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Hypertensive Disorder Complicating Pregnancy

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. Hypertensive states in pregnancy. Include: Gestational hypertension ；

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Hypertensive Disorder Complicating Pregnancy

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  1. Hypertensive Disorder Complicating Pregnancy

  2. 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

  3. Hypertensive states in pregnancy • 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

  4. Cause Chesley described preeclampsia as a“disease of theories”, because the cause is unknown. Some theories include: 1、Genetic susceptibility hypothesis 2、Immune maladaptation hypothesis 3、Placental perfusion or Ischemia Hypotheses 4、Oxidative stress hypotheses 5、Endothelial cell injury ：explains many of the clinical findings in preeclampsia 6、…….

  5. High-risk factors • Tensity • Age • Social status • Climate changes abruptly • Fat • High tension of uterus：multiplets、hydramnios • Family history • Bad birth history • Complications：DM、chronic nephritis…

  6. Pathology Blood pressure elevate Higher periphery resistance Vessel stenosis Spasm of vessels Injury of endotheliocyte Proteinuria Edema Hypertension

  7. These effects are separated into maternal and fetal consequences; however, these aberrations often occur simultaneously.

  8. Clinical findings——Edema • 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.）

  9. Clinical findings——Hypertension • Hypertension is the most important criterion for the diagnosis of preeclampsia • That too may occur suddenly • Many young primigravidas have 100-110/60-70mmHg 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

  10. Clinical findings——Proteinuria • 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

  11. Clinical findings——Differing clinical picture • 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 renal failure

  12. Classification • Gestational hypertension • Preeclampsia • Eclampsia • Preeclampsia superimposed upon chronic hypertension • Chronic hypertension

  13. 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

  14. Preeclampsia • Minimum criteria: • 1、Proteinuria ≥300mg/24 hours or ≥1+ dipstick • 2、BP≥140/90mmHg after 20 weeks’ gestation

  15. 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

  16. Eclampsia Seizures that cannot be attributed to other causes in a woman with preeclampsia

  17. 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

  18. 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

  19. 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

  20. Diagnosis • Clinical symptoms and physical signs • Auxiliary examinations Differential diagnosis • According to clinical manifestations.

  21. Complications of mother • Heart failure • Cerebrova- scular accident • Placenta abruption • DIC • Renal failure • HELLP’S syndrome • Postpartum hemorrhage

  22. Complications of fetus Fetus： • FGR • fetal distress • fetal death • neonatal asphyxia

  23. Basic management objectives • 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

  24. A systematic evaluation • Detailed examination • Weight on admittance and every day thereafter. • Analysis for proteinuria at least every 2 days thereafter • Blood pressure readings in sitting position with anappropriated-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.

  25. 6 principles • Spasmolysis… • conscious-sedation … • Depressurization… • fluid expansion… • Diuresis… • pregnancy termination

  26. Mild Preeclampsia • Treatment Of Mother • Assessment of Fetal Status

  27. Severe Preeclampsia The goals of management are ： • Prevention of convulsions • Control of maternal blood pressure • Initiation of delivery

  28. Eclampsia • Control of Seizures • Controln of Hypertension • Hydralazine • Labetalol • Nifedipine • Sodium nitroprusside

  29. 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

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