HYPERTENSIVE DISORDERS OF HYPERTENSIVE DISORDERS OF PREGNANCYPREGNANCY

CLINICAL CLASSIFICATION OF HYPERTENSIVECLINICAL CLASSIFICATION OF HYPERTENSIVEDISORDERS OF PREGNANCYDISORDERS OF PREGNANCY

1. Gestational hypertension (without proteinuria)1. Gestational hypertension (without proteinuria)

2. Gestational proteinuria (without hypertension)2. Gestational proteinuria (without hypertension)

3. Gestational proteinuric hypertension (pre-eclampsia)3. Gestational proteinuric hypertension (pre-eclampsia)

B.B. CHRONIC HYPERTENSION AND CHRONIC RENAL DISEASECHRONIC HYPERTENSION AND CHRONIC RENAL DISEASE

1. Chronic hypertension (without proteinuria)1. Chronic hypertension (without proteinuria)

2. Chronic renal disease (proteinuria with or without HTN2. Chronic renal disease (proteinuria with or without HTN

3. Chronic HTN/ CRD with superimposed pre-eclampsia 3. Chronic HTN/ CRD with superimposed pre-eclampsia

C.C. UNCLASSIFIED HYPERTENSION AND/OR PROTEINURIAUNCLASSIFIED HYPERTENSION AND/OR PROTEINURIA

1. Unclassified1. Unclassified hypertension (with out proteinuria)hypertension (with out proteinuria)

2. Unclassified2. Unclassified proteinuria (with out hypertension)proteinuria (with out hypertension)

3. Unclassified3. Unclassified proteinuric hypertensionproteinuric hypertension

A. . GESTATIONAL HYPERTENSION AND /OR PROTEINURIAGESTATIONAL HYPERTENSION AND /OR PROTEINURIA

P.I.H

HTN/ or PTN developing after 20 weeks of pregnancy, during labour or the puerperium in a previously normotensive non-proteinuric woman

(ISSHP)

PRE-ECLAMPSIA

Hypertension and Proteinuria Occurring after the 20th week of gestation in a previous

normotensive, non proteinuric woman

ECLAMPSIA ECLAMPSIA Above signs + fits.

SUPERIMPOSED PRE – ECLAMPSIASUPERIMPOSED PRE – ECLAMPSIARise of 30 mm hg systolic Or 15 mm hg diastolic above previous levels with proteinuria

• One measurement of DBP of 110 mm Hg or more

OR

• Two consecutive measurements of DBP > 90 mm Hg 4 h or more apart.

HYPERTENSION

PROTEINURIA • Protein excretion of 300 mg or more in 24 hours urine

OR• Two random clean catch or catheter urine specimen with 2+ (1 gm albumin/L) or more

PATHOGENESISPATHOGENESIS

1.1. Rejection phenomenonRejection phenomenon2.2. Uteroplacental ischaemiaUteroplacental ischaemia3.3. Imbalance between prostacyclin andImbalance between prostacyclin and ThromboxaneThromboxane4.4. Decreased GFR with salt and water Decreased GFR with salt and water

retention.retention.5.5. Decreased intra vascular volumeDecreased intra vascular volume6.6. Increased central nervous system Increased central nervous system

irritabilityirritability7.7. D.I.CD.I.C8.8. Dietry factorsDietry factors9.9. Uterine muscle stretchUterine muscle stretch10.10. Genetic factorsGenetic factors

Exact cause is unknown some theories areExact cause is unknown some theories are:

DAMAGE TO ENDOTHELIAL CELLS

DEFICIENCY OF (ENDOTHELIAL DERIVED RELAXING FACTOR)

PLATELET AGGREGATION

VASOSPASM

HYPERTENSION

NORMAL PREGNANCYNORMAL PREGNANCY

VasodilatationVasodilatation

Uteroplacental blood flowUteroplacental blood flow

Platelet aggregationPlatelet aggregation

ThromboxaneThromboxane

ThromboxaneThromboxaneProstacylinProstacylin

VasodilatationVasodilatation

Uteroplacental blood flowUteroplacental blood flow

Platelet aggregationPlatelet aggregation

PRE -ECLAMPSIA

Prostacyclin

PLATELET AGGREGATION SENSITIVITY TO PRESSOR AGENTS

UTEROPLACENTAL CIRCULATION

HAEMATOLOGICAL SYSTEM

LIVER KIDNEYS LUNGS BRAIN

IUGR FETAL DISTRESS

IUD

H. ANAEMIA THROMBOCYTOPENIA

HEPATOCELLULAR DAMAGE

PROTEINURIA PERFUSION ABNORMALITIES

FITS I.C.H

BLINDNES

PROSTACYCLIN DEFICIENCY

THROMBOTIC THROMBOCYTOPENIC PURPURA

ACUTE FATTY LIVER LIVER RUPTURE

RENAL FAILURE

PRE DISPOSING FACTORS• Age 20 yrs in primi > 30 yrs in all.• Race• Climate• Diet• Social status• Multiparty• Multiple gestation• Molar pregnancy• Pre existing hypertension• Previous h/o preclampsia, eclampsia• Family history of PIH• Diabetes mellitus • Non immune hydrops• Anti phospholipid antibody syndrome•

Collagen disease

FOETALFOETAL1.1. Intra uterine growth retardationIntra uterine growth retardation2.2. Intra uterine deathIntra uterine death3.3. PrematurityPrematurity4.4. Intrapartum foetal distress or still birthIntrapartum foetal distress or still birth

MATERNALMATERNAL 1.1. EclampsiaEclampsia2.2. Abruptio placentaeAbruptio placentae3.3. D.I.C D.I.C 4.4. Retinal complications Retinal complications 5.5. Renal failureRenal failure6.6. Liver failureLiver failure7.7. Hypertensive encephalopathyHypertensive encephalopathy

FOETALFOETAL1.1. Intra uterine growth retardationIntra uterine growth retardation2.2. Intra uterine deathIntra uterine death3.3. PrematurityPrematurity4.4. Intrapartum foetal distress or still birthIntrapartum foetal distress or still birth

MATERNALMATERNAL 1.1. EclampsiaEclampsia2.2. Abruptio placentaeAbruptio placentae3.3. D.I.C D.I.C 4.4. Retinal complications Retinal complications 5.5. Renal failureRenal failure6.6. Liver failureLiver failure7.7. Hypertensive encephalopathyHypertensive encephalopathy

COMPLICATIONS

MILD DBP OF < 160/110 No Proteinuria MODERATE

BP OF > 160/110 + Proteinuria SEVERE

1. BP OF > 160/110 mm Hg2. Proteinuria - 5 G IN 24 hoursor 3 – 4 + on Dipstick3. Oliguria < 500 mls in 24 hours

4. Cerebral & visual disturbances5. Epigastric pain 6. Thrombocytopenia7. Pulmonary oedema 8. Jaundice

TYPES OF P.I.H

LABORATORY FINDINGS

* Haemoglobin and heamatocrit high

Fibrin split products high

Serum uric acid high

Serum creatinine high

Alkaline phosphatase high

Lactate dehydrogenase high

Platelet count low

HELLP SYNDROME

H - Haemolytic anaemia El - Elevated liver enzymes LP - Low platelets

HELLP SYNDROME

H - Haemolytic anaemia El - Elevated liver enzymes LP - Low platelets

MANAGEMENT

Prevention

1. Low dose aspirin It inhibits platelet cyclooxygenase And blocks synthesis of thromboxane

2. Nutritional supplements

3. Oral calcium

4. Fish oils

5. Dipyridamole

6. Antihypertensive drugs

MANAGEMENT

Prevention

1. Low dose aspirin It inhibits platelet cyclooxygenase And blocks synthesis of thromboxane

2. Nutritional supplements

3. Oral calcium

4. Fish oils

5. Dipyridamole

6. Antihypertensive drugs

MANAGEMENT

Delivery is the only available cure for PIH Aim of management is to determine

the optimum time of delivery

MILD PREECLAMPSIA LESS THAN 37 WKS.

Bed rest in left lateral position

Increases venous return to heart cardiac output uterine and kidney perfusion

B.P. Monitoring

Urine check BD for proteinuria

Daily weight

LFTs, uric acid, electrolytes and Serum albumin weekly

Coagulation profile

Anti hypertensives when DBP-100 mm Hg

After initial hospitalization review in

OPD weekly.

FETAL SURVEILLANCE

1) Detailed USG to rule out multiple pregnancy, hydrops and

H. Mole.

2) Non-stress test (twice weekly)

3) Contraction stress test (weekly)

4) Biophysical profile (weekly)

5) Growth scan (10-14 day)

6) Doppler flow studies

HOSPITALIZATION IF:

(1) Progression of the disease (2) NST is non reactive (3) Oligohydramnios (4) I.U.G.R.

SEVERE PRE ECLAMPSIA

Principle of Treatment

1. Prevent convulsions

2. Control maternal blood pressure

3. Prevent complications

4. Deliver a surviving neonate

to a surviving mother

PREVENTION OF CONVULSIONS

1. Magnesium sulphate

2 – 4 g in 10% d. Solution I.V. Stat followed by 1.5 to 2 g/hour.

10 g in 50% solution – 2 doses of 5 g each injected deep in each

buttock followd by 5 g IM every 4 hours.

2. Diazepam

Respitry depression, hypotonia, hypothermia, hyperbilirubinaemia

3. Lytic cocktail

4. Thiopentone sodium

CONTROL OF HYPERTENSION

1. Hydralazine – direct arterialvasodilator. Increases cardiac output and renal and uterine perfusion

* 20 mgs in 250 ml D/W iv slowly * 5 mgs iv Stat. If no fall in BP the dose is increased in 5 mg

increments (10, 15, 20)

2. Methyldopa – 250mg 2stat. 3. Labetalol – 20 – 80 boluses. 4. Calcium channel blockers 5. Tridil (5, 25 mg), Isokit (10 mg).

INDICATIONS FOR DELIVERY

MATERNAL - HELLP SYNDROME - DIC - ECLAMPSIA - ABRUPTIO PLACENTAE - PROM - WARNING SYMPTOMS

e-g HEADCHE, BLURRING OF VISION, EPIGASTRIC PAIN, HYPERREFLEXIA

FETAL - FETAL DISTRESS

- OLIGOHYDRAMNIOS - IUGR - POSTIVE CST - BPS < 6

MODE OF DELIVERY

ELECTIVE C. SECTION

1. Cervix is not effaced and os is closed 2. CPD 3. Maturity less than 34 weeks 4. Severe placental insufficiency.

LABOUR INDUCED BY

Prostin E2 pessary

Misoprostol

Forewater amniotomy

Syntocinon infusion

Careful intrapartum fetal and maternal monitoring.

Second stage shortened by ventouse or forceps

ECLAMPSIA

FROM GREEK WORD ‘LIKE A FLASH OF LIGHTENING’

20% Without warning symptom 80% Follow severe Pre–eclampsia

Antepartum ______ 50 % Intra partum ______ 30 % Post partum ______ 20 %

Fits 07 days after delivery is not due to

Eclmpsia

THE SEIZURES OCCUR IN FOUR STAGES

STAGE I - PREMONITORY - 20 –30 SECONDS

STAGE II - TONIC - 30 – 60 SECONDS

STAGE III - CLONIC - 60 – 90 SECONDS

STAGE IV - COMA - MIN TO HOURS

D/D OF ECLAMPSIA

Epilepsy

Cerebral Malaria

Meningitis

Tetanus

Septicaemia

Brain Abscess & Tumours

Hypoglycemia

MANAGEMENT

AIM IS TO :

(1) TREAT CONVULSIONS AND PREVENT

FURTHER FITS

(2) CONTROL BLOOD PRESSURE

(3) PREVENT COMPLICATIONS

(4) DELIVERR FETUS

(5)

MANAGEMENT

GENERAL MEDICAL OBSTETRIC STETRIC MANAGEMENT