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HYPERTENSIVE DISORDERS IN PREGNANCYHYPERTENSIVE DISORDERS IN PREGNANCY Hypertension in pregnancy is the most common cause of maternal and fetal morbidity and mortality. Pregnancy induced hypertension (PIH) is exclusively a human disease What is hypertension in Pregnancy?HYPERTENSION IN PREGNANCYBlood pressure more than 140/90 mm HgSystolic blood pressure more than 140 mm HgDiastolic BP more than 90 mm Hg How would you classify the hypertensive disorders in pregnancy?HYPERTENSIVE DISORDERS IN PREGNANCYcategorised as (a) Gestational hypertension(PIH) (b) Preeclampsia and eclampsia (c) Chronic hypertension (d) Preeclampsia superimposed on chronic hypertension What is gestational hypertension- (Pregnancy Induced Hypertension- PIH)?Pregnancy-induced hypertension (Gestational hypertension) (a)Gestational hypertension(PIH) is defined as the maternal blood pressure of systolic 140 or diastolic 90 mm Hg or more on two occasions observed for the first time in pregnancy . The blood pressure returns to normal within 12 weeks of delivery. No proteinuria

What is preeclampsia?PREECLAMPSIA(b)Preeclampsia is blood pressure more than 140/90 mm Hg after 20 weeks of pregnancy and Proteinuria of more than 300 mg in 24 hours What is chronic hypertension?CHRONIC HYPERTENSION(c)Chronic hypertension is blood pressure measurement of 140/90 mm Hg or greater on two occasions before 20 weeks of gestation (No gestational trophoblastic disorders) or BP more than 140/90 mm Hg diagnosed after 20 weeks of gestation but persisting beyond 12 weeks postpartum What is PREECLAMPSIA SUPERIMPOSED ON CHRONIC HYPERTENSION?PREECLAMPSIA SUPERIMPOSED ON CHRONIC HYPERTENSION(d)Preeclampsia superimposed on chronic hypertension is chronic hypertension and proteinurea In chronic hypertension proteinuria occurs after 20 weeks of gestation or sudden increase in BP, proteinuria and low platelet count in a patient who had high BP and proteinuria before 20 weeks of gestationDEFINITION- PREECLAMPSIAPre eclampsia is BP of > 140/90 with proteinuria of > 300 mg/day What is the pathophysiology of pre-eclampsia?AETIOLOGY OF PREECLAMPSIA Exact cause is not known, but placental dysfunction seems to be integral to the development of the syndrome in most women.PATHOPHYSIOLOGYPreeclampsia is primarily a disorder of placental dysfunction leading to a syndrome of endothelial dysfunction with associated vasospasm.Failure of villi to invade spiral arterioles in early pregnancy leading to ischemia and damage.This leads to release of chemical mediators into maternal circulation.

This leads to 2 major pathological changes:Generalized vasospasm due to increased sensitivity of vascular system to circulating catecholamineHypertensionMultiple endothelial damage leading to leakage of albumin and fluid into interstitial space resulting in tissue edema.The pregnant woman may manifest dysfunction of multiple organ systems, including the central nervous, hepatic, pulmonary, renal, and hematological systems.

What are the predisposing factors for pre-eclampsia ?PREDISPOSING FACTORS FOR PRE ECLAMPSIAAge Young and Old(extremes of reproductive age)Parity Primigravidas:double the incidenceSocial status lower:Increased incidenceGenetic predisposition run in familiesRenal disordersObesityFamily history and past historySLEThrombophilia

PREDISPOSING FACTORS FOR PRE ECLAMPSIALarger placenta- multiple pregnancy, diabetes, trohpoblastic disorders Multiple pregnancies 20% in twin pregnancies 4% in singleton pregnanciesPHYSIOLOGICAL CHANGES OF BLOOD PRESSURE IN PREGNANCYBP 12 24 40 P.O.A.(weeks)24P.O.A(weeks)

What is Eclampsia?ECLAMPSIAEclampsia is seizures in preeclampsia after excluding other causes of fitsECLAMPSIAEclampsia can occur without hypertension in 16%Without proteinuria in 14%SYSTEMIC EFFECT OF PREECLAMPSIACardiovascularCardiac output in normal pregnancy increase by 30-50%In preeclampsia, the cardiac output is either maintained or increasedThere is increase in peripheral resistance which may lead to extravasation of fluid into the extracellular spaceResult in pulmonary edemaCerebralThere is increase in cerebral vascular resistanceSevere hypertension can lead to rupture in the arterioles resulting in cerebral haemorrhage1/3 of patient die of eclampsia has cerebral haemorrhage.Other changes that occur are: -cerebral edema -thrombosisHematologicalExpansion of blood volume is approximately 20%Hemoconcentration can lead to decrease in regional perfusionIncrease in vascular tone result in endothelial injury which result in microangiopathic hemolysisManifestation can be in form of: -thrombocytopenia -anemia - fragmentation of red blood cellsEndocrinologicalThere is alteration in vascular sensitivity to the endogenous hormoneThere is decreased in prostacyclin production by placentaThis result in increased thromboxane A2/prostacyclin ratio which lead to further increase in vascular tone and blood pressureHepaticPeriportal hemorrhagic necrosis in periphery part of liver lobuleThis lead to subcapsular hemorrhages which lead to the epigastric pain seen with imminent eclampsiaRenalRenal perfusion rate decreased by 20% resulting in 30% reduction in the glomerular filtration rateGlomerular capillary endotheliosis is pathognomonic of preeclampsiaThe swollen glomerular cells further decrease the lumen size.

COMPLICATION OF PREECLAMPSIA

MOTHERFETAL

MATERNAL COMPLICATIONS OF PREECLAMPSIAEclampsiaBecause of high blood pressure Cerebro-vascular accidents and congestive cardiac failurePPROM Neurological deficitAcute renal failureAbruptio placentaPostpartum hemorrhage (normal blood loss: Vaginal delivery:500ml, caesarean:1000ml, caesarean hysterectomy:1500ml)Preterm laborHELLP syndrome

MATERNAL COMPLICATIONSEclampsia(siezures)Occur in 1 in every 2000 pregnancies with severe preeclampsia between 200 weeks of gestation till 10 days postpartum38% in antenatal, 18% intranatal, 44% in the postnatalLiver dysfunction,acute renal failure,adult respiratory distress syndrome and disseminated intravascular coagulopathy (DIVC) are also known to occur with eclampsiaUsually start in a sequence

Unconcious for a brief momentTwitching of muscle of face, tongue , and limbsEyeballs rolls and become fixedBody goes in tonic spasmRespiration ceases for around half a minute with tongue protruding outAfter this the muscle goes into alternate contraction and relaxationTwitching starts at one side of face followed by one side of extremities and then the whole bodyThen patient goes into brief coma and does not has memory of the preceding event when she recover from the coma.

(2) High blood pressure: Congestive Cardiac failure (due to hypertension +/- fluid overload) Cerebro-vascular accidentsFibrinoid necrosis of walls of arteriolesrupture results in Cerebral Haemorrhage37FETAL COMPLICATIONSIUGROligohydraminos (AFI 150/100mmHgProteinuria of > 1+ after excluding UTISign and symptoms of impending eclampsiaOn admission: (preeclampsia profile investigation)Monitor 4 hourly BP, pulse rate, input/output chart and daily proteinInitiate antihypertensive therapy (1st line therapy- Methyldopa or Labetolol)MANAGEMENT: PRE-ECLAMPSIAAIMTo prolong the pregnancy to reduce the fetal risks but balance with the risk to the motherAll patients diagnosed with preeclampsia require admission to assess the severity and to determine the further care plan.Principle of managementConservative management for mild casesActive intervention and delivery in severe casesTermination of pregnancy is a definitive treatment

PREECLAMPSIA- GRADINGMild Preeclampsia BP 140/mm Hg Proteinuria 300 mg/ 24 hr urine (+)Moderare preeclampsia BP 150/100 mm Hg Proteinuria 400 mg/24 hr urine (++)Severe Preeclampsia BP 160/100 m Hg Proteinuria 500 mg/24 hr urine (+++)SEVERE PRE-ECLAMPSIAControl blood pressureAntihypertensive drug (ex: alpha methyl Dopa)Prolong the pregnancyPrevent convulsionPritchards regimen (Magnesium Sulphate)LD: 4g slow IV over 4-5min, 10gms IM (5gms deep IM in each buttock)MD: 5g every 4th hourly in alternate buttock till 24h after the fit or delivery whichever is laterDelivery of babyINDICATION TO DELIVERIn severe preeclampsia where the systolic BP will > 160mmHg and / diastolic BP > 110 mmHg along with abnormal preeclampsia profile. Parameter which indicates urgent delivery are as follow:POG: 38 weeksBP > 160/110 mmHg despite therapyPlatelet < 100,000/mlSerum fibrinogen < 150mg/dlProteinuria > 5gms in 24 hoursUric acid > 450 mmol/LCreatine > 1.2mg/dlCTG,BPP: any acute compromiseDoppler: reversal of diastolic flowOphthalmoscope: grade IV changes