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Hypertansive disorders in pregnancy

Explore the hemodynamic and biochemical changes in normal pregnancy, as well as the different types of hypertensive disorders that can occur during pregnancy. Learn how to manage these disorders and understand the potential complications they can pose.

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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 HEELP 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 • İn stage 1 and 2 HT, mayrequirelessorevenantihypertansivesif BP is controlled • Methyldopa is preferredagentfortreatment • İn womenwhoenterpregnancywithwell-controlled BP, sameregimen can be continued • ACE andARBsarecontraindicated

  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. Risk factors

  18. Renal abnormalities in preeclampsia

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

  20. 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

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

  22. Classification of Preeclampsia

  23. Severe preeclampsia 2013 criteria do not include -proteinuria >5 grams/24 hours and -fetal growth restriction as features of severe disease Hypertension in pregnancy: Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122:1122

  24. HEELP Syndrome • HEmolysis • ElevatedLiverFunctionTests • LowPlatelets

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

  26. 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

  27. Treatment of Preeclampsia 2

  28. 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%

  29. 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

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

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

  32. 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

  33. 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 HEELP syndrome -Treatment: plasma exchange or plasmapheresis

  34. 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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