pIH intro. Gestational hypertension other

Pih Introduction

1. HYPERTENSIVE DISORDERS OF PREGNANCY

2. INTRODUCTION Hypertensive disorders of pregnancy – leading cause of maternal and perinatal mortality Hypertensive disorders – 14 % of all maternal deaths

3. CLASSIFICATION THE NATIONAL HIGH BLOOD PRESSURE EDUCATION PROGRAMME,2000 (NHBPEP ,2000) 1. Gestational hypertension, also known as pregnancy induced hypertension (PIH) 2. Pre-eclampsia 3. Eclampsia 4. Chronic hypertension 5 .Chronic hypertension with superimposed pre-eclampsia

4. CLASSIFICATION INTERNATIONAL SOCIETY FOR THE STUDY OF HYPERTENSION IN PREGNANCY (ISSHP ,2018) HYPERTENSION ARISING AT OR AFTER 20 WEEKS OF PREGNANCY : Gestational hypertension – BP more than or equal to 140/90 mmHg , without proteinuria , hematolgical or biochemical abnormalities. Pre-eclampsia – BP more than or equal to 140/90 mmHg , with proteinuria and / or evidence of maternal organ or placental dysfunction. Other condition – Transient gestational hypertension. HYPERTENSION KNOEN BEFORE PREGNANCY OR DIAGNOSED IN FIRST 20 WEEKS : Chronic hypertension – BP more than or equal to 140/90 mmHg , secondary to other causes such as renal condition, vascular pathology etc.. Chronic hypertension with superimposed pre-eclampsia – worsening BP / new onset proteinuria/ evidence of dysfunction of any one of maternal organs consistent with pre-eclampsia in women with chronic hypertension. Other conditions – white coat hypertension, masked hypertension.

5. GESTATIONAL HYPERTENSION/ PIH Hypertension develops for first time in pregnancy after 20 weeks o f gestation. NO proteinuria NO biochemical abnormalities NO hematolgical abnormalities NO FGR NO Maternal organ or placental dysfunction
BP returns to normal within 12 weeks postpartum
Final diagnosis is made only after 12 weeks postpartum PIH ➡️ pre- eclampsia

6. TRANSIENT GESTATIONAL HYPERTENSION It is a de novo hypertension that develops in the second or third trimester and resolves without treatment during the pregnancy. Women diagnosed with transient gestational hypertension have a - 20% chance of developing pre-eclampsia - 20% chance of developing gestation hypertension .

7. PRE-ECLAMPSIA As per the earlier diagnostic criteria, pre-eclampsia is the development of hypertension and significant proteinuria after 20 weeks of gestation. Current criteria to diagnose pre-eclampsia (ISSHP, 2018 ) New-onset hypertension after 20 weeks of gestation accompanied by >1 of the following new-onset conditions:
• Proteinuria • Serum creatinine >1.1 mg/dL indicating renal insufficiency
• Elevated transaminases alanine aminotransferase or aspartate aminotransferase indicating hepatic dysfunction (twice the upper limit of normal concentration)
• Platelet Count <1,00,000/micro L indicating hematological complication • Neurological complications, including altered mental status, blindness, stroke, clonus, severe headaches . and persistent visual scotomata • Pulmonary edema • Uteroplacental dysfunction presenting as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis or stillbirth

8. CHRONIC HYPERTENSION A diagnosis of chronic hypertension complicating pregnancy is made when hypertension is diagnosed before pregnancy or is diagnosed before 20 weeks of gestation

9. CHRONIC HYPERTENSION SUPERIMPOSED WITH PRE-ECLAMPSIA About 25% of women with chronic hypertension will develop superimposed pre-eclampsia. These rates may be higher in women with underlying renal disease. A diagnosis of pre-eclampsia superimposed on chronic hypertension is made if there is worsening of blood pressure/in the presence of new-onset proteinuria/or if there is evidence of dysfunction of any one of maternal organs consistent with pre-eclampsia.

10. ECLAMPSIA Eclampsia is characterised by the occurrence of new onset tonic- clonic seizures and/or coma during pregnancy, labour or the puerperium . In 80-90% of cases, eclampsia is preceded by pre-eclampsia. However, in a smaller proportion of cases, the presentation of eclampsia is atypical, without the classical signs of pre -eclampsia , hypertension and proteinuria. Postnatal pre-eclampsia is more dangerous.

11. PRE-ECLAMPSIA Pre-eclampsia is a multi-organ disorder characterised by the development of hypertension and significant proteinuria and/or evidence of one of the maternal organ dysfunction after 20 weeks of gestation. INCIDENCE OF PRE-ECLAMPSIA IN INDIA : 10.3% .

12. CRITERIA FOR DIAGNOSING HYPERTENSION IN PREGNANCY • Hypertension is diagnosed in pregnancy if the systolic blood pressure is ≥140 mmHg or if díastolic blood pressure is ≥90 mmHg or more on two occasions at least four hours apart after 20 weeks of gestation in a woman with previously normal blood pressure. • SEVERE HYPERTENSION is diagnosed if the systolic blood Pressure is ≥160 mmHg or diastolic blood pressure is ≥110 mmHg and can be confirmned within 15 minutes to facilitate timely antihypertensive therapy.

13. CRITERIA FOR DIAGNOSING PROTEINURIA The gold standard for diagnosing abnormal proteinuría in pregnancy is - 24-hour urinary protein excretion of ≥300 mg per day. However, monitoring this is time consuming, and therefore, proteinuria is assessed by screening urine with an - automated dipstick . If positive (≥1+, 30 mg/dL), then a spot urine protein/ creatinine ( PCr ) ratio should be performed. A PCr ratio of 30 mg/ mmol is abnormal. Proteinuria is also considered significant if it is 2+ on the dipstick (>100 mg/dL); 3+ indicates that urinary protein is 300 mg/dL and 4+ indicates 1,000 mg/dL of urinary protein.

14. SIGNIFICANCE OF EDEMA The presence of edema is not an essential criterion to diagnose pre-eclampsia as it may occur in a normal pregnancy as well as other pathological conditions such as anemia, cardiac failure and renal disease . However, in patients with pre-eclampsia, when there is persistent pedal edema which does not resolve on taking rest, edema in dependent areas such as the vulva, pre-sacral edema or generalised edema , it indicates the severity of the condition.

15. SEVERITY OF PRE-ECLAMPSIA MILD PRE-ECLAMPSIA • Systolic BP is greater than 140 mmHg • Diastolic BP is greater than 90 mmHg on two successive measurements 4-6 hours apart • Proteinuria is >3 g in a 24-hour sample or 2+ in a random sample SEVERE PRE-ECLAMPSIA • Systolic BP >160 mmHg • Diastolic BP > 110 mmHg
• Proteinuria greater than 5 g in a 24-hour collection or more than 3+ in two random urine samples In the absence of proteinuria, any of the following clinical findings and investigations suggest organ involvement.
• Serum creatinine >1.1 mg/dL . • Platelet count <1,00,000/micro L
• Liver enzymes >twice the normal • Pulmonary edema
• New-onset visual and neurological disturbances • Oliguria with less than 500 mL urine output I in 24 hours

16. IMMINENT SIGNS AND SYMPTOMS

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