Hypertensive Disorders in Pregnancy

1. Hypertensive Disorders in Pregnancy By Agnibho Mondal BismoyMondal Atrayo Law Debtanu Banerjee Debjit Ghosh

2. Incidence • Hypertensive disorders are among the most significant & still now unresolving problem complicating almost one in ten pregnancies • Responsible for 16% of Maternal Mortatlityin developing countries • Commonest cause of iatrogenic prematurity accounting 15% of all premature births & 20% of very LBW births

3. Hypertension in Pregnancy • Systolic B.P. > 140 mmHg • and/or • Diastolic B.P. > 90 mmHg • Documented on two occasions • At least 6 hours apart • Not more than 7 days apart • Other Criteria (Not part of definition currently) • SBP increased by 30mmHg • DBP increased by 15mmHg • Mean Arterial Pressure increased by 20mmHg

4. Classification

5. Normal Blood Pressure changes in Pregnancy

6. What is Significant Proteinuria in Pregnancy • Total protein in 24 hours urine > 300mg • Protein : Creatinine ratio in random sample > 0.1

7. Gestational Hypertension • New onset of hypertension after 20 weeks of gestation without proteinuria, followed by return of B.P. to normal within 12 weeks post-partum.

8. Preeclamsia • New onset of hypertension after 20 weeks of gestation along with properly documented proteinuria, followed by return of B.P. to normal within 12 weeks post-partum.

9. Eclampsia • Generalized tonic-clonic seizure in a patient with Preeclampsia not attributed to any other cause.

10. Chronic Hypertension in Pregnancy • Hypertension before pregnancy / Diagnosed before 20 weeks of pregnancy not due to gestational trophoblastic disease. • Hypertension diagnosed after 20 weeks but persistent after 12 weeks postpartum

11. Etiology : 1. Essential HTN (Most Common) 2. Secondary HTN : • Genetic: Glucocorticoid remediable aldosteronism, Liddle Syndrome • Renal : Parenchymal, Renovascular • Endocrine : Primary hyperaldosteronism, cushing syndrome, Pheochromocytoma • Vascular : Aortic coarctation, Estrogen use • Others

12. Superimposed Preeclampsia On Chronic Hypertension • New onset proteinuria in hypertensive women but no proteinuria before 20 weeks' gestation • A sudden increase in proteinuria or blood pressure or platelet count < 100,000/L in women with hypertension and proteinuria before 20 weeks' gestation

13. Risk Factors

14. Risk Factors: Cont.

15. Risk Factors: Cont.

16. PATHOPHYSIOLOGY:

18. 2 stage model for preeclampsia ???

19. Reduced placental implantation –Stage-1 • PREDISPOSING FACTORS: • Abnormal implantation • Association with microvascular diseases (diabetes, hypertension etc.) • Association with large placentas (hydrops, multiple gestation, hydatidiform mole)

23. uterine artery DOPPLER In preeclamptic mother: Showing early diastolic NOTCH Decreased EDF (due to high resistance) In normal mother

24. Placental hypoxia • Immunological factors • Placental enzymes • Genetic factors (MTHFR, F5,) • Oxidative stress • ???????????????????

25. What causes maternal syndrome ??? What gets into maternal circulation??????

26. Maternal Syndrome stage-II • not just hypertension and proteinuria • But also involves different end organs

27. Physiology of maintain uteroplacental flow in Normal pregnancy • Placenta releases angiotensinase  destruction of angiotensin-II(a potent vasoconstrictor) BP stabilized • Vascular synthesis of PGI-2 and NO in excess  vasodilation  BP stabilized & uteroplacental flow maintains • Release of VEGF  restores uteroplacental flow

28. Normal balance of agonist & anta-gonistic factors: • 1.vasodialator & vasoconstrictor • 2. angiogenic and antiangiogenic factors

29. 1.vasodialator & vasoconstrictor placenta Syncytiotrophoblast & endothelium

30. 2. angiogenic and antiangiogenic factors

33. Pathophysiology for different organ damage:

34. Basic mechanism of different organ damage: • Increased vasoconstriction • Decreased organ perfusion : • Increased endothelial dysfunction – capillary leak, oedema, Pulmonary oedema, proteinuria. • Activation of coagulation: DIC, low platelets • Haemoconcentration

36. Pathophysiology of different organ damage:

38. CVS involvement:

39. Hematological system

40. Renal system involvement: • ↓ed renal perfusion :(d/t ↓ed blood volume & ↑ed afferent arteriolar pr.) • ↓ed GFR : d/t • glomerular capillary endotheliosis • Endothelial dysfunction + mesangial swelling + BM disruption • (but podocyte disruption minimal) • Oliguria • ↑ed creatinine level • ↑ed uric acid

41. Hepatic involvement:

42. Brain involvement:

43. Lungs involvement:

44. Diagnosisof HDP

45. Diagnosing Preeclampsia-Eclampsia: o liver involvement -raised AST, ALT (>70 IU/l) -severe upper abdominal pain o neurological involvement -severe headache -persistent visual disturbances -hyperreflexia with sustained clonus -convulsions (eclampsia) -stroke o pulmonary oedema o fetal growth restriction o placental abruption • Blood pressure ≥ 140/90 mm of Hg (at or after 20 weeks of gestation) on 2 occasions at least 6 hours apart during bed rest. (≥ 160/90 mm of Hg is severe disease) • accompanied by one or more of: o significant proteinuria -urinary dipstick 2+-random urinary protein/creatinine ratio ≥ 30 mg/mmol-24 hour urine excretion ≥300 mg/24 hrs o renal involvement -serum creatinine ≥ 90 mmol/L or -oliguria (<400 ml in 24 hrs) o haematological involvement -platelet count<1 lakh

46. HELLP Syndrome: -Hemolysis: • LDH > 600 U per L • Abnormal PBS showing schistocytes, burr cells. • Serum bilirubin ≥ 1.2 mg per dL -Elevated Liver enzymes: • AST and ALT >70 IU/l -Low Platelet count: • <1 lakh/cubic mm

47. History -special points • Patient Particulars: Age young or >35 yrs, nulliparity, low SES -risk factors • Chief Complaints:Swelling of legs or other parts of body (face, abdominal wall, vulva, or whole body and tightness of the ring on the finger.) Severe disease -Headache, visual changes, nausea, vomiting, abdominal or epigastric pain, and oliguria, insomnia, vaginal bleeding, seizures. • Present Obstetric History: Onset,Duration, Severity of Htn/Proteinuria and H/o drug intake • Past Obstetric History: H/o any hypertensive disorder of pregnancywith week of onset. Also note the interval since last pregnancy, gestational age at delivery. Any foetal complications. • PastHistory: of pre-existing hypertension, renal disease, diabetes, thrombophilia, or thyroid disorder. • FamilyHistory: of Htn, Preeclampsia, Diabetes, CVD

48. Physical Examination: • Obesity/BMI>35 kg/m2 • Weight (serial measurements): Gain in wt at the rate of >1 lb a week or >5 lbs a month in the later months of pregnancy may be the earliest sign of preeclampsia. • Oedema (all sites): has to be pathological, meaning visible pitting edema demonstratable over the ankles after 12 hrs bed rest. • Pulse (in all 4 limbs) • B.P.: • right arm, sitting/supine, arm at level of heart, cuff length=1.5 times of arm circumference, diastolic BP is the disappearance of Korotkoff sounds (phase V) • taken on 2 occasions at least 6 hrs apart for confirmation of diagnosis. • CVS examination: auscultation for heart rate, rhythm, splitting of S2, murmurs. • Ophthalmic examination: retinal haemorrage, nicking of veins, arteriole/vein ratio 3:1 from 3:2, papilloedema • Deep tendon reflexes: hyperreflexia/presence of clonus

49. How to Measure Blood Pressure • Sitting Position • Patient Relaxed • Arm well supported • Measured in right arm • Cuff at heart level • Proper cuff size (80% of arm circumference) • Slow deflation of bladder (2mmHg/s) • From start of Korotkoff I to end of Korotkoff V

50. Obstetric Examination: Nothing special is found except features of IUGR, oligohydramnios in some cases.