Presenter : Sumit Gupta

Moderator : Prof. Anjan Trikha

IntroductionIncidence : 5-7% of all pregnancies.

Maternal and perinatal mortality & morbidity:

50-60,000 deaths/year

Developed countries: Leading cause of prematurity

Pregnancy Induced Hypertension

Hypertensive disorders of pregnancy

ClassificationIst classified in 1972 by ACOG

National High Blood Pressure Education Program: 2000

Recent: ACOG 2013.

Preeclampsia & Eclampsia:

Chronic Hypertension.

Chronic Hypertension with superimposed Preeclampsia

Gestational Hypertension

Preeclampsia: Not a triadHypertension:

After 20 wks, MC near term

SBP> 140 or DBP>90

SBP>160 or DBP>110 → Initiate treatment

Proteinuria: 24 hour excretion>300mg in 24 hours.

Single sample: Urine protein: Creatinine >3.0 As good as 24 hr sample.

Dipstick test: +1 reading. False +ve Used only when other tests aren’t available.

EdemaNon specific. “Physiological in pregnancy”

Korotkoff 5

2 readings 4

hours apart

PreeclampsiaPreeclampsia without Proteinuria,

Hypertension with

Thrombocytopenia (<100000).

S. Cr>1.1 or 2X of previous value w/o any renal disease

Pulmonary edema

Elevated AST/ALT (2X the normal value).

S/s of intracranial or visual abnormalities.

Severe preeclampsia

Severe preeclampsia SBP>160 or DBP>110.

Thrombocytopenia (<100000).

S. Cr>1.1 or 2X previous value w/o any renal disease

Pulmonary edema

Rt upper quadrant pain, Elevated AST/ALT (2X the normal).

S/s intracranial or visual abnormalities.

Mild preeclampsia “Preeclampsia without severe features”.

Chronic HypertensionChronic Hypertension

Hypertension diagnosed either before conception or before 20 weeks pregnancy

Gestational hypertension persisting 12 weeks postpartum.

Chronic hypertension with superimposed preeclampsia Preeclampsia

Incidence 4-5 times more in Hypertensive.

Worse prognosis

Both mother and child.

Chronic HypertensionChronic hypertension with superimposed

preeclampsia

New onset Proteinuria

After 20 weeks in known hypertensive (<20 weeks).

No Proteinuria

Thrombocytopenia (<100000).

S. Cr>1.1 or 2X previous value.

Pulmonary edema

Rt upper quadrant pain or Elevated AST/ALT (2X the normal)

Sudden worsening of hypertension or need to ↑ t/t in previously controlled patient.

Gestational HypertensionGestational Hypertension

New onset ↑BP after 20 weeks

No proteinuria

Transient nature (if not→?? Chr. HTN)

Enhanced surveillance : Risk of HTN ↑ ↑.

“Late” or post partum hypertensionNormotensive during gestation.

Mild HTN post partum (2weeks-6months)

Labile BP

Normalizes upto 1 year.

Risk FactorsDemographic factors

Age>35 years(2X than 20-29 years).

Ethnicity: African Americans, Hispanic

Severe hypertension→ require intense therapy.

Genetic factors

Previous history of Preeclampsia(7X more likely)

Multiple affected pregnancies.

Family history for Preeclampsia(2-4X more)

History of placental abruption, IUGR or IUD

Risk FactorsMedical Conditions

Obesity ↑BMI 5-7kg/m2 ↑ 2X risk

Chronic Hypertension

Diabetes Mellitus

Chronic renal disease, APLA syndrome, SLE

ObstetricMultiple Gestation, H. mole

BehavioralCigarette smoking protective

↓ 30-40%. Dose related effect.

Physical activity protective

Partner related risk factorsNulliparity.

Pathophysiology Normal pregnancy

Cytotrophoblast of embryo invade the spiral arteries of pregnant uterus

Remodeling of smooth muscle of uterine arteries S Spiral artery diameter ↑

Intervillous space has very low resistance to blood flow and remodeled arteries Nonresponsive to vasoconstrictors

PathophysiologyPreeclampsia

Asymptomatic First stageAbnormal placental implantation

Symptomatic Second stage

Release of angiogenic factors into

Maternal circulation

Asymptomatic first stageAbnormal placental implantation

Cytotrophoblast of embryo invade the spiral arteries of pregnant uterus

Remodeling of smooth muscle of uterine arteries S spiral artery diameter ↑

Intervillous space has very low resistance to blood flow and remodeled arteries Nonresponsive to vasoconstrictors

Incomplete cytotrophoblastic

invasion

of spiral arteries

No remodeling of spiral

arteries and diameter

remains small . Exaggerated

response to vasopressors

Superficial Placentation

↓ placental perfusion,

placental infarcts, IUGR

Placental ischemia gradually

worsens

Abnormal placental implantation Complex interplay of vascular, environmental, genetic

and immune factors.

Immune factors.

↓ NK cells &↑ macrophages and chemokines in placenta.

NK cells facilitate trophoblastic invasion.

Macrophages

↑ ↑ inflammation: inhibits placentation.

HLA C and HLA DR are associated with ↑ risk.

Abnormal placental implantation

Angiotensin receptor-1 Antibodies.

Act as agonist and ↑ sensitivity to angiotensin II

Defective remodeling of placenta vasculature

Block trophoblastic invasion.

↑production of reactive oxygen species.

↑ Sflt-1 (Receptor for VEGF)

Hypertension and proteinuria.

Oxidative stress

Cause atherosclerosis and atherosis

Symptomatic second stageRelease of angiogenic factors intoMaternal circulation

Symptomatic second stage Endothelial dysfunction:

Key event

Placental hypoxia → antiangiogenic substances released into maternal circulation.

Soluble fms like tyrosine kinase-1(sFlt-1) and Soluble endoglin (sEng)

Antagonize angiogenesis

Bind to and ↓ VEGF and PIGF.

Symptomatic second stage

Maternal Syndrome Preeclampsia: multisystem disorder

•AIRWAY

•Pharyngolayngeal edema

•Tracheal diameter ↓ ↓

•Difficulty in direct

laryngoscopy

•Subglottic edema

• Airway obstruction

PULMONARY

•Pulmonary edema

•3% of preeclampsia.

•More in elderly

multigravida, superimposed

Chr. HTN or oliguria

↓ Plasma oncotic

pressure

↑ Vascular permeability.

•Excess iv fluids.

CVS

•Vasospasm

•SVR and BP ↑ ↑

•↑ Sensitivity to

catecholamines

•Hyper dynamic circulation

↑ C.O

•Misleading CVP

measurement

•High risk: ↓ LV

function, ↓ ↓SVR

•Severe form plasma vol. ↓

HEPATIC

•Rt hypochondrium and epigastric

pain.

•D/t sub capsular hematoma

•Periportal hemorrhage and

sinusoidal

fibrin deposits.

•HELLP syndrome

• Spont. Hepatic rupture

•Rare but fatal(32% mortality)

Maternal Syndrome Preeclampsia.CNS

•Severe headache, hyper

excitability,

•Loss of cerebral auto

regulation, vasogenic

edema

•Cerebral hemorrhage and

edema

•PRES: Posterior

Reversible

Encephalopathy

Syndrome.

•Eclampsia: Seizures

OPTHALMOLOGICAL

•Scotoma, blurred vision

and amaurosis

•Retinal arteriolar spasm

•Bilateral retinal

detachmentRENAL

•“Glomerular capillary

endotheliosis”

Most Characteristic lesion.

•GFR ↓ (↑ in N pregnancy).

•Proteinuria( ∆stic criteria)

•Uric acid ↑ ( early detection).

•Oliguria

Occurs late & correlates with

severity.

•Renal failure

•With DIC, APH and IUFD.

HEMATOLOGICAL

•Thrombocytopenia: MC

hematological abn

•Severe disease or HELLP.

•Severe disease:

Hypercoagulable.

(↓ Blood Volume & ↑

Viscosity)

•Mild disease: hypocoagulable

•DIC

Fetal Syndrome PreeclampsiaLeading cause of IUGR

Preterm labor

NICU admission

IUD → DIC & PPH in mother

Prophylaxis

Prevents imbalance b/w thromboxane & prostacyclin.

Modest risk reduction (15-20%) but no S/E.

No. Needed To Treat

Low risk 500 Vs High risk NNT: 50

Started in late Ist trimester

H/o Preeclampsia causing preterm delivery<34 weeks.

Preeclampsia in > 1 pregnancy.

Low dose Aspirin 60-80 mg

Prophylaxis

Believed to reduce oxidative stress.

No benefit in multicentre trials

Benefit in females with calcium deficiency 1.5-2g in patients with low base line intake or high risk.

No benefit in females with adq. calcium intake.

No Benefit.

Diuretics: no benefit

Vitamin C(1000mg) and E(400 IU)

Calcium supplementation.

Dietary salt restriction

Prophylaxis

No benefit in pregnant patients

Risk of DVT ↑

Exercise : 30 min or more

Protective

Improves uterine blood flow, placental angiogenesis and endothelial function

Bed rest and no physical activity

InvestigationsInitial evaluation:

CBC with Plt. Count

S. Creatinine level

LFT (AST, ALT, and S.bil.)

Uric acid

Marker of severity

Detects disease early.

Urine analysis

24 hr Urine protein

Urine protein to creatinine ratio.

Danger signs → Headache, Unusual change in vision, ↓Urine,

epigastric/ labor pain Hospitalize

Severe Preeclampsiarepeated daily Mild Preeclampsia:Repeated weekly

Proteinuria Not evaluated again if +ve for preeclampsia

InvestigationsFetal evaluation

USG evaluation for fetal weight

Amniotic fluid index(AFI)

Daily fetal movement count(DFMC)

NST & BPP

Gestational Hypertension: Weekly NST

Preeclampsia: Bi Weekly NST

Umbilical artery Doppler:

Screening: no benefit

Indicates severity of IUGR

↓ DFMC /Fundal Ht<3cm (Prompt NST & AFI)

Investigations.Coagulation profile

Platelet count >100,000: Not needed.

Plt. Count<100,000: PT and aPTT.

Additional studies

DIC Risk: Abruptio, liver disease, HELLP

Induction of labor: platelets repeated 6 hrly.

ManagementAnti HTN drugs

Only if BP>160/110mmHg

No benefit if BP>140/90 but<160/110

↓progression to severe HTN.

Risk of fetal growth retardation

No change in maternal or fetal mortality or prematurity.

First line drugs: Methyldopa, Labetalol

Second line drugs: Hydralazine, Nifedipine,.

C/I: Ace inhibitors or ARBS

Anti Hypertensive drugs

Labetalol

• 100mg BD

• S/E: CHF, Asthma

• Discontinue :liver dysfunction

Methyldopa

• 250 mg TDS

• S/E: dry mouth, somnolence, sedation

Nifedipine

• 10-30 TDS

• S/E: Edema,

• headache, allergic hepatitis

Atenolol

• 50-100mg OD

• S/E: Heart Block, IUGR

Anti Hypertensive drugs.For Emergency Control.

Management. Observe for 24-48 hours

Corticosteroids if gestational age <34 weeks.

Monitor: USG, FHR, investigations and danger signs daily.

MgSO4 for severe preeclampsia.

Oral anti HTN drugs

C/I to expectant management → delivery

Eclampsia DIC Pulmonary edema Uncontrolled HTN

Non Viable fetusAbnormal fetal test resultsAbruptio placentaeIUD

Management. Deliver after 48 hrs with corticosteroids

Persistent symptoms

HELLP

IUGR, Severe oligohydramnios

USG Doppler: Reversal of flow

Labor

Significant Renal dysfunction

ManagementRoute of delivery

Vaginal delivery in all Unless Cesarean is indicated.

CorticosteroidsAll patients between 24- 34 weeks of gestation

Beneficial in HELLP syndrome

Fetal lung maturity.

Dexamethasone or Betamethasone

Seizure prophylaxisSevere Preeclampsia & Eclampsia

MgSO4

Long term outcome

↑ Risk of

Chronic Hypertension

DM

Ischemic Heart disease.

AHA: Preeclampsia risk factor for cardiovascular disease.

Renal failure.

↑ Risk for

Recurrent Preeclampsia

Preeclampsia with IUGR or Preterm Birth

ADVICE

BP, FBS, Lipids and

BMI yearly

Aerobic Exercise

5 days/ week -30min.

Avoid Tobacco

ComplicationsCerebrovascular accident

↑ risk of intracerebral and subarachnoid hemorrhage.

↑ ↑ risk with DIC or HELLP

Loss of cerebral autoregulation → Vasogenic edema

Systolic BP better than DBP or MAP at predicting adverse events

Majority are Hemorrhagic (93%) and occur in post partum

ComplicationsPulmonary edema

3% cases of preeclampsia

More in elderly multigravida or women with superimposed preeclampsia

Presents in 2-3 days after delivery

T/t underlying cause (sepsis, cardiac failure)

O2, Fluid restriction, diuretics

Rapid Resolution

ComplicationsRenal Failure

Rare complication

HELLP and severe preeclampsia

Majority Pre-renal or Intra-renal (ATN) Resolution completely

B/L cortical necrosis High maternal mortality and morbidity

DIC, HELLP, Abruptio placentae, IUD, Sepsis etc

Abruptio placentae:2% of preeclampsia (3X risk);

Chronic Hypertension.

EclampsiaNew onset seizures or unexplained coma in a

Preeclamptic patient

During pregnancy or postpartum.

No preexisting neurological disorder.

0.1-5.9/10,000 pregnancies

Most Commonly

Intrapartum or 48Hrs after delivery

Late Eclampsia: 48Hrs after delivery to 4 wks postpartum

EclampsiaRisk factors

Young nullipara

Multifetal & Molar pregnancy

Preexisting Hypertension, renal or cardiac disease.

SLE or non immune hydrops

Maternal Complications:

Pulmonary aspiration, pulmonary edema, Cerebrovascular accident, venous thromboembolism, ARF or death

Fetus

IUGR, Prematurity

EclampsiaSigns or symptoms

80% premonitory symptoms. MC Headache or Visual disturbances.

Photophobia, Right upper quadrant pain, Hyperreflexia

Seizures abrupt onset Facial twitching →Tonic phase (15-20 seconds).

Generalized clonic phase →apnea for 1 minute.

Postictal state with variable period of coma .

Poor neurocognitive outcomeUsually temporary ( focal motor deficit, blindness etc).

Can be permanent as well

HELLP syndromeVariant of severe preeclampsia

Maternal mortality ↑↑ (DIC, pulmonary edema, APH, Liver failure etc.)

Sibai’s criteria

Hemolysis•Abn Periph. Blood smear MAHA(Schistocytes&BURR cells)•↑ S. bilirubin>1.2mg%

•↑S. LDH>600IU/L

Low platelets•Platelet count

<100,000/cumm

Elevated liver enzymes

•↑AST>70IU/L•↑LDH>600IU/L

HELLP syndromeNot candidates for expectant management

Seizures: IV magnesium

Anti HTN: BP>160/110 mmHg.

Corticosteroids for fetal lung maturity.

Platelets:

Spontaneous bleeding or platelet count <20,000.

Sub capsular hematoma d/t liver rupture

Serial USG/MRI

Surgery/ Embolization.

Thank YOU

Seizure prophylaxisMgSO4

↓ Risk for Eclampsia Maternal death Abruptio placentae.

No benefit Maternal morbidity Fetal/neonatal outcome. Preeclampsia w/o severe disease.

↑ Risk Hypotension Muscle weakness Respiratory depression.

Seizure prophylaxisMOA

↓peripheral vascular resistance

NMDA agonist ↑ seizure threshold

Protects blood brain barrier

Dose:

4-6gm over ½ hour f/b infusion of 1-2gm/hr

For caesarean

2hr before procedure.

Continued till 12 hrs postpartum.

MgSO4 toxicity1.5-2.0 meq/l : normal plasma level

4.0-8.0 meq/l :therapeutic range

5.0-10.0 meq/l: p-q interval prolong, wide QRS

10.0 meq/l : loss of deep tendon reflexes

15.0 meq/l :Respiratory paralysis

25.0 meq/l : cardiac arrest

ANTIDOTE – CALCIUM Gluconate

Eclampsia

Airway

• Left lateral position, jaw thrust.

• Bag and mask ventilation.

• Avoid Oropharyngeal airway,

• Nasopharyngeal airway

Breathing

• Continue Bag and mask ventilation.

• Apply pulse oximeter and monitor SpO2

Circulation

• Secure IV access

• Monitor BP and ECG

Stop convulsions

MgSO4

4-6g IV over 20 min

1-2g/hr IV maintenance

2g iv over 10 min for recurrent seizures

Antihypertensive therapy

Labetalol or Hydralazine

Induction of labor