1. Hypertensive Disorder
Complicating Pregnancy

2. 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

3. 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

4. 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.

5. 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、…….

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…

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

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

9. 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.）

10. Clinical findings——Hypertension
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

11. 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

12. 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

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

14. 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

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

16. 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

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

19. 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

20. 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

21. 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

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

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

24. Complications of fetus
FGR
fetal distress
fetal death
neonatal asphyxia

25. 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

26. 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.

27. 6 principles Spasmolysis… conscious-sedation … Depressurization…
fluid expansion…
Diuresis…
pregnancy termination

28. Mild Preeclampsia
Treatment Of Mother
Assessment of Fetal Status

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

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

31. 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