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HYPERTENSIVE DISORDERS IN PREGNANCY

Shanro Mayra Vega Sri Wahyuni

Deadly triad causes of maternal morbidity and mortality related to pregnancy : Hypertensive disorders complicating pregnancy Hemorrhage Infection

How pregnancy incites or aggravated hypertension remains unsolved Hypertensive disorders significant unsolved problems in obstetrics.

CLASSIFICATION
I. Gestational hypertension (formerly pregnancyinduced hypertension or transient hypertension) II. Preeclampsia

III.Eclampsia
IV.Preeclampsia superimposed on chronic hypertension V. Chronic hypertension

INCIDENCE & RISK FACTOR


Parity, ras, genetic, environment Other risk factor : Nulliparous Hyperplacentosis

Mola

hydatidosa Multiple gestation Diabetes mellitus Hydrops foetalis Giant baby

Age (< 15 y.o ; > 35 y.o) Renal disease & chronic hypertension

ETIOLOGY
Abnormal trophoblastic invasion of uterine

vessels
Immunological intolerance

Maternal maladaptation / inflammatory

changes of normal pregnancy


Dietary deficiencies
Genetic influence

CRITERIA

Gestational hypertension :
BP

> 140/90 mmHg for first time during pregnancy no proteinuria BP returns to normal by 12 weeks postpartum

Preclampsia :
BP

> 140/90 mmHg after 20 weeks gestation proteinuria > 300 mg/24 hr or > 1+ dipstick

Eclampsia :
Preeclampsia

+ seizure

CRITERIA

Superimposed Preeclampsia :
new

onset proteinuria > 300 mg/24 hr BP or platelet count > 100.000/mm3 in hypertensive women but no proteinuria < 20 weeks gestation

Chronic hypertension :
BP

> 140/90 mmHg before pregnancy / diagnosed before 20 weeks gestation Hypertension first diagnosed after 20 weeks gestation persistent after 12 weeks postpartum

PATHOPHYSIOLOGY
Maternal vascular disease Faulty placentation
Genetic, immunologic, or inflammatory factor Reduced uteroplacental perfusion Vasoactive agent : Prostaglandin Nitric oxide Endothelins Vasospasme Hypertension Endothelial dysfunction Capillary leak Activation of coagulation Edema Proteinuria ThromboLiver Hemocytopenia ischemia concentration Noxious agent : Cytokines Lipid perox.

Excessive trophoblast

Oliguria

Seizure

Abruption

ORGAN CHANGES
1. Cardiovascular

Hypertension Cardiac output Thrombocytopenia Coagulation defect Bleeding DIC Plasma blood volume Permeability Edema

2. Placenta

Necrosis IUGR Fetal distress Abruptio placentae

3. Renal

Capillary endotheliosis Uric acid cleareance GFR Oliguria Proteinuria Renal failure

4. Brain

Edema Hypoxia Acute attack / seizure Cerebrovascular accident / hemorrhage Coma

5. Liver

Changes in liver function test Liver enzyme Icterus HELLP syndrome (Hemolysis, Elevated Liver enzym, Low Platelet count) Edema Subcapsular hematome / hemorrhage Necrosis, perinatal hemorrhage

6. Eyes

Pupillary edema Ischemia Amaurosis Hemorrhage Retinal defects Blindness Edema Ischemia Necrosis Hemorrhage Respiratory failure

7. Lung

PREDICTION
Roll-Over Test Uric acid Fibronectin Coagulation activation Oxidative stress Cytokine Placenta peptide DNA fetus Uterine artery doppler Velocitometry

PREVENTION
A. Non-medical Dietary manipulation
Low calorie, high protein, salt restriction Ca, Zn, Mg, Omega-3 PUFA, evening primrose oil

Bedrest not proven

Habits :

Intense prenatal care


Avoid smoking

Avoid cafein
Compliance

B. Medical
Diuretics worsening hypovolemia Antihypertension not proven Antithrombotic : Low-dose aspirin not proven Dypiridamole Antioxidant : vitamin C, vitamin E, -carotene, lipoic acid

PROGNOSIS
Eden Criteria :

Prolonged coma
Heart rate > 120 x /minute Temperature > 380 C Systolic pressure > 200 mmHg Seizure > 10 x

Proteinuria > 10 gr/L per day


No edema

Prognosis worsened if there are : Cardiomegaly Decreased renal function

Retinal complication
BP > 200/120 mmHg

PROGNOSIS
Maternal death due to PE : + 0,5% Ecl : + 5% Perinatal death : + 20%

MANAGEMENT
Basic management objective :
Termination of pregnancy with the least

possible trauma to mother and fetus


Birth of an infant who subsequently thrives

Complete restoration of health to the mother

MANAGEMENT
1. Mild Preeclampsia a. Outpatient
If the patient refuse to be hospitalized Home rest Diet (high protein, low fat, carbohydrat) Vitamins Antenatal care visite weekly

b. Hospitalization
No improvement after 2 weeks outpatient care

Weight gain > 2 kg/week


Severe symptoms of preeclampsia

2. Severe Preeclampsia
Conservative : < 37 weeks gestation, no fetal distress and no symptoms of impending eclampsia : Severe headache Severe visual disturbance Vomit Epigastric pain Progressive BP Active : termination of pregnancy !

I. DRUG THERAPHY
Anticonvulsion MgSO4 8 gr 40%; 4 gr every 4-6 hours Antihypertension : Hydralazine 2 mg i.v 100 mg in 500 cc NaCl Clonidine Nifedipine Metyldopa Labetolol Etanolol Diltiazem etc

Others : Diuretics Cardiotonics Antipyretics Antibiotics Analgesics

II. OBSTETRICAL MANAGEMENT


Mature induction Parturient augmentation Delivery : forceps extraction sectio cesaria

ECLAMPSIA
Classification : - Antepartum - Intrapartum - Post partum : early : 24 hours - 7 days late : > 7 days

Eclampsia sine eclampsia


Eclampsia intercurrent

MANAGEMENT
ICU ! Internal department, neurology department, etc

Drug theraphy :
MgSO4 : 4 gr 20% i.v

Loading 8 gr 40% i.m maintenance : 4 gr 40% i.m / 4 - 6 hours Supportive : same as preeclampsia Management of coma : together with neurologic department
Obstetrical management :

termination of pregnancy !

THANK YOU

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