CLASSIFICATION OF HYPERTENSIVE DISORDERS

IN PREGNANCY

Wilhelm Steyn

BUENOS AIRES 1992

PREECLAMPSIA

OR PRE-ECLAMPSIA?

THE CLASSIFICATION

Only diastolic blood pressure

Korotkoff IV

ASSHP NHBPEP

BUT…

Hypertension and proteinuria, the two diagnostic criteria for preeclampsia, constitute a very small part of the pathophysiology of the syndrome

SOME CONSIDERATIONS

• Inaccuracies in detecting true proteinuria

• Pathophysiology of pre-eclampsia – maternal liver, kidneys, brain, coagulation

– placental blood flow

Endothelial function / Inflammation

Place

ntation

Place

ntation

Normal

Abnormal

Normal

Abnormal

Normal

Abnormal

No Pre-eclampsia No IUGR

Pre-eclampsia (Late) No IUGR

No Pre-eclampsia IUGR

Pre-eclampsia (Early) IUGR

Pre-eclampsia IUGR

Back to ISSHP 2001

• ASSHP / NHBPEP – Chronic hypertension

– Gestational hypertension

– Pre-eclampsia

– Superimposed Pre-eclampsia

• ASSHP definite symptoms and signs

• NHBPEP highly suggestive

ISSHP 2001

Systolic blood pressure

Proteinuria??

Symptoms and signs

<20 week’s gestation not pre-eclampsia

Symptoms and signs pre-eclampsia

>20 week’s gestation surveillance

NICE

2013

ACOG (2013)

• Preeclampsia – eclampsia

• Chronic hypertension

• Chronic hypertension with superimposed preeclampsia

• Gestational hypertension

ACOG Pre-eclampsia

• Platelets < 100000/microliter • Impaired liver function • New renal insufficiency • Pulmonary edema • Visual disturbances

NOT IUGR

ISSHP 2014

NO CONSENSUS

PROTEINURIA??

WHY CHANGE?

• Inaccuracies in the measurement of proteinuria

• Mercury sphygmomanometry

• Potential for severe maternal complications in de novo hypertension without proteinuria

• White coat hypertension

• Biomarkers, particularly angiogenic factors

• Number of scholarly guidelines

REVISED CLASSIFICATION (2013)

Chronic hypertension

Gestational hypertension

Pre-eclampsia (de novo / superimposed)

White coat hypertension

HYPERTENSION

• 140/90 mm Hg

• Mercury sphygmomanometry gold standard – Aneroid - may be inaccurate

– Automated device

• Minimum of two BP measurements to diagnose hypertension

• Remain elevated after overnight rest in hospital or in a day assessment unit.

CHRONIC HYPERTENSION

• Pre-pregnancy / First trimester

– ESSENTIAL

– SECONDARY

Pre-eclampsia / Gestational hypertension

• New hypertension after 20 weeks’ gestation

• If the earlier blood pressure is unknown ??

–Pre-eclampsia

–Hypertension

UNCLASSIFIED

PRE-ECLAMPSIA

• Hypertension plus one of

1. Proteinuria

2. Other maternal organ dysfunction

3. Uteroplacental dysfunction NOT SEVERE

NOT EARLY/LATE

PRE-ECLAMPSIA

• 1. Proteinuria

– spot urine protein/creatinine >30 mg/mmol [0.3 mg/mg]

– >300 mg/day or at least 1 g/L

– ‘2 + ’ on dipstick testing

PRE-ECLAMPSIA

• 2. Other maternal organ dysfunction: – Renal insufficiency (creatinine >90 umol/L)

– Liver involvement

• elevated transaminases – at least twice upper limit of normal

• ± right upper quadrant or epigastric abdominal pain

PRE-ECLAMPSIA

• 2. Other maternal organ dysfunction: – Neurological complications (examples include

eclampsia, altered mental status, blindness, stroke, or more commonly hyperreflexia when accompanied by clonus, severe headaches when accompanied by hyperreflexia, persistent visual scotomata)

– Haematological complications (thrombocytopenia – platelet count below 150,000/dL, DIC, haemolysis)

PRE-ECLAMPSIA

• 3. Uteroplacental dysfunction • Foetal growth restriction

Gestational hypertension

• De novo hypertension after 20 weeks gestation

• No abnormality defining pre-eclampsia

• Usually benign

• 25% Pre-eclampsia – Before 32 weeks

HYPERTENSION WITHOUT PROTEINURIA

• Laboratory investigations required

• Referral of patients local decision making strategies

Superimposed pre-eclampsia

• Commonly have impaired renal function and/or proteinuria

• Diagnosed when another feature develops – new onset liver dysfunction – thrombocytopenia – neurological features

• Diagnostic test such as serum / urine angiogenic or inflammatory factors

WHITE-COAT HYPERTENSION

• 25%

• Normal 24 h ABPM in the first half of pregnancy

• Regular home blood pressure assessments

• No antihypertensives before 160–170/110 mmHg.

• Limited studies on outcome

– 50% gestational hypertension / pre-eclampsia??

– risk of pre-eclampsia doubled

REVISED CLASSIFICATION (2013)

Chronic hypertension

Gestational hypertension

Pre-eclampsia (de novo / superimposed)

White coat hypertension