Hypertensive Disorders of Pregnancy

Qu Quanxin

Tianjin First Centre Hospital

Definition

It is a condition that the pregnant women appear at least 2 of the 3 signs, including hypertension, proteinuria and edema after 20th week of pregnancy.

Classification• Preeclampsia/eclampsia• Chronic hypertension• Chronic hypertension with

superimposed preeclampsia• Gestational hypertension

Preeclampsia

• Definition A syndrome unique to pregnancy characterized by the new onset of hypertension and proteinuria in the latter half of gestation.

• Criteria the development of hypertesion(≥140/90mmHg); and proteinuria(≥0.3g/24h)

Eclampsia• Definition Seizures in a woman that

cannot be attributed to other causes

Chronic hypertension• Exist hypertension prior to pregnancy, the

development of hypertension prior to 20 weeks’ gestation, or in cases where hypertension is first noted during pregnancy, persistence of elevated blood pressures greater than 12 weeks’ postpartum

Chronic hypertension with superimposed preeclampsia

• New-onset proteinuria developed on the basis of chronic hypertension (≥0.3g/24h) after the 20th week of gestation

Gestational hypertension• Hypertension without proteinuria first

appears after 20 weeks’ gestation or within 48 to 72 hours after delivery and resolves by 12 weeks’ postpartum.

Etiology• Genetic factor• Immunologic factor• Endocrinologic factor• Nutritional factor• Infectious factor

Pathology Uteroplacental ischemia

‘toxins’

Hypertension and vascular spasmus

Ischmia and impairment of varies organs

(liver function, renal function, heart function, cerebral lesion, etc)

Result in signs and symptoms

(headache, faint, nause, epigastric pain, convulsion, coma, etc)

Fluid retention

During the normal pregnency period, the average weight gain is about 12kg. In the first trimester, a loss of weight maybe happen for morrning sickness. In the second and third trimester, the average weight gain is about 0.5kg/wk. If the weight gain is greater than 1kg/wk, closely measurement for blood pressure and urine specimen investigation should be done

Hypertension

The blood pressure fluctates within the range of 110-120/60-70mmHg in a rest condition. The standards of hypertension used in general medicine are not appropriate in obstetrics. The dividing point between physiology and pathology is accepted as 140/90mmHg or increase of 30/15mmHg over the baseline reading. During pregnancy period, the increased blood pressure should be below 30/15mmHg

Edema

During normal pregnancy period, the extracellular fluid increases about 2500ml. The excessive fluid retention eventually results in edema and is often firstly found over the lower subcutaneous surface of the tibia by gentle sustained pressure, and gradually the feet and ankles are obviously swoolen.

Proteinuria

The proteinura means that the protein components mainly including albuminuria and globulins are found in urine sample. But there are many causes can give rise to proteinuria , which contamination from vaginal discharge, urinary tract infection and chronic renal disease.

Signs and Syndrome

Mild hypertension

Slightly increase on pressure

Edema

Proteinuria.

+ Edema only limits on feet and calf

and can not disappear after rest.

++ Edema develops to thigh.

+++ Edema raise to vulva and abdomen.

++++ Edema distributes to all of the body

and sometimes company with ascites

Moderate hypertension

BP≥150/100mmHg,but <160/110mmHg

Proteinuria≥ 0.5g/24hn or +

Edema

Headach,nausea and vomiting,faint,etc

Serious hypertension

BP ≥ 160/110mmHg for at least 12h

Protein in the urine is over 5g/24h or +++~++++

Creatinine level increases

Function of liver impaired obviously

Function of the placenta impaired

Fetus IUGR, asphyxia and even death

Pre-eclampsia

On the above basic, the patient appears headache, giddy and faint, nausea, epigastric pain and even vomiting, this is called pre-eclampsia. If the patient does not accept treatment appropriately and in time, she will develop to eclampsia.

Eclampsia

The patient abruptly comes forth convulsion with or without coma. During convulsion, the patient stops breathing temporarily and face becomes cyanose. This will last for about 1min. After convulsion, patient often drops into coma.

Diagnosis

☛History

☛Signs and symptoms

☛Investigations

Investigations

✏Blood RT and coagulators, combination of CO2 and function of renal and liver

✏Urine RT

✏Bottom of the eyes

✏ECG, B-ultrasound

✏CT, MRI

✏Placenta function

Differentiation

•Chronic hypertension

•Chronic nephritis

Influence to pregnant

women and fetus

Pregnant women: heart failure,liver and kidney function failure, DIC, plcenta abruption, HELLP,postpartum haemorrhage

Fetus:preterm labor, oligohydramnios, IUGR, fetal distress, death, stillbirth, neonatal death,etc

TherapyRelife convulsion SedationAntihypertension Diuretics Delivery To terminate pregnancy is the key to resolve the problem. The method to end pregnancy includes induced labour by oxytocin or caesaren section.

Management for pre-eclampsia and eclampsia

* Keep the patients in a quiet circumstance and reduce external stimuli as possible

* Relief convulsion

* Reduce blood pressure

* Relief pain during delivery either by vaginal or operation

QuestionIf the patients appeared BP 150/100mmHg, proteinuria (++), edema(++) at 34 gestational age, then the diagnosis should be:

A. Mild degree of PIHB. Moderate degree of PIH C. Serious degree of PIHD. Pre-eclampsiaE. Eclampsia

QuestionThe influence on pregnant women with PIH is

A.Form plcenta praeviaB.Result in megaloblastic anemiaC.Result in abruptio plcentaD.Result in gestational diabeticsE. Result in iron-deficiency anemia

QuestionThe influence on fetus in pregnant women with PIH is

A.Fetal malformationB.Fetal heart diseaseC.Fetal heamorrhageD.Fetal anemiaE.IUGR

* Definition of Hypertensive Disorders of

Pregnancy

* Types of Hypertensive Disorders of Pregnancy

and the diagnostic standard

* Degree of edema in Hypertensive Disorders of

Pregnancy