HYPERTENSIVE DISORDERS

IN PREGNANCY
Dr. Johanes C. Mose,dr, SpOG

Department of Obstetrics & Gynecology, Faculty of Medicine , Padjadjaran University Bandung

 Trias

main cause of maternal death

Preeclampsia/eclampsia Haemorrhage Infection

Hasan

Sadikin Hospital

20 - 30% of maternal death 30 - 40% of perinatal death

Classification :
I. Pregnancy - Induced Hypertension (PIH) 1. preeclampsia 2. eclampsia 3. hypertension without proteinuria or pathologic edema II. Pregnancy - Aggravated Hypertension (PAH) = Underlying hypertension worsened by pregnancy 1. Superimposed preeclampsia 2. Superimposed eclampsia III. Transient Hypertension IV. Coinsidental Hypertension (chronic hypertension)

Preeclampsia/Eclampsia

Etiology : unknown Predisposing factors :

1. Primigravida 2. Hyperplacentosis hydatidiform mole gemelli diabetes mellitus hydrops fetalis giant baby 3. Age (< 15 years ; > 35 years) 4. Familial & genetic 5. Kidney disease and chronic hypertension

Theories about the cause

Immunological mechanism Genetic predisposition

Dietary deficiencies
Vasoactive compounds Endothelial dysfunction

Criteria

Preeclampsia : trias Eclampsia : PE + Seizure Chronic hypertension : hypertension without edema and proteinuria < 20 weeks gestation persists > 6 weeks after delivery Pregnancy agrravated hypertension : chronic hypertension superimposed preeclampsia or eclampsia Transient hypertension : Develops after 2nd trimester Mild elevation Without edema an proteinuria Regresses within 10 days after delivery

 Hypertension

Increase systole > 30 mmHg Increase diastole > 15 mmHg > 140/90 mmHg Sudden increase in weight > 500 gr/weeks or > 2 pounds/weeks > 2 kg/weeks or > 6 pounds/weeks > 13 kg/entire pregnancy

Edema

pitting edema

Protein

> 0.3 gr/L/24 hs or > 1 gr/L/6 hs or 2 + qualitative test

uria

Pathophysiology
Inhibition Immunologic reaction of trophoblast invasion Free radical

Hypoxia

Endothelial
Vasoconstrictor
- Thromboxane - Endothelin - etc

dysfunction
Permeability
Coagulation edema proteinuria DIC

Vasodilator
- No - Prostacyclin - etc

Hypertension

Maternal & Fetal Consequences

1. Cardiovascular changes

Hypertension Cardiac out put Thrombocytopenia Coagulation disorders Haemorrhages DIC Decrease blood plasm volume Increase permeability edema

2. Placenta

Necrosis Intrauterine growth restriction Fetal distress Abruptio placentae Capillary endotheliosis Decrease uric acid clearance Decrease glomerular filtration rate Oliguria Proteinuria Kidney / renal failure

3. Kidney :

4. Brain :

Edema Hypoxia Seizure / convulsion Cerebrovascular accident / hemorrhage coma

5. Liver :

Liver function test alteration Increase levels of liver enzym Icterus HELLP syndrome (hemolysis, elevated liver enzym, low platelet caunt) Edema Hemorrhage/sub capsular hematoma Periportal hemorrhage, necrosis

6. Eye

Papil edema Ischemia Amaurosis Hemorrhage Retinal detachment Blindness Edema Ischemia Necrosis Hemorrhage Respiratory failure

7. Lung :

Diagnosis
Preeclampsia : Pregnancy of 20 weeks or more Hypertension Proteinuria edema

Eclampsia : Preeclampsia with Convulsion / Seizure

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

Treatment
Prevention :
1. Dietary manipulation
Low caloric diet High protein diet Low salt diet Nutritional supplementation : Ca, Mg, Zn, Fish oil, evening primrose oil, etc

2. Pharmacologic manipulation :
Diuretics Anti hypertensives b-sympathomimetics Anti thrombotic agents : Low dose aspirin Dipyridamole Dazoxiben Heparin Vitamin E

3. Personal habit changes :

Frequent prenatal care Daily rest in lateral position Keep same partner

Avoid or reduce smoking

Avoid or reduce coffee

Diagnosis

Mild preeclampsia Severe preeclampsia

1. 2. 3. 4. 5. 6. 7. 8.

Blood pressure : > 160/110 mmHg Proteinuria > 5 gr/24 hs (> 4 +) Oliguria < 500 cc/24 hs or creatinine plasma Visual and cerebral disturbances Epigastric or right upper quadrant pain Lung edema and cyanosis IUGR HELLP syndrome

Treatment
1. Mild preeclampsia
a. Out patient care
Bed rest / lateral position Diet (high protein, low fat, carbohydrate and salt) Mild sedatives : phenobarbital (3 x 30 mg/day) or Diazepam (3 x 2 mg/day) during 7 days Vitamins Antenatal visit every week

b. Inpatient care/Hospitalization :
No response in 2 weeks out patient care Body weight increase > 2 kg/weeks Symptoms of severe preeclampsia

Treatment
Severe preeclampsia
conservative : < 37 weeks, no fetal distress and signs of impending eclampsia
Severe headache Severe visual disturbance Vomiting Epigastric pain Progressive increase of Blood pressure

Active : pregnancy termination

I. Drug therapy :
Anti convulsive MgSO4 8gr 40%; 4 gr every 4-6 hours Anti hypertensive :

Hydralazine 2 mg i.v NaCl drips Clonidine Nifedipine Methyldopa Labetalol Etenolol Dielthiazem etc

100 mg in 500 cc

 Others : Diuretic Cardiotonic Antipyretic Antibiotic Pain killer

II. Obstetrical management :

Mature induction Parturient augmentation Delivery : pervaginam : forcipal extraction caesarean section

Eclampsia :
Classification :
- Antepartum - Intrapartum - Post partum : early : 24 hours - 7 days late : > 7 days Eclampsia sine eclampsia
Eclampsia intercurrent

Treatment
Placed in I.C.U Cooperation with : Internal depart., Neurologic depart,

etc

Drug therapy : MGSO4 : 4 gr 20% i.v

8 gr 40% i.m maintenance : 4gr 40% i.m / 4 - 6 hs Supportive : same with PE Management of coma : In cooperation with Neurologic dept.
Obstetrical management

Loading

Termination of pregnancy

Prognosis
Eden criteria (1922)

Prolonged coma
Pulse rate > 120 x/m Temperature > 1030 F Systolic pressure > 200 mmHg Seizure > 10 x

Proteinuria > 10 gr/ltr

No edema

CHRONIC HYPERTENSION (Coincidental hypertension) Definition : Hypertension (> 140/90 mmHg) < 20 weeks gestation

Persists long after delivery

 Underlying disorders :
Essential familial hypertension

(Hypertensive vascular disease) Arterial abnormalities Renovascular hypertension Coartation of the aorta Endocrine disorders diabetes cushing syndrome primary aldosteronism pheochromocytoma thyrotoxicosis

 Glomerulonephritis (acute & chronis) Renoprival hypertension chronic gromerulo nephritis chronic renal insufficiency diabetic nephropathy Connective tissue diseases lupus erythematosus scleroderma periartenitis nodosa Poly cystic kidney disease Acute renal failure Obesity

 Essential hypertension : Chronic hypertension due to arterio sclerosis complications :

heart ischemia renal failure retinal bleeding

 Prognosis, Worsen if :
heart enlargement
Decrease renal function

Retinal complication
Blood pressure > 200/120 mmHg

Preeclampsia

Treatment :
Hospitalization

Incooperation with related departments