HYPERTENSIVE DISORDERS

IN PREGNANCY

Department of Obstetrics & Gynecology,

Medicine Faculty of UKI
Jakarta
 Trias main cause of maternal death
Preeclampsia/eclampsia
Haemorrhage
Infection

Hasan Sadikin Hospital

20 - 30% of maternal death
30 - 40% of perinatal death
 Classification :
I. Pregnancy - Induced Hypertension (PIH)
1. preeclampsia
2. eclampsia
3. hypertension without proteinuria or pathologic
edema
II. Pregnancy - Aggravated Hypertension (PAH)
= Underlying hypertension worsened by pregnancy
1. Superimposed preeclampsia
2. Superimposed eclampsia
III. Transient Hypertension

IV. Coinsidental Hypertension (chronic hypertension)

Preeclampsia/Eclampsia
Etiology : unknown
Predisposing factors :
1. Primigravida
2. Hyperplacentosis
hydatidiform mole
gemelli
diabetes mellitus
hydrops fetalis
giant baby
3. Age (< 15 years ; > 35 years)
4. Familial & genetic
5. Kidney disease and chronic hypertension
Theories about the cause

Immunological mechanism

Genetic predisposition

Dietary deficiencies

Vasoactive compounds

Endothelial dysfunction
Criteria
Preeclampsia : trias
Eclampsia : PE + Seizure
Chronic hypertension :
hypertension without edema and proteinuria
< 20 weeks gestation
persists > 6 weeks after delivery
Pregnancy agrravated hypertension :
chronic hypertension superimposed preeclampsia or
eclampsia
Transient hypertension :
Develops after 2nd trimester
Mild elevation
Without edema an proteinuria
Regresses within 10 days after delivery
 Hypertension :
Increase systole > 30 mmHg
Increase diastole > 15 mmHg
> 140/90 mmHg

Edema : pitting edema

Sudden increase in weight
> 500 gr/weeks or > 2 pounds/weeks
> 2 kg/months or > 6 pounds/weeks
> 13 kg/entire pregnancy

Protein uria
> 0.3 gr/L/24 hs or
> 1 gr/L/6 hs or
2 + qualitative test
Pathophysiology
Inhibition of trophoblast invasion

Immunologic Hypoxia Free radical

reaction

Endothelial dysfunction

Vasoconstrictor Vasodilator Permeability

- Thromboxane - No
- Endothelin - Prostacyclin Coagulation
- etc - etc

Hypertension edema proteinuria DIC

Maternal & Fetal Consequences
1. Cardiovascular changes
Hypertension
Cardiac out put
Thrombocytopenia
Coagulation disorders
Haemorrhages
DIC
Decrease blood plasm volume
Increase permeability
edema
2. Placenta
Necrosis
Intrauterine growth restriction
Fetal distress
Abruptio placentae

3. Kidney :
Capillary endotheliosis
Decrease uric acid clearance
Decrease glomerular filtration rate
Oliguria
Proteinuria
Kidney / renal failure
4. Brain :
Edema
Hypoxia
Seizure / convulsion
Cerebrovascular accident / hemorrhage
coma
5. Liver :
Liver function test alteration
Increase levels of liver enzym
Icterus
HELLP syndrome
(hemolysis, elevated liver enzym, low
platelet caunt)
Edema
Hemorrhage/sub capsular hematoma
Perinatal hemorrhage, necrosis
6. Eye
Papil edema
Ischemia
Amaurosis
Hemorrhage
Retinal detachment
Blindness

7. Lung :
Edema
Ischemia
Necrosis
Hemorrhage
Respiratory failure
Diagnosis
Preeclampsia :
Pregnancy of 20 weeks or more
Hypertension
Proteinuria
edema

Eclampsia :
Preeclampsia with
Convulsion / Seizure
Prognosis

Maternal death due to PE : + 0,5%

Ecl : + 5%
Perinatal death + 20%
Treatment

Prevention :
1. Dietary manipulation
Low caloric diet
High protein diet
Low salt diet
Nutritional supplementation : Ca, Mg,
Zn, Fish oil, evening primrose oil, etc
2. Pharmacologic manipulation :
Diuretics
Anti hypertensives
b-sympathomimetics
Anti thrombolic agents :
Low dose aspirin
Dipyridamole
Dazoxiben
Heparin
Vitamin E
3. Personal habit changes :

Frequent prenatal care

Daily rest in lateral position

Keep same partner

Avoid or reduce smoking

Avoid or reduce coffee

Diagnosis

Mild preeclampsia
Severe preeclampsia
1. Blood pressure : > 160/110 mmHg
2. Proteinuria > 5 gr/24 hs (> 4 +)
3. Oliguria < 500 cc/24 hs or creatinine plasma
4. Visual and cerebral disturbances
5. Epigastric or right upper quadrant pain
6. Lung edema and cyanosis
7. IUGR
8. HELLP syndrome
Treatment
1.Mild preeclampsia
a.Out patient care
Bed rest / lateral position
Diet (high protein, low fat, carbohydrate and
salt)
Mild sedatives : phenobarbital (3 x 30 mg/day)
or
Diazepam (3 x 2 mg/day) during 7 days
Vitamins
Antenatal visit every week
b. Inpatient care/Hospitalization :

No response in 2 weeks out patient

care
Body weight increase > 2 kg/weeks
Symptoms of severe preeclampsia
Treatment
Severe preeclampsia
conservative : < 37 weeks, no fetal
distress and signs of impending eclampsia
Severe headache
Severe visual disturbance
Vomiting
Epigastric pain
Progressive increase of Blood pressure

Active : pregnancy termination

I. Drug therapy :
Anti convulsive MgSO4 8gr 40%;
4 gr every 4-6 hours
Anti hypertensive :
Hydralazine 2 mg i.v 100 mg in 500 cc
NaCl drips
Clonidine
Nifedipine
Methyldopa
Labetalol
Etenolol
Dielthiazem
etc
 Others :
Diuretic
Cardiotonic
Antipyretic
Antibiotic
Pain killer

II. Obstetrical management :

Mature induction
Parturient augmentation
Delivery :
pervaginam : forcipal extraction
caesarean section
Eclampsia :
Classification :
- Antepartum
- Intrapartum
- Post partum :
early : 24 hours - 7 days
late : > 7 days

Eclampsia sine eclampsia

Eclampsia intercurrent
Treatment
Placed in I.C.U
Cooperation with : Internal depart., Neurologic depart,
etc
Drug therapy :
MGSO4 : 4gr 20% iv Loading
maintenance : 1 gram MgSo4 /jam/ drips
Supportive : same with PE
Management of coma :
In cooperation with Neurologic dept.
Obstetrical management
Termination of pregnancy
Prognosis
Eden criteria (1922)
Prolonged coma
Pulse rate > 120 x/m
Temperature > 1030 F
Systolic pressure > 200 mmHg
Seizure > 10 x
Proteinuria > 10 gr/ltr
No edema
CHRONIC HYPERTENSION
(Coincidental hypertension)

Definition :
Hypertension (> 140/90 mmHg)
< 20 weeks gestation
Persists long after delivery
 Underlying disorders :
Essential familial hypertension
(Hypertensive vascular disease)
Arterial abnormalities
Renovascular hypertension
Coartation of the aorta
Endocrine disorders
diabetes
cushing syndrome
primary aldosteronism
pheochromocytoma
thyrotoxicosis
 Glomerulonephritis (acute & chronis)
Renoprival hypertension
chronic gromerulo nephritis
chronic renal insufficiency
diabetic nephropathy
Conective tissue diseases
lupus erythematosus
scleroderma
periartenitis nodosa
Poly cystic kidney disease
Acute renal failure
Obesity
 Essential hypertension :
Chronic hypertension due to
arterio sclerosis
complications :
heart ischemia
renal failure
retinal bleeding
 Prognosis, Worsen if :
heart enlargement
Decrease renal function
Retinal complication
Blood pressure > 200/120 mmHg
Preeclampsia
Treatment :
Hospitalization

Incooperation with related

departments