Hypertensive Disorders in Pregnancy Woman’s Hospital School of Medicine Zhejing University He jin

Special 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 Include:

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. Transient hypertension

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 （ albuminuria, hypertension ） 5 、 Maternal MODS, perinatal fetal poor prognosis and death

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

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 、 The lack of a variety of nutrition materials(such as trace elements …….) Cause

Spasm of vessels Vessel stenosis Higher periphery resistance Blood pressure elevate Injury of endotheliocyte ProteinuriaEdemaHypertension Pathology

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

Pathophysiological changes Basic diseases: Systemic small artery spasm Brain, heart, lung, liver, kidney and other vital organs severe ischemia Cause heart, liver and kidney failure, pulmonary edema and cerebral edema, and even convulsions, coma; Placental abruption and placental dysfunction, Activated clotting process, leading to DIC.

Clinical manifestations After 20 weeks of pregnancy hypertension, edema, proteinuria. Light may have mild symptoms or dizziness, blood pressure increased slightly with edema or mild proteinuria Severe headache, vertigo, nausea, vomiting, persistent right upper abdominal pain, blood pressure increased significantly, increased proteinuria, edema, and even coma and convulsions

Diagnosis Based on history, clinical manifestations, signs and laboratory examinations to make a diagnosis, and should watch for complications and clotting mechanism. 1. History 2. Hypertension 3. Urine protein 4. Edema 5. Auxiliary examination: blood test, liver and kidney function test, urine examination, fundus examination, invasive hemodynamic monitoring, ECG and echocardiography

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 —— Edema

Hypertension is the most important criterion for the diagnosis of preeclampsia That too may occur suddenly Many young primigravidas have /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 —— Hypertension

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 24H urine protein have more meaningful Clinical findings —— Proteinuria

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 Clinical findings —— Differing clinical picture

Classification Gestational Preeclampsia Gestational Preeclampsia Preeclampsia Preeclampsia Eclampsia Eclampsia Superimposed preeclampsia on Superimposed preeclampsia on chronic hypertension chronic hypertension Chronic hypertension in pregnancy Chronic hypertension in pregnancy

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 Diagnostic thinking: confirmed Maternal blood pressure during pregnancy for the first time ≥ 140/90mmHg, but the urine protein (-) Throughout pregnancy without the development of preeclampsia Blood pressure returned to normal at 12 weeks postpartum

1 、 Proteinuria ≥300mg/24 hours or ≥1+ dipstick 2 、 BP≥140/90mmHg after 20 weeks’ gestation 3 、 May be associated with headache ， visual disorder ， upper abdominal pain Early onset preeclampsia (<34 weeks of gestation ) Preeclampsia Diagnostic thinking Urine protein appears: an important basis for preeclampsia The result: (PIH) contraction of small blood vessels in the body caused reduction in renal blood flow Marked ： damage to renal function in pregnant women caused reduction in renal blood flow Marked ： damage to renal function in pregnant women

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(<10,000/L) 8 、 Dysfunction of liver 9 、 FGR ， oligohydramnios 10 、 Headache ， visual disorder ， upper abdominal pain 11 、 Hepatic subcapsular hematoma 12 、 Cerebral vascular accident

Eclampsia Seizures that cannot be attributed to other causes in a woman with preeclampsia Diagnostic thinking Seizure: on the basis of preeclampsia, or associated with coma

Superimposedpreeclampsia on Superimposed preeclampsia on chronic hypertension 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 /mm 3 in women with hypertension and proteinuria ， before 20 weeks’ gestation Diagnostic thinking preeclampsia HypertensionBefore pregnancy or before 20 weeks Hypertension :Before pregnancy or before 20 weeks Blood pressure was still high after 12 weeks postpartum

Chronic hypertension in pregnancy 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 Diagnostic thinking Hypertension Before pregnancy or before 20 weeks Blood pressure was still high after 12 weeks postpartum

Differential diagnosis  According to clinical manifestations.  PIH Chronic nephritis with pregnancy  Eclampsia  Epilepsy Encephalitis Brain tumor Rupture of cerebral vascular malformations Diabetic hyperosmolar coma Hypoglycemic coma

Complications of mother Heart failure Cerebrova- scular accident Placenta abruption DIC Renal failure HELLP’S syndrome Postpartum hemorrhage More frequently in severe type

Fetus ： FGR fetal distress fetal death neonatal asphyxia Complications of fetus

 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 Basic management objectives

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.

Management Antispasmodic Lowers blood pressure Timely termination of pregnancy There are indications those fluid expansion and diuretic Monitoring and promoting fetal growth and development

General treatment Rest The state of the mother and fetus should be closely monitor Intermittent oxygen Balanced diet

conscious-sedation Diazepam (valium): –relatively strong sedative effect, anticonvulsant, muscle relaxant effect –on the fetus and newborn: less affected Lytic cocktail: –extensive inhibition of the nervous system, contribute to spasm blood pressure, control of eclampsia convulsions

Spasmolysis The main method :treatment of eclampsia and severe preeclampsia Relieve angiospasm Relieve symptoms Prevent seizures. Magnesium sulfate often as the first preferred drug

Depressurization Objective: –to extend the gestational age –changing perinatal outcomes Principles: non-toxic side effects on the fetus does not affect cardiac output, renal blood flow and placental perfusion, sudden drop in blood pressure can reduce excessive.

Depressurization Indications: systolic blood pressure ≥ 160 or diastolic blood pressure 110mmHg or mean arterial blood pressure ≥ 110mmHg essential hypertension those with antihypertensive drugs before pregnancy

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

fluid expansion Generally not in favor of expansion Only for severe hypoproteinemia, anemia Albumin, plasma, whole blood

Diuresis Generally do not advocate Only for: –pulmonary edema –systemic edema persons –acute heart failure –excessive blood volume potentially associated with pulmonary edema

 Effective measures  Indications :  severe preeclampsia after active treatment 24 to 48 hours were no noticeable improvement  Severe preeclampsia has more than 34 weeks gestational age  Severe preeclampsia and gestational age less than 34 weeks, but placental dysfunction, the fetus has matured pregnancy termination

Indications : Severe preeclampsia, gestational age less than 34 weeks –placental dysfunction, the fetus has not matured used dexamethasone to promote fetal lung maturity control 2 hours after eclampsia may consider termination of pregnancy

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

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

Mode of delivery Vaginal delivery: –a stable condition –cervical ripening Cesarean section: –obstetric indication –cervical conditions are not mature enough in the short term vaginal deliveries –induction failure –significantly lower placental function –fetal distress

The treatment principle of eclampsia The main cause : maternal and fetutal mortality Control seizures Correct hypoxia and acidosis Control of blood pressure Termination of pregnancy after control seizure

anticipation Conducted in second trimester –close follow-up should be positive Mean arterial pressure Roll over test Rheology Test Determination of urinary calcium

Hellp syndrome Diagnostic criteria –hemolysis, elevated liver enzymes, and thrombocytopenia. Principles –early diagnosis –early treatment –timely termination of pregnancy –reduce fetal and maternal mortality –active treatment PIH