5. Gestational HypertensionGestational Hypertension
Diagnosis of gestational hypertension:
Detected for first time after midpregnancy
No proteinuria
Only until a more specific diagnosis can be assigned
postpartum
If preeclampsia does not develop and
BP returns to normal by 12 weeks postpartum, diagnosis is
transient hypertension.
BP remains high postpartum, diagnosis is chronic
hypertension.
Proteinurea develops Preeclampsia is diagnosed (25%
incidence)
6. Hypertension in PregnancyHypertension in Pregnancy
Complicates 7-10% of pregnancies
– 70% Preeclampsia-eclampsia
– 30% Chronic hypertension
Eclampsia 0.05% incidence
20% of Maternal Deaths
Cause of 10% of Preterm birth
Etiology unknown
8. ** INCIDENCE: 5-10% 0f all pregnancies . 20% recurrence
This is the third most important cause of maternal mortality
worldwide
** DEFINITION OF HYPEWRTENSION:
D.B.P. > 90 mmHg or
S.B.P. > 140 mmHg or
Rise in D.B.P. of at least 15 mmHg (physiological changes) or
Rise in S.B.P. of at least 30 mmHg
** PROTIENUREA:
Proteinurea is defined as urinary excretion
0.3 g protein or greater in a 24-hour
30 mg/dl (+1 or greater on urine dip specimen)
** OEDEMA: 90% pregnancy. progressive
abandoned
+/-
10. Symptoms of Pre-eclampsiaSymptoms of Pre-eclampsia
Visual disturbances typical of preeclampsia are
scintillations and scotomata. These disturbances
are presumed to be due to cerebral vasospasm.
Headache is of new onset and may be described as
frontal, throbbing, or similar to a migraine
headache. However, no classic headache of
preeclampsia exists.
Epigastric pain is due to hepatic swelling and
inflammation, with stretch of the liver capsule.
Pain may be of sudden onset, it may be constant,
and it may be moderate-to-severe in intensity.
11. Symptoms of preeclampsiaSymptoms of preeclampsia
While mild lower extremity edema is common in
normal pregnancy, rapidly increasing or
nondependent edema may be a signal of
developing preeclampsia. However, this signal
theory remains controversial and recently has been
removed from most criteria for the diagnosis of
preeclampsia.
Rapid weight gain is a result of edema due to
capillary leak as well as renal sodium and fluid
retention.
12. Physical Findings inPhysical Findings in
PreeclampsiaPreeclampsia
Blood Pressure
Proteinurea
Retinal vasospasm or Retinal edema
Right upper quadrant (RUQ) abdominal
tenderness stems from liver swelling and
capsular stretch
13. Physical findings inPhysical findings in
PreeclampsiaPreeclampsia
– Brisk, or hyperactive, reflexes are common
during pregnancy, but clonus is a sign of
neuromuscular irritability that raises concern.
– Among pregnant women, 30% have some
lower extremity edema as part of their normal
pregnancy. However, a sudden change in
dependent edema, edema in nondependent areas
such as the face and hands, or rapid weight gain
suggests a pathologic process and warrants
further evaluation
14. •Why screening
•Accuracy. Uterine artery doppler at 24 weeks, notching on both
uterine arteries identifies 80% who will develop PET,,, 5% false
positive
15. Methods Used to Prevent Hypertensive Disorders of Pregnancy
Proper prenatal care
Low-salt diet
Diuretics
Antihypertensive drugs
Nutritional supplementation
Magnesium (365 mg/d)
Zinc (20 mg/d)
Calcium (1500–200 mg/d)
Fish oil
Antithrombotic agents Low-dose aspirin (50–150 mg/d)
Dipyridamole (225–300 mg/d)
Subcutaneous heparin (15,000 IU/d)
19. ** Mild pre-eclampsia:
diastolic /90-95 & proteinurea trace-1+
** Moderate pre-eclampsia
** Severe pre-eclampsia
** Does the treatment improve the condition?
Then why. Adv/disadv
20. CONTROL OF ACUTE SEVERE HYPERTENSION
• There is no consensus on the optimum acute treatment.
• The important objective is to reduce the blood pressure to safe levels.
(but not too low!).
• Parenteral hydralazine is used most commonly but oral nifedipine should be
considered .
The combined a- and (B- blocking agent labetalol is commonly
used.
The potent vasodilator and calcium channel blocker nifedipine is a
useful second-line treatment. Its major drawback is severe
headache.
Angiotensin-converting enzyme (ACE) inhibitors have deleterious fetal
effects and their use is not recommended. If a woman with
chronic hypertension becomes pregnant on an ACE inhibitor,
change to another anti-hypertensioe agent is advised.
LONGER-TERM CONTROL OF SEVERE HYPERTENSION
21. • There is still insufficient trial evidence to determine whether the benefits
outweigh any disadvantages.
• If it is to be used, the suggested indications are: ,-DBP >_100 mmHg
-pregnancy <_34 weeks
*fetal and maternal state otherwise good.
• Methyldopa remains the drug of first choice.
The combined a- and (B- blocking agent labetalol is commonly
used.
The potent vasodilator and calcium channel blocker nifedipine is a
useful second-line treatment. Its major drawback is severe
headache.
Angiotensin-converting enzyme (ACE) inhibitors have deleterious fetal
effects and their use is not recommended. If a woman with
chronic hypertension becomes pregnant on an ACE inhibitor,
change to another anti-hypertensioe agent is advised.
LONGER-TERM CONTROL OF SEVERE HYPERTENSION
22. Timing of delivery
• The most common grounds for delivery are:
progressive fetal compromise,
(i.e. when the baby is safer delivered).
unacceptable risk to maternal health,
e.g. uncontrollable BP, impending renal failure or heart
failure, HELLP syndrome, DIC, eclampsia .
23. The mode of delivery (caesarean section versus vaginal)
depends on:
-The seriousness of the situation
-The gestational age
-The degree of fetal/maternal compromise.
• Epidural analgesia is the method of choice for labour
(as long as a coagulation defect has been excluded).
• Appropriate facilities for the care of the newborn available