Hypertension disorder

1. 1

2. 2

3. Hypertension:
• A systolic blood pressure ≥140 mmHg, diastolic
blood pressure ≥90 mmHg or both in two occasions
taken 4 hours or more apart
• A single blood pressure recording ≥160/110 mmHg.
• A rise of 20 mm Hg MAP over the previous reading,
or when the MAP is 105 mm Hg or more should be
considered as significant.
3

4. Proteinuria
1. Two urine dipstick measurements of at least 1+(30
mg/dL) taken 6 hours apart
2. at least 300 mg of protein in a 24-hour urine sample
3. a urinary protein/creatinine ratio of 0.3 or greater.
4

5. 5
Source: williams
obstetric 26th
edition

6. Classification
1. Gestational hypertension
2. Preeclampsia
3. Eclampsia
4. Chronic hypertension
5. Superimposed preeclampsia
5.1 Superimposed pre-eclampsia without severe features
5.2 Superimposed pre-eclampsia with severe features
6

7. Rest and Digest 1.
7

8. Rest and Digest 2.
8

9. Rest and Digest 3.
9

10. Rest and Digest 4.
10

11. Rest and Digest 5.
11

12. Rest and Digest 6.
12

13. 13

14. Abnormal trophoblastic invasion
14
• Normally migration of endovascular trophoblast into
the walls of the spiral arterioles produce low-
resistance, low-pressure, high-flow uteroplacental
bed.
• In preeclampsia, trophoblastic invasion is restricted
to decidua segment of uteroplacental arteries.
• No myometrial spiral arterial invasion.

15. 15

16. . . .cont
• Myometrial musculoelastic architecture
remains intact
• Decreased blood supply to placenta
• This results placental endothelial injury &
ischemia
16

17. Vascular endothelial damage
• Placental ischemia leads to production of
placental factor (sFlt-1).
• sFlt-1 antagonize VEGF and PLGF in the
systemic circulation by binding them.
• This results systemic endothelial cell
dysfunction.
17

18. 18

19. Endothelial cell activation causes
19
• Increased capillary permeability
• Vasospasm
• PGI2 production by endothelial cells decreases
& TXA2 by platelet increases.
• Endothelin-1 (ET-1) production increases.
• NO production by endothelium decreases

20. Changes in Prostanoids
20

21. 21

22. Genetic predisposition
Genetic conflict theory
Fetal and maternal genes conflict each other to
control nutrient transfer to the fetus
The conflict hypothesis suggests that placental
factors (fetal genes) act to increase maternal BP,
whereas maternal factors act to reduce BP
When uteroplacental blood supply is inadequate,
fetal rescue strategy to increase non-placental
resistance→ SVR →endothelial cell dysfunction
22

23. Immunologic factors
The formation of blocking antibodies is
impaired for placental antigenic activity
 previous pregnancy has immunologic
effect
large area of antigenic site
 multipara with a new partner is at risk
23

24. Immunologic factors
Maternal tolerance of fetus
• Mechanisms to prevent rejection of fetus, a ’’foreign’’ tissue
• Expansion of regulatory T cells (immunosuppressive in
pregnancy during normal pregnancy
• Th2 cells promote humoral immunity, whereas Th1 cells
stimulate inflammatory cytokine secretion
• Normal pregnancy: Th1 to Th2 switch so that type 2 activity is
increased in relation to type 1(Th2 bias)
• Preeclampsia: beginning in the early second trimester in
women who develop preeclampsia, Th1 action is increased
24

25. Kidney
25
• GFR decrease by 25%
Glomerular endotheliosis
Renal hypoperfusion
Decreased plasma volume
• Acute tubular necrosis

26. Liver
26
• Hepatocyte infarction & necrosis is
accompanied by periportal hemorrhage.
• Bleeding may extend to collect beneath
hepatic capsule- subcapsular hematoma
• Liver enzymes increases in the systemic
circulation

27. Brain
27
• Intracerebral bleeding due to the
hypertension
• Edema, hypermia, ischemia, thrombosis
focal or diffuse
• Amaurosis –occipital lobe vasogenic edema
--10% follows convulsion
--resolve within 4hr-8days

28. Others
28
Lung –capillary oncotic pressure decreases
-endothelial integrity disrupts
-hydrostatic pressure increases- predispose
to non-cardiogenic pulmonary edema
Eye – retinal vasospasm, retinal edema, retinal
detachment
-blindness is uncommon

29. 29

30. 1. Gestational hypertension
• Hypertension without proteinuria or other features of
preeclampsia developing after the 20th week of
pregnancy or within 48 hours of delivery in a
previously normotensive woman
30

31. Management of GHTN
Manage as an outpatient:
• Monitor BP, urine (for proteinuria) and fetal condition
weekly
– If blood pressure worsens or the woman develops features
of pre-eclampsia, manage as pre-eclampsia
• Counsel the woman and her family about danger signs
indicating severe pre-eclampsia or eclampsia
• If all observations remain stable, allow to proceed with
spontaneous labor and childbirth
• If spontaneous labor has not occurred before term, induce
labor at term
31

32. Preeclampsia
Definition
• A new onset of hypertension and proteinuria after 20
weeks of gestation in a previously normotensive
woman.
Sub-classification
1. Pre-eclampsia without severe features
2. Pre-eclampsia with severe features
32

33. Risk factors of PE
First pregnancy
Age <18 or >35 years
Multiple gestation
History of hypertension
Renal disease
Diabetes
 Obesity
 Family history of pre-eclampsia
33

34. From research
• The risk increases in those who have limited sperm
exposure with the same partner before conception
protective effect
• Abortions
• Previous success pregnancy with same partner
34

35. 35

36. Preeclampsia
Pre-eclampsia with severe features
 Headache & blurred vision
 Oliguria (<400 ml/24 hours)
 Epigastric or right upper quadrant pain,
 Difficulty of breathing (pulmonary edema)
 Low platelet count (<100,000/µl)
 Liver enzymes elevated more than twice the upper limit
of normal range,
 serum creatinine higher than 1.1 mg/dl or
 a doubling (or higher) of the baseline serum creatinine
concentration in the absence of other renal disease.
36

37. • AST/ALT/: >70IU/L
• Creatinine: >1mg/dl
• LDH >600 IU/L) and
• bilirubin (>1.2 mg/dL)
• A serum uric acid level ≥ 4.5 mg/dL indicates the
presence of preeclampsia.
• Blood urea level remains normal or slightly raised
37

38. Treatment of PE without severe features
Management varies depending on the gestational
age
1. GA<37 Weeks
a. Outpatient
b. Admission
2. GA≥37 Weeks
38

39. GA≤37wks as outpatient
Twice weekly outpatient follow-up
Monitor BP, fetal condition, CBC, liver and renal
function tests twice weekly
Counsel about the danger signs associated with
features of severe pre-eclampsia
Encourage the woman to eat a normal diet
Orient on fetal movement counting (kick chart) daily
Do not give anticonvulsants or anti-hypertensives
unless clinically indicated
Delivery at 37 completed weeks
39

40. GAl≤37wks as Inpatient
If outpatient mgt’s not possible or close observation
preferred or preeclampsia worse rapidly:
Admit to hospital
Urine output & weight (daily), FHB & kick chart daily
BP, Urine protein, fetal condition twice weekly
 If the diastolic DBP decrease to normal levels or her
condition remains stable manage as outpatient
 If clinical features worsen (urinary protein level
increased), manage as severe preeclampsia
 Do not give diuretics
40

41. 2.GA ≥37complete wks
Delivery is recommended
Anticonvulsant during labor
41

42. B. TREATMENT OF PE WITH SEVERE
FEATURES
The steps of management include:
1. General measures:
2. Prevent convulsion
3. Control hypertension
4. Delivery / expectant management in selected cases
42

43. 1.General Measures
 Admit the patient urgently
 Manage in left lateral position
 Setup IV line & infuse maintenance fluids(?)
 maintain urine output at >30ml/hr & maintain a strict fluid
balance chart
 Prepare equipment for convulsion management at bed side
 Never leave the patient alone
 Monitor vital signs, FHB & reflexes
 Auscultate the lung bases for fine crepitation.
 If they occur, withhold fluids & administer a diuretic
(furosemide 40 mg IV stat)
43

44. 2. Anticonvulsant therapy
44
• Magnesium sulfate (MgSO4) schedules for severe pre-
eclampsia and eclampsia
Loading dose
 MgSO4 20% solution, 4g IV over 5 minutes (mix 8 ml of 50%
Mgso4 solution with 12ml of D5W or 09% normal saline to
make 20% solution )
 Follow promptly with 10g of 50% MgSO4 solution, 5g in each
buttock as deep IM injection with 1mL of 2% lidocaine in the
same syringe.
 Warn the woman that a feeling of warmth will be felt when
Mgso4 is given.
 If convulsion recurs after 15 minutes, give 2g MgSO4 (20%
solution) IV over 5 minutes (?)

45. 2. Anticonvulsant therapy
Maintenance dose
5g MgSO4 (50% solution) + 1 mL lidocaine 2% IM
every 4 hours into alternate buttocks.
Continue treatment with MgSO4 for 24 hours after
delivery or the last convulsion, whichever occurs last
45

46. 2. Anticonvulsant therapy
Diazepam:
• increases the risk of respiratory depression and newborn
apnea, in babies who may already be suffering from the effects
of utero-placental ischemia & pre-term birth.
• The effect may last several days.
• Loading dose
– Diazepam10 mg IV slowly over 2 minutes
– If convulsion recur, repeat the same dose
• Maintenance dose
– Diazepam 40 mg in 500 ml IV fluids (N/S or Ringer's
lactate) no of drops titrated to keep the woman sedated but
arousable
46

47. MgSO4 toxicity (?)
47

48. 48

49. 49

50. 3.Control hypertension
• anti-hypertensives if the SBP is ≥160 mmHg and/or
DBP ≥110 mmHg
Drug of choice for acute control
1. Hydralazine
 Give 5 mg IV slowly every 20 minutes until blood
pressure is lowered (to DBP 90-110 mmHg).
• The maximum dose is 20 mg per 24 hours
50

51. 51
Source: Williams obstetric 26th
edition

52. 3.Control hypertension
2. Labetalol
Oral treatment:
 Administer 200 mg; repeat dose after one hour until the
treatment goal is achieved
 The maximum dose is 1200mg in 24 hours
Intravenous treatment:
 Administer 10 mg IV
 The dose can be doubled to 20mg, 40mg and then 80mg with
10-minute intervals until desired effect obtained
 The maximum total dose is 300 mg; then switch to oral
treatment
52

53. 3.Control hypertension
3. Nifedipine
 administer 10 mg orally
 Repeat dose after 30 minutes if response is inadequate
until optimal blood pressure is reached
 The maximum total dose is 30 mg in the acute treatment
setting
 For maintenance therapy10-20 mg PO bid is given.
4. Alpha methyldopa
Administer 250-750 mg every six to eight hours.
The maximum dose is 3000 mg per 24 hours.
53

54. 4. Planning delivery
Gestational age < 28 weeks
Termination of pregnancy
 Gestational age ≥ 28 weeks and <34 weeks:
Expectant management is recommended, provided
that there is no indication for delivery
(what are they ?)
54

55. 4. Planning delivery
Indications for delivery during Expectant
management :
 Failure to control HTN with two AHTN drugs with a
maximum dose in 48 hours
 Persistent maternal severity symptoms
 HEELP Syndrome and Eclampsia
 Pulmonary edema or left ventricular failure
 IUFD and DIC
 Severe renal dysfunction
55

56. 4. Planning delivery
For expectant management:
Transfer to maternity ward
Follow vital signs every 4 hours
CBC, every other day
Liver enzymes, creatinine, Fetal surveillance twice
weekly
Fetal kick count daily
Administer Dexamethasone 6 mg IM every 12 hours
for 2 days or Betamethasone 12 mg daily for 2 days
56

57. 4. Planning delivery
Gestation 34 to 37 Weeks
Expectant management if there is stable feto-
maternal condition (no uncontrolled maternal
hypertension, worsening maternal status and fetal
distress )
Gestation after 37 completed Weeks
regardless of severity features, giving birth is
recommended.
57

58. 4. Planning delivery
• MODE OF DELIVERY: depends on GA, fetal
condition, presentation, cervical condition & maternal
condition
Indication for C/S:
– Unfavorable cervix (firm, thick, closed) esp. in seriously ill
patients
– Poor progress of labor
– Patient has not entered active labor within 8 hrs of
induction of labor
– If there is evidence of fetal distress, or other obstetric
indications
58

59. 4. Planning delivery
POSTPARTUM MANAGEMENT
• Watch closely for at least 2 hours after delivery for
complications such as shock, PPH & eclampsia.
• Anticonvulsive therapy should be maintained for 24 hrs to
48 hrs after delivery or the last convulsion, whichever
occurs last.
• Continue anti-hypertensive therapy as long as the blood
pressure is ≥ 110mmhg
• Continue to monitor urine output & check for coagulation
failure, LFT and RFT
• Postnatal follow-up
59

60. Eclampsia
• Generalized convulsion and / or coma in a woman
with preeclampsia where the convulsion or coma is
not attributed to other causes.
60

61. Eclampsia Cont…
Stages of fit:
1. Premonitory stage: lasts about 10 -20 seconds
Patient is restless, twitching of facial muscles, eye
roll, respiration becomes spasmodic
2. Tonic stage: Lasting about 10–20 seconds, general
muscle rigidity, and whole body goes in to tonic
spasms, Backaches, features distorted by grimace,
tongue may be bitten, breathing ceases and pt
becomes cyanosed
61
6/10/2023
Obstetric II for midwives by Helen Dec
2007EC

62. Eclampsia Cont…
3. Clonic stage: Lasting about 60 – 90 minutes.
Convulsive movements frothy saliva fills the mouth,
may be stained. The woman becomes unconscious.
4. Stage of coma: Snoring( large volume of air through
narrowed space) breathing continued and may be
persistent for minutes or hours. Further convulsive
movements sometimes recur with or without pt
gaining from consciousnes.
62
6/10/2023
Obstetric II for midwives by Helen Dec
2007EC

63. Eclampsia
MANAGEMENT
 Check airway
Aspirate (suction) the mouth & throat as necessary &
ensure open airway.
Place an oral airway.
 Check breathing
If breathing, give oxygen by mask at 6 litters per minute
If not breathing, ventilate using bag and face mask.
 Check circulation
Set up IV line
Maintain intravascular volume and replace ongoing losses.
Avoid fluid overload
63

64. Eclampsia
ANTI-HYPERTENSIVE THERAPY : As stated in the
management of sever preeclampsia with severe features
FLUID BALANCE
– Keeping strict input & output record is essential and
determine serum electrolytes.
– For unconscious patient, 5% DW & RL are infused for
maintenance of nutrition & fluid balance during 24 hrs.
– Replace extra fluid loss through vomiting, diarrhea,
sweating or blood loss.
– NPO until conscious
64

65. Eclampsia
DELIVERY
• Delivery should take place as soon as the woman's
condition has stabilized, regardless of the gestational
age i.e within 12 hours of onset of convulsions
65

66. Chronic hypertension
• Hypertension that antedates pregnancy or is present
before the 20th week of pregnancy or persists after 12
weeks postpartum
Management:
• If the woman was on an antihypertensive medication
before pregnancy and her BP is well-controlled,
continue the same medication if safe in pregnancy
66

67. CHRONIC HYPERTENSION
• If the SBP≥160 mmHg or/and or DBP≥ 110 mmHg
treat with antihypertensive medications.
• If proteinuria or other signs and symptoms of pre-
eclampsia are present, consider superimposed pre-
eclampsia and manage as pre-eclampsia.
• Monitor fetal growth and induce labor at term if there
are no complications,
• If fetal growth restriction is severe and pregnancy
dating is accurate deliver
67

68. Superimposed preeclampsia
• If proteinuria or other features of pre-eclampsia
develop in a patient with chronic hypertension
Classified as
1. Superimposed pre-eclampsia without severe
features.
2. Superimposed pre-eclampsia with severe features
68

69. Atypical preeclampsia
• Defined as the development of preeclampsia (even eclampsia)
without fulfilling the standard definition or criteria:
– Early onset preeclampsia/eclampsia ≤ 20 weeks
– Late postpartum preeclampsia, eclampsia more than 48
hours postpartum
– Women with gestational hypertension or gestational
proteinuria presenting with symptoms of preeclampsia,
ELLP.
• Women with atypical preeclampsia and who have other
diagnostic criteria of severe preeclampsia should be treated as
if they have severe preeclampsia
69

70. 70

71. Algorithm for the Mx of HELLP syndrome.

72. Prevention
Low-Dose Aspirin
• Early successes of 60/81-mg or 50-150mg aspirin
• Reduce the incidence of preeclampsia were attributed
to selective thromboxane suppression with resultant
dominance of endothelial prostacyclin

73. 73
Tried in trials and results have revealed minimal to no
benefit

74. Thank you
74