HYPERTENSIVE DISORDERS IN

PREGNANCY

Dr. dr. Herlambang Noerjasin, SpOG (K)

Maternal Fetal Division

Department of Obstetrics & Gynecology,
Faculty of Medicine , Jambi University
Jambi
 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
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

 Edema : pitting edema

 Sudden increase in weight
 > 500 gr/weeks or > 2 pounds/weeks
 > 2 kg/weeks or > 6 pounds/weeks
 > 13 kg/entire pregnancy

 Protein uria
 > 0.3 gr/L/24 hs or
> 1 gr/L/6 hs or
 2 + qualitative test
Pathophysiology

Inhibition of trophoblast invasion

Immunologic Hypoxia Free radical

reaction

Endothelial dysfunction

Vasoconstrictor Vasodilator Permeability

- Thromboxane - No
- Endothelin - Prostacyclin Coagulation
- etc - etc

Hypertension edema proteinuria DIC

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

3. Kidney :
 Capillary endotheliosis
 Decrease uric acid clearance
 Decrease glomerular filtration rate
 Oliguria
 Proteinuria
 Kidney / renal failure
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

7. Lung :
 Edema
 Ischemia
 Necrosis
 Hemorrhage
 Respiratory failure
Diagnosis

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

Eclampsia :
 Preeclampsia with
 Convulsion / Seizure
Prognosis

Maternal death due to PE : + 0,5%

Ecl : + 5%
Perinatal death + 20%
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. Blood pressure : > 160/110 mmHg
2. Proteinuria > 5 gr/24 hs (> 4 +)
3. Oliguria < 500 cc/24 hs or creatinine plasma
4. Visual and cerebral disturbances
5. Epigastric or right upper quadrant pain
6. Lung edema and cyanosis
7. IUGR
8. 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 100 mg in 500 cc
NaCl drips
 Clonidine
 Nifedipine
 Methyldopa
 Labetalol
 Etenolol
 Dielthiazem
 etc
 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
Loading
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
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
Thank you