Hypertensive disorder in pregnancy
Hypertension
Half of these hypertensive-related deaths were deemed preventable (Breg, 2005)
Second most common cause of maternal mortality and an important cause of perinatal
mortality and morbidity
Prevalent in young women of low socio- economic status without prenatal care
Hypertension in pregnancy
Blood Pressure of = or > 140/90 mmHg
Blood Pressure must be manifested on at least two occasions taken six hours
apart
Risk factor
Primiparity: only well accepted risk factor
Immunologic factors
○ Failure of trophoblasts invasion as a rejection by the maternal body towards
the
trophoblast antigens
Previous pregnancy complicated with preeclampsia / eclampsia/ HELLP
Family history of preeclampsia
Age under 20 or over 35 years old
Body mass index
○ Higher BMI increases risk of preeclampsia
Underlying medical condition
○ Vascular, connective or renal disorders
Pregnancy related condition
○ Conditions with increased trophoblast mass like hydrops fetalis, multifetal
gestation, H-mole
Primipaternity
○ Immunologic habituation to paternal antigens trough contact between the
sperm and the female genital tract
○ New sexual partner will expose the mother to new paternal antigens to
which she may not be tolerant
○ A man who has fathered a preeclamptic pregnancy in a different woman
Sexual cohabitation
○ Longer period of sexual cohabitation with the father before conception
reduces risk of preeclampsia
Maternal infection
○ Urinary tract infection and periodontal disease
Gestational age at delivery in the first pregnancy
○ Previous preterm or SGA increases the risk of preeclampsia
Socioeconomic status
○ Poor social status due to problems in access to prenatal care
Classification of hypertension in pregnancy
Chronic Hypertension
Gestational Hypertension
Pre-eclampsia
Chronic Hypertension with Superimposed Pre- eclampsia
Eclampsia
CHRONIC HYPERTENSION
Blood Pressure of ≥140/90 mmHg
Prior to pregnancy
Before 20 weeks age of gestation (or prior to pregnancy) and
Persists after 12 weeks postpartum
Renal Changes
Renal perfusion and GFR are reduced
Glomerular endotheliosis blocking filtration barrier
Increase endothelial leak causing elevated urine sodium
Increase excretion of urinary podocytes
Pre Eclampsia
Hypertension occurring after 20 weeks age of gestation with or without proteinuria
proteinuria is an objective marker
Evidence of multiorgan involvement may include
Thrombocytopenia
Renal dysfunction
Hepatocellular necrosis
Central nervous system perturbations
Pulmonary edema
GESTATIONAL HYPERTENSION
Hypertension with no proteinuria and occurs after 20 weeks age of
gestation or postpartum
A temporary diagnosis during pregnancy which has to be confirmed 12 Weeks
afterdelivery
Transient Hypertension: If Blood Pressure is normal
Chronic Hypertension: If Hypertension persists
PRE-ECLAMPSIA WITH SEVERE FEATURES
Blood Pressure of ≥160mmHg (Systolic Pressure) or ≥110 mmHg (Diastolic
Pressure)
Either one of the following:
o Decreased Platelet count/Thrombocytopenia
o Oliguria
o Increased Serum Creatinine
o Congestive Heart Failure
o Pulmonary Edema
o Epigastric/Right upper quadrant pain
o Elevated liver enzymes
o Persistent headache
o Visual or Cerebral disrurbances
PRE ECLAMPSIA SUPERIMPOSED ON CHRONIC HYPERTENSION
Chronic underlying hypertension blood pressures
>140/90 mm Hg
before pregnancy or before 20 weeks’ gestation, or both
It also tends to be more severe and more often is accompanied by fetal-growth
restriction.
Signs and Symptoms:
New onset proteinuria
Various End Organ Dysfunction or Pre- eclampsia
Incidence and Risk Factors
Young and Nulliparous women
Genetic predisposition
Race and Ethnicity
SLE
Prior Stillbirth
CKD
ART
Prior Abruptuon
Diabetes
Prior preeclampsia
CHTN
ECLAMPSIA
Diagnosed pre-eclampsia with conclusive seizure
Convulsion is not caused by coincidental neurologic disease
Preeclampsia Syndrome
Etiology
● Placental implantation with abnormal trophoblastic invasion of uterine vessels
● Immunologic maladaptive tolerance between maternal, paternal (placental) and fetal
tissues
● Maternal maladaptation to cardiovascular or inflammatory changes of normal pregnancy
● Genetic factors including inherited predisposing genes and epigenetic influences
Prevention
● High dose calcium
○ 1.5 to 2 grams/day before 32 weeks (low & high risk women)
● Low dose aspirin
○ 60-80 mg/day to start on the 2nd trimester
○ Monitor platelet and coagulation profiles
○ Monitor fetal ductus arteriosus and AFV by ultrasound
HELLP Syndrome
There is no universally accepted strict definition of HELLP syndrome, and thus its
incidence varies by investigator.
HELLP syndrome complications
eclampsia
placental abruption
acute kidney injury
pulmonary edema
Stroke
hepatic hematoma
coagulopathy
acute respiratory distress syndrome
sepsis were other serious complications
Women with preeclampsia and HELLP syndrome typically have worse outcomes than
preeclamptic women without the HELLP constellation
Things to consider for hypertension in pregnancy
Age of gestation
o Once 34 weeks AOG is reached, delivery is recommended for maternal safety
o Severity of disease
Eclampsia mandates delivery regardless AOG
Severe preeclampsia patients are usually delivered once 34 weeks AOG is achieved
Conservative measurement at <34 weeks in high-risk centers
Mild preeclampsia can be managed as out-patient
o Maternal Evaluation
Regular monitoring of multiple-organ symptoms, vital signs, body weight, input &
output, laboratory tests
o Fetal status
Regularly monitor fetal movements, NST or CST, BPP, fetal growth,
doppler studies
Steroids
o Nursery capability for 34 weeks babies
