Pregnancy hypertension case presentation

hypertension in pregnancy a high risk case

1. PREGNANCY PREGNANCY
HYPERTENSION HYPERTENSION
PLENOS | PRECIA

2. • Terminology and Classification
• Diagnosis
• Risk Factors
• Etiopathogenesis
• Prediction and Prevention
• Management
• Long-Term Consequences

3. 4 Types of Hypertensive Disease:
(Working Group of the National High Blood Pressure Education Program)

• Gestational Hypertension
• Formerly termed pregnancy-induced hpn
• Transient Hypertension – if preeclampsia
syndrome does not develop and
hypertension resolves by 12 weeks
postpartum

4. • Preeclampsia and eclampsia syndrome
• Preeclampsia syndrome superimposed on
chronic hypertension
• Chronic Hypertension

5. Gestational Hypertension

• Systolic BP > 140 or diastolic BP > 90 mm Hg for
first time during pregnancy
• No proteinuria
• BP returns to normal before 12 weeks postpartum
• Final diagnosis made only postpartum
• May have other signs or symptoms of
preeclampsia, for example, epigastric discomfort
or thrombocytopenia

6. Preeclampsia

• Minimum criteria:
• BP > 140/90 mm Hg after 20 weeks
gestation
• Proteinuria > 300 mg/24 hours or > 1 +
dipstick

7. Preeclampsia

• Increased certainty of preeclampsia:
• BP > 160/110 mm Hg
• Proteinuria 2.0 g/24 hours or > 2 + dipstick
• Serum creatinine > 1.2 mg/dL unless known to be
previously elevated
• Platelets < 100,000/ uL
• Microangiopathic hemolysis – increased LDH
• Elevated serum transaminase levels – ALT or AST
• Persistent headache or other cerebral or visual
disturbances
• Persistent epigastric pain

8. Eclampsia

• Seizures that cannot be attributed to other causes in
a woman with preeclampsia

Superimposed Preeclampsia On Chronic Hypertension

• New onset proteinuria > 300 mg/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/ uL in women with
hypertension and proteinuria before 20 weeks’
gestation

9. Chronic Hypertension

• BP > 140/90 mm Hg before pregnancy or diagnosed
before 20 weeks’ gestation not attributable to
gestational trophoblastic disease
OR
• Hypertension first diagnosed after 20 weeks’ gestation
and persistent after 12 weeks postpartum

10. • Age
• Nulliparous
• Race
• Ethnicity
• Genetic Predisposition
• Environment
• Socioeconomic Status
• Seasonal Influences
• Obesity
• Multifetal Gestation

11. Gestational hypertensive disorders are more likely
to develop in women who:

• Are exposed to chorionic villi for the first time
• Are exposed to a superabundance of
chorionic villi, as with twins or H mole
• Have preexisting renal or cardiovascular
disease
• Are genetically predisposed to hypertension
developing during pregnancy

12. Regardless of precipitating etiology, the
cascade of events that leads to the preeclampsia
syndrome is characterized by a host of
abnormalities that result in vascular endothelial
damage and subsequent vasopasm, transudation
of plasma, and ischemic and thrombotic sequelae.

13. Preeclampsia as Two-Stage Disorder



Stage 1
Poor Placentation
(Early)
Stage 2
Placental Oxidative Stress
(Late)
Fetal Growth Restriction Systemic Release of Placental
Factors
Systemic Inflammatory
Response, Endothelial
Adhesion
Preeclampsia Syndrome

14. Etiology

• Placental implantation with abnormal trophoblastic
invasion of uterine vessels
• Immunological maladaptive tolerance between maternal,
paternal (placental) and fetal tissues
• Maternal maladaptation to cardiovascular or
inflammatory changes of normal pregnancy
• Genetic factors including inherited predisposing genes as
well as epigenetic influences

15. Provocative pressor test
• Roll-over test
• Isometric exercise test
• Angiotensin II infusion test

Uterine artery doppler velocimetry
• Increased uterine artery velocimetry
determined by doppler ultrasound in the
first or middle trimester
(serves as a predictive test for
preeclampsia)

16. Pulse wave analysis
• Finger arterial pulse “stiffness” is an indicator
for cardiovascular risk

17. Prevention
Dietary Manipulation
• Low-salt diet
• Calcium supplementation
• Fish oil supplementation

18. • Cardiovascular Drugs
• Diuretics
• Antihypertensive drugs
• Antioxidants
• Ascorbic acid (vitamin C)
• @-tocopherol (vitamin E)

19. • Antithrombotic Drugs
• Low-dose aspirin
• Aspirin/dypiridamole
• Aspirin + heparin
• Aspirin + ketanserin

20. The basic management objectives for any pregnancy
complicated by preeclampsia are:

• 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

21. • Early Diagnosis of Preeclampsia
• Evaluation
• Hospitalization is considered at least initially for
women with new-onset hypertension, especially
if there is persistent or worsening hypertension or
development of proteinuria.

22. • Consideration for Delivery
• Termination of pregnancy is the only cure for
preeclampsia
• Elective Cesarean Delivery
• Hospitalization versus Outpatient Management
• Antihypertensive Therapy for Mild to Moderate
Hypertension

23. • Delayed Delivery
• Delayed Delivery with Early-Onset Severe
preeclampsia
• Expectant Management of Midtrimester
Severe Preeclampsia
• Glucocorticoids for Lung Maturation
• Corticosteroids to Ameliorate HELLP
Syndrome

24. • Eclampsia
• Magnesium Sulfate to control convulsions
• Severe Hypertension

25. • Counseling for Future Pregnancies
• Long-Term Sequelae
• Cardiovascular and Neurovascular Morbidity
• Renal Sequelae
• Neurological Sequaelae

26. THANK THANK
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