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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
Mola
Age (< 15 y.o ; > 35 y.o) Renal disease & chronic hypertension
ETIOLOGY
Abnormal trophoblastic invasion of uterine
vessels
Immunological intolerance
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
3. Renal
Capillary endotheliosis Uric acid cleareance GFR Oliguria Proteinuria Renal failure
4. Brain
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
Habits :
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
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
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
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
ECLAMPSIA
Classification : - Antepartum - Intrapartum - Post partum : early : 24 hours - 7 days late : > 7 days
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