PREGNANCYRELATED HYPERTENSION

FRANS O H PRASETYADI

SUBDEPT. OF OBSTETRICS & GYNECOLOGY DR. RAMELAN INDONESIAN NAVAL HOSPITAL S U R A B A Y A

INTRODUCTION

One of the deadly triad maternal morbidity & mortality US incidence in 2001 : 3.7% of pregnancies 16% pregnancy-related deaths ( US, 2003 ) Challenge the medical & obstetrical skills of the health care team understanding the patophysiology of the HT disorders disease of theories
recognition of the pharmacokinetic changes occuring during pregnancy & the possible fetal effects of therapeutic agents

Management & impact on the mother & fetus depend on whether :

HT antedated the pregnancy, or

HT as the marker of pregnancy-specific vasospastic syndrome several systems of nomenclature and classification

TERMINOLOGY AND CLASSIFICATION

The NIH working group on hypertension in pregnancy ( 2000 ):

Gestational hypertension Preeclampsia-eclampsia Superimposed PE on chronic hypertension Chronic hypertension

GESTATIONAL HYPERTENSION

BP 140/90 For the 1st time during pregnancy No proteinuria BP returns to normal < 12 weeks postpartum Final diagnosis made only postpartum May have other signs or symptoms of PE, i.e. : epigastric discomfort or thrombocytopenia

PREECLAMPSIA

Minimum criteria

BP 140/90 after 20 weeks of gestation Proteinuria 300 mg/24 hr or 1+ dipstick

Increased certainty of preeclampsia

BP 160/110 Proteinuria 2.0 g/24 hr or 2+ dipstick Serum creatinine > 1.2 mg/dL unless known to be previously elevated Platelets < 100,000/mm3 Microangiopathic hemolysis ( LDH ) Elevated ALT or AST Persistent headache or other cerebral or visual disturbance Persistent epigastric pain

ECLAMPSIA

Seizures that cannot be attributed to other causes in a woman with preeclampsia

SUPERIMPOSED PREECLAMPSIA

New onset proteinuria 300 mg/24 hr 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

CHRONIC HYPERTENSION

BP 140/90 before pregnancy or diagnosed before 20 weeks gestation not attributable to gestational trophoblastic disease, or Hypertension first diagnosed after 20 weeks gestation and persistent after 12 weeks postpartum

PREECLAMPSIA

Major cause of - Maternal mortality ( 15-20% in developed countries ) and morbidities ( acute and long-term) - Perinatal deaths - Preterm birth - IUGR, oligohydramnios, abnormal oxygenation Those morbidities & mortalities are in women who : -develop the disorder before 33 weeks gestation -in those w/ pre-existing medical disorders -in those from developing countries

Etiology and pathophysiology ?

Likely to develop in women who : 1. are exposed to chorionic villi for the first time
2. are exposed to a superabundance of chprionic villi, as with twins or hydatidiform mole 3. have preexisting vascular disease

4. are genetically predisposed to hypertension developing during pregnancy

PREECLAMPSIA

Is a multisystem disorder of unknown cause that is unique to human pregnancy Characterised by abnormal vascular response to placentation that is associated with : - systemic vascular resistance - enhanced platelet aggregation - activation of the coagulation system, and - endothelial dysfunction Clinical manifestations : maternal syndrome fetal syndrome

Maternal and fetal complications in severe preeclampsia

Maternal complications
abruptio

Neonatal complications
Preterm

placentae ( 1-4% ) DIC / HELLP syndr ( 10-20%) Pulmonary oedema/aspiration (2-5%) ARF (1-5%) Eclampsia ( <1% ) Liver failure or haemorrhage (<1%) Stroke ( rare ) Death ( rare ) Long-term cardiovascular morbidity

delivery (15-67%) Fetal growth restriction (10-25%) Hypoxia-neurologic injury (<1%) Perinatal death ( 1-2%) Long-term cardiovascular morbidity assiciated w/ LBW ( fetal origin of adult disease hypothesis ) i.e. premature atherosclerosis

DIAGNOSIS PE

HT + proteinuria, >20 weeks gestation, normotensive beforehand BP measurements : 2 occasions, 4-6 h apart & <7 days Accurate dx depends on precise BP measurements ( ie, cuff size, position of arm at heart level, & calibration of equipment ) important in obese women. Definitive test 4 proteinuria : quantitative over 24 h To be regarded serious / severe if ? HT or proteinuria might be absent in 10-15% HELLP syndr & in 38% of eclampsia

 Tekanan darah 160/110

Kriteria minimum

Proteinuria 2 gram/24 jam atau dipstick +2 Serum kreatinin > 1,2 mg/dL Trombosit < 100,000/mm3

Tensi 140/90 setelah 20 minggu kehamilan

Proteinuria 300mg/24 jam atau dipstick +1

Hemolisis mikroangiopatik (LDH meningkat) ALT dan AST meningkat Sakit kepala persisten/gangguan visus/gangguan pada otak Nyeri epigastrium persisten

Hipertensi Gestasional Preeklampsia Eklampsia Superimposed preeklamsia Hipertensi kronis

RISK FACTORS
-Limited sperm exposure -Primipaternity -Pregnancy after donor insemination, oocyte donation, embryo donation -Protective effectof partner change in the case of previous PE pregnancy -Maternal or pregnancy-related risk factors -Extremes of maternal age -Multifetal gestation -PE in a previous pregnancy -Chronic HT or renal disease -Rheumatic disease -Maternal low birthweight -Obesity & insulin resistance -Pregestational DM -Maternal infections -Pre-existing thrombophilia -Maternal susceptibility genes -Family history of PE -Smoking ( reduced risk ) -Hydropic degeneration of placenta -PCOS, recurrent abortions

Epidemiology & risk factors

2% - 7% in healthy nulliparous women Generally regarded as a disease of first pregnancy Importance of paternal factors : dangerous father Primipaternity concept ? >< women w/ no previous PE ~ risk of PE with increasing time interval between births Concept : healthy pregnancy is a state of systemic inflammation, at least in the 3rd trimester PE is the extreme end of a range of maternal systemic inflammatory responses engendered by the pregnancy itself

In pregnancy, the spiral arteries are remodeled by extravillous trophoblast cells and NK cells. The left panel shows the nonpregnant endometrium in the secretory phase of the menstrual cycle just before menstruation. The right panel shows the endometrium in the second half of normal pregnancy when the spiral arteries are remodeled to a depth that penetrates the myometrium. The middle panel shows the situation in preeclampsia where the extent and depth of remodeling is less than in normal pregnancy. These vascular changes are effected by extravillous trophoblast cells (EVT) with the help of activated NK cells. In the process, the enlarged vessels become lined with endovascular trophoblast cells (ENVT)

Karakteristik:
Kerusakan endotel Vaskuler dengan: vasospasme, transudasi plasma sequele iskemik dan trombotik
Dugaan Penyebab: (2003, Sibai)

Invasi trofoblastik abnormal terhadap vasa uterina Intoleransi imunologis antara jaringan ibu dan janin Maladaptasi maternal terhadap perubahan Kardiovaskuler dan proses radang Defisiensi diet Pengaruh genetik

Figure 4 Unifying hypothesis of pre-eclampsia pathophysiology

Noris M et al. (2005) Mechanisms of Disease: pre-eclampsia Nat Clin Pract Neprol 1: 98114 doi:10.1038/ncpneph0035

Maternal Vasculer disease

Faulty Placentation

Excessive Trophoblasts

Genetic, immunologic, or inflamatory factors

Reduced uteroplacental perfusion

Vasoactive agents: Prostaglandins, nitric Oxide, Endothelins

Noxious agents: Cytokines, Lipid Peroxidases

Endothelial Activation
Vasospasm Capillary leak Activation of Coagulation Trombocytopenia Edema uteroplacental Hemoconcentrati perfusion on Proteinuria
Reduced

Hypertension Seizures Oliguria Liver ischemia Abruption

Aktivasi, agregasi, konsumsi + volume dan usia platelet trombositopenia Waktu thrombin meningkat Defisiensi faktor pembekuan karena penyakit penyerta Fibronectin cenderung meningkat

Berhubungan dengan: Tekanan afterload Tekanan Preload Ekstravasasi cairan

Hemolisis LDH, perubahan bentuk eritrosit. Akibat gangguan endotelhemolisis mikroangiopati

CO meningkat CO menurun + resitensi Hemokonsentrasi perifer meningkat Hati-hati pada perdarahan waktu persalinan

 RAA system menurun akibat retensi air + Na Vasopressin tetap Atrial natriuretik peptide menurun

Kerusakan endotel retensi cairan edema generalisata Elektrolit cenderung tetap normal Pada kejang eklamsia pH dan bicarbonat

Hiperperfusi Perdarahan akibatruptur Kehilangan arteri autoregulasi Edema, iskemi, aliran darah hyperemia,trombosis, perdarahan serebral Klirens plasenta menurun

Laju aliran darah plasenta menurun

Infark arteri retina Ablasio retina Edema korteks dan defek visual

Prediction of PE

No known biomarkers No efective predictors Doppler velocimetry of uterine artery blood flow in 2nd trimester might be useful ( RI or early diastolic notch uni- or bilateral ) for those at very high risk

Fetal Velocity Waveforms

Medical Physiology Lippincott Williams & Wilkins, 2nd edition 2004

Prevention of PE
Pregnancy outcome
No reduction in PE No reduction in PE No effect in low-risk or highrisk populations Reduced PE in those at high-risk & with low baseline dietary calcium intake No effect on perinatal outcome 19% reduction in risk of PE 16% reduction in fetal or neonatal deaths Reduced PEin women w/ renal dis. & in women w/ thrombophilia Reduced PE in one trial Risk of women developing severe HT reduced by half, but not risk of PE

Diet

and exercise (I) Protein or salt (II)restriction Mg or Zn supplementation (I) Fish-oil supplementation & other sources of fatty acids (I) Calcium supplementation (I)

Recommendation
Insuff. evidence to recommend Not recommended* Insufficient evidence to recomm.* Recommended for women at high risk of gestational HT, & in communities w/ low dietary calcium intake Consider in high-risk populations

Low-dose

aspirin (I)

Heparin

or low-molecularweight heparin (III) Antioxidant vitamins (C,E) (II) Anti-HT medications in women w/ chronic HT

Lack of randomised trials, not recommended Insufficient evidence to recomm. No evidence to recommend for prevention

Levels of evidence (I IV) as outlined by the US Preventive Task Force. *Insufficient evidence - small

Management of PE

Adequate & proper prenatal care is most important (

signs & symptoms, progression of the condition to severe state

identification of women at high risk, early detection by the recognition of clinical

The main objective : safety of the mother Delivery or expectant? ~ fetal gestational age, fetal status, severity of
maternal condition at time of assessment

Management of PE
Preeclampsia
Maternal & fetal assessment

Gestational age 38 weeks

At 34 weeks gestation: - Severe PE - Labour or rupture of membranes - Abnormal fetal testing - Severe oligihydramnios or fetal growth restriction

YES

Deliver

NO
Mild disease Severe disease < 23 weeks

Hospital or office management Maternal and fetal assessment

22 32 weeks

33 34 weeks

Worsening maternal or fetal condition 38 weeks Labour or rupture of membranes

Steroids Anti-HT Daily assessment of maternal-fetal conditions Delivery at 34 weeks

Steroids

Delivery after 48 h