HYPERTENSION IN

PREGNANCY

BY RT FARHAN ZIA
RT AYAZ UR REHMAN
RT AMIR SAID
RT ANOUSHA
CLINICAL CASE
•
You are seeing a new patient in emergency or ICU and the nurse records her
sitting blood pressure at 150/90 and on repeat, 154/98. The urine dip was
negative except for 1+ protein. The patient complains of having a mild
headache earlier that morning that resolved after eating breakfast. She
also complains of increased swelling in her legs and feet and says that
her blood pressure yesterday at the drug store was 150/100. She is 26
weeks’ pregnant. Do you begin antihypertensive therapy? Do you need
any further evaluation?
LECTURE OUTLINES
• INTRODUCTION
• GESTATIONAL HYPERTENSION
• TYPES OF GESTATIONAL HYPERTENSION
• INCIDENCES
• RISK FACTORS
• PATHOPHYSIOLOGY
• MULTI ORGAN SYSTEM INVOLMENT
• MANAGEMENT
• REFERENCES
HYPERTENSION
• High blood pressure (also referred to as HBP, or hypertension) is when
your blood pressure, the force of blood flowing through your blood
vessels, is consistently too high
• To survive and function properly, your tissues and organs need the
oxygenated blood that your circulatory system carries throughout the
body. When the heart beats, it creates pressure that pushes blood
through a network of tube-shaped blood vessels, which include
arteries, veins and capillaries.
HYPERTENSIVE DISORDER
• Hypertensive disorders occur in up to 10% of pregnancies worldwide
and cause substantial perinatal morbidity and mortality of both
mother and fetus.
• Hypertensive disease is directly responsible for approximately 12.3%
of maternal deaths in the United States.
• The incidence of preeclampsia has increased by 25% in the United
States during the past two decades. The exact cause of hypertension
associated with pregnancy remains unknown.
CLASSIFICATION

• Various classifications of hypertensive disorders in pregnancy have

been proposed

• Because hypertensive disorders in pregnancy represent a spectrum of

disease, classification systems should be used as a guide only

Chronic hypertension

• Chronic hypertension is defined as hypertension present before

pregnancy

• Or before the 20th week of gestation or that persists longer than the

postpartum period (i.e., 12 weeks after delivery).

GESTATIONAL HYPERTENSION
• The hypertension occuring solely because of pregnancy, the raise in
blood pressure is apparent after 20 weeks of gestation and cures
spontanously after the delivery.
• This include pregnancy induced hypertension and pre-eclampsia
• Hypertension that develops for the first time after 20 weeks of
gestation in the absence of proteinuria is termed gestational
hypertension.
• Proteinuria is high levels of protein in your urine defined as urinary
excretion of 0.3 g protein or higher in a 24-hour urine specimen.
TYPES OF GESTATIONAL
HYPERTENSION
• Pregnancy induced hypertension:
Gestataional hypertension with raised blood pressure as the sole
clinical feature
• Preeclampsia:
Is the development of hypertension with proteinuria after 20 weeks of
gestation.Blood pressure of ≥140 mmHg systolic or ≥90 mmHg diastolic
that occurs after 20 weeks of gestation in a woman with previously
normal blood pressure
• Eclampsia
Eclampsia is the additional presence of convulsions (grand mal or
tonic– clonic seizures) in a woman with preeclampsia that is not
explained by a neurologic disorder.
Eclampsia occurs in 0.5% to 4% of patients with preeclampsia. Most
cases of eclampsia occur prior to or within 24 hours of delivery, but
up to 10% of cases are diagnosed between 2 and 10 days postpartum.
 RISK FACTORS
• Systemic lupus erythematosus *
• Pre-gestational diabetes
• Chronic renal disease
• Multifetal pregnancy
• Pre-pregnancy BMI >30
• Previous stillbirth
• Nulliparity
• Maternal age >40
• stressful job
* SLE is an autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation
and tissue damage in the affected organs. It can affect the joints, skin, brain, lungs, kidneys, and blood vessels.
• Increased pre-pregnancy BMI
• Reduced school education
• Previous pre-eclampsia
Pathophysiology
Normal

• The uteroplacental circulation is unlike anyother adult arteries it lacks

microcirculation there are no arterioles , capillaries or venules

• hence spiral arteries are end arteries and more than 100 spiral

arteries deliver the 500ml/min of blood normally required at the end

of term pregnancy directly into the intervillous space

• in normal pregnancy the spiral arteries of the placental bed

undergoes series of physiological changes

• these physiological chnages converts the vessels supplying the

placenta from musclar end arteries to wide mouthed by the end of

first trimester
Lack of second wave of tropoblastic invasion

• The second wave of trophoblast invasion is usaually completed by the 18 week of

gestation

• if this not happend the vascular supply is decreased

• leads to resctricted blood flow

• (TROH-foh-BLAST) A thin layer of cells that helps a developing embryo attach to the

wall of the uterus, protects the embryo, and forms a part of the placenta.
Maternal organ system involvment
• cardiovascular
• Renal sytem
• Liver
• Blood HELLP Syndrome
• Brain
• Respiratory system
RENAL SYSTEM
• In pre eclampsia the first change in the renal system is tubular
dysfunction. Where uric acid absorption increases leads to decrease
UA clearances causes hyperuricemia
• Hyperuricemia distinguished gestational hypertension from chronic
hypertension.
• Uric acid level in normal pregnancy increases with increases in
gestational time i.e 0.28,0.29,0.34,0.39,mmol/L at 16,28,32,36 week
of gestation respectively.
• Second thing after tubular involvement is glomerular endothelosis
• Glomerular-Endothelosis is a glomerular lesion of pre eclampsia is the
swelling of glomerular endothelial cells which narrow down and
sometimes occuelde the capillary lumin leads to proteinuria
• Normal pregnancy protein loss is 300mg/24hrs while in pre eclampsia
the protein loss increase upto 5g/24hrs
• Preeclampsia common cause of nephrotic syndrome in pregnancy
• Subsequent rise in creatinine urea and hypocalciuria
• The end stage of renal involvement is acute renal failure
• Proteinuria leads to hypoalbuminemia which leads to generalized
edema , ascites pleural effusion and pulmonary, cerebral and
laryngeal oedema .
Cardiovascular System
• B.P= Cardiac output * peripheral resistance
• Primary maternal heamodynamics adaptation is the fall in peripheral
resistance leading to fall in blood pressure
• Factors for decrease peripheral resistance= progesterone
• Increases prostacyline thromobaxane A2 ratio
• NO2
• Endothelial derived vasodilator
• There is significant vasodilation throughout the normal pregnancy
• In pre eclampsia there is increase in peripheral resistance due to
vasoconstriction poor plasma volume expansion and abnormal and
reduced cardiac output
• The raise in B.P is thus primarily a reflection of raised peripheral
resistance
• Results from endothelial demage with possibly reduced production of
endothelial derived vasodilator
• Obestetrical hypertension is 140/90 mmHg B.P lower than this limit in
1st half of pregnancy
• In second half of pregnancy it is recommended to use 170/110mmHg
Liver
• liver involvment is associated with the elevation of liver enzymes and
bilirubin which may progress to clinical jaundice and latter to hepatic
failure
• dearangment of LFTs is seen in approximatly 20% cases of pre
eclampia and about 2/3 of women dying from eclampsia have a
specifc lesions in liver
• Degree of liver involvment is independent of hypertension and
proteinuria and may occue even in their absences
Blood

• In pre eclampsia there is a activation of coagulation and fibronyltic

system

• The activation of coagulation and fibronyltic system results in the

consumption of clotting factors and plateletes
HELLP SYNDROME
• HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets)
syndrome is a life-threatening pregnancy complication usually
considered to be a variant of preeclampsia. Both conditions usually
occur during the later stages of pregnancy, or soon after childbirth
• HELLP syndrome was named by Dr. Louis Weinstein in 1982 after its
characteristics
• H (hemolysis, which is the breaking down of red blood cells)
• EL (elevated liver enzymes)
• LP (low platelet count)
MANAGMENT
BRAIN

• In pre eclampia there is increased perfusion pressure and increased

cerebral resistances with no change in cereberal blood flow

• In case of eclampsia there is intense vasoconstrication of cereberal

arteries which is probably meant to prevent uncontrolled increase in
tissue perfusion and demageto the microcirculation distal to
arterioles
• Eclampsia is a form of hypertensive encephalpathy which include

• cereberal heamorrhages

• petechial heamorrhages
RESPIRATORY SYSTEM

• Pulmonary edema may occur and can be related to decreased colloid

oncotic pressure, pulmonary capillary leak, left heart failure,
iatrogenic fluid overload, or a combination of these factors.

• And this will lead to the admission in intensive care unit

MANAGMENT
INITIAL EVALUTION

• Visual disturbances, or unusually severe or

persistent headaches are indicative of vasospasm.
• RUQ pain may indicate liver involvement,
presumably involving distension of the liver
capsule.
• Any history of loss of consciousness or seizures,
even in the patient with a known seizure disorder,
may be significant.
Accurate Bp measurment
History
• any history of episodic hypertension would suggest the possibility of
pheaocromocytoma
• Tumor that forms in the center of the adrenal gland (gland located
above the kidney) that causes it to make too much adrenaline.
• EXAMINATION
• the radial and femoral pulses should be palpated simultanously to
look for the radiofemoral dely which is characteristics featue of
coarctation of aorta
• Coarctation of the aorta is a birth defect in which a part of the aorta is
narrower than usual
INVESTIGATION
• Urine testing — Proteinuria is diagnosed by analyzing the urine (called
a urinalysis), often with a dipstick test. However, dipstick testing is not
very precise. Also, people should have the urine test repeated to
determine whether or not the proteinuria is transient or persistent
CLINICAL FOLLOW-UP
• This patient may have chronic hypertension or may be developing
preeclampsia. Since she is a new patient, you obtain a careful history
and perform a physical examination. She has no history of chronic
hypertension and no other chronic medical disorders. Because of the
risk of adverse outcome for mother and fetus if the diagnosis is
preeclampsia, you plan to evaluate her further. You send her to Labor
and Delivery for laboratory tests, maternal blood pressure
monitoring, and fetal evaluation with ultrasonography and fetal heart
rate monitoring.
FURTHER READING
• Fndamental of obstetrics by
ARSHAD CHOHAN