LPU - ST.

CABRINI COILLEGE OF MEDICINE

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

MEDICAL COMPLICATIONS
IN PREGNANCY
ODESSA NAVOR-ORELLANA, MD, MHA, FPOGS
OBSTETRICIAN AND GYNECOLOGIST
FELLOW, PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIETY
MEMBER, PHILIPPINE SOCIETY OF GYNECOLOGIC ENDOSCOPY
MASTERS, HOSPITAL ADMINISTRATION
 HYPERTENSION
IN PREGNANCY

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 LEARNING
OBJECTIVES
HYPERTENSION IN PREGNANCY

• To differentiate the different types of

hypertension in pregnancy
• To identify risk factors and explain the
pathophysiology of pregnancy-induced
hypertension
• To enumerate the effects of pregnancy-
induced hypertension on the mother and
on the infant
• To familiarize one’s self with the
management options in the treatment of
hypertension in pregnancy

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
HYPERTENSIVE DISORDERS
IN PREGNACY
EPIDEMIOLOGY
• Hypertensive disorders complicate 6-8% of pregnancies
• Leading cause of maternal and fetal morbidity and mortality
• 16% of maternal deaths are related to hypertension

1 2 3 4
PREECLAMPSIA
GESTATIONAL PRE-ECLAMPSIA- CHRONIC
SUPERIMPOSED ON
HYPERTENSION ECLAMPSIA HYPERTENSION OF
CHRONIC
SYNDROME ANY ETIOLOGY
HYPERTENSION

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 DEFINITION

HYPERTENSION PROTEINURIA EDEMA CONVULSION

• >/= 140 mmHg systolic • Urinary protein • Swelling of the hands • convulsion not
• >/= 90 mmHg diastolic spillage of 300 mg or or the face attributed to any
• on 4 occasions at least more in 24 hours other causes
• Pedal edema after an
4 hours apart • Urinary protein
over-night rest
concentration of 100
mg/dL or more in 2
random specimens
taken 6 hrs apart

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 CLASSIFICATION

GESTATIONAL PRE-ECLAMPSIA ECLAMPSIA CHRONIC

HYPERTENSION HYPERTENSION

1. BP >140/90 mmHg 1. BP >140/90 mmHg 1. BP >140/90 mmHg 1. BP >140/90 mmHg

> 20 weeks AOG to > 20 weeks AOG to > 20 weeks AOG to < 20 weeks AOG to
< 12 weeks postpartum < 12 weeks postpartum < 12 weeks postpartum > 12 weeks postpartum
+/-
2. Proteinuria 2. Proteinuria 2. Proteinuria
>300mg / 24hr >300mg / 24hr >300mg / 24hr
Protein : Crea > 0.3 Protein : Crea > 0.3 Protein : Crea > 0.3
Dipstick 1+ Dipstick 1+ Dipstick 1+
+/-
3. With convulsions 3. With convulsions

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
Maternal Complication: Hypertension
Odessa Navor-Orellana, MD, FPOGS
Maternal Complication: Hypertension
Odessa Navor-Orellana, MD, FPOGS
 1. Primiparity
2. Advanced maternal age (older than 40 yrs old)
3. Previous preeclamptic pregnancy
4. Chronic hypertension or chronic renal disease
RISK FACTORS 5.
or both
History of thrombophilia
6. Multifetal pregnancy
7. In vitro fertilization
8. Family history of preeclampsia
9. Type I or type II diabetes mellitus
10. Obesity
11. Systemic lupus erythematosus

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 1. Placental implantation with abnormal
trophoblastic invasion of uterine vessels

• shallow invasion
ETIOLOGY • abnormally narrow spiral arterioles
• impaired placental blood flow – diminished
perfusion – hypotoxic environment – release
of placental debris – SIRS

2. Immunological maladaptive tolerance between

maternal, paternal (placental), and fetal tissues

• Acute graft rejection

• Dose dose effect (↑ paternal antigen)
• Subsequent pregnancy with same partner is
immunized against pre-eclampsia

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 3. Maternal maladaptation to cardiovascular or
inflammatory changes of normal pregnancy

• Endothelial Cell Activation (↑ TNa/IL1)

ETIOLOGY • ↑ lipid laden macrophages foam cells
→ ATHEROSIS
• ↑ microvascular coagulation
→ THROMBOCYTOPENIA
• ↑ capiliary permeability
→ PROTEINURIA / EDEMA

4. Genetic factors including inherited

predisposing genes and epigenetic influences.
• multifactorial polygenic disorder
• ~20% - daughters / sisters
• ~40% - twins
• ~60% - monozygotic twins

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 1. Vasospasm
• Vascular constriction → HYPERTENSION
• Endothelial cell damage – interstitial leakage
of platelets and fibrinogen
PATHOGENESIS → THROMBOCYTOPENIA

2. Endothelial cell activation

• ↓ PGI-2, ↑ TxN-A2 → VASOCONSTRICTION

3. ↑ Endothelins → VASOCONSTRICTION

4. Angiogenic imbalance → UTEROPLACENTAL

INSUFFIENCY

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 • Are exposed to chorionic villi for the first time
(primigravid)

• Are exposed to a superabundance of chorionic

ETIO- villi, as with twins or hydatidiform mole

PATHOGENESIS • Have preexisting conditions of endothelial cell

activation or inflammation such as chronic
hypertension, diabetes or renal or cardiovascular
disease

• Are genetically predisposed to hypertension

developing during pregnancy

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 VASCULAR IMMUNOLOGIC GENETIC
DISEASE
(primigravid, multifetal and
molar pregnancy)

PATHOGENESIS Inadequate Trophoblastic

Invasion of Spiral arteries

↓ Placental Perfusion

↑ Endothelial “Toxins”

Generalized Endothelial Injury

↑ Vascular ↓ Production of PG-I2 & Intravascular

Permeability Endogenous Vasodilators Coagulation &
Fibrin Deposition

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 PATHOPHYSIOLOGY OF PRE-ECLAMPSIA

FUNCTIONAL FUNCTIONAL FUNCTIONAL

Increased Vascular ↓ Production of PG-I2 & Intravascular

Permeability Endogenous Vasodilators Coagulation & Fibrin
Deposition

CLINICAL CLINICAL CLINICAL

MANIFESTATION MANIFESTATION MANIFESTATION

Proteinuria and Edema ↑ Vascular Resistance, Thrombocytopenia,

↑ Sensitivity to Vasopressors, Hemolysis, DIC
Poor Organ Perfusion

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 COMPLICATIONS

CARDIO-VASCULAR HEPATIC SYSTEM

SYSTEM

HEMATOLOGIC
HYPERTENSION CEREBRO-VASCULAR
SYSTEM

RENAL SYSTEM UTERO-PLACENTAL

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 1. ↓ Cardiac preload caused by diminished
hypervolemia of pregnancy
→ HEMOCONCENTRATION

CARDIO- 2. ↑ Cardiac afterload caused by hypertension

→ HYPERDYNAMIC VENTRICULAR FUNCTION
VASCULAR 3. Endothelial activation with inter-endothelial
extravasation of intravascular fluid into the
extracellular space and importantly, into the
lung
→ PULMONARY EDEMA

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 1. Thrombocytopenia <100,000/uL

2. Hemolysis: RBC destruction

• microidiopathic hemolysis - ↑ serum LDH
HEMATOLOGIC • abnormalities in RBC morphology –
schizocytosis, spherocytosis, reticulocytosis

3. Derangements in plasma clotting factors

• ↑ FDP, Fibrino-peptides A/B
• ↓ Factor VIII, Anti-thrombin III, Protein C&S
• pT, aPTT, and fibrinogen not necessary

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 ↑ Renal Afferent Arteriole Resistance
- ↓ Renal Perfusion - ↓ GFR

1. Proteinuria > 300 mg/day

RENAL • Protein:Creatinine Ratios < 130 to 150 mg/g,
• indicate a low likelihood of proteinuria
exceeding 300 mg/day
• albumin is the most commonly measured
protein

2. Glomerular Capillary Endotheliosis (swelling)

• blocks filtration barrier
• ↑ Creatinine

3. Acute Tubular Necrosis

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 1. RUQ or midepigastric pain or tenderness
• symptomatic, severe diseases

2. ↑ ALT/AST
HEPATIC • as part of HELLP syndrome

3. Hepatic infarction
4. Hemorrhage – Subcapsular Hematoma
5. Acute Fatty Liver of Pregnancy (AFLP)
• hypertension, thrombocytopenia, ↑ creatinine,
↑ ALT/AST

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 1. ↑ LDH
• Microidiopathic Hemolysis

2. ↑ ALT/AST
HELLP • Elevated Liver Enzymes

SYNDROME 3. ↓ (Low ) Platelet Count

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 2 Theories:

CEREBRO- 1. Severe Hypertension

• over cerebrovascular regulation
VASCULAR • ↓ cerebral blood flow – ischemia – cytotoxic
edema – INFARCTION

2. Sudden Hypertension
• normal cerbrovascular regulation
• artery: vasodilatation and constriction;
capillary: disruption of end-capillary pressure
• ↑ hydrostatic pressure – hyper-perfusion –
vasogenic edema – ENCEPHALOPATHY and
SEIZURE

3. Combination

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 Clinical Manifestations:

cont. 1. Headache* and scotoma+

• precedes eclampsia (70%*, 30%+)
CEREBRO- • common, reversible+

VASCULAR 2. Convulsion

3. Blindness
• causes:
• occipital – Amaurosis
• retina – Purtcher Retinopathy, Retinal
Detachment, Permanent Blindness

4. Generalized cerebral edema

• from lethargy, confusion, blurring to
obtundation to coma

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 1. OLIGOHYDRAMNIOS

UTERO- 2. FETAL GROWTH RESTRICTION

PLACENTAL Uterine Artery Blood Flow

• measurement of blood velocity through certain
vessels (uterine arteries) via Doppler Ultrasound

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
Maternal Complication: Hypertension
Odessa Navor-Orellana, MD, FPOGS
 1. Dietary Manipulation
• sodium restriction (dietary salt)*
• fish oil capsules*
• Vitamin C and E supplementation*
PREVENTION • calcium supplementation
2. Bed rest or restriction of other physical activity*
3. Low dose aspirin
• initiated before 16 weeks AOG
• may help reduce severe preeclampsia, but
not mild preeclampsia

*no evidence

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 OBJECTIVES:

1. Termination of pregnancy with the least

MANAGEMENT possible trauma to mother and fetus
2. Birth of an infant who subsequently thrives
3. Complete restoration of health to the mother

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 To bring down the BP in order to decrease the
risk of encephalopathy & cerebrovascular
accidents but not too low as to compromise
blood supply to the utero-placental unit.
ANTI-
HYPERTENSIVE • start anti-hypertensive medications when
BP > 160/100 mmHg
MEDICATIONS • maintain mean arterial pressure below 126
mmHg (but not less than 105) & the diastolic BP
below 105 mmHg (but not less than 90)

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 DRUGS FOR URGENT CONTROL OF
HYPERTENSION IN PREGNANCY
Drug Concerns & Comments

Hydralazine (drug of choice) Long experience

Labetolol Low experience; ¯ tachycardia & arrhythmia
Nifedipine May inhibits labor; MgS04 interaction
Diazoxide May inhibits labor; Causes hyperglycemia
Relatively Contraindicated
Nitroprusside Cyanide toxicity; Agent of last resort

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 DRUGS FOR NON-URGENT CONTROL OF
HYPERTENSION IN PREGNANCY
Drug Concerns or Comments
Methyldopa (drug of choice) Well documented safety
Hydralazine Long experience w/ few adverse effects;
Useful in combination with symphatholytics;
Neonatal Thrombocytopenia
Labetolol FGR
b-receptor blocker Fetal bradycardia; FGR
Avoided in asthmatics, AV conduction defects & diabetics
Nifedipine May inhibits labor; MgS04 interaction
Thiazide Diuretic Volume depletion & electrolyte imbalance
Avoided in gout & diabetics
Contraindicated
ACE inhibitors Fetopathy, Oligohydramnios, FGR;
Neonatal Anuric Renal Failure

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 MAGNESIUM SULFATE (drug of choice)
• acts as a peripheral myo-neural agent &
recently shown to have CNS effect in blocking
seizures
ANTI- • Desirable:
• ↓ SVR & MAP
CONVULSANT • ­ CO
• ↓ platelet aggregation & activation
• Undesirable:
• ↓ myometrial contractility
• ¯ short-term FHR variability

• Methods of Administration:
• Loading Dose: 4-6 gm slow IV + 10 gm IM
Maintenance: 5 gm IM every 4 hrs
OR
• Loading Dose: 4 gm IV in 20 min
Maintenance: 2 gm/hr IV drip (Soluset)

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 • Fluid input & output
• Fundoscopic eye grounds

• Laboratory Tests
DETECTION OF • Hematocrit w/ platelet
• 24-hr urinary protein spillage
END-ORGAN • BUN, creatinine, uric acid
• SGOT, SGPT, LDH
DAMAGE • NST, Biophysical Profile & Doppler Velocimetry

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 Delivery: the only cure for preeclampsia

AOG Far From Term

• Mild – temporize for fetal lung maturation
• Severe – if no improvement ® deliver

TERMINATION Contraindications to Conservative Management

OF PREGNANCY • Eclampsia
• Severe Hypertension

• Pulmonary Edema
• HELLP syndrome
• Hepato-Renal Dysfunction
• Coagulopathy
• Abruption
• Pre-viable Fetus
• Fetal Compromise

• Route
• NSD - Preferred
• CS – unfavorable cervix, urgency of delivery
Maternal Complication: Hypertension
Odessa Navor-Orellana, MD, FPOGS
 • Recurrent severe Hypertension
• Recurrent symptoms of severe Preeclampsia
• Eclampsia

• Progressive Renal insufficiency (serum creatinine

MATERNAL concentration > 1.1 mg/dL or a doubling of the

serum creatinine concentration in the absence of

INDICATION other renal disease)

• persistent Thrombocytopenia or HELLP syndrome

FOR DELIVERY • Pulmonary edema

• suspected Abruptio placenta

• progressive Labor or rupture of membranes

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 • Gestational age of 34 0/7 weeks (may vary by
institution)

• severe fetal Growth restriction (<5th percentile)

• persistent Oligohydramnios

FETAL • Biophysical profile score of 4/10 or less on at least

two occasions 6 hours apart

INDICATION • Reversed end-diastolic flow on umbilical artery

Doppler studies

FOR DELIVERY • recurrent Variable or Late decelerations during

non-stress testing

• fetal Death

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
 1. The earlier preeclampsia is diagnosed in the
index pregnancy, the greater the likelihood of
Recurrence in a future pregnancy.

2. The recurrence of preeclampsia is higher for

LONG TERM Multiparous women who develop preeclampsia.

SEQUELAE 3. Women with early-onset preeclampsia are at

higher risk for underlying Thombophilias.

4. Those with recurrent pregnancy hypertension are

at increased risk for chronic Hypertension and
subsequent Renal disease.

5. The ccurrence of preeclampsia places a woman

at risk for chronic Hypertension, ischemic Heart
disease and Stroke later in life.

Maternal Complication: Hypertension

Odessa Navor-Orellana, MD, FPOGS
THANK
YOU
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