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Hypertension in PregnancyHypertension in Pregnancy

ClassificationClassificationChronic hypertension

Gestational hypertension (only during pregnancy)

Preeclampsia Superimposed upon chronichypertension or Renal Disease

Preeclampsia - eclampsia

Transient hypertension (only after pregnancy)

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Chronic HypertensionChronic Hypertension

Defined as hypertension

diagnosed

Before pregnancy

Before the 20th week of gestation

During pregnancy and not resolvedpostpartum

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Gestational HypertensionGestational Hypertension

Gestational Hypertension:

Systolic >140

Diastolic>90

No Proteinurea

25% Develop Preecla!psia

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Gestational HypertensionGestational Hypertension

Diagnosis of gestational hypertension: Detected for first time after midpregnancy o proteinuria

!nly until a more specific diagnosis can "e assignedpostpartum

#f preeclampsia does not de$elop and %P returns to normal "y &' ees postpartum* diagnosis is

transient hypertension+

%P remains high postpartum* diagnosis is chronichypertension+

Proteinurea de$elops Preeclampsiais diagnosed (',incidence)

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"o!plicates #10% o$ prenancies

#0% Preecla!psiaecla!psia

&0% "'ronic 'ypertension

(cla!psia 0)05% inci*ence

20% o$ +aternal Deat's"ause o$ 10% o$ Preter! ,irt'

(tioloy un-no.n

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/oun $e!ale & $ol* increase* ris-

$ricans 2 $ol* increase* ris-

+ulti$etal prenancies

.ins

riplets

Hypertensionenal Disease

"ollaen 3ascular Disease

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Blood pressure

Measure blood pressurein the sitting position, with the

cuff at the level of the heart. Inferior vena caval

compression by the gravid uterus while the patient is

supine can alter readings substantially, leading to an

underestimation of the blood pressure. Blood pressures

measured in the left lateral position similarly may yieldfalsely low values if the blood pressure is measured in

the higher arm and the cuff is not maintained at heart

level.

llow women to sit !uietlyfor "#$0 minutes beforemeasuring the blood pressure.

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%ecord &orotkoff soundsI 'the first sound(and I) 'the muffling of sound( to denote thesystolic blood pressure '*+B( and D+B,respectively. In about " of women, an

e-aggerated gap e-ists between the fourth'muffling( and fifth 'disappearance( &orotkoffsounds, with the fifth sound approaching ero.In this setting, record both the fourth and fifth

sounds 'eg, $20/0/10 with sound I $20, soundI) 0, sound ) 10(.

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19 years ol* la*y G1 P0 .as seen at t'e antenatal clinic at &2 .ee-s

estation $or routine c'ec- up) n ea!ination s'e loo-e* enerally

.ell6 ,loo* pressure .as 150790 pulse 807! .it' lo.er li!, oe*e!a

) terus .as appropriate $or *ate .it' a via,le $etus) rine analysis

s'o.e* protein)

; .'at is t'e *ianosis

; .'at investiations to per$or!

; .'at treat!ent to co!!ence

19 years ol* la*y G1 P0 .as seen at t'e antenatal clinic at &2 .ee-s

estation $or routine c'ec- up) n ea!ination s'e loo-e* enerally

.ell6 ,loo* pressure .as 150795 pulse 807! .it' lo.er li!, oe*e!a

) terus .as appropriate $or *ate .it' a via,le $etus) rine analysis

s'o.e* protein)




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19 years ol* la*y G1 P0 .as a*!itte* to t'e la,our .or* at &2 .ee-s

estation co!plainin o$ 'ea*ac'e) n ea!ination s'e loo-e*

enerally un.ell6 irrita,le6 epiastric pain6 nausea < ,loo* pressure.as 1=07110 pulse 907! .it' lo.er li!, an* a,*o!inal .all oe*e!a

6 re$lees eaerate*) terus .as s!all $or *ate .it' a via,le

$etus) rine analysis s'o.e* protein)




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?N"?D(N"(: 510% 0$ all prenancies ) 20% recurrence

'is is t'e t'ir* !ost i!portant cause o$ !aternal !ortality.orl*.i*e

D(@?N??N @ H/P(A(NS?N:

D)B)P) > 90 !!H or

S)B)P) > 140 !!H or

ise in D)B)P) o$ at least 15 !!H Cp'ysioloical c'anes or

ise in S)B)P) o$ at least &0 !!H

P?(N(:

+roteinurea is defined as urinary e-cretion 0.3 g protein or greater in a 21#hour

30 mg/dl '4$ or greater on urine dip specimen(

(D(+: 90% prenancy)proressive

a,an*one*

7

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E(nlare* placenta e)FFFF)

EPreeistin 'ypertension6 renalEPreeistin vascular *isease

EP0 >>>> !ultip

E@a!ily 'istory

ENe. 'us,an*

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E,nor!al trop'o,last invasionF

$irst 12 .ee-s6 t'e *eci*ual se!ents o$ t'e spiral arteries

are inva*e*F increase* $lo. to interrvellous spaceF ,y 20

.ee-s trop'o,last inva*es intra!yo!etrial se!ent o$ spiral

arteries>>> re*uce resistance to ,loo* $lo. to placenta)C'i'

volu!e

?n P( trop'o,last invasion is patc'y < spiral arteries retain

t'eir !uscular .allsF) eason

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ENor!al prenancy: !ar-e* perip'eral vaso*ilatationF) 4 $ol* increasein prostacyclin CPG?2 nor!al t'ro!,oane an* increase* nitric oi*e ,y

vascular en*ot'eliu!

EPreecla!psia: no c'ane7re*uction in prostacyclin an* N))

synt'esisFF) 3asospas! an* en*ot'elial cell *ys$unction>>> plateletactivation an* !icro areate $or!ation

?t is a !ulti oran a$$ectin *isease7 syn*ro!e

'e!orr'ae an* necrosis in !any orans66 arteriolar constriction

-i*neys: lo!erioloen*ot'eliosis

acute at'erosis o$ spiral arteries6 platelets !icro

areates

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Pathophysiologic Abnormalities in Preeclampsia

Generalized vasospasm Activation of coagulation system Abnormal hemostasis Altered thromboxane-prostacyclin ratio Endothelial cell injury

Abnormal hemodynamics Reduced uteroplacental blood flow

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PathophysiologyPathophysiology

Heart: Generally unaffected. cardiacdecompensation in the presence of pree/istingheart disease+

0idney: Renal lesions (glomerularendotheliosis). G1R and renal "lood flodecrease. hyperuricemia. proteinuria may appearlate in clinical course. hypocalciuria. alterations

in calcium regulatory hormones. impairedsodium e/cretion. suppression of reninangiotensin system+

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PathophysiologyPathophysiology

Coagulation System: Throm"ocytopenia.lo antithrom"in ###. higher fi"ronectin+

2i$er: H322P syndrome (hemolysis* ele$ated 42Tand 4ST* and lo platelet count)+

CS: 3clampsia is the con$ulsi$e phase ofpreeclampsia+ Symptoms may include headache

and $isual distur"ances* including "lurred $ision*scotomata* and* rarely* cortical "lindness+

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Symptoms of PreeclampsiaSymptoms of Preeclampsia3isual *istur,ances typical o$ preecla!psia are

scintillations an* scoto!ata) 'ese *istur,ances are

presu!e* to ,e *ue to cere,ral vasospas!)

Hea*ac'e is o$ ne. onset an* !ay ,e *escri,e* as

$rontal6 t'ro,,in6 or si!ilar to a !iraine

'ea*ac'e) Ho.ever6 no classic 'ea*ac'e o$

preecla!psia eists)

(piastric pain is *ue to 'epatic s.ellin an*in$la!!ation6 .it' stretc' o$ t'e liver capsule) Pain

!ay ,e o$ su**en onset6 it !ay ,e constant6 an* it

!ay ,e !o*eratetosevere in intensity)

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Symptoms of preeclampsiaSymptoms of preeclampsia

A'ile !il* lo.er etre!ity e*e!a is co!!on innor!al prenancy6 rapi*ly increasin ornon*epen*ent e*e!a !ay ,e a sinal o$*evelopin preecla!psia) Ho.ever6 t'is sinalt'eory re!ains controversial an* recently 'as ,eenre!ove* $ro! !ost criteria $or t'e *ianosis o$

preecla!psia)

api* .ei't ain is a result o$ e*e!a *ue tocapillary lea- as .ell as renal so*iu! an* $lui*retention)

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Physical Findings inPhysical Findings in

PreeclampsiaPreeclampsiaBloo* Pressure

Proteinurea

etinal vasospas! or etinal e*e!a

i't upper ua*rant C; a,*o!inal

ten*erness ste!s $ro! liver s.ellin an*

capsular stretc'

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Physical findings inPhysical findings in

PreeclampsiaPreeclampsia Bris-6 or 'yperactive6 re$lees are co!!on

*urin prenancy6 ,ut clonus is a sin o$neuro!uscular irrita,ility t'at raises concern)

!on prenant .o!en6 &0% 'ave so!elo.er etre!ity e*e!a as part o$ t'eir nor!al

prenancy) Ho.ever6 a su**en c'ane in

*epen*ent e*e!a6 e*e!a in non*epen*ent areassuc' as t'e $ace an* 'an*s6 or rapi* .ei't ainsuests a pat'oloic process an* .arrants$urt'er evaluation

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EA'y screenin

Eccuracy) terine artery *oppler at 24 .ee-s6 notc'in on ,ot'

uterine arteries i*enti$ies 80% .'o .ill *evelop P(666 5% $alse

positive

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Maternal

55 6etal

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Methods Used to Prevent Hypertensive Disorders of Pregnancy

Proper prenatal care ow-salt diet !iuretics

Antihypertensive drugs "utritional supplementation

#agnesium $%&' mg(d) *inc $+, mg(d) alcium $.',,/+,, mg(d)

0ish oil

Antithrombotic agents ow-dose aspirin $',/.', mg(d) !ipyridamole $++'/%,, mg(d) 1ubcutaneous heparin $.'2,,, 34(d)

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Low doses of aspirin do help prevent

pre-eclampsia, but there is littleinformation about whether they are ofbenefit for treatment of established pre-eclampsia cochrane 22 April 2003

Pre-eclampsia is a condition in pregnancy involving high bloodpressure and protein in the urine5 3t can lead to seriouscomplications and death5 As pre-eclampsia affects blood clotting2antiplatelets $drugs li6e aspirin which can prevent blood clots) areused for pre-eclampsia5 7he review of trials found that low doses

of aspirin lowered the ris6 of pre-eclampsia a little $.'8 loweringin the ris6)2 with a similar lowering in the ris6 of the baby dying$.98) and a very small lowering in the ris6 of the baby beingborn too early $:8)5 !oses less than ;'mg appear to be safe5

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alcium supplements may prevent high blood

pressure and help prevent preterm labour!cochrane 22 April 2003

%eviewers7 conclusions8"alciu! supple!entation appears to ,e ,ene$icial $or .o!en at

'i' ris- o$ estational 'ypertension an* in co!!unities .it' lo.

*ietary calciu! inta-e) pti!u! *osae reuires $urt'er

investiation)

Main results8

(leven stu*ies .ere inclu*e*6 all o$ oo* uality) 'ere .as a !o*est

re*uction in 'i' ,loo* pressure .it' calciu! supple!entation ) 'e e$$ect

.as reatest $or .o!en at 'i' ris- o$ 'ypertensionCrelative ris- 0)456 95%

con$i*ence interval 0)&1 to 0)== an* t'ose .it' lo. ,aseline *ietary calciu!

Crelative ris- 0)496 95% con$i*ence interval 0)&8 to 0)=2)

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9:;;+ *M:

B%?+@I> +;A:=@:

+?;M>=%< >:D:M

A?@: %:=; 6I;?%:A:%:B%; 9:M>%%9:

)I*?; DI*@?%B=A:* C B;I=D=:**

9:+@IA %?+@?%:

:;:A@%>;*@+%@?M A>;;+*:

S3R#!5S C!6P2#C4T#!S: -

H/P((NS?N D?NG P(GNN"/

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A?%: / +%:):=@ +%>%:**I>= #

A;>*: M>=I@>%I=

%:D?A: B;>>D +%:**?%: #@@%:@# $10/0

+%>M>@: 6>:@; M@?%I@;>= +%:==A< '31 # 3E F::&*(

@> A9I:): 6>:@; M@?%I@< @:%MI=@I>=

D:;I):%BG:A@I):* >6 M=:M:=@



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;>>& 6>% ++:%=A: >6 >MI=>?*

6:@?%:*

DI;%D B.+ 1 @IM:*, M>=I@>%?%I=: >?@+?@ C @:*@ 6>% +%>@:I=?%I

H?;I. / H?=@

;@.DD< F:I9@:):%< 1@9 D?=@, ;.6.@. ';D9(

F::&;

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DI;< # A;I=IA; 6>:@; M>=I@>%I= #

69*, 6?=D; 9t. BD>MI=; I%@9,

;IH?>%, 6>:@; M>):M:=@ A>?=@, A.@.?* # >= DMI**I>= C @9:= 3 F::&;% 6>:@; BI>+9% )>;?M:D>+;;:% ?* 6>% +;A:=@; B;>>D

6;>F ):;>AI@< :):%< 1@9 D 6>% M@?%I@ 5F 4C0. S.6.,. H7P.,0./S85/

0here is no consens$s on the optim$m ac$te treatment&

0he important o(

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0here is still ins$fficient trial evidence to determine whether the (enefits o$tw

any disadvantages& 8f it is to (e $sed the s$ggested indications are: -#BP ?@1!! mmHg

-pregnancy A@=2 wee9s

fetal and maternal state otherwise good&

"ethyldopa remains the dr$g of first choice&

7he combined a- and $B- bloc6ing agent labetalol is commonly used5

7he potent vasodilator and calcium channel bloc6er nifedipine is a usesecond-line treatment5 3ts major drawbac6 is severe headache5

Angiotensin-converting enzyme (AC! inhibitors have deleterious fetal effeand their use is not recommended5 3f a woman with chronichypertension becomes pregnant on an AE inhibitor2 change to anotanti-hypertensioe agent is advised5

>5/.,-0.,3 C5/0,5> 5F S.6.,. H7P.,0./S85/

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77iming of delivery? 7he most common grounds for delivery are>progressive fetal compromise $i5e5 when the baby is safer

delivered)uunacceptable ris6 to maternal health2 e5g5 uncontrollable BP2impending renal failure or heart failure2

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@he mode of delivery 'caesarean section versus vaginal( depends

on8

t'e seriousness o$ t'e situation

t'e estational ae

t'e *eree o$ $etal7!aternal co!pro!ise)

E (pi*ural analesia is t'e !et'o* o$ c'oice $or la,our Cas lonas a

coaulation *e$ect 'as ,een eclu*e*)

E ppropriate $acilities $or t'e care o$ t'e ne.,orn availa,le

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