Hypertension in Pregnancy - Derian

Hypertension in
Pregnancy
Derian Irawan – 4 0 6 1 72061
P E M B I M B I N G – D R . Miko Susanto, S P.O G
K E PA N I TE RA A N O B STE TRI DA N G I N E KO LOG
I
RS S U MB E R WA R A S - FK U N TA R
Hypertension in Pregnancy
Hypertensive disorders complicate5 to10
percent ofall pregnancies, and together they
are one member of the deadly triad—along
with hemorrhage and infection—that
contributes greatly to maternal morbidity
and mortality
preeclampsia syndrome, either alone or
superimposed on chronic hypertension, is
the most dangerous
Hypertension in Pregnancy
new-onset hypertension during
pregnancy—termed gestational
hypertension—is followed by signs and
symptoms of preeclampsia almost half
the time
preeclampsia is identified in 3.9 percent
of all pregnancies
Classification ACOG 2013
1. Gestational hypertension—evidence for
the preeclampsia syndrome does not
develop and hypertensionresolves by
12 weeks postpartum
2. Preeclampsia and eclampsia syndrome
3. Chronic hypertension of any etiology
4. Preeclampsia superimposed on chronic
hypertension.
Gestational Hypertension
This diagnosis is made in women whose blood
pressures reach 140/90 mm Hg or greater for the first
time after midpregnancy, but in whom proteinuria is
not identified
Almost half of these women subsequently develop
preeclampsia syndrome, which includes findings such
as headaches or epigastric pain, proteinuria, and
thrombocytopenia.
10 percent of eclamptic seizures develop before
overt proteinuria can be detected.
B.P. returns to normal by 12 weeks post partum
Preeclampsia Syndrome
Best described as a pregnancy-specific
syndrome that can affect virtually every organ
system
“Preeclampsia (PE) is a multisystemic
complication of pregnancy often characterized
with the onset of hypertension and
proteinuria after 20 weeks of gestation in a
previously normotensive women.”
PE is more than HTG + Proteinuria
Preeclampsia Syndrome
Appearance of proteinuria remains an important
diagnostic criteria
Proteinuria is an objective marker and reflects the system-
wide endothelial leak, which characterizes the
preeclampsia syndrome.
Abnormal protein excretion is arbitrarily defined by
◦24-hour urinary excretion exceeding 300 mg;
◦a urine protein:creatinine ratio ≥ 0.3; or
◦persistent 30 mg/dL (1+ dipstick) protein in random urine
samples
Proteinuria not present in all PE Patients
Diagnosis
Indicators of
Severity Some symptoms are considered to
be ominous.
Headaches or visual disturbances
such as scotomata can be
premonitory symptoms of
eclampsia.
Epigastric or right upper quadrant
pain frequently accompanies
hepatocellular necrosis, ischemia, and
edema that ostensibly stretches
Glisson capsule.
This characteristic pain is frequently
accompanied by elevated serum
hepatic transaminase levels.
Indicators of
Severity Finally, thrombocytopenia is also
characteristic of worsening
preeclampsia as it signifies
platelet activation and
aggregation as well as
microangiopathic hemolysis.
Other factors indicative of
severe preeclampsia include
renal or cardiac involvement
and obvious fetal-growth
restriction, which also attests to
its duration.
Eclampsia
In a woman with preeclampsia,a
convulsion that cannot be attributed
to another cause is termed eclampsia.
The seizures are generalized and
may appear before, during, or after
labor.
10% occur in 48 hours after labor
PE Superimposed on Chronic
Hypertension
Regardless of its cause, any chronic hypertensive
disorder predisposes a woman to develop
superimposed preeclampsia syndrome.
Chronic underlying hypertension is diagnosed in
women with documented blood pressures ≥ 140/90
mm Hg before pregnancy or before 20 weeks’
gestation, or both
Difficult to diagnosis if women 1st visit in mid
pregnancy
◦blood pressure normally decreases during the second and early
third trimesters in both normotensive and chronically
hypertensive women
PE Superimposed on Chronic
Hypertension
In some women with chronic hypertension, their blood
pressure increases to obviously abnormal levels, and this
is typically after 24 weeks.
If new-onset or worsening baseline hypertension is
accompanied by new-onset proteinuria or other
findings, then superimposedpreeclampsia is
diagnosed.
Compared with “pure” preeclampsia, superimposed
preeclampsia commonly develops earlier in pregnancy. It
also tends to be more severe and often is accompanied
by fetal-growth restriction
Risk
Factors
Y oung and nulliparous women are particularly vulnerable
to developing preeclampsia, whereas older women are at
greater risk for chronic hypertension with superimposed
preeclampsia
obesity,
multifetal gestation,
maternal age,
hyperhomocysteinemia,
and metabolic syndrome
Smoking – ironically associated with reduced risk
for hypertension during pregnancy
Prior history of preeclampsia
Etiopathogenesis
Prediction
Measurement during early pregnancy—or across
pregnancy— of various biological, biochemical, and
biophysical markers implicated in
preeclampsia syndrome pathophysiology has been
proposed to predict its development.
Currently, no screening tests are predictably reliable,
valid, and economical
Prediction
Uterine Artery Doppler Velocimetry
Renal Function and Angiogenic Factors
Prevention
Antithrombotic
Antithrombotic
Managemen
t Termination ofpregnancy is the only
cure for preeclampsia.
Pregnancy complicated by gestational hypertension is
managed based on severity, gestational age, and
presence of preeclampsia.
Recommends more frequent prenatal visits if
preeclampsia is “suspected.”
Increases in systolic and diastolic blood pressure can
be either normal physiological changes or signs
of developing pathology.
Management
Targets
1. termination of pregnancy with the least possible
trauma to mother and fetus,
2. birth of an infant who subsequently thrives,
3. complete restoration of health to the mother.
One of the most important clinical questions for

successful management is precise knowledge of fetal
age.
Evaluation
Hospitalisation
for women
with new
onset HT
Bedrest?
Considerations for Delivery
Anti Hypertensive Therapy Mild to Moderate
HT treatment for early mild preeclampsia has been
Drug
disappointing as shown in representative
randomized trials
Corticosteroid for
HELLP not
recommended (ACOG)
Magnesium Sulphate
Magnesium Sulphate Prophylaxis
Management of Severe Hypertension
Hydralazine
Labetalo
lα 1 -effective intravenous
This anti-hypertensive agent is an
and nonselective β-blocker.
Some prefer its use over hydralazine because of fewer
side effects
The American College of Obstetricians and
Gynecologists (2012b) recommends
◦starting with a 20-mg intravenous bolus.
◦If not effective within 10 minutes, this is followed by 40 mg,
then 80 mg every 10 minutes.
◦Administration should not exceed a 220-mg total dose
per treatment cycle.
Nifedipine
Diuretics NOT to be Used
Anesthesia
Complications of PE
Renal Failure
Hemolysis,
elevated liver
enzymes and low
platelet (HELLP)
syndrome
Visual Changes
Cerebral Liver Hemorrhage

Hemorrhag and Rupture
e
Eclampsi
a
Future Pregnancies
Long Term Consequence
how pregnancy incites or aggravates
hypertension remains unsolved despite
decades of intensive research.
remain among the most significant and

intriguing unsolved problems in
obstetrics.
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Hypertension in

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Cerebral Liver Hemorrhage

remain among the most significant and

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