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Jaycme
in
Pregnancy
By Dr SEETOHUL JAY
VICTORIA HOSPITAL
17.06.2023
INTRODUCTION
Hypertension complicates 7–10% of pregnancies, of
which:
70% are due to gestational hypertension/preeclampsia
30% are due to chronic essential hypertension.
The rate of hypertensive disorders in nulliparous women
approaches 29%.
The 6th leading cause of maternal mortality
Leading cause of neonatal mortality/morbidity, primarily
due to the effects of preterm delivery
Hypertension
• Appropriately taken blood pressure exceeding 140 mm Hg systolic or
90 mm Hg diastolic.
Four Types of Hypertensive Disease
1. Gestational hypertension—evidence for the preeclampsia
syndrome does not develop and hypertension resolves by
12 weeks postpartum
2. Preeclampsia and eclampsia syndrome
3. Chronic hypertension of any etiology
4. Preeclampsia superimposed on chronic hypertension.
Gestational Hypertension
New-onset of BP elevation after 20 weeks AOG without proteinuria.
BP returns to normal by 12 weeks postpartum
May have other signs or symptoms of preeclampsia
Transient hypertension
PREECLAMPSIA
New onset hypertension + new onset proteinuria
• 24-hour urinary excretion >300mg
• Urine protein:creatinine ratio ≥ 0.3 or
• Persistent 30mg/dL protein (dipstick 1+)
Pulmonary Edema
Severe Features of Preeclampsia
Trophoblasts invade the deciduas and This results in a small caliber vessel
the walls of the spiral arteriole to with high resistance to flow
replace the endothelium and
muscular wall to create a dilated low
resistance vessel
IMMUNOLOGICAL FACTORS
• Loss or dysregulation of tolerance of paternally derived placental and fetal
antigens
• Immune maladaptation – extravillous trophoblasts early in pregnancy
expressed reduced amounts of immunosuppressive nonclassic HLA G →
defective placental vascularization
• Women with 1597ΔC allele are predisposed to develop preeclampsia
• Possibly shared susceptibility genes with diabetes and
chronic hypertension
• Histological changes at the maternal-placental interface are suggestive of
acute graft rejection
ENDOTHELIAL CELL ACTIVATION
AFP 96 9
Fibronectin 94 65
Total Fetal DNA 88 50
hCG 89 24
Inhibin A 95 30
Activin A 89 61
PAPPA 94 10
Kallikreinuria 98 83
MANAGEMENT
Basic management objectives:
Aggressive Expectant
• High neonatal mortality and • Fetal death
morbidity due to prematurity • Asphyxial damage in utero
• Prolonged NICU stay • Increased maternal morbidity
• Long term disability
Schematic Clinical
Management Algorithm For
Suspected Severe
Preeclampsia At < 34 Weeks
PHARMACOLOGY
• The following drugs are given to immediately lower BP:
• Labetalol – first line because it has decreased S/E of
tachycardia; not available locally; Contraindicated in asthma,
heart disease
• Hydralazine – aka apresoline; available in the Philippines;
maximum dose: 20-25 mg
• Nifedipine – if both drugs are not available
• Maintenance Medications
• Do NOT give methyldopa for the purpose of immediate
reduction of BP. It should only be for maintenance.
OBJECTIVES FOR TREATMENT
A. Prevent complications B. Prevent and control
such as: Eclampsia
• Congestive heart failure • Premonitory S/Sx of
eclampsia
• Myocardial ischemia
• Presence of headache,
• Renal injury or failure
visual disturbances and
• Ischemic or hemorrhagic scotomata
stroke • Epigastric or RUQ pain
• Hyperreflexia
Magnesium Sulfate (MgSO4) Prophylaxis
Do NOT stop MgSO4 after delivery because eclampsia may still occur!
DELIVERY
Vaginal delivery
- Inducible cervix
- No fetal distress
Cesarean section
GLUCOCORTICOIDS FOR LUNG
MATURATION
• Maternal complications
- Cerebrovascular accident – hemorrhage/infarction
- Abruption placenta and DIC
- Aspiration pneumonia
- Pulmonary edema
- Renal failure
- C-P arrest
ECLAMPSIA
• Fetal Complications
- Fetal death
- Prematurity- in cases of preterm pregnancies
- Fetal complications may be due to placental
insufficiency or abruption placenta
PREVENTION OF
HYPERTENSION IN
PREGNANCY
PREVENTION OF HTN IN PREGNANCY
• Low dose aspirin – recommended in reducing the risk of
preeclampsia in patients who are moderate to high risk
• Dose – 60-80mg/day
• Calcium supplementation – may prevent preeclampsia in
patients with low dietary intake of calcium
• Dose – 1.5-2g elemental calcium/day
• Vit C, Vit E, selenium, Vit A, Fish oil – not effective
PREVENTION OF HTN IN PREGNANCY