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Hypertansive disorders in pregnancy

Learn about the hemodynamic and biochemical changes in normal pregnancy, as well as the different types of hypertensive disorders that can occur during pregnancy. Discover the management and treatment options for these conditions.

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Hypertansive disorders in pregnancy

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  1. Hypertansive disorders in pregnancy Zehra Eren,M.D.

  2. LEARNING OBJECTIVES • recall hemodynamic and biochemical changes in normal pregnancy • describe preeclampsia-eclampsia • describe chronic (preexiting ) hypertension • describe preeclampsia-eclampsia superimposed upon chronic hypertension • describe gestational hypertension • explain HELLP Syndrome • manage hypertensive disorders during pregnancy

  3. Hemodynamic and biochemical changes in normal pregnancy

  4. Cardiovascular and Renal Physiology BloodPresure (BP) Regulation: • BP fallshortlyafterconceptionandreturnto normal at term - peripheralvasodilatationandresistancetoangiotensin II (prostacyclinandprolactinlevels↑) -Nitricoxidesynthesis↑ • Renin-angiotensin-aldosteronesystem(RAAS) is stimulated, aldosterone is critical in maintainingsodiumbalance

  5. Volume Regulation • Circulatingbloodvolume↑ 50% • Redbloodcellmass↑20-30% • Cumulativesodiumretention (500-900mEq) → extrasellularfluidvolume↑ → weightgain → ‘’benign ‘’ edema of lowerextremities

  6. Renal Hemodynamics • GFR: secondtrimester↑ 50% lasttrimester↑20% returntoprepartumlevelswithin 3 monts • Normal plasmacreatininefallto 0.5 mg/dl >0.8 mg/dl shoud be consideredabnormal • Renalbloodflow↑85% ↑cardiacoutput (30-40%max) ↑renalvasodilatation (afferentandefferent)

  7. Hypertensive disorders • Systolic BP >140 mm Hg /125mmHg Diastolic BP >90 mm Hg /75mmHg • Mostcommon (10% of pregnancies) • ↑maternalandfetalmortalityandmorbidity • Leadingtoprematurebirth

  8. Causes of Hypertansion in pregnancy

  9. Chronic Hypertention • HT presentbeforepregnancyordiagnosedbeforetwentiethweek of gestation • May include HT diagnosedduringpregnancythatdoes not resolveafterdelivery • May be associatedwithnephrosclerosiswith minimal proteinuria • İncreased risk of preeclampsia, abruptioplacentae, intrauteringrowthretardationandsecondtrimesterfetaldeath

  10. Treatment

  11. Treatment • Methyldopa and labetalolarepreferredagentfortreatment • A long-acting calcium channel blocker (eg, nifedipine) can be added if needed • İn womenwhoenterpregnancywithwell-controlled BP, sameregimen can be continued • ACE inhibitors, ARBs anddirect renin inhibitorsarecontraindicated

  12. Gestational Hypertantion Essentials of Diagnosis • Maternal blood pressure elevation of ≥140 mm Hg systolic or ≥90 mm Hg diastolic on 2 occasions 6 hours apart in a previously normotensive woman ≥20 weeks' gestation • No evidence of proteinuria • Resolved after delivery ( women are at risk for chronic HT) • Risk factors: multiparity, obesity, positive family history

  13. Preeclampsia-Eclampsia • Systemic syndrome unique to pregnancy • Essentials of Diagnosis • Maternal blood pressure elevation of ≥140 mm Hg systolic or ≥90 mm Hg diastolic on 2 occasions 6 hours apart • Proteinuria ≥300 mg in a 24-hour urine specimen • Resolving with delivery • Eclapsia: occurrence of sezures

  14. Preeclampsia-Eclampsia Hypertension in pregnancy: Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122:1122

  15. Pathogenesis of preeclampsia

  16. Risk factors

  17. Renal abnormalities in preeclampsia

  18. Renal Abnormalities • Renalbloodflowand GFR fall • Decreasedurateclearenceandincreasedcalciumreabsorption→hyperuricemiaandhypocalciuria • GFR can decreaseby 30-40%→creatininelevelsincreased (1.0-1.5mg/dL) • Hyperuricemiamaycorrelatewithclinicalseverity of preeclampsia (>4.5mg/dL)

  19. Clinical features • Usuallybeginsafterthethirty-secondweekandmayseenpostpartumwithin 24-48 h afterdelivery • Usuallyresolveswithin 10 daysafterdelivery • Diastolic HT is prominent, with SP<160mmHg • SBP>200mmHg suggestpreeclampsiasuperimposed on chronic HT • When HT andproteinuriaoccurbefore 20 w, etiologiesotherthanpreeclampsiashould be sought

  20. Clinical features • Pulmonaryedemacan occurduetochanges in pulmonarycapillarypermeability • Hyperreflexiasecondarytocentralnervoussystemexcitabilityreflects of neurologicinvolvement

  21. Classification of Preeclampsia

  22. HELLP Syndrome • Hemolysis • ElevatedLiverFunctionTests • LowPlatelets

  23. HELLP Syndrome • Commonlyassociatedwith severe HT andvariabledegrees of renalfailure • May be associatedwith -pulmonaryedema -ascites -acuterenalfailure -disseminatedintravascularcoagulation

  24. Treatment of Preeclampsia • Prophylacticlow-doze aspirin orcalcium→ noevidence of significantreductionorimprovedoutcomes • Bed rest→ therapy of choiceformilddisease (BP<140/90 mmHg, proteinuria<500mg/24h, normal renalfonction,uratelevels<4.5mg, normal PLT, andnoevidence of hemolysisorhepaticdysfunction) • Optimal levels has not be defined

  25. Treatment of Preeclampsia 2

  26. Target blood pressure • 130 to 150 mm Hg systolic and 80 to 100 mm Hg diastolic • The rapidity with which blood pressure should be brought to safe levels is controversial • Cerebral or myocardial ischemia or infarction can be induced by aggressive antihypertensive therapy if the blood pressure falls below the range at which tissue perfusion can be maintained by autoregulation • Reducing mean arterial pressure by no more than 25 percent over 2 hours and achieving a target of 130 to 150 mmHg systolic and 80 to 100 mmHg diastolic seems reasonable

  27. Preeclampsia superimposed upon chronic hypertension • Difficulttodistinguishfromworseninghypertansion • Suspect in womenwith HT before 20 week of gestationwhodeveloptproteinuriaorsuddenincrease in BP • Morelikelytooccur in olderpatients • Hyperuricemia, proteiuria, orrise in serum creatininesuggestspreeclampsia • Risk in womenwithsome form of renaldisease is between 20-40%

  28. Acute Renal Failure in Pregnancy • Earlypregnancy 1.Prerenalazotemia→ hyperemesis, hemorrage of spontaneusabortion 2. Acutetubularnecrosis→ volumedepletionsecondarytohyperemesis, hemorrage of spontaneusabortion, septicabortus, Gram-negativesepsis, myoglobulinuriasecondarytoClostridiuminducedmyonecrosis of uterus 3.Renalcorticalnecrosis

  29. Renal Cortical Necrosis • Frequentlyseen in olderwomen, multigravidas, multiplgestations • Causes: abruptioplacentae, septicabortion, severe preeclampsia, amnioticfluidembolism, retainedfetus • Presentswithgrosshematuria, flankpain, severe oliguriaoranuria • Renalfunctionalrecoveryrequiresmontsand is incomplete, mayleadto ESRD

  30. Acute Renal Failure in Pregnancy • Latepregnancy 1. Acutetubularnecrosis→ preeclampsia, HELLP syndrome, bleeding in abruptioplacentae 2. Acutefattyliver of pregnancy→ presentafter 34 weekwithjaundiceandabdminalpain; associatedwith ARF

  31. Acute Renal Failure in Pregnancy 3.Postpartum acute renal failure and thrombotic thrombocytopenic purpura- hemolytic uremic syndrome -presents with severe HT, microangiopathic hemolytic anemia, thrombocytopenia and ARF days to weeks after normal pregnancy -patients can have severe deficiency of ADAMSTS-13 activity

  32. Acute Renal Failure in Pregnancy 3.Postpartum acute renal failure and thrombotic thrombocytopenic purpura- hemolytic uremic syndrome -Retained placental fragments may play a role -major clinical issue is to differantiate from preeclampsia and HELLP syndrome -Treatment: plasma exchange or plasmapheresis

  33. What Did We Learn? • - Cardiovascularandrenalhemodynamicchanges in normal pregnancy • Preaclampsia-eclampsia • Chronichypertension • Preeclampsia-eclampsiasuperimposedchronichypertension • Gestationalhypertension • Maternalevaluation • Indicationfortreatment of hypertensivedisorders • Acutetherapy • Long-term oral therapy

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