Gestational

Hypertension
SIM, Ranielle S. | A3-1
HYPERTENSIVE DISORDERS
Complicate 5 to 10% of all

pregnancies

Deadly triad -

hypertension, hemorrhage,

and infection

Most dangerous -

preeclampsia
4 TYPES OF HYPERTENSIVE DISORDERS
1. GESTATIONAL HYPERTENSION
2 . PREECLAMPSIA AND ECLAMPSIA SYNDROME

3 . CHRONIC HYPERTENSION OF ANY ETIOLOGY

4 . PREECLAMPSIA SUPERIMPOSED ON CHRONIC

HYPERTENSION

Importance: this classification gives proper distinction to preeclampsia

syndrome from other hypertensive disorders

DIAGNOSIS OF HYPERTENSIVE
DISORDERS
BP > 140 mmHg (systolic) and 90 mmHg (diastolic)

Previously, incremental increases of 30 mm Hg systolic or 15 mm Hg

diastolic from midpregnancy blood pressure values had also been

used as diagnostic criteria, even when absolute values were

<140/90 mm Hg --> this is no longer recommended

Women who have a rise in pressure of 30 mm Hg systolic or 15 mm

Hg diastolic should be observed more closely as eclamptic

seizures m a y d e v e l o p
"Delta hypetension" - Sudden rise in mean arterial pressure later

in pregnancy
 BP ≥ 140/90 mmHg for the first time after mid-

pregnancy and protenuria is NOT identified

Almost half of the women subsequently develop

GESTATIONAL
preeclampsia syndrome

Includes presentations such as headaches or

HYPERTENSION
epigastric pain, proteinuria, and thrombocytopenia.

Dangerous for mother and fetus to ignore

10% of eclamptic seizures develop before overt

proteinuria can be detected

Reclassified by some as transient hypertension if

evidence for preeclampsia does not develop and the

blood pressure returns to normal by 12 weeks postpartum

PREECLAMPSIA Pregnancy-specific syndrome that can affect

SYNDROME virtually every organ system. And, although

preeclampsia is much more than simply

gestational hypertension with proteinuria,

appearance of proteinuria remains an important

diagnostic criterion
PREECLAMPSIA
SYNDROME
PREECLAMPSIA
The more profound the signs and symptoms, the

less chance they are temporized, and more

SYNDROME likely there will be a requirement of delivery

Differentiation between nonsevere and severe

gestational hypertension or preeclampsia can

be misleading because what might be

apparently mild disease may progress rapidly to

severe disease
 ECLAMPSIA
PREECLAMPSIA
SYNDROME Convulsions

another cause
that cannot be attributed to

General seizures that may appear before,

during, or after labor

Approximately 10% of women do not develop

seizures until after 48 hours postpartum

PREECLAMPSIA SUPERIMPOSED ON
CHRONIC HYPERTENSION
Chronic underlying hypertension is diagnosed in women with

documented blood pressure 140/90 mm Hg before pregnancy or

before 20 weeks’ gestation, or both

Create problems with diagnosis and management who are

first seen after midpregnancy

During the third trimester, as blood pressures return to their

originally hypertensive levels, it may be difficult to determine

whether hypertension is chronic or induced by pregnancy

PREECLAMPSIA SUPERIMPOSED ON
CHRONIC HYPERTENSION
In some women with chronic hypertension, their blood pressure

increases to obviously abnormal levels, and this is typically after

24 weeks

New-onset or worsening baseline hypertension and is

accompanied by new-onset proteinuria or other findings

Commonly develops earlier in pregnancy

Tends to be more severe and often accompanied by fetal-growth

restriction
ETIOPATHOGENESIS
 Preeclampsia

c. Have preexisting conditions

a. Exposed to chorionic villi
of endothelial cell activation
for the 1st time
or inflammation such as

diabetes or renal or

cardiovascular disease

b. Exposed to a

superabundance of chorionic d. Genetically predisposed to

villi, as with twins or hypertension developing during
hydatidiform mole pregnancy
 Eclampsia

a. Placental implantation c. Maternal maladaptation to

with abnormal trophoblastic cardiovascular or inflammatory

invasion of uterine vessels changes of normal pregnancy

b. Immunological

maladaptive tolerance d. Genetic factors including

between maternal, paternal inherited predisposing genes

(placental), and fetal tissues and epigenetic influences

PATHOGENESIS

VASOSPASM ENDOTHELIAL CELL INCREASED PRESSOR

Activation of endothelial INJURY RESPONSES

cells result to vascular Damaged or activated Increased vascular reactivity

constriction with increased endothelial cells produce to infused norepinephrine and

resistance and subsequent less nitric oxide and secrete angiotensin II

hypertension substances tht promote

coagulation and increase

sensitivity to vasopressors
PATHOGENESIS

PROSTAGLANDINS NITRIC OXIDE

Endothelial prostacyclin (PGI2) production is Potent vasodilator synthesized from l-

decreased in preeclampsia arginine

Increased sensitivity to infused angiotensin II Inhibition may cause increase in mean

and thus, vasoconstriction arterial pressure, decrease heart rate, and

reverese pregnancy-induced refractoriness

to vasopressors

No universally accepted definition of

this syndrome and incidence varies by

the investigator HELLP

Increased likelihood of SYNDROME
hepatic hematoma and

rupture

Other side effects include

stroke, coagulopathy,

acute respiratory distress

syndrome, and sepsis

PREVENTION
PREECLAMPSIA
SYNDROME
PREVENTION
PREECLAMPSIA
HELLP
SYNDROME
Various strategies used to prevent or modify

preeclampsia

In general,
severity

none of
have

these
been

has been
evaluated.

found to
SYNDROME
be convincingly and reproducibly effective.

1. Dietary and Lifestyle Modifications

a. Low-Salt Diet

b. Calcium supplements

c. Fish Oil supplements

2. Antihypertensive Drugs
Chlorothiazide
PREVENTION
PREECLAMPSIA
HELLP
3. Antioxidants
SYNDROME
Vitamins C, D, and E SYNDROME
4. Statins
5. Antithrombotic agents
6. Low-Dose Aspirin
Oral doses of 50 - 150 mg daily

7. Low-Dose Aspirin + Heparin

MANAGEMENT
Based on severity, gestational age, and presence PREECLAMPSIA
HELLP
SYNDROME
SYNDROME
of preeclampsia. With preeclampsia, management

varies with the severity of endothelial cell injury

and multi-organ dysfunction

Task Force of the American College of

Obstetricians and Gynecologists recommends

more frequent prenatal visits if preeclampsia is

“suspected"

Increases in systolic and diastolic blood pressure

can be either normal physiological changes or

signs of developing pathology

 Basic Management Objectives for
Pregnancy Complicated by
Preeclampsia: PREECLAMPSIA
HELLP
SYNDROME
1. Termination of pregnancy

possible trauma to mother and fetus

with least
SYNDROME
2. Birth of infant who subsequently thrives

3. Complete restoration of health to the

mother

One of the most important clinical questions for successful

management is precise knowledge of fetal age

EARLY DIAGNOSIS OF
PREECLAMSIA

Traditionally, frequency of prenatal visits is

increased during the third trimester helps in

the early detection of preeclampsia

Women without overt hypertension, but in

whom early developing preeclampsia is

suspected during routine prenatal visits, are

seen more frequently

Protocol for women with new-onset

diastolic blood pressure is to have return

visits at 7-day intervals

>8​
0 mm Hg but <90 mm Hg
​

Sudden abnormal weight gain of more

than 2 pounds per week

DIURETICS
1
Thiazide diuretics

Sulfonamides → 1st group to

successfully treat chronic

hypertension

Loop-acting diuretics

Furosemide
Commonly used in nonpregnant

hypertensives

Provide sodium and water diuresis with

volume depletion
ADRENERGIC-BLOCKING
AGENTS 2
2nd class of effective

anithypertensives

Peripherally acting adrenergic

receptor blockers

Propranolol, metoprolol,
atenonol
Labetalol - most commonly used

Centrally acting adrenergic receptor

blockers

Clonidine and methyldopa

VASODILATORS
3
Hydralazine
Relaxes arterial smooth muscle and

used parentally to treat severe

peripartum hypertension

Oral hydralazine monotherapy

Used for chronic hypertension (no

longer generally used due to weak

antihypertensive effects and

resultant tachycardia)

Effective adjuct for long-term use with

other antihypertensives
CALCIUM-CHANNEL
BLOCKING AGENTS 4
Divided into 3 subclasses based on

their modificatioin of calcium entrol

into cells and interference with

binding sites on voltage-dependent

calcium channels

Nifedipine (dihydropyridiine),

Verapamil (phenylalkyl amine

derivative)

Negative inotropic effects

Theoretically, may potentiate actions

of magnesium sulfate
ANGIOTENSIN-CONVERTING
ENZYME INHIBITORS 5
Inhibit the conversion of antiotensin-1

to the potent vasocontrictor

angiotensin-II

Can cause severe fetal malfomations

when given in the second and third

trimesters

Ex. hypocalvaria and renal

dysfunctioin

Studies have also suggested that they

have teratogenic effects and thus,

NOT recommended during pregnancy

ANGIOTENSIN-
RECEPTOR BLOCKERS 6
Similar action to ACEIs but instead of

blocking production of angiotensin-II,

they inhibit the binding to its receptor

Presumed to have the same fetal

effects as ACEIs, hence is also

contraindicated during pregnancy

 Complicated by generalized tonic-clonic seizures
that increases the risk to both mother and fetus

ECLAMPSIA Major maternal complications include: placental

abruption, neurological deficits, aspiration
pneumonia, pulmonary edema, cardiopulmonary
arrest, and acute renal failure

1% of these women die

 MANAGEMENT
Magnesium sulfate is highly effective in preventing convulsions

ECLAMPSIA
in women with preeclampsia and stopping them in women with
eclampsia

1. Control of convulsions using an intravenously administered

loading dose of magnesium sulfate that is followed by a
maintenance dose, usually intravenous, of magnesium sulfate
2. Intermittent administration of antihypertensive medication to
lower blood pressure whenever it is considered dangerously high
3. Avoidance of diuretics unless there is obvious pulmonary edema,
limitation of intravenous fluid administration unless fluid loss is
excess, and avoidance of hyperosmotic agents
4. Delivery of the fetus to acheive a remission of preeclampsia
 MAGNESIUM SULFATE TO CONTROL
CONVULSIONS

ECLAMPSIA Administered parenterally

preeclampsia and eclampsia
in severe cases of

Avoids producing central nervous system

depression in either mother or fetus
May be given intravenously by continuous infusion
or intramuscularly by intermittent injection
Given during labor and 24-hrs postpartum
NOT for treatment of hypertension
 PHARMACOLOGY AND TOXICOLOGY
Magnesium sulfate USP is

·
ECLAMPSIA
MgSO4 7H2O and not simple

MgSO4.

Contains 8.12 mEq per 1g

Parenterally administered

magnesium is cleared almost

totally by renal excretion,

intoxication is unusual when the

glomerular filtration rate is

normal or only slightly

decreased
THE END.
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