1. Pregnancy: Medical Complications
By:DR.MALAK AL- HAKEEM
ASSOCIAT PROF. & CONSULTANT OBSTETRICS &GYNECOLOGY.

2. HYPERTENSIVE DISORDERS
Criteria for diagnosis
Blood pressure (BP) elevation must be sustained, and one of the following conditions must be present:
Absolute BP of ≥ 140/90 mm Hg, or
An increase in baseline diastolic BP of ≥15 mm Hg, or
An increase in baseline systolic BP of ≥ 30 mm Hg
BP elevation must be confirmed on at least two occasions at least 6 hours apart and at bed rest

3. Classification Mild preeclampsia. Criteria for diagnosis include:
BP of ≥ 140/90 mmHg or increase in diastolic BP of ≥ 15 mm Hg or increase in systolic BP of
≥ 30mmHg
Proteinuria of 1-2+ on dipstick or ≥ 300 mg on 24 hour urine collection
Edema of the face or upper extremities

4. Severe Preeclampsia. Criteria for diagnosis include:
BP of ≥ 160/110 mm Hg
Proteinuria of ≥ 3-4+ on dipstick or ≥ 5 g on
24-hour urine collection
Symptoms
Headaches resulting from cerebral edema
Visual disturbances resulting from decreased cerebral perfusion of the occipital cortex
Epigastric pain resulting from hepatocellular necrosis, edema, and ischemia stretching Glisson’s capsule

5. Laboratory Findings Mild Preeclampsia – Relative increased dias
15 mmHg, or increased syst 30 mm Hg, or absolute 140/90 Proteinuria – 1-2+ on dipstick or ≥ 300 mg/24 hr Edema of face, hands - Variable Convulsions - None Symptoms - None DIC findings - None Hemoconcentration - Mild Cyanosis, Oliguria, pulmonary edema - None

6. Severe Preeclampsia Blood pressure ≥ 160/110 mm Hg Proteinuria – 3-4+ on dipstick or ≥ 5 g/24 hr Edema of face, hands - Variable Convulsions - None Symptoms - Possible DIC findings - Possible Hemoconcentration - Marked Cyanosis, Oliguria, pulmonary edema - Possible

7. Eclampsia
Blood pressure - At least mild preeclampsia criteria Proteinuria - At least mild preeclampsia criteria Edema of face, hands - Variable Convulsions - Present Symptoms - Possible DIC findings - Possible Hemoconcentration - Marked Cyanosis, Oliguria, pulmonary edema - Possible

8. Chronic HTN
Blood pressure – Preexisting HTN or HTN
< 20 weeks Proteinuria – Variable (may be none)
Edema of face, hands - None Convulsions - None Symptoms - None DIC findings - None Hemoconcentration - None Cyanosis, Oliguria, pulmonary edema - None

9. Chronic HTN with Superimposed Preeclampsia
Blood pressure – Increased over baseline Proteinuria – At least mild preeclampsia criteria or increased over baseline
Edema of face, hands - Variable (may be none) Convulsions - None Symptoms - Possible DIC findings - Possible Hemoconcentration - Variable Cyanosis, Oliguria, pulmonary edema - Variable

10. Transient HTN
Blood pressure – At least mild preeclampsia
criteria
Proteinuria - None
Edema of face, hands - None Convulsions - None Symptoms - None DIC findings - None Hemoconcentration - None Cyanosis, Oliguria, pulmonary edema - None

11. Thrombocytopenia (<100,000/ml) resulting from vasospasm-induced macroangiopathic hemolysis
Elevated liver enzymes resulting from hepatocellular necrosis
Clinical Findings
Pulmonary edema resulting from increased capillary membrane permeability
Oliguria resulting from intrarenal vasospasm
Cyanosis resulting from right heart failure
Eclampsia is diagnosed in the presence of unexplained convulsions with other criteria for preeclampsia.
Approximately 25% occur antepartum (before labor)
Approximately 50% occur intrapartum (during labor)
Approximately 25% occur postpartum (most within first 24 hours)

12. Chronic hypertension is diagnosed with a history of preexisting hypertension either before the onset of pregnancy or before 20 weeks’ gestation (without coexisting molar pregnancy) and persisting past 6 weeks postpartum.
Chronic hypertension with superimposed preeclampsia has a worse outcome than either chronic or pregnancy – induced hypertension alone. Diagnosis requires all of the following criteria:
Presence of chronic hypertension
Increase in diastolic BP of ≥ 15mm Hg or systolic BP of ≥ 30 mm Hg
Increase in proteinuria

13. Transient hypertension, which is diagnosed with the development of hypertension without other findings of preeclampsia, is largely a retrospective diagnosis that is made after the pregnancy is over.
HELLP syndrome is a subtype of preeclampsia. The five letters make characteristics by up a mnemonic device representing the unique disease findings: Hemolysis, Elevated Liver enzymes, and Low Platelets.

14. Preeclampsia – eclampsia spectrum
Epidemiology of preeclampsia. Preeclampsia occurs only in humans and only in pregnant women beyond 20 weeks’ gestation.
Incidence. Approximately 8% of the general obstetric population develop preeclampsia.
Risks factors
Nulliparity (most common risk factors; eight times than in multiparas)
Age extremes (i.e., <20 years, >34 years)
Multiple gestation
Hydatidiform mole
Diabetes mellitus (DM)
Nonimmune fetal hydrops

15. Chronic hypertension
Preexisting renal disease
Small vessel disease (e.g., systemic lupus erythematosus, longstanding type 1 DM)
Characteristic pathology involves renal glomerular endotheliosis, which refers to swelling of the endothelial cells of the capillary loops in the glomerular tuft.
Pathogenesis involves diffuse vasospasm and capillary wall endothelial injury.
Diffuse vasospasm produces:
Altered refractory state of pregnancy against the pressor effect of renin, angiotensin II, and aldosterone

16. Systolic and diastolic hypertension
Increased capillary permeability, which results in:
Hemoconcentration from decreased intravascular volume, which leads to increased blood urea nitrogen (BUN), creatinine, uric acid, hemoglobin, and hematocrit. Diuretics should be avoided, because they may exacerbate hemoconcentration by further reducing intravascular volume.
Edema from loss of protein into extravascular space
Excessive weight gain from fluid retention.

17. Reduced systemic perfussion of the following organ systems:
Kidneys, resulting in increased BUN, creatinine, and uric acid
Uteroplacental unit, resulting in placental insufficiency, which may decrease placental nutritional function and lead to intrauterine growth restriction (IUGR) as well as decrease placental respiratory function that leads to fetal hypoxia.
Vasoactive prostaglandins imbalance, with levels of vasoconstricting thromboxane exceeding the vasodilating effect of prostacyclin

18. Capillary wall endothelial injury results in:
Fibrin deposition in the capillary beds (microangiopathic hemolytic anemia)
Platelet destruction
Disseminated intravascular coagulation (DIC)
Consumptive coagulopathy

19. Evaluation of maternal – fetal status
Evaluation of maternal – fetal status. Management is based on type and severity of hypertensive disease as well as gestational age.
Indicators of a decline in maternal well – being
Increasing BP (systolic and/or diastolic)
Worsening symptoms (i.e., headache, visual disturbances, epigastric pain)
Increasing hemoconcentration (i.e., BUN, creatinine, uric acid, hemoglobin, hematocrit)
Increasing proteinuria on 24-hour urine collection
Worsening DIC laboratory tests (e.g., decreasing platelet count, lengthening prothrombin/partial thromboplastin times (PT/PTTs), decreasing fibrinogen)

20. Indicators of a decline in fetal well-being
Nonreactive nonstress test (NST)
Positive contraction stress test (CST)
Declining biophysical profile (BPP)
Serial sonographic growth parameters showing slowing or arrest of growth
Decreasing fetal movements
Clinical approach. Management is based on the type and severity of hypertensive disease as well as gestational age. Options include aggressive inpatient, conservative inpatient, and conservative outpatient.

21. Aggressive inpatient management includes:
Diagnostic criteria
Mild or severe preeclampsia; ≥ 37 weeks’ gestation
Severe preeclampsia; <26 weeks’ gestation
Severe preeclampsia; weeks’ gestation, when associated with maternal jeopardy:
Severe persistent headache
Persistent visual changes
Hepatocellular injury
Thrombocytopenia or other evidence of DIC
Pulmonary edema
Abruptio placentae

22. Severe preeclampsia; 26-34 weeks’ gestation, when associated with fetal jeopardy:
Repetitive severe variable decelerations
Repetitive late decelarations
Repetitive BPP ≤ 4
Oligohydramnios (amniotic fluid index (AFI) ≤ 4cm)
IUGR (estimated fetal weight ≤ fifth percentile)
Chronic hypertension with superimposed preeclampsia at any gestational age
Eclampsia or HELLP syndrome at any gestational age

23. Guidelines
Maintenance of diastolic BP between 90 and 100 mm Hg. Further reduction of BP jeopardizes placental blood flow. Appropriate antihypertensive medications include:
Hydralazine (direct arteriolar vasodilator), which causes baroreceptor sympathetic stimulation (increasing heart rate (HR) and cardiac output (CO), thus preserving placental blood flow>
Labetalol (nonselective β-blocker), which preserves uteroplacental blood flow.

24. Box 4-1 Clinical Findings for Parenteral Magnesium Sulfate Dose Effect
Prevention of convulsions with intravenous (IV) magnesium sulfate
Administration of loading dose of 5g IV over 20 minutes, and maintenance infusion at 2g/hr. The maintenance IV infusion should be given for 24 hours after delivery.
Watching for clinical evidence of magnesium toxicity (Box 4-1)
Absence of toxicity is ensured as long as deep tendon reflexes are obtainable.
Box 4-1 Clinical Findings for Parenteral Magnesium Sulfate
Dose Effect
5-8 mg/dl Therapeutic level
10 mg/dl Loss of deep tendon reflexes
15 mg/dl Respiratory paralysis
25 mg/dl Cardiac arrest

25. IV calcium gluconate is the antidote for magnesium toxicity.
Initiation of delivery. Labor can be induced anticipating vaginal delivery if the patient is stable and there are no contraindications. Otherwise, cesarean delivery is indicated.
Conservative inpatient management is appropriate in the following cases:
Mild preeclampsia that is remote from term (<37 weeks). Guidelines include:
Monitoring BP every 4 hours
Performing a daily urine dipstick for protein
Performing twice-weekly 24-hour urine protein measurements

26. Performing weekly liver function tests and electrolyte levels
Initiating delivery if criteria for severe preeclampsia are met
Severe preeclampsia in carefully selected cases
All of the following criteria must be met
a) Gestational age >26 weeks but < weeks
b) BP persistently ≥ 160/110 mmHg
c) Absence of fetal jeopardy
d) Absence of maternal jeopardy

27. Guidelines include:
a) Intensive maternal and fetal monitoring in a tertiary perinatal center
b) Cautious volume expansion
c) Aggressive antihypertensive therapy (e.g., hydralizine, labetalol)
d) Anticonvulsant therapy (e.g. magnesium sulfate)
e) Corticosteroids to enhance fetal lung maturity
Initiation of delivery if maternal or fetal deterioration occurs

28. Conservative outpatient management
Patient selection criteria include:
1) Transient hypertension (i.e., BP in the
mildly elevated range, no proteinuria)
2) Uncomplicated chronic hypertension
(without superimposed preeclampsia)
Guidelines include:
1) Bed rest in the left lateral position
2) Home BP monitoring
3) Twice – weekly outpatient visits
Initiation of delivery if maternal or fetal deterioration occurs

29. Prevention. Large, prospective, randomized studies have shown that no prophylactic intervention for preeclampsia improves pregnancy outcome. This includes use of aspirin and supplemental calcium.