Hypertensive Disorders in

Pregnancy .

Direct causes of Maternal mortality

H
Hemorrhage
-

0 -

obstructed labour

u -

Unsafe abortion -

(infection ]
S
Sepsis
-

E-
Eclampsia (Hypertensive disorders ) Most Ghana
-

in common in
pregnancy
.

cause .

Pathophysiology of Pre-eclampsia .

During pregnancy the

spiral arteries
undergo vasodilatation to enhance utero
placental but in
-

,
perfusion
pre
-

eclampsia ,
the
spiral arteries become fibwsed leading to
poor perfusion of the placenta .

Man , fetal demise

his leads leads to endothelial

to the release pro-inflammatory which
dysfunction
-

of cytokines
.

The endothelial leads to

dysfunction vasoconstriction
kidney
-

retention the which

, of more salt
by
results in increased blood
an
pressure

There will also be local

Vasospwsm .

Changes in the
kidney Effects on the
Eye
-
Proteinuria -

Blurred vision

oliguria Flashing lights

-
-
.
 Effects on the lives

Inflammation
•

Hepatocellular injury
( stretching of
swelling → 12nA pain the
glisson 's capsule )
•
.

* Liver leads to elevated liver

injury enzymes

Leads to thrombi lot of platelets leading to

-

formation which consumes a

thrombocytopenia .

The blood
RBCs hit the dots the leading to hemolysis
-

in vessels .

HEKLP syndrome .

H
*
Hemolysis
-

E- Elevated

L liver
enzymes
-

L -

how

P -

Platelets

The blood to the

leakage of tconwtic
* vessels become permeable which leads
protein →
pressure
which causes

edema
generalized edema cerebral Headaches confusion (
Eclampsia)
.

→ seizures
, , ,

* You Do not need Proteinuria to

Diagnose Pre-eclampsia .

Cause
of Pre-eclampsia .

The cause is unknown .

Risk factors -

of pre elampsia
-

History of hypertensive disorders in

pregnancy
-

Extremes of
(< 20 and 735 )
age years
.

Family history pre-eclampsia

-

of

Pre Dm Gus chronic

existing hypertension
-

.
-

, ,

Anto dx anti
phospholipid
-

immune such as SLE

syndrome
-
-
.

,
 obesity
-

Blood vessel dx .

Male
*
partner tutors

•
New male
partner
.

Limited
sperm
•

exposure
.

Assisted WE
reproductive technology
-

g.

People with PTSD

-

Multiple
-

pregnancy
.

Multiparty .

*
Smoking is protective against Pre-eclampsia -

Dynamics of BP in
Pregnancy
1st stable levels due hormonal
trimester :
Bp remains
relatively or seduce
slightly compared to pre
-

pregnancy
to

vasodilatation -

2nd trimester :
Bp returns to the pre -

pregnancy
level or
they may slightly increase
-

3rd trimester :
Bp increases gradually but remains in the normal
range
.

disorders
Classification of
Hypertensive in
pregnancy
i. Gestational hypertension ÷

New onset
systolic Bp ≥ 140
mmHg and/or diastolic BP 790 mmHg at least different 4 hours
apart
-

on a occasions at

after noronotensive and

weeks
gestation
20
priory
in
of a woman .

-
No proteinuria
-
No
signs of severe features .
 Severe features :

1-
Thrombocytopenia
2- Renal insufficiency

3- Elevated liver enzymes

4. cerebral / visual
symptoms
5.
Pulmonary edema .

6.
Right upper quadrant pain .

2.
Pre-eclampsia
New onset ≥ 140
mmHg and / is DBP 90mm least different 4 hours
SBP 7-
Hg at occasions
apart after gestation in
•
on 2 20 weeks of

a
previously normotensive
patient and proteinuria .

In
*
patient without
proteinuria the
diagnosis of pre-eclampsia is still made if features of severe disease are
present
.

a
,
any

3-
Pre-eclampsia with severe Features

In a client with pre-eclampsia with the

presence of severe features .

Ibo for
i. e. SBP ≥
mmHg and ABP ≥ 110mn19
•

thrombocytopenia
•
Elevated liver
enzymes

Renal
insufficiency
•

Pulmonary edema

•
Persistent cerebral or visual
symptoms .

4. Eclampsia

A
generalized seizure in a
patient with
pre-eclampsia that cannot be attributed to
any
other cause -

Other causes
of seizures

Hypoglycemia
Cerebral malaria
-

Meningitis
-

Epilepsy
imbalance
-

Electrolyte
- Intracranial tumours
 TBI
-

Delirium tremens
-

Alcoholic intoxication

5. HELLP syndrome
it -

Hemolysis
E- Elevated

L -

Liver en
hymn

L -
low

p -

Platelets .

6. Chronic
Hypertension
Hypertension present prior to 20 weeks of gestation .

7. chronic hypertension with

superimposed pre-eclampsia .

chronic hypertension with proteinuria or severe

features

8. Post-partum pre-eclampsia
Diagnosed within 6 weeks
after delivery

9.
Post-partum pre-eclampsia with severe
features

b-
Post-partum eclampsia .

Eclampsia within 6 weeks after delivery .

1. 25
yn
old 31 weeks GA BP 130/185 mmHg Proteinuria .

, , ,

Causes of Proteinuria in
Pregnancy
t contaminated
sample bottle
Asymptomatic bacteriuria is defined as the presence of one or
2. UTI more species of bacteria growing in the urine at specified
quantitative counts (≥105 colony-forming units [CFU]/mL or ≥108
ma

3.
ASBY : Asymptomatic bacteria ? ? ?
CFU/L), irrespective of the presence of pyuria, in the absence of
signs or symptoms attributable to urinary tract infection (UTI).
pre-existing renal problem
4- A .

42 old 470 /
2-
years
36 week 6A BP loommltg proteinuria
.

,
.

, ,

Dt :
Pre-eclampsia with severe
features .

3- 25
yr
old
,
29 weeks BP = 1501100 mmHg ,
no
proteinuria ,
with frontal headache
,

Dx :
Pre-eclampsia

4. 38 old 18 weeks BP 150/100 proteinuria severe

features
years
= no no
,
,
,

DX : chronic
hypertension .

old 1701-110 mmHg

5. 18 yr school
drop out , BP =
, epigastric pain , postpartum
DX !
Postpartum pre-eclampsia with severe
features -

6. old has
32 yrs , being managed for pre-eclampsia ,
generalized tonic clonic seihnre

RBS is 1- 5mmol L

DX : seizures secondary to
hypoglycemia .
 Management
chronic
Hypertension
Review hypertensive drugs patient taking
-

anti -
has been

select
safe ones in
pregnancy

Methyl dopa
•

• Labetald

•
Hifedipine
•

Hydsalarine
•
Pthzosine can be in three
given some cases .

* unsafe Anti
hypertensive
-

-
ACEI and ARBS

•
Renal agenesis in the fetus
-

Diuretics

They reduce blood flow to the

placenta .

Beth -
blockers

Gestational Hypertension .

Give
hypensiues
-

safe anti in
pregnancy
-

Pre-eclampsia .

* All patients should be

with
pre-eclampsia hospitalized .

'

B.
they can
tip into severe features time
•
cos in short
very
a .

evaluation
•

Continuous of maternal and fetal conditions .

Delivery at term .
 Fetal kvaluation the ward
monitoring on .

I. Fetal heart rate

monitoring 2x
daily : kith hand-held utasound

2- Fetal kick count :

Cardiff technique ( to movements / Kinks in 1¥ knows )
"

3 serial ultrasound :
Height placenta
'

! Cheek
umbilical
artery doppler
4- blood
ultrasonography velocity of flow

5. Non -
stress test ( CTG )

Biophysical profit
6 .

• M -

movement

•
Amniotic fluid

•
Non -
stress test

.
T -

Tone (muscle tone

◦
B-
Breathing movement

Maternal monitoring

4-
1-
hourly Bp cheek .

2-
Daily protein cheek .

3- Fluid input and output chart -

4.
Symptom cheek .

5-
Weekly weighing .

tabs

Urine HE : Protein

RFT

FBC Platelets Hb (
:
hemolysis )
-

Liver function test

-

Serum uric acid rlmcrker of renal function

Coagulation profile
-

* 0th antihypertensives .

Delivery at term
through the fwickest possible toute .
 Pre-eclampsia with severe features

Ptiruiples of management
.

1- control BP

2.
Prevent fits

Expedite delivery
3- .

Control BP

N labetalol / w
antihypertensives N
hydrate zine
-

: .

Prevention of fit
.

First line :
Mlgsoy
2nd line :
Diazepam
-

Commonly asked

1- Mechanism of action of mg804

2. Obstetric use

3- Administration protocol
When to
4.
stop Higby .

5-
Signs of tlgsoy toxicity .

6.
Management toxicity
-

of

HWA of Mg soy
1. Blocks neuromuscular transmission and decreases acetylcholine liberated the end plate the motor
amount of at
by nerve
impulse
-
.

2- Causes All depression

3- Causes
peripheral vasodilatation

Obstetric uses

to and control
1.
prevent fits

2. To abort contractions

3- Henn protective
-

for the fetus

-
 1¥.¥g¥y administration
protocol
cheek output before giving Mgs04
RR urine
deep tendon reflexes
-

-
.

, ,

Pritchard
1-
protocol

2- 2hpm
protocol
Sibai
3-
protocol

pn-tchasdpntoat-Mgsoy.fr 50% strength and 202 strength are used .

Loading dose and maintenance doses

-

given
are

A total 14g loading dose

•
is
of given as a

• 20% -

IV
,
50%-114

•
•
Lomb of 202 IN ( 4g )

•
tomb
of
50% 1M ( 5g ) to be given in each buttock ( tog )

Maintenance dose is started after 4 hours

5g in each
alternating buttock 4 hours
•

every
-

When to
stop
to 24 hours last last
continue after the delivery whichever
-

seizure or comes
.

signs of toxicity
Abnormal
respiratory rate
-

Decreased urine output

Absence
deep tendon reflexes
-

of .

Management of toxicity
-

Give 10% calcium gluconate .

 Expedite delivery
•

Deliver in the Snicket possible way

-

Eclampsia
-

ABCs

Wait seizures to stop

-

Prevent further fit

control
Bp
-

'

Complications of Pre-eclampsia .

1-
Eclampsia
2. HFLLP syndrome
Pre
3. term
-

delivery
4. IUGR

5. stroke

6.
Pulmonary edema

7- Cardiovascular
complication

8- Fetal distress

9- Renal failure

to Increase risk of pre-eclampsia in the

future

Proven ways of reducing pre-eclampsia .

µ Low
.
dose
aspirin 181mg ) -

started between 12 -

.
28 weeks
of gestation and continue until delivery .

¥
Frequent Ark visits
.