HYPERTENSIVE DISORDERSIN PREGNANCY

Shanro Mayra VegaSri Wahyuni

Deadly triad causes of maternal morbidity and mortality related to pregnancy :Hypertensive disorders complicating pregnancyHemorrhageInfection

How pregnancy incites or aggravated hypertension remains unsolvedHypertensive disorders significant unsolved problems in obstetrics.

Gestational hypertension (formerly pregnancy-induced hypertension or transient hypertension)PreeclampsiaEclampsiaPreeclampsia superimposed on chronic hypertensionChronic hypertensionCLASSIFICATION

Parity, ras, genetic, environmentOther risk factor :NulliparousHyperplacentosisMola hydatidosaMultiple gestationDiabetes mellitusHydrops foetalisGiant babyAge (< 15 y.o ; > 35 y.o)Renal disease & chronic hypertensionINCIDENCE & RISK FACTOR

Abnormal trophoblastic invasion of uterine vesselsImmunological intoleranceMaternal maladaptation / inflammatory changes of normal pregnancyDietary deficienciesGenetic influenceETIOLOGY

CRITERIAGestational hypertension :BP > 140/90 mmHg for first time during pregnancyno proteinuriaBP returns to normal by 12 weeks postpartumPreclampsia :BP > 140/90 mmHg after 20 weeks gestationproteinuria > 300 mg/24 hr or > 1+ dipstickEclampsia :Preeclampsia + seizure

CRITERIASuperimposed Preeclampsia :new onset proteinuria > 300 mg/24 hr BP or platelet count > 100.000/mm3 in hypertensive women but no proteinuria < 20 weeks gestationChronic hypertension :BP > 140/90 mmHg before pregnancy / diagnosed before 20 weeks gestationHypertension first diagnosed after 20 weeks gestation persistent after 12 weeks postpartum

PATHOPHYSIOLOGYMaternalFaultyExcessive vascular disease placentationtrophoblast

Genetic, immunologic, or inflammatory factor

Reduced uteroplacental perfusionVasoactive agent : Noxious agent :Prostaglandin EndothelialCytokinesNitric oxide dysfunctionLipid perox.Endothelins Capillary leak VasospasmeActivation of coagulationEdemaProteinuriaHyper- Thrombo-tension Oliguria Liver Hemo- cytopenia ischemia concentration

Seizure Abruption

ORGAN CHANGES 1. CardiovascularHypertensionCardiac output ThrombocytopeniaCoagulation defectBleedingDICPlasma blood volume Permeability Edema

2. PlacentaNecrosisIUGRFetal distressAbruptio placentae

3. RenalCapillary endotheliosisUric acid cleareance GFR OliguriaProteinuriaRenal failure

4. BrainEdemaHypoxiaAcute attack / seizureCerebrovascular accident / hemorrhageComa

5. LiverChanges in liver function testLiver enzyme IcterusHELLP syndrome(Hemolysis, Elevated Liver enzym, Low Platelet count)EdemaSubcapsular hematome / hemorrhage Necrosis, perinatal hemorrhage

6. EyesPupillary edemaIschemiaAmaurosisHemorrhageRetinal defectsBlindness

7. LungEdemaIschemiaNecrosisHemorrhageRespiratory failure

PREDICTIONRoll-Over TestUric acidFibronectinCoagulation activationOxidative stressCytokinePlacenta peptideDNA fetusUterine artery doppler Velocitometry

PREVENTIONNon-medicalDietary manipulationLow calorie, high protein, salt restriction Ca, Zn, Mg, Omega-3 PUFA, evening primrose oilBedrest not proven

Habits :Intense prenatal careAvoid smokingAvoid cafeinCompliance

B. Medical

Diuretics worsening hypovolemiaAntihypertension not provenAntithrombotic :Low-dose aspirin not provenDypiridamoleAntioxidant : vitamin C, vitamin E, -carotene, lipoic acid

Eden Criteria :Prolonged comaHeart rate > 120 x /minuteTemperature > 380 CSystolic pressure > 200 mmHgSeizure > 10 xProteinuria > 10 gr/L per dayNo edemaPROGNOSIS

Prognosis worsened if there are :CardiomegalyDecreased renal functionRetinal complicationBP > 200/120 mmHg

Maternal death due to PE : + 0,5% Ecl : + 5%Perinatal death : + 20%PROGNOSIS

MANAGEMENTBasic management objective :Termination of pregnancy with the least possible trauma to mother and fetusBirth of an infant who subsequently thrivesComplete restoration of health to the mother

1. Mild Preeclampsiaa. OutpatientIf the patient refuse to be hospitalizedHome restDiet (high protein, low fat, carbohydrat)VitaminsAntenatal care visite weeklyMANAGEMENT

b. HospitalizationNo improvement after 2 weeks outpatient careWeight gain > 2 kg/weekSevere symptoms of preeclampsia

2. Severe PreeclampsiaConservative : < 37 weeks gestation, no fetal distress and no symptoms of impending eclampsia :Severe headacheSevere visual disturbanceVomitEpigastric painProgressive BP Active : termination of pregnancy !

Anticonvulsion MgSO4 8 gr 40%;4 gr every 4-6 hoursAntihypertension :Hydralazine 2 mg i.v 100 mg in 500 cc NaClClonidineNifedipineMetyldopaLabetololEtanololDiltiazemetcI. DRUG THERAPHY

Others :DiureticsCardiotonicsAntipyreticsAntibioticsAnalgesics

II. OBSTETRICAL MANAGEMENTMature inductionParturient augmentationDelivery : forceps extraction sectio cesaria

Classification :- Antepartum- Intrapartum- Post partum :early : 24 hours - 7 dayslate : > 7 daysEclampsia sine eclampsiaEclampsia intercurrentECLAMPSIA

ICU !Internal department, neurology department, etcDrug theraphy :MgSO4 : 4 gr 20% i.v 8 gr 40% i.m maintenance : 4 gr 40% i.m / 4 - 6 hoursSupportive : same as preeclampsiaManagement of coma :together with neurologic departmentObstetrical management : termination of pregnancy !MANAGEMENTLoading

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