Hypertensive disorder in pregnancy

Hypertension

 Half of these hypertensive-related deaths were deemed preventable (Breg, 2005)

 Second most common cause of maternal mortality and an important cause of perinatal
mortality and morbidity
 Prevalent in young women of low socio- economic status without prenatal care
Hypertension in pregnancy
 Blood Pressure of = or > 140/90 mmHg
 Blood Pressure must be manifested on at least two occasions taken six hours
apart
Risk factor

 Primiparity: only well accepted risk factor

 Immunologic factors
○ Failure of trophoblasts invasion as a rejection by the maternal body towards
the
 trophoblast antigens
 Previous pregnancy complicated with preeclampsia / eclampsia/ HELLP
 Family history of preeclampsia
 Age under 20 or over 35 years old
 Body mass index
○ Higher BMI increases risk of preeclampsia
 Underlying medical condition
○ Vascular, connective or renal disorders
 Pregnancy related condition
○ Conditions with increased trophoblast mass like hydrops fetalis, multifetal
gestation, H-mole
 Primipaternity
○ Immunologic habituation to paternal antigens trough contact between the
sperm and the female genital tract
○ New sexual partner will expose the mother to new paternal antigens to
which she may not be tolerant
○ A man who has fathered a preeclamptic pregnancy in a different woman
 Sexual cohabitation
○ Longer period of sexual cohabitation with the father before conception
reduces risk of preeclampsia
 Maternal infection
○ Urinary tract infection and periodontal disease
 Gestational age at delivery in the first pregnancy
○ Previous preterm or SGA increases the risk of preeclampsia
 Socioeconomic status
 ○ Poor social status due to problems in access to prenatal care
Classification of hypertension in pregnancy
 Chronic Hypertension
 Gestational Hypertension
 Pre-eclampsia
 Chronic Hypertension with Superimposed Pre- eclampsia
 Eclampsia

CHRONIC HYPERTENSION

 Blood Pressure of ≥140/90 mmHg

 Prior to pregnancy
 Before 20 weeks age of gestation (or prior to pregnancy) and
 Persists after 12 weeks postpartum
Renal Changes

 Renal perfusion and GFR are reduced

 Glomerular endotheliosis blocking filtration barrier
 Increase endothelial leak causing elevated urine sodium
 Increase excretion of urinary podocytes

Pre Eclampsia
Hypertension occurring after 20 weeks age of gestation with or without proteinuria
proteinuria is an objective marker
Evidence of multiorgan involvement may include
 Thrombocytopenia
 Renal dysfunction
 Hepatocellular necrosis
 Central nervous system perturbations
 Pulmonary edema

GESTATIONAL HYPERTENSION
Hypertension with no proteinuria and occurs after 20 weeks age of
gestation or postpartum
A temporary diagnosis during pregnancy which has to be confirmed 12 Weeks
afterdelivery
Transient Hypertension: If Blood Pressure is normal
 Chronic Hypertension: If Hypertension persists

PRE-ECLAMPSIA WITH SEVERE FEATURES

 Blood Pressure of ≥160mmHg (Systolic Pressure) or ≥110 mmHg (Diastolic

Pressure)
 Either one of the following:
o Decreased Platelet count/Thrombocytopenia
o Oliguria
o Increased Serum Creatinine
o Congestive Heart Failure
o Pulmonary Edema
o Epigastric/Right upper quadrant pain
o Elevated liver enzymes
o Persistent headache
o Visual or Cerebral disrurbances
PRE ECLAMPSIA SUPERIMPOSED ON CHRONIC HYPERTENSION
Chronic underlying hypertension blood pressures
>140/90 mm Hg
before pregnancy or before 20 weeks’ gestation, or both
It also tends to be more severe and more often is accompanied by fetal-growth
restriction.
Signs and Symptoms:
 New onset proteinuria
 Various End Organ Dysfunction or Pre- eclampsia
Incidence and Risk Factors
 Young and Nulliparous women
 Genetic predisposition
 Race and Ethnicity
 SLE
 Prior Stillbirth
 CKD
 ART
 Prior Abruptuon
 Diabetes
 Prior preeclampsia
 CHTN
ECLAMPSIA
Diagnosed pre-eclampsia with conclusive seizure
 Convulsion is not caused by coincidental neurologic disease
Preeclampsia Syndrome
Etiology
● Placental implantation with abnormal trophoblastic invasion of uterine vessels
● Immunologic maladaptive tolerance between maternal, paternal (placental) and fetal
tissues
● Maternal maladaptation to cardiovascular or inflammatory changes of normal pregnancy
● Genetic factors including inherited predisposing genes and epigenetic influences
Prevention
● High dose calcium
○ 1.5 to 2 grams/day before 32 weeks (low & high risk women)
● Low dose aspirin
○ 60-80 mg/day to start on the 2nd trimester
○ Monitor platelet and coagulation profiles
○ Monitor fetal ductus arteriosus and AFV by ultrasound
HELLP Syndrome
There is no universally accepted strict definition of HELLP syndrome, and thus its
incidence varies by investigator.
 HELLP syndrome complications
 eclampsia
 placental abruption
 acute kidney injury
 pulmonary edema
 Stroke
 hepatic hematoma
 coagulopathy
 acute respiratory distress syndrome
 sepsis were other serious complications
Women with preeclampsia and HELLP syndrome typically have worse outcomes than
preeclamptic women without the HELLP constellation

 Things to consider for hypertension in pregnancy

 Age of gestation
 o Once 34 weeks AOG is reached, delivery is recommended for maternal safety
o Severity of disease
 Eclampsia mandates delivery regardless AOG
 Severe preeclampsia patients are usually delivered once 34 weeks AOG is achieved
 Conservative measurement at <34 weeks in high-risk centers
 Mild preeclampsia can be managed as out-patient
o Maternal Evaluation
 Regular monitoring of multiple-organ symptoms, vital signs, body weight, input &
output, laboratory tests
o Fetal status
 Regularly monitor fetal movements, NST or CST, BPP, fetal growth,
 doppler studies
 Steroids
o Nursery capability for 34 weeks babies