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PREGNANCY INHYPERTENSION
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Classification
There are five types of hypertensive disease:
Gestational hypertension (formerly pregnancy-induced hypertension that included transient
hypertension). Chronic hypertension
Preeclampsia.
Eclampsia.
Preeclampsia superimposed on chronichypertension.
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Diagnosis of Hypertensive Disorders
Complicating Pregnancy
1. Preeclampsia
Minimum criteria
BP 140/90 mm Hg after 20 weeks' gestation
Proteinuria 300 mg/24 hours or 1+dipstick
Increased certainty of preeclampsia
BP 160/110 mg Hg
Proteinuria 2.0 g/24 hours or 2+ dipstick
Serum creatinine > 1.2 mg/dL unless known to be previously
elevatedPlatelets < 100,000/mm3
Microangiopathic hemolysis (increased LDH)
Elevated ALT or AST
Persistent headache or other cerebral or visual disturbance,
Persistent epigastric pain
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2. Eclampsia
Seizures that mg/24 hours in hypertensive women but no
proteinuria before 20 weeks' gestation
3. 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/mm3 in women with hypertension and
proteinuria before 20 weeks' gestation
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4. Gestational hypertension
BP 140/90 mm Hg for first time during pregnancy
No proteinuria
BP returns to normal < 12 weeks' postpartumFinal diagnosis made only postpartum
May have other signs or symptoms of preeclampsia, for example,
epigastric discomfort or thrombocytopenia
5. 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
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Pregnancy in Chronic
Hypertension
Stage Diagnostics Criteria
I There is a rise in blood pressure, but no change, but the cardiac-vascular
system, caused by arterial hypertension (no left ventricular hypertrophy on
ECG data. Changes retinopathy).
II There is a rise in blood pressure, combined with changes in the cardiovascular
system, caused by both arterial hypertension (left ventricular hypertrophy on
ECG. Angiopathy of retina), and coronary heart disease (angina) or brain
(hemodynamic disturbance of brain) but function of internal organs is notimpaired.
III Previously, high blood pressure may drop because of a heart attack or stroke.
There is significant dysfunction of the heart (heart failure), and / or brain
(stroke). and / or kidney (chronic renal insufficiency).
Classification of hypertension, used inRussia
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Classification of the degree of arterial
hypertension (WHO, 1999)
DegreeArterial Blood Pressure (mm Hg)
Systolic DiastolicI 140-159 and/or 90-99
II 160-179 and/or 100-109
III > 180 and/or > 110
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Diagnosis
Medical history, including family history.
Complaints of headaches, nose bleed, pain in
the heart region, etc. Examination: measuring blood pressure on both
hand and by repeating the measurements 5
minutes after decreasing emotional stress in
women.
ECG and fundoscopy
US, Chest X-ray, CT scan
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Clinical features
Stage I
do not feel significant physical limitations. In history, we can find complaints
of recurrent headaches, tinnitus, sleep disturbances, episodic nosebleeds.
In ECG, signs of hyperfunction of left ventricular can detect. Changes in
eye fundus are absent. Functions of kidney id not disturbed. Stage II
constant headache, shortness of breath on physical activity is seen. this
stage of disease is characterized by hypertensive crisis. Signs of
hypertrophy left ventricle are clearly showed. In eye fundus, narrowing of
arteries and arterioles lumen is detected. Moderate thickening of their walls,
compression of veins compacted arterioles. No changes in urine analysis. Stage III
Rarely pregnant,decrease ability of this group of women to conceive.
Differential diagnosis of early stages of hypertension and gestosis, as a rule, does
not cause serious difficulties, since I and II stages of the disease there are no
changes in the urine, swelling do not occur, no hypoproteinemia, no reduction of
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Effects of Chronic Hypertension on
Pregnancy
Renal or cardiopulmonary dysfunction, Aortic
dissection at term
Superimposed Preeclampsia
Placental Abruption
Maternal Economic and Lifestyle Factors
Fetal Growth Restriction Perinatal death
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Treatment
Antihypertensive medication may be withheld or discontinued.If not, convince patient of effectiveness of therapy and goodoutcome of pregnancy. Ask patient to pay attention andcomply with strict regime of the day (work, rest, sleep) andfood. Food should be easily digestible, rich in proteins andvitamins.
Antihypertensive drugs: diuretics (dichlothiazide. spironolactone. furosemide. brinaldix)
drugs acting at different levels of sympathetic system including-and -adrenergic receptors (anaprilin/propanolol, clonidine,
methyldopa), vasodilators and calcium antagonists (apressin, verapamil,
phenytidin),
antispasmodic (dibasol, papaverine, no-spa, aminophylline).
Physiotherapy shall be selected together with drug therapy:
conversations electrons, inductothermy of feet and lower
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Contraindications
ACE inhibitors should be avoided during pregnancy,as they are associated with fetal renal dysgenesis ordeath when used in the second and third trimestersand with increased risk of cardiovascular and central
nervous system malformations when used in the firsttrimester.
Angiotensin II receptor antagonists/blockers are notused during pregnancy because they have amechanism of action similar to that of ACE inhibitors.
Diuretics do not cause fetal malformations but aregenerally avoided in pregnancy, as they prevent thephysiologic volume expansion seen in normalpregnancy. They may be used in states of volume-dependent hypertension, such as renal or cardiacdisease.
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Management algorithm for severe
chronic hypertension in pregnancy
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Hospitalization
The first hospitalization of patients is in the early period of
pregnancy (up to 12 weeks.). In stage I hypertensive disease,
pregnancy continues with regular monitoring of therapist and
obstetrician. If you have stage II disease, the pregnancy can bemaintained with the absence of accompanying disorders of
cardiovascular system, kidneys, etc. Stage III of disease is an
indication of abortion.
The second hospitalization is necessary in the period of maximum
load of cardiovascular system, i.e., in 28-32 weeks. In the antenataldepartment, conduct a thorough examination of the patient and
correction of the treatment.
The third planned hospitalization should be carried out for 2-3
weeks until presumed childbirth to prepare women for childbirth.
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Labor Management
Typically, birth takes place through the birth canal. At the
same time, I stage of labor is conducted with adequate
anesthesia with ongoing antihypertensive therapy and early
amniotomy, during severe hypertension, therapy is increasedwith ganglion blockers to decrease BP to manageable hypo-
or, rather, normo-tension.
Depends on the condition of mother and fetus, period of II
stage of labor is decrease, it is indication for perineotomy or
obstetrics forceps. In III stage of labor, preventive measures are carried out to
reduce blood loss, with the latest attempts to introduce 1 ml
methylergometrine. Throughout the act of birth, prevention of
fetal hypoxia is periodically carried out.
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THE END