Hypertensive Disorder

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Hypertensive Disorder Complicating
Pregnancy
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Overview
   1?onset after 20 weeks gestation   2?Incidence
rateabout 7-12(china 9.4) 3?specially occur
in pregnancy 4?A group of symptoms
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Hypertensive states in pregnancy

• Include
• 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

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Transient hypertension
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.
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Cause

Chesley described preeclampsia as adisease of
theories, because the cause is unknown.
Some theories include 1?Genetic susceptibility
hypothesis 2?Immune maladaptation
hypothesis 3?Placental perfusion or Ischemia
Hypotheses 4?Oxidative stress hypotheses 5?Endothe
lial cell injury explains many of the clinical
findings in preeclampsia 6?.
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High-risk factors

• Tensity
• Age
• Social status
• Climate changes abruptly
• Fat
• High tension of uterusmultiplets?hydramnios
• Family history
• Bad birth history
• ComplicationsDM?chronic nephritis

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Pathology
Blood pressure elevate
Higher periphery resistance
Vessel stenosis
Spasm of vessels
Injury of endotheliocyte
Proteinuria
Edema
Hypertension
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These effects are separated into maternal and
fetal consequences however, these aberrations
often occur simultaneously.
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Clinical findingsEdema

• Dependent(??) 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
  sudden 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.)

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Clinical findingsHypertension

• Hypertension is the most important criterion for
  the diagnosis of preeclampsia
• That too may occur suddenly
• Many young primigravidas have 100-110/60-70mmHg
  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 200AM

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Clinical findingsProteinuria

• 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

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Clinical findingsDiffering clinical picture

• 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 renal
  failure

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Classification

• Gestational hypertension
• Preeclampsia
• Eclampsia
• Preeclampsia superimposed upon
• chronic hypertension
• Chronic hypertension

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Gestational hypertension
1?Blood pressure140/90mmHg 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
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Preeclampsia

• Minimum criteria
• 1?Proteinuria 300mg/24 hours or 1 dipstick
• 2?BP140/90mmHg after 20 weeks gestation

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Preeclampsia
Increased certainty of preeclampsia

• BP160/110mmHg
• Proteinuria 2g/24 hours or 2 dipstick
• Cr level of blood gt106 umol/L
• Blood platelet lt100109/L
• Persistent headache or other cerbral or visual
  disturbance
• Persistent epigastric pain

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Eclampsia
Seizures that cannot be attributed to other
causes in a woman with preeclampsia
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Pre-eclampsia superimposed upon
chronic 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 countlt 100,000 /mm3 in
• women with hypertension and proteinuria
• ,before 20 weeks gestation

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Chronic Hypertension
1?BP140/90mmHg before pregnancy or
diagnosed before 20 weeks gestation
2?Hypertension first diagnosed after 20
weeks gestation and persistent after 12
weeks postpartum
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Extremely severe preeclampsia
1?Systolic pressure160180mmHg,or diastolic
pressure110mmHg 2?Urine protein in 24 hours
gt5g 3?DIC 4?Oliguria,urine volume in 24 hours
lt500ml 5?Pulmonary edema 6?Microangiopathic
hemolysis 7?Thromocytoplets(lt10?/L) 8?Dysfunction
of liver 9?FGR ,oligohydramnios 10?Headache,visua
l disorder,upper abdominal pain
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Diagnosis

• Clinical symptoms and physical signs
• Auxiliary examinations

Differential diagnosis

• According to clinical manifestations.

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Complications of mother

• Heart failure
• Cerebrova- scular accident
• Placenta abruption
• DIC
• Renal failure
• HELLPS syndrome
• Postpartum hemorrhage

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Complications of fetus

• Fetus
• FGR
• fetal distress
• fetal death
• neonatal asphyxia

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Basic management objectives

• 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

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A systematic evaluation

• Detailed examination
• Weight on admittance and every day thereafter.
• Analysis for proteinuria at least every 2 days
  thereafter
• Blood pressure readings in sitting position with
  anappropriated-size cuff every 4 hours, except
  betweenmidnight and morning
• Measurements of plasma or seru creatinine,hematocr
  it, platelets, and serum liver enzymes
• Frequent evaluation of fetal size and amnionic
  fluid volume.

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6 principles

• Spasmolysis
• conscious-sedation
• Depressurization
• fluid expansion
• Diuresis
• pregnancy termination

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Mild Preeclampsia

• Treatment Of Mother
• Assessment of Fetal Status

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Severe Preeclampsia

• The goals of management are
• Prevention of convulsions
• Control of maternal blood pressure
• Initiation of delivery
•  

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Eclampsia

• Control of Seizures
• Controln of Hypertension
• Hydralazine
• Labetalol
• Nifedipine
• Sodium nitroprusside

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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

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