Gestational
Hypertension
SIM, Ranielle S. | A3-1
HYPERTENSIVE DISORDERS
Complicate 5 to 10% of all
pregnancies
Deadly triad -
hypertension, hemorrhage,
and infection
Most dangerous -
preeclampsia
4 TYPES OF HYPERTENSIVE DISORDERS
1. GESTATIONAL HYPERTENSION
2 . PREECLAMPSIA AND ECLAMPSIA SYNDROME
3 . CHRONIC HYPERTENSION OF ANY ETIOLOGY
4 . PREECLAMPSIA SUPERIMPOSED ON CHRONIC
HYPERTENSION
Importance: this classification gives proper distinction to preeclampsia
syndrome from other hypertensive disorders
DIAGNOSIS OF HYPERTENSIVE
DISORDERS
BP > 140 mmHg (systolic) and 90 mmHg (diastolic)
Previously, incremental increases of 30 mm Hg systolic or 15 mm Hg
diastolic from midpregnancy blood pressure values had also been
used as diagnostic criteria, even when absolute values were
<140/90 mm Hg --> this is no longer recommended
Women who have a rise in pressure of 30 mm Hg systolic or 15 mm
Hg diastolic should be observed more closely as eclamptic
seizures m a y d e v e l o p
"Delta hypetension" - Sudden rise in mean arterial pressure later
in pregnancy
BP ≥ 140/90 mmHg for the first time after mid-
pregnancy and protenuria is NOT identified
Almost half of the women subsequently develop
GESTATIONAL
preeclampsia syndrome
Includes presentations such as headaches or
HYPERTENSION
epigastric pain, proteinuria, and thrombocytopenia.
Dangerous for mother and fetus to ignore
10% of eclamptic seizures develop before overt
proteinuria can be detected
Reclassified by some as transient hypertension if
evidence for preeclampsia does not develop and the
blood pressure returns to normal by 12 weeks postpartum
PREECLAMPSIA Pregnancy-specific syndrome that can affect
SYNDROME virtually every organ system. And, although
preeclampsia is much more than simply
gestational hypertension with proteinuria,
appearance of proteinuria remains an important
diagnostic criterion
PREECLAMPSIA
SYNDROME
PREECLAMPSIA
The more profound the signs and symptoms, the
less chance they are temporized, and more
SYNDROME likely there will be a requirement of delivery
Differentiation between nonsevere and severe
gestational hypertension or preeclampsia can
be misleading because what might be
apparently mild disease may progress rapidly to
severe disease
ECLAMPSIA
PREECLAMPSIA
SYNDROME Convulsions
another cause
that cannot be attributed to
General seizures that may appear before,
during, or after labor
Approximately 10% of women do not develop
seizures until after 48 hours postpartum
PREECLAMPSIA SUPERIMPOSED ON
CHRONIC HYPERTENSION
Chronic underlying hypertension is diagnosed in women with
documented blood pressure 140/90 mm Hg before pregnancy or
before 20 weeks’ gestation, or both
Create problems with diagnosis and management who are
first seen after midpregnancy
During the third trimester, as blood pressures return to their
originally hypertensive levels, it may be difficult to determine
whether hypertension is chronic or induced by pregnancy
PREECLAMPSIA SUPERIMPOSED ON
CHRONIC HYPERTENSION
In some women with chronic hypertension, their blood pressure
increases to obviously abnormal levels, and this is typically after
24 weeks
New-onset or worsening baseline hypertension and is
accompanied by new-onset proteinuria or other findings
Commonly develops earlier in pregnancy
Tends to be more severe and often accompanied by fetal-growth
restriction
ETIOPATHOGENESIS
Preeclampsia
c. Have preexisting conditions
a. Exposed to chorionic villi
of endothelial cell activation
for the 1st time
or inflammation such as
diabetes or renal or
cardiovascular disease
b. Exposed to a
superabundance of chorionic d. Genetically predisposed to
villi, as with twins or hypertension developing during
hydatidiform mole pregnancy
Eclampsia
a. Placental implantation c. Maternal maladaptation to
with abnormal trophoblastic cardiovascular or inflammatory
invasion of uterine vessels changes of normal pregnancy
b. Immunological
maladaptive tolerance d. Genetic factors including
between maternal, paternal inherited predisposing genes
(placental), and fetal tissues and epigenetic influences
PATHOGENESIS
VASOSPASM ENDOTHELIAL CELL INCREASED PRESSOR
Activation of endothelial INJURY RESPONSES
cells result to vascular Damaged or activated Increased vascular reactivity
constriction with increased endothelial cells produce to infused norepinephrine and
resistance and subsequent less nitric oxide and secrete angiotensin II
hypertension substances tht promote
coagulation and increase
sensitivity to vasopressors
PATHOGENESIS
PROSTAGLANDINS NITRIC OXIDE
Endothelial prostacyclin (PGI2) production is Potent vasodilator synthesized from l-
decreased in preeclampsia arginine
Increased sensitivity to infused angiotensin II Inhibition may cause increase in mean
and thus, vasoconstriction arterial pressure, decrease heart rate, and
reverese pregnancy-induced refractoriness
to vasopressors
No universally accepted definition of
this syndrome and incidence varies by
the investigator HELLP
Increased likelihood of SYNDROME
hepatic hematoma and
rupture
Other side effects include
stroke, coagulopathy,
acute respiratory distress
syndrome, and sepsis
PREVENTION
PREECLAMPSIA
SYNDROME
PREVENTION
PREECLAMPSIA
HELLP
SYNDROME
Various strategies used to prevent or modify
preeclampsia
In general,
severity
none of
have
these
been
has been
evaluated.
found to
SYNDROME
be convincingly and reproducibly effective.
1. Dietary and Lifestyle Modifications
a. Low-Salt Diet
b. Calcium supplements
c. Fish Oil supplements
2. Antihypertensive Drugs
Chlorothiazide
PREVENTION
PREECLAMPSIA
HELLP
3. Antioxidants
SYNDROME
Vitamins C, D, and E SYNDROME
4. Statins
5. Antithrombotic agents
6. Low-Dose Aspirin
Oral doses of 50 - 150 mg daily
7. Low-Dose Aspirin + Heparin
MANAGEMENT
Based on severity, gestational age, and presence PREECLAMPSIA
HELLP
SYNDROME
SYNDROME
of preeclampsia. With preeclampsia, management
varies with the severity of endothelial cell injury
and multi-organ dysfunction
Task Force of the American College of
Obstetricians and Gynecologists recommends
more frequent prenatal visits if preeclampsia is
“suspected"
Increases in systolic and diastolic blood pressure
can be either normal physiological changes or
signs of developing pathology
Basic Management Objectives for
Pregnancy Complicated by
Preeclampsia: PREECLAMPSIA
HELLP
SYNDROME
1. Termination of pregnancy
possible trauma to mother and fetus
with least
SYNDROME
2. Birth of infant who subsequently thrives
3. Complete restoration of health to the
mother
One of the most important clinical questions for successful
management is precise knowledge of fetal age
EARLY DIAGNOSIS OF
PREECLAMSIA
Traditionally, frequency of prenatal visits is
increased during the third trimester helps in
the early detection of preeclampsia
Women without overt hypertension, but in
whom early developing preeclampsia is
suspected during routine prenatal visits, are
seen more frequently
Protocol for women with new-onset
diastolic blood pressure is to have return
visits at 7-day intervals
>8
0 mm Hg but <90 mm Hg
Sudden abnormal weight gain of more
than 2 pounds per week
DIURETICS
1
Thiazide diuretics
Sulfonamides → 1st group to
successfully treat chronic
hypertension
Loop-acting diuretics
Furosemide
Commonly used in nonpregnant
hypertensives
Provide sodium and water diuresis with
volume depletion
ADRENERGIC-BLOCKING
AGENTS 2
2nd class of effective
anithypertensives
Peripherally acting adrenergic
receptor blockers
Propranolol, metoprolol,
atenonol
Labetalol - most commonly used
Centrally acting adrenergic receptor
blockers
Clonidine and methyldopa
VASODILATORS
3
Hydralazine
Relaxes arterial smooth muscle and
used parentally to treat severe
peripartum hypertension
Oral hydralazine monotherapy
Used for chronic hypertension (no
longer generally used due to weak
antihypertensive effects and
resultant tachycardia)
Effective adjuct for long-term use with
other antihypertensives
CALCIUM-CHANNEL
BLOCKING AGENTS 4
Divided into 3 subclasses based on
their modificatioin of calcium entrol
into cells and interference with
binding sites on voltage-dependent
calcium channels
Nifedipine (dihydropyridiine),
Verapamil (phenylalkyl amine
derivative)
Negative inotropic effects
Theoretically, may potentiate actions
of magnesium sulfate
ANGIOTENSIN-CONVERTING
ENZYME INHIBITORS 5
Inhibit the conversion of antiotensin-1
to the potent vasocontrictor
angiotensin-II
Can cause severe fetal malfomations
when given in the second and third
trimesters
Ex. hypocalvaria and renal
dysfunctioin
Studies have also suggested that they
have teratogenic effects and thus,
NOT recommended during pregnancy
ANGIOTENSIN-
RECEPTOR BLOCKERS 6
Similar action to ACEIs but instead of
blocking production of angiotensin-II,
they inhibit the binding to its receptor
Presumed to have the same fetal
effects as ACEIs, hence is also
contraindicated during pregnancy
Complicated by generalized tonic-clonic seizures
that increases the risk to both mother and fetus
ECLAMPSIA Major maternal complications include: placental
abruption, neurological deficits, aspiration
pneumonia, pulmonary edema, cardiopulmonary
arrest, and acute renal failure
1% of these women die
MANAGEMENT
Magnesium sulfate is highly effective in preventing convulsions
ECLAMPSIA
in women with preeclampsia and stopping them in women with
eclampsia
1. Control of convulsions using an intravenously administered
loading dose of magnesium sulfate that is followed by a
maintenance dose, usually intravenous, of magnesium sulfate
2. Intermittent administration of antihypertensive medication to
lower blood pressure whenever it is considered dangerously high
3. Avoidance of diuretics unless there is obvious pulmonary edema,
limitation of intravenous fluid administration unless fluid loss is
excess, and avoidance of hyperosmotic agents
4. Delivery of the fetus to acheive a remission of preeclampsia
MAGNESIUM SULFATE TO CONTROL
CONVULSIONS
ECLAMPSIA Administered parenterally
preeclampsia and eclampsia
in severe cases of
Avoids producing central nervous system
depression in either mother or fetus
May be given intravenously by continuous infusion
or intramuscularly by intermittent injection
Given during labor and 24-hrs postpartum
NOT for treatment of hypertension
PHARMACOLOGY AND TOXICOLOGY
Magnesium sulfate USP is
·
ECLAMPSIA
MgSO4 7H2O and not simple
MgSO4.
Contains 8.12 mEq per 1g
Parenterally administered
magnesium is cleared almost
totally by renal excretion,
intoxication is unusual when the
glomerular filtration rate is
normal or only slightly
decreased
THE END.
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