Hypertensive Disorder Complicating Pregnancy

Overview 1、onset after 20 weeks gestation   2、Incidence rate：about 7-12%（china 9.4％） 3、specially occur in pregnancy 4、A group of symptoms

Hypertensive states in pregnancy Include: Gestational hypertension； Preeclampsia; Eclampsia; Chronic hypertension in pregnancy (either essential or secondary to renal disease， endocrine disease, or other causes); Pre-eclampsia superimposed upon chronic hypertension ？Transient hypertension

Transient hypertension 1.Transient hypertension is the development of hypertension after midpregnancy or in the first 24 hours postpartum without other signs of preeclampsia or preexisting hypertension. 2.This condition is often predictive of the later development of essential hypertension. 3.Transient hypertension is a retrospective diagnosis and, if uncertainty exists regarding the diagnosis, these patients should be managed as if they had preeclampsia.

Cause Chesley described preeclampsia as a“disease of theories”, because the cause is unknown. Some theories include: 1、Genetic susceptibility hypothesis 2、Immune maladaptation hypothesis 3、Placental perfusion or Ischemia Hypotheses 4、Oxidative stress hypotheses 5、Endothelial cell injury ：explains many of the clinical findings in preeclampsia 6、…….

High-risk factors Tensity Age Social status Climate changes abruptly Fat High tension of uterus：multiplets、hydramnios Family history Bad birth history Complications：DM、chronic nephritis…

Pathology Spasm of vessels Blood pressure elevate Vessel stenosis Higher periphery resistance Spasm of vessels Injury of endotheliocyte Proteinuria Edema Hypertension

These effects are separated into maternal and fetal consequences; however, these aberrations often occur simultaneously.

Clinical findings——Edema Dependent（下垂） edema is a normal finding in pregnancy Undependent edema of the hands and face present upon Morning arising is considered pathologic Weight gain in excess of 2kg/week or particularly sudden weight gain over 1 or 2 days should raise the suspicion of preeclampsia Preeclampsia may occur without edema.（39% of eclamptic patients in one series had no edema.）

Clinical findings——Hypertension Hypertension is the most important criterion for the diagnosis of preeclampsia That too may occur suddenly Many young primigravidas have 100-110/60-70mmHg duing the second trimester. An increase of 15mmHg or 30mmHg should be considered ominous The blood pressure is often quite labile.It usually falls during sleep in patients with mild preeclampsia and chronic hypertension But in patients with severe preeclampsia ，blood pressure may increase during sleep, eg, the most severe hypertion may occur at 2:00AM

Clinical findings——Proteinuria Proteinuria is the last sign to develop Eclampsia may occur without proteinuria. Sibai and associates found no proteinuria will have glomeruloendotheliosis on kidney biopsy Proteinuria in preeclampsia is an indicator of fetal jeopardy The incidence of SGA infants and perinatal mortality is markedly increased in patients with proteinuric preeclampsia

Clinical findings——Differing clinical picture Preeclampsia-eclampsia is a multisystem disease with varying clinical presentations. One patient may present with eclamptic seizures, another with liver dysfunction and intrauterine growth retardation, another with pulmonary edema, stillanother with abruption placenta and renal failure

Classification Gestational hypertension Preeclampsia Eclampsia Preeclampsia superimposed upon chronic hypertension Chronic hypertension

Gestational hypertension 1、Blood pressure≥140/90mmHg first onset in gestational period and recover within 12 weeks post partum 2、Urine protein negative 3、Patients may superimpose upper abdo- minal pain and thrombocytopenia 4、Final diagnosis should be made post partum

Preeclampsia Minimum criteria: 1、Proteinuria ≥300mg/24 hours or ≥1+ dipstick 2、BP≥140/90mmHg after 20 weeks’ gestation

Preeclampsia Increased certainty of preeclampsia: BP≥160/110mmHg Proteinuria 2g/24 hours or ≥2+ dipstick Cr level of blood >106 umol/L Blood platelet <100×109/L Persistent headache or other cerbral or visual disturbance Persistent epigastric pain

Eclampsia Seizures that cannot be attributed to other causes in a woman with preeclampsia

Pre-eclampsia superimposed upon chronic hypertension New-onset proteinuria ≥300mg/24 hours in hypertensive women ，but no proteinuria before 20 weeks’ gestation； A sudden increase in proteinuria or blood pressure or platelet count< 100,000 /mm3 in women with hypertension and proteinuria ，before 20 weeks’ gestation

Chronic Hypertension 1、BP≥140/90mmHg before pregnancy or diagnosed before 20 weeks’ gestation 2、Hypertension first diagnosed after 20 weeks’ gestation and persistent after 12 weeks’ postpartum

Extremely severe preeclampsia 1、Systolic pressure≥160～180mmHg，or diastolic pressure≥110mmHg 2、Urine protein in 24 hours >5g 3、DIC 4、Oliguria，urine volume in 24 hours <500ml 5、Pulmonary edema 6、Microangiopathic hemolysis 7、Thromocytoplets(<10万/L) 8、Dysfunction of liver 9、FGR ，oligohydramnios 10、Headache，visual disorder，upper abdominal pain

Differential diagnosis Clinical symptoms and physical signs Auxiliary examinations Differential diagnosis According to clinical manifestations.

Complications of mother Heart failure Cerebrova- scular accident Placenta abruption DIC Renal failure HELLP’S syndrome Postpartum hemorrhage

Complications of fetus FGR fetal distress fetal death neonatal asphyxia

Basic management objectives Termination of pregnancy with the least possible trauma to mother and fetus Birth of an infant who subsequently thrives Complete restoration of health to the mother

A systematic evaluation Detailed examination Weight on admittance and every day thereafter. Analysis for proteinuria at least every 2 days thereafter Blood pressure readings in sitting position with anappropriated-size cuff every 4 hours, except betweenmidnight and morning Measurements of plasma or seru creatinine,hematocrit, platelets, and serum liver enzymes Frequent evaluation of fetal size and amnionic fluid volume.

6 principles Spasmolysis… conscious-sedation … Depressurization… fluid expansion… Diuresis… pregnancy termination

Mild Preeclampsia Treatment Of Mother Assessment of Fetal Status

Severe Preeclampsia The goals of management are ： Prevention of convulsions Control of maternal blood pressure Initiation of delivery  

Eclampsia Control of Seizures Controln of Hypertension Hydralazine Labetalol Nifedipine Sodium nitroprusside

pregnancy termination Blood pressure consistently higher than 100 mmHg diastolic in a 24-h period or confirmed higher than 110 mmHg Rising serum creatinine Persistent or severe headache Epigastric pain Abnormal liver function tests Thrombocytopenia HELLP syndrome Eclampsia Pulmonary edema Abnormal antepartum fetal heart rate testing SGA fetus with failure to grow on serial ultrasound examinations