Hypertensive Disorders Complicating Pregnancy

Beijing Obstetrics & Gynecology hospital

Hou Lei

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Case1

A 17-year-old G1P0, at 26 weeks’ gestation

complaining of a severe headache.

Her past medical and surgical histories are

unremarkable.

Her BP is 150/100 and she has 2+ protein on

urinalysis.
Case2

A 38-year-old G4P0 , at 36 weeks’ gestation for

routine prenatal visit.

She has a history of chronic hypertension, which

has been well controlled on labetalol 200 mg bid.

Her physical examination is unremarkable, but

her BP is 170/90.
Hypertensive disorders complicate

5-10% of all pregnancies

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it is the leading cause of maternal death in the world.
in developed countries

16 % of maternal deaths were reported to be due to

hypertensive disorders (In the US from 1998 to 2005)

10% for maternal deaths in France ( 2003 -2007)

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 classification

1. Gestational hypertension
2. Pre-eclampsia and eclampsia syndrome

3. Chronic hypertension
4. Preeclampsia superimposed on chronic hypertension.

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 gestational hypertension

+ higher BP/proteinuria…

Pre-eclampsia
eclampsia
hypertension

Chronic hypertension

+ higherBP/proteinuria………

Preeclampsia superimposed on chronic

hypertension 7
Gestational hypertension
 BP≥ 140/90mmHg for the first time during
pregnancy ( ≥20 weeks)

 No proteinuria

 BP returns to normal < 12 weeks’

postpartum

 Final diagnosis made only postpartum

 Preeclampsia
￭ preeclamspia
- BP≥140/90mmHg after 20weeks' gestation and
- Proteinuria ≥300mg/24hrs or ≥1+dipstick

￭ severe preeclampsia ( anyone of the following item)

- BP≥160/110mmHg
- Proteinuria ≥ 5g/24hrs or ≥3+dipstick
- Oliguria , Serum creatinine elevated
- Elevated ALT or AST, subcapsular liver hematoma
- Platelets <100000/mm3
- Microangiopathic hemolysis (Increased LDH)
-Persistent headache or other cerebral or visual disturbance
- Persistent epigastric pain
- pulmonary edema, ascites 9
 Eclampsia
preeclampsia+convulsion

Seizures that cannot be attributed to other

causes in woman with preeclampsia

Seizures may appear before, during, of after labor

10 % of seizures develop after 48 hours postpartum

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 Chronic hypertension

 BP ≥140/90 mmHg before pregnancy or

diagnosed before 20weeks’ gestation (not
attributable to gestational trophoblastic
disease)

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 Preeclampsia superimposed on
Chronic Hypertension

Women diagnosed as Chronic Hypertension


+
New-onset proteinuria
 A sudden increase in blood pressure
 with other severe features

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early onset preeclampsia
--------- 20-33+6 weeks

Late onset preeclampsia

------------- after 34 weeks

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Case1

A 17-year-old G1P0 presents to your office at 26

weeks’ gestation complaining of a severe
headache.

Her past medical and surgical histories are

unremarkable.

Her BP is 150/100 and she has 2+ protein on

urinalysis.
Case2

A 38-year-old G4P0 presents to your office at 36

weeks’ gestation for routine prenatal visit.

She has a history of chronic hypertension, which

has been well controlled on labetalol 200 mg bid.

Her physical examination is unremarkable, but

her BP is 170/90.
Diagnosis of Hypertensive Disorders

Sign: Symptoms:

headache Hypertension
visual disturbances
Blindness
Proteinuria
abdominal pain edema
Weakness
convulsion

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edema is a common finding in normal
pregnancy
approximately 1/3 of eclamptic women
have no edema

edema is not considered as part of the

diagnosis of preeclampsia.

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 Incidence and Risk Factor

Nullipara (3:1)
Age older than 40 years (3:1) OR ( odds ratio )
Black race (1.5:1)
Family history (5:1)
Chronic renal disease (20:1)
Chronic hypertension (10:1)
Antiphospholipid syndrome (10:1)
Diabetes mellitus (2:1)
Twin gestation (4:1)
High body mass index (3:1)

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 etiology
preeclampsia is a pregnancy-specific
syndrome that can affect virtually every
organ system.

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 Abnormal Trophoblastic Invasion
In normal implantation, endovascular trophoblasts
invade the uterine spiral arteries endovascular
trophoblasts replace the vascular endothelial and
muscular linings to enlarge the vessel diameter.

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 Abnormal Trophoblastic Invasion
placental blood flow

hypoxic environment in placenta

release of placental debris or cytokines

systemic inflammatory response

endothelial damage
vasospasm
interstitial leakage
hypertension Edema 、proteinuria 21
Pathogenesis Vasospasm

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Cardiovascular System
Blood volume
hypoproteinemia

 With severe hemoconcentration

 Sensitive to vigorous fluid therapy.

 Sensitive to even normal blood loss at delivery.

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 Blood and Coagulation
Platelet
 Thrombocytopenia

severe vasospasm -> endothelial damage

-> Platelet activation, aggregation, consumption -> “exhausion”
-> thrombocytopenia (Harlow, 2002)

 HELLP syndrome : hemolysis (H) , elevated liver enzymes

(EL), and low platelets (LP) (Weinstein, 982)

 Neonatal thrombocytopenia
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 hemolysis
microangiopathic hemolysis

thrombus 25
 Kidney
 Proteinuria

 Acute renal failure

Tubular necrosis, cortical necrosis -> oligouria,
anuria,

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 Liver
 Elevated Liver enzyme

 subcapsular liver hematoma (1.6%)

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 Brain
 Gross hemorrhage – severe hypertension
Chronic hypertension

 reversible posterior leukoencephalopathy

syndrome

Blindness Rare 4 hr to 8 day.

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 Uteroplacental perfusion
 Vasospasm ->
 placental
perfusion ->
FGR、 fetal distress

Edema in uterus ，placenta ->

placental abruption, postpartum
hemorrhage
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 Prevention

 Salt restriction -> ×

 Prenatal Ca supplementation -> ×
 Low-dose aspirin was effective in preventing
preeclampsia . 80mg of aspirin daily from 12th
weeks until 37 weeks
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Lab
Urine If >1+ proteinuria on dipstick , 24 h
urine
collection for quantify proteinuria

CBC ( Hb、platelet）

Serum alanine aminotransferase (ALT) and

aspartate aminotransferase (AST)

Serum creatinine Uric acid

Peripheral blood smear、Serum lactate

dehydrogenase (LDH) 31
Echocardiography
ultrosound
Head CT

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 For baby
B-US to assess the status of the fetus and evaluate for
growth restriction , umbilical artery Doppler
ultrasonography, to assess blood flow

The standard fetal nonstress test and the mainstay of

fetal monitoring

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management

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Gestational hypertension

monitor
Discharge home

Follow up in 3-7days

Consider delivery at term

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 preeclampsia

monitor treatment
Delivery before 37 wks
hospitalized and monitored

immature fetus is treated with corticosteroids to

accelerate fetal maturity

preeclampsia without severe features are induced

after 37 weeks' gestation
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 Severe preeclampsia

monitor treatment
Contraindications for indications for
expectant treatment expectant treatment

Delivery Delivery
before 34 wks

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Delivery
is the only cure for preeclampsia.

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Seizure treatment and prophylaxis

IVmagnesium sulfate :
A loading dose of 4 g is given by infusion pump over
5-10 minutes, followed by an infusion of 1 g/hr
maintained for 24 hours

we administer intrapartum and

postpartum magnesium sulfate
seizure prophylaxis to
all women with preeclampsia
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 Monitor for signs of MGSO4 toxicity :

Respirations are not depressed >12bpm

Urine output >30ml/h

serum magnesium level <3mmmol/L

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 Lower hyperension
β-receptor blocker labetalol

calcium-channel blockers nifedipine

Antihypertensive treatment is recommended for severe

hypertension (SBP >160 mm Hg; DBP >110 mm Hg).

The goal of hypertension treatment is to maintain BP around

140/90 -150/100mm Hg.

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