal assessment will involve . Any past history of hypertension or renal Any past history of hypertension or renal

disease prior to pregnancy or previous disease prior to pregnancy or previous pregnancy.pregnancy.

Symptoms of sever preeclampsia like Symptoms of sever preeclampsia like headache, visual changes, nausia and headache, visual changes, nausia and vomiting, abdominal or epigasteric pain .vomiting, abdominal or epigasteric pain .

Examination .Examination . B/P , weight gain, edema, fundal height, B/P , weight gain, edema, fundal height,

and reflexes.and reflexes.

Investigation .Investigation . Urine for protein, CBC, liver function test, Urine for protein, CBC, liver function test,

urea and electrolyte ,uric acid .urea and electrolyte ,uric acid . Fetal assessment.Fetal assessment. Fetal growth chartFetal growth chart by ultrasound by ultrasound

biophysical profile Doppler study and fetal biophysical profile Doppler study and fetal kick chart non stress test.kick chart non stress test.

If the mother disease is mild and no If the mother disease is mild and no evidence of fetal compromise evidence of fetal compromise management consist of bed rest and management consist of bed rest and observation.observation.

The patient should be delivered by the The patient should be delivered by the

time she reached 38 weeks or she started time she reached 38 weeks or she started to develop signs and symptoms of to develop signs and symptoms of worsening the disease, or there is worsening the disease, or there is evidence of fetal compromise .evidence of fetal compromise .

In mild cases patient can be managed as In mild cases patient can be managed as outpatient .outpatient .

Criteria of severe preeclampsia .Criteria of severe preeclampsia . Severe hypertension systolic more than Severe hypertension systolic more than

160mmHg and diastolic equal or more 160mmHg and diastolic equal or more than 110mmHg.. than 110mmHg..

Heavy proteinuria 5 gm in 24 hour urine Heavy proteinuria 5 gm in 24 hour urine collection .collection .

Oliguria less than 500ml per 24 hour .Oliguria less than 500ml per 24 hour . Cerebral or visual disturbance.Cerebral or visual disturbance. Pulmonary edema and cyanosis .Pulmonary edema and cyanosis . Epigasteric or right upper quadrant pain .Epigasteric or right upper quadrant pain . HELLP syndrome .characterized by.HELLP syndrome .characterized by. Hemolysis, Elevated Liver enzyme, Low Hemolysis, Elevated Liver enzyme, Low

Platelet . Platelet .

ECLAMPSIA.ECLAMPSIA. Is the presence tonic- clonic seizures that Is the presence tonic- clonic seizures that

usually complicate severe PET .usually complicate severe PET . 25% occur ante nataly before labor 50% 25% occur ante nataly before labor 50%

during labor and 25% occur post nataly during labor and 25% occur post nataly after delivery.after delivery.

Antihypertensive therapy.Antihypertensive therapy. Should be initiated when diastolic B/P is Should be initiated when diastolic B/P is

more than 105mmHg to prevent CNS more than 105mmHg to prevent CNS hemorrhage .hemorrhage .

Hydralazine and labetalol are used to Hydralazine and labetalol are used to control severe hypertension .control severe hypertension .

Nifedipine calcium ion influx inhibitor Nifedipine calcium ion influx inhibitor blocker is an other option .blocker is an other option .

Alpha methyldopa is save to be use in Alpha methyldopa is save to be use in chronic hypertension .chronic hypertension .

Management of eclampsia .Management of eclampsia . It is a true obstetric emergency .It is a true obstetric emergency . Stabilize and deliver.Stabilize and deliver. Room is dark with minimum noise.Room is dark with minimum noise. Clear airway and give oxygen mask .Clear airway and give oxygen mask . Insert IV line for blood test and drug and Insert IV line for blood test and drug and

fluid administration .fluid administration . Foley catheter for input and output Foley catheter for input and output

charting .charting . The best and safest drug for controlling The best and safest drug for controlling

convulsion is magnesium sulfate convulsion is magnesium sulfate

After stabilization delivery Is considered After stabilization delivery Is considered

either by induction of labor or by caesarian either by induction of labor or by caesarian section .section .

Prophylaxis against convulsion is Prophylaxis against convulsion is continued after delivery .continued after delivery .