HYPERTENSIVE DISORDERS IN PREGNANCY Shanro Mayra Vega Sri Wahyuni
HYPERTENSIVE DISORDERSIN PREGNANCY
Shanro Mayra VegaSri Wahyuni
Deadly triad causes of maternal morbidity and mortality related to pregnancy :Hypertensive disorders complicating pregnancyHemorrhageInfection
How pregnancy incites or aggravated hypertension remains unsolvedHypertensive disorders significant unsolved problems in obstetrics.
Gestational hypertension (formerly pregnancy-induced hypertension or transient hypertension)PreeclampsiaEclampsiaPreeclampsia superimposed on chronic hypertensionChronic hypertensionCLASSIFICATION
Parity, ras, genetic, environmentOther risk factor :NulliparousHyperplacentosisMola hydatidosaMultiple gestationDiabetes mellitusHydrops foetalisGiant babyAge (< 15 y.o ; > 35 y.o)Renal disease & chronic hypertensionINCIDENCE & RISK FACTOR
Abnormal trophoblastic invasion of uterine vesselsImmunological intoleranceMaternal maladaptation / inflammatory changes of normal pregnancyDietary deficienciesGenetic influenceETIOLOGY
CRITERIAGestational hypertension :BP > 140/90 mmHg for first time during pregnancyno proteinuriaBP returns to normal by 12 weeks postpartumPreclampsia :BP > 140/90 mmHg after 20 weeks gestationproteinuria > 300 mg/24 hr or > 1+ dipstickEclampsia :Preeclampsia + seizure
CRITERIASuperimposed Preeclampsia :new onset proteinuria > 300 mg/24 hr BP or platelet count > 100.000/mm3 in hypertensive women but no proteinuria < 20 weeks gestationChronic hypertension :BP > 140/90 mmHg before pregnancy / diagnosed before 20 weeks gestationHypertension first diagnosed after 20 weeks gestation persistent after 12 weeks postpartum
PATHOPHYSIOLOGYMaternalFaultyExcessive vascular disease placentationtrophoblast
Genetic, immunologic, or inflammatory factor
Reduced uteroplacental perfusionVasoactive agent : Noxious agent :Prostaglandin EndothelialCytokinesNitric oxide dysfunctionLipid perox.Endothelins Capillary leak VasospasmeActivation of coagulationEdemaProteinuriaHyper- Thrombo-tension Oliguria Liver Hemo- cytopenia ischemia concentration
Seizure Abruption
ORGAN CHANGES 1. CardiovascularHypertensionCardiac output ThrombocytopeniaCoagulation defectBleedingDICPlasma blood volume Permeability Edema
2. PlacentaNecrosisIUGRFetal distressAbruptio placentae
3. RenalCapillary endotheliosisUric acid cleareance GFR OliguriaProteinuriaRenal failure
4. BrainEdemaHypoxiaAcute attack / seizureCerebrovascular accident / hemorrhageComa
5. LiverChanges in liver function testLiver enzyme IcterusHELLP syndrome(Hemolysis, Elevated Liver enzym, Low Platelet count)EdemaSubcapsular hematome / hemorrhage Necrosis, perinatal hemorrhage
6. EyesPupillary edemaIschemiaAmaurosisHemorrhageRetinal defectsBlindness
7. LungEdemaIschemiaNecrosisHemorrhageRespiratory failure
PREDICTIONRoll-Over TestUric acidFibronectinCoagulation activationOxidative stressCytokinePlacenta peptideDNA fetusUterine artery doppler Velocitometry
PREVENTIONNon-medicalDietary manipulationLow calorie, high protein, salt restriction Ca, Zn, Mg, Omega-3 PUFA, evening primrose oilBedrest not proven
Habits :Intense prenatal careAvoid smokingAvoid cafeinCompliance
B. Medical
Diuretics worsening hypovolemiaAntihypertension not provenAntithrombotic :Low-dose aspirin not provenDypiridamoleAntioxidant : vitamin C, vitamin E, -carotene, lipoic acid
Eden Criteria :Prolonged comaHeart rate > 120 x /minuteTemperature > 380 CSystolic pressure > 200 mmHgSeizure > 10 xProteinuria > 10 gr/L per dayNo edemaPROGNOSIS
Prognosis worsened if there are :CardiomegalyDecreased renal functionRetinal complicationBP > 200/120 mmHg
Maternal death due to PE : + 0,5% Ecl : + 5%Perinatal death : + 20%PROGNOSIS
MANAGEMENTBasic management objective :Termination of pregnancy with the least possible trauma to mother and fetusBirth of an infant who subsequently thrivesComplete restoration of health to the mother
1. Mild Preeclampsiaa. OutpatientIf the patient refuse to be hospitalizedHome restDiet (high protein, low fat, carbohydrat)VitaminsAntenatal care visite weeklyMANAGEMENT
b. HospitalizationNo improvement after 2 weeks outpatient careWeight gain > 2 kg/weekSevere symptoms of preeclampsia
2. Severe PreeclampsiaConservative : < 37 weeks gestation, no fetal distress and no symptoms of impending eclampsia :Severe headacheSevere visual disturbanceVomitEpigastric painProgressive BP Active : termination of pregnancy !
Anticonvulsion MgSO4 8 gr 40%;4 gr every 4-6 hoursAntihypertension :Hydralazine 2 mg i.v 100 mg in 500 cc NaClClonidineNifedipineMetyldopaLabetololEtanololDiltiazemetcI. DRUG THERAPHY
Others :DiureticsCardiotonicsAntipyreticsAntibioticsAnalgesics
II. OBSTETRICAL MANAGEMENTMature inductionParturient augmentationDelivery : forceps extraction sectio cesaria
Classification :- Antepartum- Intrapartum- Post partum :early : 24 hours - 7 dayslate : > 7 daysEclampsia sine eclampsiaEclampsia intercurrentECLAMPSIA
ICU !Internal department, neurology department, etcDrug theraphy :MgSO4 : 4 gr 20% i.v 8 gr 40% i.m maintenance : 4 gr 40% i.m / 4 - 6 hoursSupportive : same as preeclampsiaManagement of coma :together with neurologic departmentObstetrical management : termination of pregnancy !MANAGEMENTLoading
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