Hypertensive Disorder Complicating Pregnancy

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

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

Hypertensive states in pregnancy

Chesley described preeclampsia as a“disease of theories”, because the cause is unknown. Some theories include:1 、 Genetic susceptibility hypothesis2 、 Immune maladaptation hypothesis3 、 Placental perfusion or Ischemia Hypotheses

4 、 Oxidative stress hypotheses

5 、 Endothelial cell injury ： explains many of the clinical findings in preeclampsia6 、…… .

Cause

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

Spasm of vessels

Vessel stenosis

Higher periphery resistance

Blood pressure elevate

Injury of endotheliocyte

Proteinuria Edema Hypertension

Pathology

These effects are separated into

maternal and fetal consequences;

however, these aberrations often

occur simultaneously.

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 100-110/60-70m

mHg 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 proteinuri

a. 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

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 rena

l failure

Clinical findings——Differing clinical picture

Classification

Gestational hypertensionGestational hypertension

PreeclampsiaPreeclampsia

EclampsiaEclampsia

Preeclampsia superimposed uPreeclampsia superimposed upon pon

chronic hypertensionchronic hypertension

Chronic hypertensionChronic hypertension

Gestational hypertension

1、 Blood pressure≥140/90mmHg

first onset in gestational period and recover wit

hin 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

Minimum criteria:

1 、 Proteinuria ≥300mg/24 hours or ≥1+ dipstick

2 、 BP≥140/90mmHg after 20 weeks’ gestation

Preeclampsia

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

Eclampsia

Seizures that cannot be attributed to other

causes in a woman with preeclampsia

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

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

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

Diagnosis

Clinical symptoms and physical signs

Auxiliary examinations

Differential diagnosis

According to clinical manifestations.

Complications of mother

Heart failureCerebrova- scular accidentPlacenta abruptionDICRenal failureHELLP’S syndromePostpartum hemorrhage

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 thereafte

r Blood pressure readings in sitting position with anapp

ropriated-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.

Spasmolysis…

conscious-sedation …

Depressurization…

fluid expansion…

Diuresis…

pregnancy termination

6 principles

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 

Eclampsia

Control of Seizures Controln of Hypertension Hydralazine Labetalol Nifedipine Sodium nitroprusside

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