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Adrian Setiawan, M.D.

Department of Obstetrics and


Gynecology,Faculty of Medicine
KRIDA WACANA CHRISTIAN UNIVERSITY

HYPERTENSIVE DISORDERS OF
PREGNANCY

General Classification
Preeclampsia or Eclampsia (hypertension and

proteinuria unique to pregnancy)


Chronic hypertension
Chronic hypertension with superimposed
preeclampsia
Gestational or transient hypertension
(National Institutes of Health Working Group
Report on High Blood Pressure in Pregnancy,2000.

Adopted by ACOG ,2002)

Diagnosis of Hypertension
Blood pressure readings vary depending on

maternal position and the gestational age of


the pregnancy.
Tends to be lower in the LLD position, higher
in the sitting position.
In the supine position some elevated
pressure, some have supine hypotension due
to compression of the vena cava by the
uterus.

Arterial blood pressure normally declines

during 1st and 2nd trimester


The diagnosis of hypertension should be
reserved for patients with a systolic greater
than or equal to 140 mmHg or a diastolic
greater than or equal to 90 mmHg.
BP should be taken in the sittting or lateral
decubitus position after woman has rested at
least 10 minutes.

PREECLAMPSIA
A syndrome unique to pregnancy, characterized by

the new onset of hypertension and proteinuria in the


latter half of gestation divided into mild and severe
preeclampsia.
Classically affecting the first pregnancy, but also
occurs in multiparas or change in husband
Two criteria for diagnosis of preeclampsia : the BP
140/90 mmHg and development of new onset
proteinuria after 20th wks AOG.
Proteiunuria defined as 0.3 gram protein in a 24
hour urine collection ,
usually correlates 30 mg/dl (+1 on dipstick)

Criteria for Severe


Preeclampsia
BP 160/110 mmHg at rest on two occasions

at least 6 hr apart
Proteinuria 5 gram in a 24 h urine collection
or qualitative +3
Oliguria (< 500 ml in 24 hr)
Cerebral or visual disturbances
Pulmonary edema or cyanosis

Epigastric or right upper quadrant pain


Impaired liver function (elevated liver

enzyme)
Thrombocytopenia
Fetal growth restriction

(ACOG, Practice Bulletin No.33, Washington,DC,2002)

Eclampsia
Is the presence of tonic clonic seizures in a

woman with preeclampsia that cannot be


attributed to other causes.

Chronic Hypertension
The diagnosis of chronic hypertension

requires at least one of the following : known


hypertension before pregnancy, development
of hypertension before 20 weeks gestation,
or, in cases in which hypertension is first
noted during pregnancy, persistence of
elevated blood pressures greater than 12
weeks postpartum.

Chronic Hypertension with


Superimposed Preeclampsia
The diagnosis of gestationla hypertension is
made if hypertension without proteinuria first

appears after 20 weeks gestation or within 48 to


72 hours after delivery and resolves by 12 weeks
postpartum.
The diagnosis of gestational hypertension can
only be made in retrospect, if the pregnancy has
been completed without the development of
proteinuria and if the blood pressure has
returned to normal before the 12 week
postpartum.

Etiology Preeclampsia /
Eclampsia
Preeclampsia is called a disease of theories,

because genetic,immunologic,vascular,
hormonal, nutritional, and behavioral factors
have all been proposed as causes. No single
definitive cause has been identified and the
origins of the disease are considered to be
multifactorial.

Placental ischemia, or hypoxia appears to be

central to the development of the disease


and has been attributed to failure of the
cytotrophoblasts to adequately invade the
uterine spiral arteries and establish the low
resistance uteroplacental circulation
characteristic of normal pregnan

It is postulated that uteroplacental ischemia

results in oxidative stress leading to


production and release of toxins that enter
the circulation and cause widespread
inflammation, endothelial dysfunction and
activation of the coagulation system.
Endothelial dysfunction leads to imbalance
between different classes of locally produced
vasoconstrictors and vasodilators.

Endothelial changes also appear to involve a


relative deficiency in the production of nitric

oxide, a vasodilator and inhibitor of platelet


aggregation along with increased production of
endothelin-1. Endothelin 1 is an extremely
potent vasoconstrictor and activator platelets.
The net effect of these processes would be
spread vasoconstriction leading to hypoxic and
ischemic damage in different vascular
beds,systemic hypertension, the HELLP
syndrome or DIC and worsening placental
ischemia.

Pathophysiology
Generalized vasospasm
GFR and renal blood flow are significantly

lower
Damage of glomerular membranes ,
increasing their permeability to proteins and
leading to proteinuria.
Cerebral vascular resistance is high in
patients with PE and Eclampsia

Pathology
Lack of decidualization of the myometrial

segments of the spiral arteries


Glomerular capillary endotheliosis
Ischemia, hemorrhage and necrosis in many
organs, presumably secondary to arteriolar
constriction.

Clinical and laboratory


manifestations
Weight gain and edema
Elevation of blood pressure
Proteinuria
Increase serum uric acid concentration
Thrombocytopenia
Liver function : elevated serum enzyme levels

(alanine aminotransferase and aspartate


aminotransferase)

Retroplacental hemorrhage or abruptio


Visual disturbance
Laboratory : CBC, platelet count,LDH,

Ureum, creatinin and uric acid, urinalysis 24


hour urine for protein and creatinine, liver
function tests.

Evaluation and management


Delivery is the only definitive cure for

preeclampsia and eclampsia after a period of


stabilization, regardless of the gestational
age of the fetus.
Seizure prophylaxis : magnesium sulfate
Antihypertensive therapy : hydralazine,
labetalol, nifedipine, methyldopa

MANAGEMENT OF PREECLAMPSIA

ADEQUAT AND PROPER PRENATAL CARE

IDENTIFICATION OF WOMEN AT HIGH RISK

EARLY DETECTION BY THE RECOGNATION OF CLINICAL


SIGNS AND SYMPTOMS

THE PROGRESSION OF CONDITION TO SEVERE STATE

MATERNAL AND PERINATAL OUTCOME IN WOMEN WITH MILD


PREECLAMPSIA, > 36 WEEKS GESTATION ARE USUALLY

FAVOURABLE

MATERNAL AND PERINATAL OUTCOMES DEPEND ON :

GESTATIONAL AGE AT TIME OF DISEASE ONSET


SEVERITY OF DISEASE
QUAITY OF MANAGEMENT
PRESENCE OR ABSENCE OF PRE-EXISTING MEDICAL
DISORDERS

MILD PREECLAMPSIA
AMBULATORY CARE
BED REST : NOT NECESSARILY
REGULAR DIET, NO SALT RESTRICTION
PRENATAL VITAMIN

NO OTHER MEDICATION : ANTI HYPERTENSIVE,


SEDATIVE, DIURETICS
ANTENAL VISIT : EVERY WEEK

HOSPITAL CARE

PERSISTENT HYPERTENSION MORE THAN 2 WEEKS

PERSISTENT PROTENURIA MORE THAN 2 WEEKS

ABNORMAL LABORATORY TEST

ABNORMAL FETAL GROWTH

ONE OR MORE SIGN AND SYMPTOM SEVERE PE

OBSTETRIC MANAGEMENT

GESTATIONAL AGE < 37 WEEKS


~ SIGN AND SYMPTOM ARE NOT WORSENED
MAINTAIN UNTIL TERM

GESTATIONAL AGE > 37 WEEKS


~ WAIT UNTIL THE ONSET OF LABOR
~ CERVIX IS FAVORABLE, INDUCTION OF LABOR

SEVERE PREECLAMPSIA

MEDICAL TREATMENT

OBSTETRIC MANAGEMENT :

CONSERVATIVE : -

PREGNANCY 37 WEEKS

ACTIVE

PREGNANCY 37 WEEKS

: -

FETAL INDICATION

MATERNAL INDICATION

MEDICAL TREATMENT :

HOSPITALIZE
TOTAL BED REST
FLUID THERAPY : RINGER LACTATE, DEXTROSE 5%.
Mg SO4 IV
ANTI HYPERTENSION :
HYDRALAZIN
LABETALOL
NIFEDIPINE : 10 20 mg / ORALLY EVERY - 1 H,
MAX : 120 mg / 24 Hours
DIURETIC
: NOT RECOMMENDED
ANTI OXYDANT : N-ACETYL CYSTEIN
CORTICOSTEROID + LUNG MATURITY 34 WEEKS

OBSTETRIC MANAGEMENT

CONSERVATIVE MANAGEMENT:

GOAL

: TO IMPROVE INFANT OUTCOME,


WITHOUT COMPROMISING THE MOTHER

PREGNANCY 37 WEEKS, IMPENDING ECLAMPSIA (-)

ACTIVE MANAGEMENT : TO TERMINATE THE PREGNANCY

INDICATION
FETAL

: - PREGNANCY 37 WEEKS
- IUGR AND ABNORMAL
BIOPHYSICAL PROFILE

MATERNAL : - PERSISTENT HYPERTENTION


- IMPENDING ECLAMPSIA
- COMPLICATION : HELLP SYNDROME,

ABRUPTIO PLAC., OLIGURIA


ROUTE OF DELIVERY :

VAGINAL DELIVERY IS PREFERABLE THAN CS.

ECLAMPSIA : PE + CONVULSION
BASIC MANAGEMENT :
CONTROL THE AIRWAY, BREATHING, CIRCULATION (ABC)

STABILIZE THE MOTHER


CONTROL CONVULSION
CORRECT MATERNAL HYPOXEMIA / ACIDEMIA

PREVENT COMPLICATION : HYPERTENSION CRISIS


TERMINATE PREGNANCY

MEDICAL TREATMENT :
SAME AS SEVERE PREECLAMPSIA

COMPLICATION : P.E AND ECLAMPSIA

MOTHER

BABY

HELLP SYNDROME

IUGR

LIVER RUPTURED

PREMATURE LABOR

PULMONARY EDEMA

INTRA CRANIAL HAEMORRHAGE

RENAL FAILURE

CEREBRAL PALSY

ABRUPTIO PLACENTAE

PNEUMO THORAX

DIC

IUFD

CEREBROL VASCULER ACCIDENT


MATERNAL DEATH

HELLP SYNDROME
FIRST DISCRIBED BY WEINSTEIN 1982:
ACRONYM OF : H

INCIDENCE :

HEMOLYSIS

EL

ELEVATED LIVER ENZYM

LP

LOW PLATETLED COUNT

2%-12% AMONG PATIENTS WITH


PREECLAMPSIA.
30% OCCURS IN POSTPARTUM

CRITERIA DIAGNOSTIC
LABORATORY FINDING:

HEMOLYSIS
ABNORMAL PERIPHERAL SMEAR : SCHISTOCYTES AND
BURR CELLS
TOTAL BILIRUBIN LEVEL > 1,2 mg/Dl
LACTATE DEHYDROGENASE LEVEL > 600 /L

ELEVATED LIVER FUCTION


SGOT LEVEL 70 / L (LDH)
LACTATE DEHYDROGENASE LEVEL > 600 /L

LOW PLATELET COUNT


PLATELET COUNT < 100.000/m3
THE LABORATORY DIAGNOSTIC CRITERIA USED AT THE UNIVERSITY OF TENNESSEE
DIVISION OF MATERNAL FETAL MEDECINE, MEMPHIS TN. WITLIN AND SIBAI (1999)

CLASSIFICATION BASED ON PLATELET COUNT


(MISSISIPPI):
CLASS I : PLATELET 50.000/m3

WITH : LDH 600 U/L


SGOT 40 U/L
CLASS II : PLATELET 50.000/m3 - < 100.000/m3
WITH : LDH 600 U/L
SGOT 40 U/L
CLASS II : PLATELET 50.000/m3 - < 150.000/m3
WITH : LDH 600 U/L
SGOT 40 U/L

MANAGEMENT OF HELLP SYNDROME

MATERNAL STABILISATION IS THE MAYOR PRIORITY

BEGIN WITH A STANDART MANAGEMENT OF SEVERE


PREECLAMPSIA

HELLP SYNDROME IS NOT AN INDICATION FOR CS

MEDICAL MANAGEMENT

SAME AS SEVERE PREECLAMPSIA

WHEN THROMBOCYTE COUNT IS < 50.000 mm3, 10 UNITS


OF THROMBOCYTE OR FRESH WHOLE BLOOD MUST BE
GIVEN

WHEN PATIENT IS COMATOUS, SHE MUST BE TAKEN TO


THE ICU

WHEN THROMBOCYTE COUNTS IS < 50.000/mm3


FIBRINOGEN LEVEL, PROTHROMBINE TIME, PARTIAL
THROMBOPLASTIN TIME, D-DIMMER MUST BE CHECKED
TO FIND DIC

OBSTETRIC MANAGEMENT
WHEN MOTHERS IS STABLE TERMINATE THE
PREGNANCY OR CONSERVATIVE MANAGEMENT.
CONSERVATIVE MANAGEMENT CAN BE DONE
WHEN :

THE BLOOD PRESSURE < 160/110 m g


THE OLIGURIA RESPONSE TO FLUID
REPLACEMENT

THERE IS NO EPIGASTRIC PAIN


THE GESTATIONAL AGE IS < 34 WEEKS

COMPLICATION
THE COMPLICATIONS THAT CAN OCCUR IN
HELLP SYNDROME ARE : NEUROLOGIC

DISORDER, PULMONARY EDEMA, ABRUPTIO


PLACENTA, DIC AND UGR