Hypertensive Disorders in Pregnancy Woman’s Hospital School of Medicine Zhejing University He jin.
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Transcript of Hypertensive Disorders in Pregnancy Woman’s Hospital School of Medicine Zhejing University He jin.
Hypertensive Disorders in Pregnancy
Woman’s Hospital School of Medicine Woman’s Hospital School of Medicine Zhejing UniversityZhejing University
He jinHe jin
Special
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
Include:
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.
Transient hypertension
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 ( albuminuria, hypertensio
n ) 5 、 Maternal MODS, perinatal fetal poor prognosis and
death
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
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 、 The lack of a variety of nutrition materials(such as
trace elements …….)
Cause
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.
Pathophysiological changes
Basic diseases: Systemic small artery spasm Brain, heart, lung, liver, kidney and other vital
organs severe ischemia Cause heart, liver and kidney failure,
pulmonary edema and cerebral edema, and even convulsions, coma;
Placental abruption and placental dysfunction,
Activated clotting process, leading to DIC.
Clinical manifestations
After 20 weeks of pregnancy hypertension, edema, proteinuria. Light may have mild symptoms or dizziness,
blood pressure increased slightly with edema or mild proteinuria
Severe headache, vertigo, nausea, vomiting, persistent right upper abdominal pain, blood pressure increased significantly, increased proteinuria, edema, and even coma and convulsions
Diagnosis Based on history, clinical manifestations, signs and laboratory e
xaminations to make a diagnosis, and should watch for complic
ations and clotting mechanism.
1. History
2. Hypertension
3. Urine protein
4. Edema
5. Auxiliary examination: blood test, liver and kidney function tes
t, urine examination, fundus examination, invasive hemodynami
c monitoring, ECG and echocardiography
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 s
udden 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 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
24H urine protein have more meaningful
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 PreeclampsiaGestational Preeclampsia
PreeclampsiaPreeclampsia
EclampsiaEclampsia
SuperimposedSuperimposed preeclampsia on preeclampsia on
chronic hypertensionchronic hypertension
Chronic hypertension in pregnChronic hypertension in pregnancyancy
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
Diagnostic thinking: confirmed Maternal blood pressure during pregnancy for the first time ≥ 140/90mmHg, but the urine protein (-) Throughout pregnancy without the development of preeclampsia
Blood pressure returned to normal at 12 weeks postpartum
1 、 Proteinuria ≥300mg/24 hours or ≥1+ dipstick
2 、 BP≥140/90mmHg after 20 weeks’ gestation
3 、 May be associated with headache , visual disorder , upper abdominal pain
•Early onset preeclampsia (<34 weeks of gestation )
Preeclampsia
Diagnostic thinkingDiagnostic thinking Urine protein appears: an important basis for preeclampsia Urine protein appears: an important basis for preeclampsia The result: (PIH) contraction of small blood vessels in the body The result: (PIH) contraction of small blood vessels in the body
caused reduction in renal blood flow caused reduction in renal blood flow Marked Marked :: damage to renal function in pregnant womendamage to renal function in pregnant women
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(<10,000/L)
8、 Dysfunction of liver
9、 FGR , oligohydramnios
10、 Headache, visual disorder, upper abdominal pain
11、 Hepatic subcapsular hematoma
12 、 Cerebral vascular accident
Eclampsia
Seizures that cannot be attributed to other
causes in a woman with preeclampsia
Diagnostic thinking Seizure: on the basis of preeclampsia, or associated with coma
SuperimposedSuperimposed preeclampsia on preeclampsia on chronic hypertensionchronic 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
Diagnostic thinkingDiagnostic thinking preeclampsiapreeclampsiaHypertensionHypertension :Before pregnancy or before 20 weeks Before pregnancy or before 20 weeks Blood pressure was still high after 12 weeks postpartum Blood pressure was still high after 12 weeks postpartum
Chronic hypertension in Chronic hypertension in pregnancypregnancy
1 、 BP≥140/90mmHg before pregnancy or
diagnosed before 20 weeks’ gestation2 、 Hypertension first diagnosed after 20
weeks’ gestation and persistent after 12
weeks’ postpartum
Diagnostic thinkingDiagnostic thinking Hypertension Hypertension Before pregnancy or before 20 weeks Before pregnancy or before 20 weeks Blood pressure was still high after 12 weeks postpartum Blood pressure was still high after 12 weeks postpartum
Differential diagnosis
According to clinical manifestations. PIH Chronic nephritis with pregnancy Eclampsia Epilepsy
Encephalitis
Brain tumor
Rupture of cerebral vascular malformations
Diabetic hyperosmolar coma
Hypoglycemic coma
Complications of mother
Heart failureCerebrova- scular accidentPlacenta abruptionDICRenal failureHELLP’S syndromePostpartum hemorrhage
More frequently in severe type
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.
Management
Antispasmodic Lowers blood pressure Timely termination of pregnancy There are indications those fluid
expansion and diuretic Monitoring and promoting fetal growth
and development
General treatment
Rest The state of the mother and fetus
should be closely monitor Intermittent oxygen Balanced diet
conscious-sedation
Diazepam (valium):– relatively strong sedative effect, anticonvul
sant, muscle relaxant effect – on the fetus and newborn: less affected
Lytic cocktail:– extensive inhibition of the nervous system,
contribute to spasm blood pressure, control of eclampsia convulsions
Spasmolysis
The main method :treatment of eclampsia and severe preeclampsia
Relieve angiospasm Relieve symptoms Prevent seizures. Magnesium sulfate often as the first pref
erred drug
Depressurization
Objective: – to extend the gestational age– changing perinatal outcomes
Principles: non-toxic side effects on the fetus does not affect cardiac output, renal blood flow and placental perfusion, sudden drop in blood pressure can reduce excessive.
Depressurization
Indications: systolic blood pressure ≥ 160 or diastolic blood pressure 110mmHg or mean arterial blood pressure ≥
110mmHg essential hypertension those with
antihypertensive drugs before pregnancy
Depressurization
Control of Seizures Controln of Hypertension Hydralazine Labetalol Nifedipine Sodium nitroprusside
fluid expansion
Generally not in favor of expansion Only for severe hypoproteinemia, anemi
a Albumin, plasma, whole blood
Diuresis
Generally do not advocate Only for:
– pulmonary edema– systemic edema persons– acute heart failure – excessive blood volume potentially
associated with pulmonary edema
Effective measures Indications : severe preeclampsia after active treatment 24 to
48 hours were no noticeable improvement Severe preeclampsia has more than 34 weeks ge
stational age Severe preeclampsia and gestational age less tha
n 34 weeks, but placental dysfunction, the fetus
has matured
pregnancy termination
pregnancy termination
Indications : Severe preeclampsia, gestational age less th
an 34 weeks– placental dysfunction, the fetus has not matured
• used dexamethasone to promote fetal lung maturity
control 2 hours after eclampsia may consider termination of pregnancy
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
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
Mode of delivery Vaginal delivery:
– a stable condition– cervical ripening
Cesarean section: – obstetric indication– cervical conditions are not mature enough in the
short term vaginal deliveries– induction failure– significantly lower placental function– fetal distress
The treatment principle of eclampsia The main cause : maternal and fetutal
mortality Control seizures Correct hypoxia and acidosis Control of blood pressure Termination of pregnancy after control s
eizure
anticipation
Conducted in second trimester– close follow-up should be positive
Mean arterial pressure Roll over test Rheology Test Determination of urinary calcium
Hellp syndrome
Diagnostic criteria– hemolysis, elevated liver enzymes, and thrombocy
topenia.
Principles– early diagnosis – early treatment– timely termination of pregnancy– reduce fetal and maternal mortality – active treatment PIH