Hypertensive Disorders in Pregnancy

Chronic hypertension - HTA before gestation Gestational hypertensionhypertension- new onset HTA after 20. GW at a prior normotensive , no proteinuria PreeclampsiaPreeclampsia - new onset HTA with proteinuria Eclampsia - Preeclampsia with general seizures Superimposed preeclampsia on chronic HTA

What is preeclapsia?
Definition: Preeclampsia: HBP ( sBP140mmHg or dBP90mmHg) and proteinuria (0,3g/24h or 30mg/dl) occurring after the 20th GA at a previous normotensive woman Epidemiology Preeclampsia occurs in 2 to 10% of pregnancies worldwide, in some regions there is a higher or lower incidence. In the Western world, it affects 227% of all pregnancies, while in other areas the incidence can be up to three times greater . It remains a major cause of maternal and fetal morbidity and mortality . Preeclampsia is accounted for every third case of major obstetrical morbidity, for a fivefold higher perinatal mortality and worldwide for at least 50,000 maternal deaths per year .

Introduction
a leading cause of maternal and fetal/neonatal mortality and morbidity worldwide (HELLP, Eclampsia) early identification of patients with an increased risk for preeclampsia is important goal highly sensitive and specific physiologic and biochemical markers offer prediction and diagnostic tool

Pathophysiology
PE the disease of "Theories" 2 stages Stage 1: Alterations in placental perfusion - placenta is considered the key point with placenta hypoperfusion due to abnormalities in implantation and vascular remodeling Stage 2: Systematical reduced perfusion including vasoconstriction, microthrombi and reduced plasma volume due to edema

Risk Factors
Parity Maternal Age Ethnicity History of hypertension Obesity Diabetes Collagen vascular diseases Renal diseases Thrombophilias: - resistance to activated protein C and the factor V Leiden mutation - elevated levels of homocysteine and homozygotsity for the methylenetetrahydropholate reductase (MTHFR) Family history of PE Prolonged interval between pregnancies Limitted exposure to paternal antigen: Short period of cohabitation - Artificial insemination - Barrier contraceptives Risk factors associated with pregnancy: MultipleMultiple -fetus pregnancy - Structural congenital abnormalities - Hydrops fetalis - Chromosomal abnormalities - Molar pregnancy Risk factors associated with the partner: Primipaternity - Partner that previous fathered a preeclamptic pregnancy Exogen factors: - Stress -Psychosocial pressure due to work

Diagnosis
Cardinal Signs of Preeclampsia Hypertension usually the first sign Proteinuria Other Signs of PE Sudden, rapid weight gain Brisk reflexes Decreased urinary output Laboratory abnormalities Clinical significant edema Symptoms of PE Headache (Edema/vascular) = > Severe Visual changes => Severe CNS changes Epigastric or RUQ pain=>Severe General malaise

Predictive factors
Inhibin A and activin A Placental growth factor (PlGF), vascular endothelial growth factor (VEGF), soluble vascular endothelial growth factor receptorreceptor-1 (sVEGFR(sVEGFR-1) or soluble fmsfms-like tyrosine kinasekinase-1 (sFlt(sFlt -1) Placental protein 13 (PP(PP-13) Pregnancy-associated plasma protein PregnancyA (PAPP(PAPP-A) Human chorionic gonadotrophin (HCG) Soluble endoglin (sEng) Alphafetoprotein (AFP) CorticotropinCorticotropin -releasing factor (CRF) and CRFCRF-binding protein (CRF(CRF -BP) Leptin Insulin-like growth factor Insulinfactor-1 (IGF(IGF-1) and IGFIGF-binding proteinprotein-1 (IGFBP(IGFBP -1) Homocysteine Asymmetric dimethylarginine (ADMA) Maternal serum fetal erythroblasts and cellcell -free fetal DNA Uterine artery Doppler sonography Combination of biochemical markers with uterine artery Doppler sonography

Patients with Proteinuria

Yeses-60% NoNo -40%
60 50 40 30 20 10 0 % yes no

Multiple pregnancies
35 30 25 20 15 10 5 0 Number with multiple pregnan cies no multiple pregnan cies

FH History of Cardiac Diseases

80 70 60 50 40 30 20 10 0 % FH of card ac d ases No FH of card as d seases 3-D Column 3

Severity
Late onset preeclampsia (onset after 34.GA) with mild form has better maternal and fetal outcome than early onset preeclampsia (onset before 34. GA) where maternal and fetal complications increase.

Maternal complications
Eclampsia Renal failure Hepatic rupture, Liver failure Hemolysis, elevated liver enzymes and low platlet count (HELLP) Cerebrovascular accident (CVA),Cerebral hemorrhage, Cerebral Edema Dissemisnated intravascular coagulation (DIC) Pulmonary Edema Increased perinatal mortality and morbidity due to increased preterm delivery, uteroplacental insufficiency and abruption (particularly in HELLP and severe prepreeclampsia). Late cardiovascular complications

Fetal Complications
Preterm birth Intrauterine growth restriction (IUGR) Hypoxia Neurological damages Future cardiovascular risk

Discussion
Nulliparity is a well known risk for preeclampsia . The study population showed that most of the affected women were nullipaorous. The risk factor of extremes of age was represented as well. But in our study population most of the preeclampsia cases occurred in patients aged 25 to 34 years. This is explained by the fact that most women give birth in this age period. Nevertheless there was one case of preeclampsia in the extreme low age in a patient of 16 years. In the preeclampsia extreme ages of over 35 years were 12% of the preeclamptic women.

Discussion
Multi-fetus pregnancies show an increase risk for Multipreeclampsia . In this study 9% of the patients were pregnant with twins, half of this women developed severe preeclampsia. Obesity is strongly associated with preeclampsia . Though there were just two reports of obesity in the in the patients files, by calculating the BMI prior to pregnancy we can distributed as follows: 32% overweight 19% obese grade I 5% obese grade II 4% obese grade III A positive history of gestational hypertension and chronic hypertension increase the risk for preeclampsia . Four patients reported of gestational hypertension and 2 had a positive history of chronic hypertension .

Conclusion
The risk factors that we have identified can be used to assess risk at the booking visit, so that a suitable surveillance routine to detect prepreeclampsia can be planned for the rest of the pregnancy. Educating all pregnant women about how to recognize danger signals would help, since clinically dangerous preeclampsia can develop very rapidly. Good obstetrical practice will identify known risk factors but will not enable physicians to determine the risk value for a particular pregnancy

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