Hypertension in PregnancyHypertension in PregnancyClassificationClassification

Chronic hypertension

Gestational hypertension (only during pregnancy)

Preeclampsia Superimposed upon chronic hypertension or Renal Disease

Preeclampsia - eclampsia

Transient hypertension (only after pregnancy)

Chronic HypertensionChronic Hypertension

Defined as hypertension diagnosed

Before pregnancy Before the 20th week of gestation During pregnancy and not resolved

postpartum

Gestational HypertensionGestational Hypertension

Gestational Hypertension:– Systolic >140– Diastolic>90– No Proteinurea– 25% Develop Pre-eclampsia

Gestational HypertensionGestational Hypertension

Diagnosis of gestational hypertension: Detected for first time after midpregnancy No proteinuria Only until a more specific diagnosis can be assigned

postpartum

If preeclampsia does not develop and BP returns to normal by 12 weeks postpartum, diagnosis is

transient hypertension. BP remains high postpartum, diagnosis is chronic

hypertension. Proteinurea develops Preeclampsia is diagnosed (25%

incidence)

Hypertension in PregnancyHypertension in Pregnancy

Complicates 7-10% of pregnancies– 70% Preeclampsia-eclampsia– 30% Chronic hypertension

Eclampsia 0.05% incidence20% of Maternal DeathsCause of 10% of Preterm birthEtiology unknown

Hypertension in PregnancyHypertension in Pregnancy

Young female 3 fold increased riskAfricans 2 fold increased riskMultifetal pregnancies

– Twins– Triplets

HypertensionRenal DiseaseCollagen Vascular Disease

** INCIDENCE: 5-10% 0f all pregnancies . 20% recurrence

This is the third most important cause of maternal mortality worldwide

** DEFINITION OF HYPEWRTENSION:

D.B.P. > 90 mmHg or

S.B.P. > 140 mmHg or

Rise in D.B.P. of at least 15 mmHg (physiological changes) or

Rise in S.B.P. of at least 30 mmHg** PROTIENUREA: Proteinurea is defined as urinary excretion

0.3 g protein or greater in a 24-hour 30 mg/dl (+1 or greater on urine dip specimen)

** OEDEMA: 90% pregnancy. progressive

abandoned

+/-

•Enlarged placenta e.g………….

•Pre-existing hypertension, renal

•Pre-existing vascular disease

•P0 >>>> multip

•Family history

•New husband

Symptoms of Pre-eclampsia Symptoms of Pre-eclampsia Visual disturbances typical of preeclampsia are

scintillations and scotomata. These disturbances are presumed to be due to cerebral vasospasm.

Headache is of new onset and may be described as frontal, throbbing, or similar to a migraine headache. However, no classic headache of preeclampsia exists.

Epigastric pain is due to hepatic swelling and inflammation, with stretch of the liver capsule. Pain may be of sudden onset, it may be constant, and it may be moderate-to-severe in intensity.

Symptoms of preeclampsia Symptoms of preeclampsia

While mild lower extremity edema is common in normal pregnancy, rapidly increasing or nondependent edema may be a signal of developing preeclampsia. However, this signal theory remains controversial and recently has been removed from most criteria for the diagnosis of preeclampsia.

Rapid weight gain is a result of edema due to capillary leak as well as renal sodium and fluid retention.

Physical Findings in Physical Findings in Preeclampsia Preeclampsia

Blood Pressure ProteinureaRetinal vasospasm or Retinal edema Right upper quadrant (RUQ) abdominal

tenderness stems from liver swelling and capsular stretch

Physical findings in Physical findings in Preeclampsia Preeclampsia

– Brisk, or hyperactive, reflexes are common during pregnancy, but clonus is a sign of neuromuscular irritability that raises concern.

– Among pregnant women, 30% have some lower extremity edema as part of their normal pregnancy. However, a sudden change in dependent edema, edema in nondependent areas such as the face and hands, or rapid weight gain suggests a pathologic process and warrants further evaluation

•Why screening

•Accuracy. Uterine artery doppler at 24 weeks, notching on both uterine arteries identifies 80% who will develop PET,,, 5% false positive

Methods Used to Prevent Hypertensive Disorders of Pregnancy

 Proper prenatal care  Low-salt diet  Diuretics  Antihypertensive drugs  Nutritional supplementation

  Magnesium (365 mg/d)  Zinc (20 mg/d)  Calcium (1500–200 mg/d)  Fish oil

 Antithrombotic agents   Low-dose aspirin (50–150 mg/d)  Dipyridamole (225–300 mg/d)  Subcutaneous heparin (15,000 IU/d)

HELLP SYNDROME ABRUPTIO PLACENTAE PULMONARY OEDEMA ACUTE RENAL FAILURE CEREBRAL HAEMORRHAGE VISUAL DISTURBANCES & BLINDNESS HEPATIC RUPTURE ELECTROLYTIC IMBALANCE POSTPARTUM COLLAPSE

SERIOUS COMPLICATIONS: -

CURE / PREVENT PROGRESSION -– CLOSE MONITORING

REDUCE BLOOD PRESSURE -TATRGET- 140/90

PROMOTE FOETAL MATURITYPROLONG PREGNANCY (34 - 36 WEEKS)

– TO ACHIEVE FOETAL MATURITY TERMINATION

DELIVERY- DELIVERY- BEST DAY, BEST WAY & BEST PLACE

PREVENT / MANAGE COMPLICATIONS

OBJECTIVES OF MANAGEMENT

HYPERTENSION DURING PREGNANCY

** Definite treatment is delivery (ending the pregnancy).

But,

Mother vs. Fetus

** Mild pre-eclampsia:

diastolic /90-95 & proteinurea trace-1+

** Moderate pre-eclampsia

** Severe pre-eclampsia

** Does the treatment improve the condition?

Then why. Adv/disadv

CONTROL OF ACUTE SEVERE HYPERTENSION• There is no consensus on the optimum acute treatment.

• The important objective is to reduce the blood pressure to safe levels. (but not too low!).

• Parenteral hydralazine is used most commonly but oral nifedipine should be considered .

The combined a- and (B- blocking agent labetalol is commonly used.

The potent vasodilator and calcium channel blocker nifedipine is a useful second-line treatment. Its major drawback is severe headache.

Angiotensin-converting enzyme (ACE) inhibitors have deleterious fetal effects and their use is not recommended. If a woman with chronic hypertension becomes pregnant on an ACE inhibitor, change to another anti-hypertensioe agent is advised.

LONGER-TERM CONTROL OF SEVERE HYPERTENSION

• There is still insufficient trial evidence to determine whether the benefits outweigh any disadvantages.

• If it is to be used, the suggested indications are: ,-DBP >_100 mmHg

-pregnancy <_34 weeks

*fetal and maternal state otherwise good.

• Methyldopa remains the drug of first choice.

The combined a- and (B- blocking agent labetalol is commonly used.

The potent vasodilator and calcium channel blocker nifedipine is a useful second-line treatment. Its major drawback is severe headache.

Angiotensin-converting enzyme (ACE) inhibitors have deleterious fetal effects and their use is not recommended. If a woman with chronic hypertension becomes pregnant on an ACE inhibitor, change to another anti-hypertensioe agent is advised.

LONGER-TERM CONTROL OF SEVERE HYPERTENSION

Timing of delivery

• The most common grounds for delivery are:

progressive fetal compromise, (i.e. when the baby is safer delivered).

unacceptable risk to maternal health, e.g. uncontrollable BP, impending renal failure or heart failure, HELLP syndrome, DIC, eclampsia .

The mode of delivery (caesarean section versus vaginal) depends on:

-The seriousness of the situation-The gestational age-The degree of fetal/maternal compromise.

• Epidural analgesia is the method of choice for labour (as long as a coagulation defect has been excluded).• Appropriate facilities for the care of the newborn available