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I. Gestational hypertension
BP >= 140/90 mmHg for first time during
pregnancy
No proteinuria
BP returns to normal < 12 wk postpartum
Final diagnosis made only postpartum
May have other signs & symptoms of
preeclampsia , eg. epigastric discomfort or
thrombocytopenia
Underlying causes of
Chronic Hypertension
III. Preeclampsia
Preeclampsia
Mild preeclampsia
BP >= 140/90 mmHg after 20 wk gestation
Proteinuria >= 300 mg/24hr or >=1+ dipstick
Severe preeclampsia
Anyone who meets at least two of the
following signs:
IV. Eclampsia
Seizures that cannot be attributed to other
V. Superimposed preeclampsia
New onset proteinuria >= 300mg/24 hr in
Diagnosis
Gestational HT
Also called transient HT
Final Dx : after delivery , by exclusion
BP : resting BP , Korotkoff phase V is
Preeclampsia
Superimposed preeclampsia
1. Hypertension (>=140/90) is documented
antecedent to pregnancy
2. Hypertension is detected before 20 wk , unless
there is GTD
3. Hypertension persists long after delivery
Additional previous Hx or family Hx of HT
End organ damage : LVH , retinal change
Risk abruption , IUGR , preterm & death
Etiology?
Etiology
1. Abnormal trophoblastic invasion of uterine
vessels
2. Immunological intolerance between
maternal and fetoplacental tissues
3. Maternal maladaptation to cardiovascular
or inflammatory changes of normal
pregnancy (vasculopathy)
4. Dietary deficiencies
5. Genetic influences
Complications
Cardiovascular system
Increase after load
Preload diminish
Endothelial activation with extravasation
Decreased cardiac output
Hemoconcentration from
generalized
vasoconstriction and endothelial
dysfynction
Decreased blood volume
platelet activation,
aggregation & consumption
Increased platelets activating factor &
thrombopoietin
Clotting factors decrease
Erythrocytes rapid hemolysis (increase
LDH , schizocyte , MAHA)
Kidney
RPF & GFR reduced
Uric acid elevated
Creatinine clearance reduced , oliguria
Diminished urinary Ca due to increased
tubular reabsorption
Urine sodium elevated
Urine osmolality , U:P Cr , FE Na :
prerenal mechanism
Liver
Periportal hemorrhage in liver periphery
Elevated transaminase
HELLP syndrome
Bleeding cause hepatic rupture(mortality
HELLP syndrome
No strict definition
Incidence 20% of severe preeclampsia or
eclampsia
Factors contributing to death : include
stroke , coagulopathy , ARDS , ARF ,
sepsis
Insufficient evidence : adjunctive steroid
Brain
Headache & visual symptoms associated
with eclampsia
Two cerebral pathology related
1. gross hemorrhage due to ruptured a.
caused by severe HT
2. more widespread , edema hyperemia ,
ischemia , thrombosis & hemorrhage
caused by preeclampsia
Prediction
Biological , biochemical & biophysical
markers
To identify markers of
faulty placentation
reduced placental perfusion ,
endothelial cell activation & dysfunction ,
activation of coagulation
HOW?
Uric acid
Decreased renal urate excretion in
preeclampsia
Serum uric acid exceeding 5.9 at 24 wk
(PPV 33%)
Not useful in differentiating GHT from
preeclampsia
Fibronectin
Endothelial cell activation
Low sensitivity 69%
Positive predictive vaules 12%
Higher levels by 12 wks (PPV 29% NPV
98%)
Coagulation activation
Thrombocytopenia and platelet
dysfunction
Increased destruction cause platelet
volumes increase (younger platelet)
Preeclampsia : PAI-1 increase increased
relative to PAI-2 because of endothelial
cell dysfunction
Cytokines
Released by vascular endothelium
&
Fetal DNA
Fetal DNA in maternal serum
At the time endothelial activation , fetal
Prevention
Salt restriction : ineffective
Inappropriate diuretic therapy
Low dietary calcium
Antioxidant
39% reduction in risk of preeclampsia (RR
0.61)
Reduced risk of SGA infant (RR 0.64)
More preterm birth (RR 1.38)
No difference in develop preeclampsia
among low & high risk (RR 0.66 & 0.44)
GA : no diff (<20wk VS before & after
20wk)
Dietary salt
Reduce dietary salt intake vs continue a
normal diet
No effect in preeclampsia (RR 1.11)
Insuffient evidence for reliable conclusions
about effect of advice to reduce diet salt
Management
Management
Early prenatal detection
Antepartum hospital management
Termination of pregnancy
Antihypertensive drug therapy
increased surveillance
New-onset diastolic BP 81-89 mmHg or
sudden abnormal wt gain (> 2 lb/wk during
3rd trimester)
OPD surveillance unless overt HT ,
proteinuria , visual disturbances or
epigastric discomfort
2. Antepartum management
Admit if new onset HT , esp persistent or
Antepartum management
Evaluate fetal size , AF
Reduced physical activity
Sedative not prescribed
Ample, not excess, protein & calories diet
Sodium & fluid intake not limit or forced
Further Mg depend on : severity ,
Preeclampsia-Initial Evaluation
Serial blood pressure measurements
Urine protein excretion
Fetal monitoring
Tests to rule out HELLP and other
Severe PreeclampsiaManagement
Seizure prophylaxis
Blood pressure control
Delivery
Preeclampsia-Term Pregnancy
Delivery is a short-term goal
Induction of labor is appropriate after
maternal-fetal observation/stabilization
Cesarean reserved for standard obstetric
indications
Cesarean may be recommended in cases
of severe preeclampsia where delivery is
remote
Preeclampsia-Preterm
Pregnancy
Mild preeclampsia - expectant
Preeclampsia-Preterm
Pregnancy
Severe preeclampsia - controversial
Delivery for poor maternal condition is
Preeclampsia-Preterm
Pregnancy
Hospitalization
Magnesium sulfate for seizure prophylaxis, at
least during initial observation period
Blood pressure control to range of 140155/90-105 (labetalol or nifedipine)
Daily assessment of maternal-fetal condition
Preeclampsia-Preterm
Pregnancy
lung maturation
3. Termination of pregnancy
Delivery is the cure for preeclampsia
Headache , visual disturbances or
Termination of pregnancy
Preterm
vaginal delivery
c-section if indicated
4. Antihypertensive drug
To prolong pregnancy , or modify perinatal
outcomes
Antihypertensive drug
term
Conservative or expectant management in
selected group
Sibai 1985 : SPE 18-27 wk : perinatal
mortality 87% , no mothers died , placental
abruption eclampsia , consumptive
coagulopathy , RF , encephalopathy ,
intracerebral hemorrhage , ruptured
hepatic hematoma
Glucocorticoids
Not worsen maternal HT
Decrease RDS , improve fetal survival
No evidence : benefit to ameliorate
Eclampsia-Management
Preeclampsia complicated by generalized
tonic-clonic convulsions OR
Fatal coma without convulsions also
Major complications included placental
abruption (10%) , neuro deficit (7%) ,
aspiration pneumonia (7%) , pulm edema
(5%) , arrest (4%) , ARF (4%) , death (1%)
Eclampsia
Duration of coma variable
Hypercarbia , lactic acidemia , fetal brady
cardia
High fever
Proteinuria
Diminished urine output , hemoglobinuria
Pronounced edema
Proteinuria & edema disappear within 1 wk
BP return within a few days to 2 wk PP
Eclampsia
Differential diagnosis : epilepsy ,
Treatment
1. control of convulsions using IV MgSO4
2. Intermittent IV or oral of antihypertensive
drug to lower Diastolic BP <100
3. Avoidance of diuretics , limit IV fluid
adminstration , avoid hyperosmotic agents
4. Delivery
Continuous IV regimen
4-6 gm MgSO4 dilute in 100 ml fluid , admin
over 15-20 min
Begin 2 g/hr in 100 ml IV maintenance
Measure Mg level at 4-6 hr , adjust level
between 4-7 mEq/L
MgSO4 discontinued 24 hr after delivery
Intermittent intramuscular
Give 4 g MgSO4 IV , rate not exceed 1
g/min
Follow with 10 g MgSO4 : 5 g injected
each buttock through 3 inch long , 20
gauge needle , (add 1 ml of 2% lidocaine)
If convulsions persist after 15 min , give 2
g more IV slowly
Give 5 g MgSO4 IM q 4 hr
MgSO4 discontinue 24 hr after delivery
MgSO4
Effective anticonvulsant without producing
MgSO4
Almost totally cleared by renal excretion
Monitor urine output , DTR , RR
Maintained level 4-7 mEq/L
IM & IV regimen , no significant difference
Mg level
Mg 10 mEq/L : patellar reflex disappear
> 10 mEq/L : respiratory depression
> 12 mEq/L : respiratory paralysis & arrest
Cr >1.3 : half dose MgSO4
MgSO4
Fetal effects
Promptly cross placenta
Neonatal depression occurs only if severe
hypermagnesemia at delivery
Decrease in beat-to-beat variability
Possible protective effect against cerebral palsy
in VLBW infants
Substantial gross motor dysfunction reduced
No serious harmful effects
Antihypertensive
Hydralazine suggested if persistent
Antihypertensives
1& nonselective -blocker
Lower BP more rapidly , associated
tachycardia
NHBPEP(2000) : recommends 20 mg IV
bolus , if not effective within 10 min ,
followed by 40 mg , then 80 mg q 10 min
but not exceed 220 mg total dose per
episode treated
Labetolol : IV
Antihypertensives
Nifedipine 10 mg Oral , repeated in 30 min
Persistent postpartum HT
Hydralazine 10-25 mg IM q 4-6 hr
If HT persists or recur : oral labetolol or
Fluid therapy
Lactate Ringers Solution , rate 60 ml to
125 ml/hr
Unless unusual fluid loss : N/V , diarrhea ,
excessive blood loss
Oliguria : maternal blood volume
constricted, admin IV fluid more vigorously
Women with eclampsia already has
excessive extracelular fluid
Pulmonary edema
Invasive monitoring
Use of pulmonary artery catheterization
Reserved for women with severe cardiac
Delivery
After eclamptic sz , labor often ensues