Hypertension in Pregnancy

Pregnancy
Induced
Hypertension
Jun Ma
Dept. of Obstetrics & Gynecology
The First Hospital of Xian Jiaotong Univ
Introduction
Incidence: China: 9.4%, worldwide: 7-12%
The most common and yet serious conditions seen

in obstetrics
cause substantial morbidity and mortality in the

mother and fetus
Death due to cerebral hemorrhage, aspiration

pneumonia, hypoxic encephalophathy,
thromboembolism, hepatic rupture, renal failure
Hypertension in pregnancy
Definition
Diastolic BP 90 mmHg
Systolic BP 140 mmHg
Or as an increase in the diastolic BP of 15

mmHg or in the systolic blood pressure of 30
mmHg, as compared to previous pressure
The increased blood pressures be present on

at least two separate occasions, > 6h apart
Classification
Classification of Hypertensive
Disorders in Pregnancy (ACOG)
Pregnancy-induced hypertension
Preeclampsia
Mild
Severe
Eclampsia
Chronic hypertension preceding pregnancy
Chronic hypertension with superimposed PIH
Superimposed preeclampsia
Superimposed eclampsia
Gestational hypertension
Classification (1)
1.
Pregnancy-induced hypertension:
Hypertension associated with proteinuria and edema,
occurring primarily in nulliparas after the 20th week or
near term.
Preeclampsia
mild
BP 140/90mmHg
Onset after 20 weeks gestation

Proteinuria (>300mg/24-hr urine collection) or +
Epigastric discomfort
Thrombocytopenia
Classification (2)
severe
BP 160/110 mmHg
Marked proteinuria (>1-2 g/24-hr urine collection or 2+

or more), oliguria
Cerabral or visual disturbances such as headache and

scotomata
Pulmonary edema or cyanosis
Epigastric or right upper quadrant pain (probably

caused by subcapsular hepatic hemorrhage)
Evidence of hepatic dysfunction, or thrombocytopenia
Classification (3)
Eclampsia
Meets the criteria of preeclampsia
Presence of convulsions, not attributable

to other neurological disease,
Occurrence: 0.5 -4 %, with 25%

occurring in the 1st 72 hs postpartum
Classification (4)
2. Chronic hypertension proceeding
pregnancy (essential or secondary to
renal disease, endocrine disease, or
other causes)
BP 140/90 mmHg
Presents before 20 wk gestation
Persists beyond 12 wk postpartum
Classification (5)
3. Chronic hypertension with superimposed
preeclampsia or eclamptia
Coexistence of preeclampsia or eclampsia with

preexisting chronic hypertension
Cause greatest risk
When diagnosis is obscure, it is always wise to

assume that the findings represent
preeclampsia and treat accordingly.
Classification (6)
4.
Gestational hypertension: not mentioned in

the ACOG
Finding of hypertension in late pregnancy in the

absence of other findings suggestive or
preeclampsia
Transient hypertension of pregnancy
May develop into chronic hypertension if

elevated BP persists beyond 12 weeks
postpartum
High risk factors
Nulliparous
<18ys or >40 ys, multiple pregnancy
Has previous gestational hypertensive

disorders
Chronic nephritis
Diabetic
Malnutrition
Low social status
Hydatidiform mole
Etiology: UNCLEAR
Immune mechanism (rejection phenomenon,

insufficient blocking Ab)
Injury of vascular endothelium----disruption of the

equilibrium between vasoconstriction and
vasodilatation, imbalance between PGI and TXA
Compromised placenta profusion
Genetic factor
Dietary factors: nutrition deficiency
Insulin resistance
Increase CNS irritability
Pathophysiology
Central nervous system
Raised BP disrupt autoregulation
Increased permeability due to vasospasm--thrombosis of arterioles, microinfarcts, and petechial

hemorrhage
Cerebral edema: increased intracranial pressure
CT scan (1/3-1/2 positive): focal hypodensity
Cerebral angiography: diffuse arterial

vasoconstriction
EEG: nonspecific abnormality (75% in eclamptic

patient)
Eyes
Serous
retinal detachment
Cortical blindness
Pulmonary system
Pulmonary edema
Cardiogenic or noncardiogenic
Excessive fluid retention, decreased hepatic

synthesis of albumin, decreased plasma
colloid oncotic pressure,
Often occurs postpartum
Aspiration of gastric contents: the most

dreaded complications of eclamptic
seizures
Kidneys
Characteristic lesion of preeclampsia:

glomeruloendotheliosis
Swelling of the glomerular capillary

endothelium
Decreased GFR
Fibrin split products deposit on basement

membrane
Proteinuria
Increase of plasma uric acid, creatinine,
Liver
The spectrum of liver disease in

preeclampsia is broad
Subclinical involvement
Rupture of the liver or hepatic infarction
HELLP syndrome: hemolysis, elevated

liver enzymes and low platelets
Cardiovascular system
Generalized vasoconstriction, low-output,

high-resistance state
Untreated preeclamptic women are

significantly volume-depleted
Capillary leak
Cardiac ischemia, hemorrhage, infarction,

heart failure
Increased sensitivity to vasoconstrictor effects

of angiotensin
Blood (1)
Volume: reduced plasma volume
Normal physiologic volume expansion
does not occur
Generalized vasoconstriction and capillary
leak
Hematocrit
Blood (2): coagulation
Isolated thrombocytopenia: <150,000/ml
Microangiopathic hemolytic anemia
DIC (5%)
HELLP syndrome: in severe preeclampsia
1.
schistocytes on the peripheral blood smear
2.
lactic dehydrogenase > 600 u/L
3.
total bilirubin > 1.2 mg/dl
4.
aspartate aminotransferase >70 U/L
5.
platelet count <100,000/mm3
Misdiagnosis: hepatitis, gallbladder disease, ITP
Endocrine system
Vascular sensitivity to catecholamines

and other endogenous vasopressors
such as antidiuretic hormone and
angiotensin II is increased in
preeclampsia
Disequilibrium of prostacyclin/
thromboxane A2
Placenta perfusion
500 mm vs 200 mm
Acute atherosis of spiral arteries: fibrinoid

necrosis of the arterial wall, the presence of
lipid and lipophages and a mononuclear cell
infiltrate around the damaged vessel---vessel obliteration---- placental infarction
Fetus is subjected to poor intervillous blood

flow
IUGR or stillbirth
Clinical findings (1)

Symptoms and signs
1. Hypertension
Diastolic pressure 90 mmHg or
Systolic pressure 140 mmHg or
Increase of 30/15 mmHg

2. Proteinuria
>300 mg/24-hr urine collection or
+ or more on dipstick of a random urine

3. Edema
Weight gain: 1-2 lb/wk or 5 lb/wk is

considered worrisome
Degree of edema
Preeclampsia may occur in women

with no edema
Most recent reports omit it from the

definition

4.
Differing clinical picture in preeclampsiaeclampsia crises: patient may present with
Eclamptic seizures
Liver dysfunction and IUGR
Pulmonary edema
Abruptio placenta
Renal failure
Ascites and anasarca

Laboratory findings (1)
Blood test: elevated Hb or Hct, in severe cases, anemia
secondary to hemolysis, thrombocytopenia, FDP
increase, decreased coagulation factors
Urine analysis: proteinuria and hyaline cast, specific
gravity > 1.020
Liver function: ALT and AST increase, alkaline

phosphatase increase, LDH increase, serum albumin
Renal function: uric acid: 6 mg/dl, serum creatinine
may be elevated

Laboratory findings (2)
Retinal check:
Other tests: ECG, placenta function,

fetal maturity, cerebral angiography,
etc
Differential diagnosis
Pregnancy complicated with chronic

nephritis
Eclampsia should be distinguished

from epilepsy, encephalitis, brain
tumor, anomalies and rupture of
cerebral vessel, hypoglycemia shock,
diabetic hyperosmatic coma
Complications
Preterm delivery
Fetal risks: acute and chronic

uteroplacental insufficiency
Intrapartum fetal distress or stillbirth
IUGR
Oligohydramnios
Predictive evaluation (1)

1. Mean arterial pressure, MAP= (sys.
Bp + 2 x Dia. Bp) /3
MAP> 85 mmHg: suggestive of
eclampsia
MAP > 140 mmHg: high likelihood of
seizure and maternal mortality and
morbidity
Predictive evaluation (2)

2. Roll over test: ROT
Preeclamptic patients are more

sensitive to angiotensin II
Difference between Bp obtained at

left recumbent position and supine
position (at a 5 min interval)
Positive: > 20 mmHg
3. Urine calcium/ creatinine < 0.04
Prevention
Calcium supplementation: not effective

in low risk women bur show effect in high
risk group
Aspirin (antithrombotic): uncertain
Good prenatal care and regular visits
Baseline test for high-risk women
Eclampsia cannot always be prevented, it

may occur suddenly and without warning.
Treatment
A.
Mild preeclampsia: bed rest & delivery

Hospitalization or home regimen
Bed rest (position and why) and daily weighing
Daily urine dipstick measurements of proteinuria
Blood pressure monitoring
Fetal heart rate testing
Periodic 24-h urine collection
Ultrasound
Liver function, renal function, coagulation
A. Mild preeclampsia: bed rest & delivery
Observe for danger signals: severe

headache, epigastric pain, visual
disturbances
Sedatives: debatable
B. Severe preeclampsia:
Prevention of convulsion: magnesium

sulfate or diazepam and phenytoin
Control of maternal blood pressure:

antihypertensive therapy
Initiation of delivery: the definitive mode of

therapy if severe preeclampsia develops at
or > 36 wk or if there is evidence of fetal lung
maturity or fetal jeopardy.
Magnesium sulfate
1. Decreases the amount of
acetylcholine released at the
neuromuscular junction
2. Blocks calcium entry into neurons
3. Vasodilates the smaller-diameter
intracranial vessels
Magnesium sulfate
1. Prevent convulsion
2. Virtually ineffective on blood pressure
3. i.v. or i.m.
5g loading dose 5-10 min, i.v.
1-2g/hr constant infusion
Total dose: 20-30 g/d
Toxicity:
Diminished or loss of patellar reflex
Diminished respiration
Muscle paralysis
Blurred speech
Cardiac arrest
How to prevent toxicity?
Frequent evaluation of patellar reflex and

respirations
Maintenance of urine output at >25 ml/hr

or 600 ml/d
Reversal of toxicity:
1. Slow i.v . 10% calcium gloconate

2. Oxygen supplementation
3. Cardiorespiratory support
Antihypertensive therapy:
reduce the Dia. pressure to 90-110 mmHg
Indication
Bp> 160/110 mmHg
Dia. Bp > 110 mmHg
MAP > 140 mmHg
Chronic hypertension with previous

antihypertensive drugs usage
Antihypertensive therapy
Medications:
Hydrolazine: initial choice
Labetolol
Nifedipine
Nimoldipine
Methyldoe
Sodium nitroprusside
Mechanism
of action
Effects
hydralazine
Direct peripheral
vasodilation
CO, RBF maternal flushing,

headache, tachycardia
labetalol
a, b- adrenergic
blocker

headache, neonatal
depressed respirations
Medication
CO, RBF maternal

orthostatic hypotension
Headache, no neonatal
effects
nifedipine
Calcium channel
blocker
methyldopa
Direct peripheral
arteriolar vasodilation headache, tachycardia
sodium nitroprusside
Direct peripheral
vasodilation
Metabolite (cyanide)
toxic to fetus
Plasma expander
Diuretics
Delivery
Indication of termination of pregnancy
1. Preeclampsia close to term

2. <34 wk with decreased placental
function
3. 2 hs after control of seizure
Delivery
Induction of labor
1.
First stage: close monitor, rest and sedation
2.
Second stage: shorten as much as possible
3.
Third stage: postpartum hemorrhage
Cesarean section
1.
Induction of labor unsuccessful
2.
Induction of labor not possible
3.
Maternal or fetal status is worsening
Eclampsia
No aura preceding seizure
Multiple tonic-clonic seizures
Unconsciousness
Hyperventilation after seizure
Tongue biting, broken bones, head

trauma and aspiration, pulmonary
edema and retinal detachment
Management
Control of seizure
Control of hypertension
Delivery
Proper nursing care

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Hypertension in Pregnancy

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Pregnancy

Incidence: China: 9.4%, worldwide: 7-12%

The most common and yet serious conditions seen

cause substantial morbidity and mortality in the

Death due to cerebral hemorrhage, aspiration

Systolic BP 140 mmHg

Or as an increase in the diastolic BP of 15

The increased blood pressures be present on

Onset after 20 weeks gestation

Marked proteinuria (>1-2 g/24-hr urine collection or 2+

Cerabral or visual disturbances such as headache and

Pulmonary edema or cyanosis

Epigastric or right upper quadrant pain (probably

Evidence of hepatic dysfunction, or thrombocytopenia

Meets the criteria of preeclampsia

Presence of convulsions, not attributable

Occurrence: 0.5 -4 %, with 25%

Presents before 20 wk gestation

Persists beyond 12 wk postpartum

Coexistence of preeclampsia or eclampsia with

Cause greatest risk

When diagnosis is obscure, it is always wise to

Gestational hypertension: not mentioned in

Finding of hypertension in late pregnancy in the

Transient hypertension of pregnancy

May develop into chronic hypertension if

High risk factors

<18ys or >40 ys, multiple pregnancy

Has previous gestational hypertensive

Low social status

Immune mechanism (rejection phenomenon,

Injury of vascular endothelium----disruption of the

Compromised placenta profusion

Dietary factors: nutrition deficiency

Increase CNS irritability

Central nervous system

Raised BP disrupt autoregulation

Increased permeability due to vasospasm--thrombosis of arterioles, microinfarcts, and petechial

Cerebral edema: increased intracranial pressure

CT scan (1/3-1/2 positive): focal hypodensity

Cerebral angiography: diffuse arterial

EEG: nonspecific abnormality (75% in eclamptic

Excessive fluid retention, decreased hepatic

Often occurs postpartum

Aspiration of gastric contents: the most

Characteristic lesion of preeclampsia:

Swelling of the glomerular capillary

Fibrin split products deposit on basement

Increase of plasma uric acid, creatinine,

The spectrum of liver disease in

Rupture of the liver or hepatic infarction

HELLP syndrome: hemolysis, elevated

Generalized vasoconstriction, low-output,

Untreated preeclamptic women are

Cardiac ischemia, hemorrhage, infarction,

Increased sensitivity to vasoconstrictor effects

Blood (2): coagulation

Isolated thrombocytopenia: <150,000/ml

Microangiopathic hemolytic anemia