case

• Zhang Ping, female, 36 years old ,nulliparity.

• Chief complaint :"stop menses for 32 weeks,two weeks of lower limbs
edema, dizziness and blurred vision for one hour.". Response and fetal
movement pregnancy occurs as scheduled, two weeks ago, no obvious
incentive to both lower extremities edema, no improvement after the
break. An hour ago appeared dazed and confused.
• Past without hypertension, history of chronic nephritis.
   

1
 • Palpation: T36.7 ℃, P78 beats / min, BP175/110mmHg, no abnormal
heart and lung auscultation, abdominal bulging, LOA, edema + + +
• Laboratory examination: Hb108g/L, Hct0.45.
• Urinalysis showed protein + + +.
• Ultrasound examination:BPD9.0cm, FL7.2cm, placental calcification
Ⅱ.
• Fetal heart rate monitor: reactive NST.

2
 • Question:
1.What is the diagnosis of the patient ?
2.What is the diagnosis based on ?
3.How to deal with it?

3
 Hypertensive Disorders in Pregnancy
Guo Lin Lin
Department of Ob & Gy
The First Affiliated Hospital of
Liaoning Medical University

4
 General consideration
• A group of diseases ,hypertension and pregnancy exist together
• 7%-10% In developing countries
• May lead to maternal and perinatal death

5
 Definition

• Hypertension ： SBp≥140mmHg and （ or ） DBp≥90mmHg

on two occasions at least 6 hours apart but within 7 days.

• Proteinuria: is defined as excretion of ≥ 0.3 g protein in a 24 hours

urine sample, or ≥ 1 + on dipstick in a random sample after excluding
urinary tract infection.

6
 Classification M
and
clinical manifestation
• Gestational hypertension
• Preeclampsia
• Eclampsia
• Chronic hypertension
• Superi mpos ed preecl amps i a on Chronic hypertension

7
 preeclampsia
• It is unique to pregnancy with onset after 20 weeks of gestation.

• It is a multisystem disorder.

• 2%-8% of pregnancies.

• A major cause of maternal morbidity, perinatal death and

premature delivery.

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 Etiology
 Not clear
 T heories:
a. Immunologic response
b. Circulating toxins
c. Endogenous vasoconstriction
d. Endothelial damage
e. Primary disseminated intravascular coagulation
f. Oxidation stress

15
 Stage1
(Poor Placentation)
early
Etiology ↓
Stage 2
• Two stage theory
(Placental oxidation stress)
• Stage 1 is caused by faulty late

endovascular ↓
trophoblastic remodelling Systemic release of Fetal growth
which cause stage 2 placental factors restriction
clinical syndrome ↓
Systemic inflammatory
response, endothelial activation
↓
Pre eclampsia syndrome

16
 请在此输入您的文本。

a. nulliparity
b. obesity
c.Multiple gestation

d.Family history of preeclampsia or eclampsia

High
risk e. Pre-existing hypertension or renal disease
factor
f. Previous preeclampsia or eclampsia
g. diabetes mellitus
h. Antiphospholipid antibody syndrome
i. Molar pregnancy
j. Nonimmune hydrops.

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 pathophysiology
• Basic pathological changes
 Spasm of systemic small vessels
 Vascular endothelial damage
All organs including the fetoplacental unit show evidence of poor
perfusion.

18
 Brain ：
• Major changes: cerebral vasospasm, vascular
endothelial injury, Lead to cerebral ischemia,
cerebral hemorrhage , edema, thrombosis.

• patient: headache, dizzy, nausea and vomiting, etc.

• Serious: vision loss and blindness ， even eclampsia

and in a coma

19
 Eye: Fundus inspection .
• Changes in the retinal arteries reflect the severity of disease.
There may be retinal arteries spasm 、 retinal edema and retinal
detachment .

• Patient: poor sight 、 blindness.

20
 Kidney
• The expansion of glomerular and swelling of the endothelial cells,
Plasma protein leakage from glomerular and form proteinuria.
• Renal dysfunction ： GFR↓,BUN↑,UA ↑,oliguria

21
 Liver:
• because of hepatic vasospasm → hepatic ischemia and edema →
liver enlargement and hepatic dysfunction: ALT/AST↑,

HELLP syndrome (hemolysis, elevated liver enzymes,

low platelets)

22
 Cardiovascular system
• Generalized vasospasm → Increased peripheral resistance → BP↑
→cardiac load ↑ →loaden of heart ↑ →heart failure, pulmonary
edema.

•Patient: breath heard.

23
 Blood system:
• Platelet activation and depletion

• Coagulopathy

• Decreased plasma volume

• Increased blood viscosity

24
 Placenta-fetus
•Placenta hypoperfusion → function↓ 、 placenta abruption.
•Fetus: IUGR 、 fetal distress 、 death.

25
 pathophysiology
Spasm of systemic small vessels ,Vascular endothelial damage

poor perfusion of organs , multiple organs dysfunction

IUGR 、
proteinuria headache 、 Retinal edema 、 Fetal
Hepatic Malcardial
Renal convulsion 、 detachment 、 distress 、
dysfunction 、 ischemia 、
dysfunction coma 、 blindness Abruptio
HELLP syndrome Heart failure
placenta

26
 diagnosis
1 history

2 hypertension

3 proteinuria

4 assist examination

27
 Differential diagnosis
• Preeclampsia ---chronic nephritis complicating
pregnancy

28
 Complication
Fetal risks :
• intrapartum fetal distress or stillbirth.
• intrauterine growth restriction

Maternal risks:
• Eclampsia
• Cerebrovascular accidents
• Abruptio placentae
• HELLP syndrome

29
 Management
aim

30
 Management
• Assessing severity of preeclampsia
 Severe features:
1. BP: SBP≥160mmHg and （ or ） DBP≥110mmHg
2. Thrombocytopenia (platelet count < 100 ×109/L);
3. Impaired liver function:(liver enzymes ALT 、 AST ↑twice
normal concentration), severe persistent right upper
quadrant or epigastric pain

31
 4.Progressive renal insufficiency(serum creatinine
concentration ＞ 1.1mg/ dl or a doubling
of the serum creatinine concentration in the absence
of other renal disease)
5 、 pulmonary edema
6 、 New-onset cerebral or visual disturbances
preeclampsia with severe features = severe preeclampsia
preeclampsia without severe features = mild preeclampsia

32
 Management
preeclampsia without severe features
 Close monitoring maternal and fetal condition, terminate pregnancy
timely.
 Expectant Management
• at home or hospital
• relative rest
• daily urine protein, BP monitoring.
• fetal testing: NST 1-2 times/week.
• CBC(Hct and Plt), liver, renal function test 1-2times/week

33
 • count fetal movement, labor signs or vaginal bleeding.

• Ultrasound:10-14d.amniotic fluid volume, estimated fetal weight.

• warning signs: as headache,visual disturbances, epigastric pain,and
nause 、 vomiting.

34
 Management
preeclampsia without severe features

Expectant Management:

≥37W gestation with severe features

termination hospitalization

35
 Management
preeclampsia with severe features

 The definitive treatment of severe preeclampsia is delivery.

 Pregnancy ＜ 24 Weeks ：
 induced for delivery
 Pregnancy ＞ 34 Weeks ：
 Induction and delivery
 steroid to promote fetal lung maturity and then delivery
after 48 hours.

36
 Management
preeclampsia with severe features

 Pregnancy between 24 and 28 Weeks:

 depends on fetal and maternal situations and hospital, expectant
treatment or terminate timely.
 Pregnancy between 28 and 34 Weeks
 active expectant treatment and then terminate

37
 Management
Expectant Management of severe preeclampsia

 close fetal and maternal monitoring:

a. Platelet count: <100 x 109/l consider termination of delivery.

b. Hematocrit and hemoglobin.

c. Uric acid: is measure of fine renal tubular function. So used to assess the

disease severity.

38
 d. renal function test: Serum urea and serum creatinine.

e. Liver function test

The above evaluation is done at 24-48 hours interval.

f. daily urine protein, BP monitoring.

g. daily fetal maternal testing :daily NST, fetal movement count,

ultrosound…

39
 Expectant Management of severe preeclampsia
1. Bed rest: left-lateral position
2. Daily weight measurement
3. Anti-spasm treatment: MgSO4
4. Anti-hypertensive treatment
5. Steroid :to accelerate lung.
＜ 35w ， may delivery in 1w.dexamethasone ,6mg bid, im ×2d.
6. Termination of Delivery

40
 6. Termination of Delivery ※indications
• Bp ≥ 160/100 despite treatment.
• Urine output ＜ 400ml/24 hours.
• Platelet count ＜ 50 x 109/l
• Progressive increase in serum creatinine.
• LDH > 1000IU/L.
• NST show Repetitive late deceleration with poor variability
• Severe IUGR with oligohydramnios.
• Decreased fetal movement.
• Reversed umbilical diastolic blood flow
45
 • Vaginal delivery
• No indications of cesarean section
• estimates that can end the delivery in a short time
• observe the changes of self-conscious symptom , Antihypertensive treatment
(BP<160/110mmHg), MgSO4, FHR, Prevention of postpartum hemorrhage

• cesarean section

46
 Prediction and Prevention
• Roll over test or supine pressor test: G18-22 weeks
• Doppler study of uterine artery:
• Low level of PAPP-A:
• Isometric exercise

 Prevention
• Aspirin and antiplatelet agent:
• Diet and exercise:
• vitamins C and E:

47
 HELLP SYNDROME

48
 D efinition
“HELLP” is an abbreviation of the three main features of the s
yndrome: Hemolysis 、 Elevated Liver enzymes 、 Low Platelet count

•HELLP syndrome is a life-threatening obstetric complication .

•T he incidence rate is 2- 12% of severe preeclampsia.

•70% antepartum, 30% postpartum ,usually within 48 hours of delive

ry.

49
 Clinical manifestation
• nausea and vomiting (50% ),

• malaise of a few days' duration (90%),

• epigastric or right upper quadrant pain (65%).

• There can be vague abdominal pain, flank or shoulder pain,

hematuria, gastrointestinal bleeding or gum bleeding.

50
 • In 70% of cases onset is antepartum and in 30% postpartum .
usually within 48 hours of delivery.

• Hypertension and proteinuria is variable.

51
 D iagnosis
• HELLP syndrome can be difficult to diagnose due to the variability of
symptoms among pregnant women

• The diagnosis relies mainly on the laboratory tests

① Intravascular hemolysis: Fragmented red blood cells on periphera

l smear. Increased bilirubin ≥1.2 mg/ dl.
② Increased LDH ≥ 600 ID / l
③ Elevated liver enzyme: ALT≥40U/L OR AST≥70U/L ，
④ Low platelet : PLT ＜ 100×109 /L.
52
 T reatment
• Similar to the treatment of severe preeclampsia.
• Termination:Individualized and timely.
Hellp syndrome is not a indications of cesarean section.

53
 • Zhang Ping, female, 36 years old ,nulliparity.
• Chief complaint :"stop menses for 32 weeks,two weeks of lower limbs
edema, dizziness and blurred vision for one hour.".Response and fetal
movement pregnancy occurs as scheduled, two weeks ago, no obvious
incentive to both lower extremities edema, no improvement after the
break. An hour ago appeared dazed and confused.
• Past without hypertension, history of chronic nephritis.
   

54
 • Palpation: T36.7 ℃, P78 b/min, BP175/110mmHg, no abnormal
heart and lung auscultation, abdominal bulging, LOA, edema + + +
• Laboratory examination: HGb108g/L, Hct0.45.
• Urinalysis showed protein + + +.
• Ultrasound examination:BPD9.0cm, FL7.2cm, placental
calcification Ⅱ.
• Fetal heart rate monitor: reactive NST.

55
 • Question:
1. What is the diagnosis of the patient ?
severe preeclampsia
2. What is the diagnosis based on ?
32 weeks gestation.
lower limbs edema,dizziness and blurred vision
Past without hypertension
BP175/110mmHg,Urine protein+++

56
 • Question:
3. how to deal with it ?
• Hospitalization
• MgSO4
• Nifedipine / Labetalol
• Steroid
• terminate:≥34w

57
 1. Which of the following are seen in pre eclampsia:
a. Hypertension
b. Proteinuria
c. Convulsions
d. Pedal edema
•Ans. a, b

58
 2. In preeclampsia, impending sign of eclampsia is:
a. Visual symptoms
b. Weight gain of 2 lb per week
c. Severe proteinuria of 10 gm
d. Pedal edema

59
 3. All are prognostic indicators of preeclampsia except:
a. Low platelet count
b. Serum Na
c. Elevated liver enzymes
d. Serum uric acid

60
 4 、 Which is not a feature of HELLP syndrome:
a. Thrombocytopenia
b. Eosinophilia
c. Raised liver enzyme
d. Hemolytic anemia

61
 5. A 27-year primigravida presents with preeclampsia with blood
pressure of 150/100 mm Hg at 32 weeks gestation with no other
complications. Subsequently her BP is controlled on treatment. If there
are no complications, pregnancy should be terminated at:
a. 40 completed weeks
b. 37 completed weeks
c. 35 completed weeks
d. 34 completed weeks

62
 6 、 What is the basic pathological changes of Hypertensive
Disorders Complicating Pregnancy?
•A ． Excessive water sodium retention
•B ． blood concentration
•C ． blood coagulation dysfunction
•D ． Spasm of systemic small vessels

63
 7 、 Excessive doses of magnesium sulfate in the treatment of
Hypertensive Disorders Complicating Pregnancy, the first appeared of
the toxicity reaction is:
• a. breathing slows

• b. dizziness, low blood pressure

• c. low heart reat

• d. knee reflex drops or disappear

64
 8 、 A 38 year old primigravida attends the prenatal clinic for
booking at 9 weeks gestation. She tells you she has a history of high
blood pressure, which has been investigated by physicians in the past
with no cause found. Her blood pressure is usually Controlled with
atenolol 100mg daily. (atenolol-antihypertensive drug)
•Possible diagnosis:
• A. Gestational hypertension B. Eclampsia
• C. Essential hypertension D. Preeclampsia

65
 9 、 Nulliparity ， 27 year old ， 36 weeks gestation ，
•having a Lower extremity edema for half a month,Having a headache for
three days ， this morning feel blurred vision,and severe headache. urine
dipstick testing shows proteinuria of ++. She admits to no history of renal
problems now or in the past.
•which is most likely to be found by Physical examination?
A ． HR>110bpm
B ． BP 160/110mmHg
C ． splenomegaly
D ． hepatomegaly

66
 第七版《妇产科学》配套课件
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THANKS FORfor
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67
67 YOUR
YourATTENTION
Attention
 Eclampsia

 preeclampsia + convulsions and or unexplained coma during

pregnancy or postpartum .
 Incidence : 1/ 2000 in developing countries.

68
 Signs
a. Initial or prodromal phase: There may be aura and convulsive
movement which begins around mouth.
b. Tonic phase: The entire body become rigid, face contorted, ar
m flexed, fist clenched, respiration ceases for 15-20s.
c. Clonic phase: There are jerky movement, start from facial mus
cle to involve entire body. There is frothing and may be cyanose
d. This phase last for approximately 1 minute.
d. Recovery: The movement slowly subside .
Respiration is resumed and patient passes in coma of variable du
ration.
69
 Management of Eclampsia
 General measures: airway,Oxygen
 Control of convulsion: first line medicine- MgSO4 超链接
 Control hypertension:
 Delivery:the definitive treatment. 超链接

70
 treatment
• Individualized treatment
 gestationla hypertension
rest, sedation, close minitoring maternal and infant ,
antihypertension according to the indictation.
 preeclampsia
sedation, aitispasm, antihypertension and diuresis according to the indictatio
n, minitoring maternal and infant, terminate pregnancy timely.
 eclampsia
control the seizures , terminate pregnancy timely

71
 Control of convulsion
• MgSO4: loading dose:4-6g +25% GS 20ml iv injection,15-20min.
Maintenance dose: 1-2 g/h,ivgtt.
• Diazepam:10mg,im or iv ( ＞ 2min)
• Lytic cocktail:The combination of chlorpromazine 50mg,
promethazine 50mg and pethidine100mg. 1/3 or 1/2 im.
• Phenytoin: 0.1g,im.Itis given 1/V in initial loading
dose of 15-18 mg/ kg body weight followed by 100 mg 1/V
every 8 hours to prevent recurrence.

72
 Delivery
• Vaginal delivery is safe option
• cesarean section is choice of treatment if:
i. If fetus is older than 34 weeks, mature and alive and
patient is not in labor.
ii. If contemplated induction delivery is going
to be long.
iii. Other obstetric reasons.

73