Hypertensive Disorders in Pregnancy

Woman’s Hospital School of Medicine Woman’s Hospital School of Medicine Zhejing UniversityZhejing University

He jinHe jin

Special

Gestational hypertension ；Preeclampsia; Eclampsia; Chronic hypertension in pregnancy (either essential or secondary to renal disease ， endocrine disease, or other causes); Pre-eclampsia superimposed upon chronic hypertension Transient hypertension

Include:

1.Transient hypertension is the development of hypertension after midpregnancy or in the first 24 hours postpartum without other signs of preeclampsia or preexisting hypertension.2.This condition is often predictive of the later development of essential hypertension. 3.Transient hypertension is a retrospective diagnosis and, if uncertainty exists regarding the diagnosis, these patients should be managed as if they had preeclampsia.

Transient hypertension

Overview

   1 、 onset after 20 weeks gestation 2 、 Incidence rate ： about 7-12% （ china 9.4％） 3 、 specially occur in pregnancy 4 、 A group of symptoms （ albuminuria, hypertensio

n ） 5 、 Maternal MODS, perinatal fetal poor prognosis and

death

Tensity Age Social status Climate changes abruptly Fat High tension of uterus ： multiplets 、 hydramnios Family history Bad birth history Complications ： DM 、 chronic nephritis…

High-risk factors

Chesley described preeclampsia as a“disease of theories”, because the cause is unknown. Some theories include:1 、 Genetic susceptibility hypothesis2 、 Immune maladaptation hypothesis3 、 Placental perfusion or Ischemia Hypotheses

4 、 Oxidative stress hypotheses

5 、 Endothelial cell injury ： explains many of the clinical findings in preeclampsia6 、 The lack of a variety of nutrition materials(such as

trace elements …….)

Cause

Spasm of vessels

Vessel stenosis

Higher periphery resistance

Blood pressure elevate

Injury of endotheliocyte

Proteinuria Edema Hypertension

Pathology

These effects are separated into

maternal and fetal consequences;

however, these aberrations often

occur simultaneously.

Pathophysiological changes

Basic diseases: Systemic small artery spasm Brain, heart, lung, liver, kidney and other vital

organs severe ischemia Cause heart, liver and kidney failure,

pulmonary edema and cerebral edema, and even convulsions, coma;

Placental abruption and placental dysfunction,

Activated clotting process, leading to DIC.

Clinical manifestations

After 20 weeks of pregnancy hypertension, edema, proteinuria. Light may have mild symptoms or dizziness,

blood pressure increased slightly with edema or mild proteinuria

Severe headache, vertigo, nausea, vomiting, persistent right upper abdominal pain, blood pressure increased significantly, increased proteinuria, edema, and even coma and convulsions

Diagnosis Based on history, clinical manifestations, signs and laboratory e

xaminations to make a diagnosis, and should watch for complic

ations and clotting mechanism.

1. History

2. Hypertension

3. Urine protein

4. Edema

5. Auxiliary examination: blood test, liver and kidney function tes

t, urine examination, fundus examination, invasive hemodynami

c monitoring, ECG and echocardiography

Dependent （下垂） edema is a normal finding in pregnancy

Undependent edema of the hands and face present upon

Morning arising is considered pathologic Weight gain in excess of 2kg/week or particularly s

udden weight gain over 1 or 2 days should raise the suspicion of preeclampsia

Preeclampsia may occur without edema. （ 39% of eclamptic patients in one series had no edema. ）

＋———＋＋＋＋

Clinical findings——Edema

Hypertension is the most important criterion for the diagnosis of preeclampsia

That too may occur suddenly Many young primigravidas have 100-110/60-70m

mHg duing the second trimester. An increase of 15mmHg or 30mmHg should be considered ominous

The blood pressure is often quite labile.It usually falls during sleep in patients with mild preeclampsia and chronic hypertension

But in patients with severe preeclampsia ， blood pressure may increase during sleep, eg, the most severe hypertion may occur at 2:00AM

Clinical findings——Hypertension

Proteinuria is the last sign to develop Eclampsia may occur without proteinuria.

Sibai and associates found no proteinuria will have glomeruloendotheliosis on kidney biopsy

Proteinuria in preeclampsia is an indicator of fetal jeopardy

The incidence of SGA infants and perinatal mortality is markedly increased in patients with proteinuric preeclampsia

24H urine protein have more meaningful

Clinical findings——Proteinuria

Preeclampsia-eclampsia is a multisystem disease with varying clinical presentations.

One patient may present with eclamptic seizures,

another with liver dysfunction and intrauterine growth retardation,

another with pulmonary edema, stillanother with abruption placenta and rena

l failure

Clinical findings——Differing clinical picture

Classification

Gestational PreeclampsiaGestational Preeclampsia

PreeclampsiaPreeclampsia

EclampsiaEclampsia

SuperimposedSuperimposed preeclampsia on preeclampsia on

chronic hypertensionchronic hypertension

Chronic hypertension in pregnChronic hypertension in pregnancyancy

Gestational hypertension

1、 Blood pressure≥140/90mmHg

first onset in gestational period and recover within 12 weeks post partum

2、 Urine protein negative

3、 Patients may superimpose upper abdo- minal pain and thrombocytopenia

4、 Final diagnosis should be made post partum

Diagnostic thinking: confirmed Maternal blood pressure during pregnancy for the first time ≥ 140/90mmHg, but the urine protein (-) Throughout pregnancy without the development of preeclampsia

Blood pressure returned to normal at 12 weeks postpartum

1 、 Proteinuria ≥300mg/24 hours or ≥1+ dipstick

2 、 BP≥140/90mmHg after 20 weeks’ gestation

3 、 May be associated with headache ， visual disorder ， upper abdominal pain

•Early onset preeclampsia (<34 weeks of gestation )

Preeclampsia

Diagnostic thinkingDiagnostic thinking Urine protein appears: an important basis for preeclampsia Urine protein appears: an important basis for preeclampsia The result: (PIH) contraction of small blood vessels in the body The result: (PIH) contraction of small blood vessels in the body

caused reduction in renal blood flow caused reduction in renal blood flow Marked Marked ：： damage to renal function in pregnant womendamage to renal function in pregnant women

severe preeclampsia

1、 Systolic pressure≥160～ 180mmHg， or diastolic pressure≥110mmHg

2、 Urine protein in 24 hours >5g

3、 DIC

4、 Oliguria， urine volume in 24 hours <500ml

5、 Pulmonary edema

6、Microangiopathic hemolysis

7、 Thromocytoplets(<10,000/L)

8、 Dysfunction of liver

9、 FGR ， oligohydramnios

10、 Headache， visual disorder， upper abdominal pain

11、 Hepatic subcapsular hematoma

12 、 Cerebral vascular accident

Eclampsia

Seizures that cannot be attributed to other

causes in a woman with preeclampsia

Diagnostic thinking  Seizure: on the basis of preeclampsia, or associated with coma

SuperimposedSuperimposed preeclampsia on preeclampsia on chronic hypertensionchronic hypertension

New-onset proteinuria ≥300mg/24 hours in

hypertensive women ， but no proteinuria

before 20 weeks’ gestation ；A sudden increase in proteinuria or blood

pressure or platelet count< 100,000 /mm3 in

women with hypertension and proteinuria

， before 20 weeks’ gestation

Diagnostic thinkingDiagnostic thinking preeclampsiapreeclampsiaHypertensionHypertension :Before pregnancy or before 20 weeks Before pregnancy or before 20 weeks Blood pressure was still high after 12 weeks postpartum Blood pressure was still high after 12 weeks postpartum

Chronic hypertension in Chronic hypertension in pregnancypregnancy

1 、 BP≥140/90mmHg before pregnancy or

diagnosed before 20 weeks’ gestation2 、 Hypertension first diagnosed after 20

weeks’ gestation and persistent after 12

weeks’ postpartum

Diagnostic thinkingDiagnostic thinking Hypertension Hypertension Before pregnancy or before 20 weeks Before pregnancy or before 20 weeks Blood pressure was still high after 12 weeks postpartum Blood pressure was still high after 12 weeks postpartum

Differential diagnosis

According to clinical manifestations. PIH Chronic nephritis with pregnancy Eclampsia Epilepsy

Encephalitis

Brain tumor

Rupture of cerebral vascular malformations

Diabetic hyperosmolar coma

Hypoglycemic coma

Complications of mother

Heart failureCerebrova- scular accidentPlacenta abruptionDICRenal failureHELLP’S syndromePostpartum hemorrhage

More frequently in severe type

Fetus ： FGR fetal distress fetal death neonatal asphyxia

Complications of fetus

Termination of pregnancy with the least possible trauma to mother and fetus

Birth of an infant who subsequently thrives

Complete restoration of health to the mother

Basic management objectives

A systematic evaluation

Detailed examination Weight on admittance and every day thereafter. Analysis for proteinuria at least every 2 days thereafte

r Blood pressure readings in sitting position with anapp

ropriated-size cuff every 4 hours, except betweenmidnight and morning

Measurements of plasma or seru creatinine,hematocrit, platelets, and serum liver enzymes

Frequent evaluation of fetal size and amnionic fluid volume.

Management

Antispasmodic Lowers blood pressure Timely termination of pregnancy There are indications those fluid

expansion and diuretic Monitoring and promoting fetal growth

and development

General treatment

Rest The state of the mother and fetus

should be closely monitor Intermittent oxygen Balanced diet

conscious-sedation

Diazepam (valium):– relatively strong sedative effect, anticonvul

sant, muscle relaxant effect – on the fetus and newborn: less affected

Lytic cocktail:– extensive inhibition of the nervous system,

contribute to spasm blood pressure, control of eclampsia convulsions

Spasmolysis

The main method :treatment of eclampsia and severe preeclampsia

Relieve angiospasm Relieve symptoms Prevent seizures. Magnesium sulfate often as the first pref

erred drug

Depressurization

Objective: – to extend the gestational age– changing perinatal outcomes

Principles: non-toxic side effects on the fetus does not affect cardiac output, renal blood flow and placental perfusion, sudden drop in blood pressure can reduce excessive.

Depressurization

Indications: systolic blood pressure ≥ 160 or diastolic blood pressure 110mmHg or mean arterial blood pressure ≥

110mmHg essential hypertension those with

antihypertensive drugs before pregnancy

Depressurization

Control of Seizures Controln of Hypertension Hydralazine Labetalol Nifedipine Sodium nitroprusside

fluid expansion

Generally not in favor of expansion Only for severe hypoproteinemia, anemi

a Albumin, plasma, whole blood

Diuresis

Generally do not advocate Only for:

– pulmonary edema– systemic edema persons– acute heart failure – excessive blood volume potentially

associated with pulmonary edema

Effective measures Indications : severe preeclampsia after active treatment 24 to

48 hours were no noticeable improvement Severe preeclampsia has more than 34 weeks ge

stational age Severe preeclampsia and gestational age less tha

n 34 weeks, but placental dysfunction, the fetus

has matured

pregnancy termination

pregnancy termination

Indications : Severe preeclampsia, gestational age less th

an 34 weeks– placental dysfunction, the fetus has not matured

• used dexamethasone to promote fetal lung maturity

control 2 hours after eclampsia may consider termination of pregnancy

Mild Preeclampsia

Treatment Of Mother

Assessment of Fetal Status

Severe Preeclampsia

The goals of management are ：

Prevention of convulsions Control of maternal blood pressure Initiation of delivery 

pregnancy termination

Blood pressure consistently higher than 100 mmHg diastolic in a 24-h period or confirmed higher than 110 mmHg

Rising serum creatinine Persistent or severe headache Epigastric pain Abnormal liver function tests Thrombocytopenia HELLP syndrome Eclampsia Pulmonary edema Abnormal antepartum fetal heart rate testing SGA fetus with failure to grow on serial ultrasound examinations

Mode of delivery Vaginal delivery:

– a stable condition– cervical ripening

Cesarean section: – obstetric indication– cervical conditions are not mature enough in the

short term vaginal deliveries– induction failure– significantly lower placental function– fetal distress

The treatment principle of eclampsia The main cause : maternal and fetutal

mortality Control seizures Correct hypoxia and acidosis Control of blood pressure Termination of pregnancy after control s

eizure

anticipation

Conducted in second trimester– close follow-up should be positive

Mean arterial pressure Roll over test Rheology Test Determination of urinary calcium

Hellp syndrome

Diagnostic criteria– hemolysis, elevated liver enzymes, and thrombocy

topenia.

Principles– early diagnosis – early treatment– timely termination of pregnancy– reduce fetal and maternal mortality – active treatment PIH