Hypertensive Disease in Pregnancy: A. Kurdi Syamsuri
Hypertensive Disease in Pregnancy: A. Kurdi Syamsuri
DISEASE IN
PREGNANCY
A. Kurdi Syamsuri
INTRODUCTION
MMR : Indonesia 357/100000, Malaysia/Vitnam
160/100000, Singapore 6/100000.
Hypertensive disorders complicate 5-10%
pregnancies
Contributes greatly to maternal morbidity and
mortality—along with hemorrhage and
infection
Cause of MMR : Hemorrhage : 28%, Eclampsia :
24 %, Infection : 11%
HYPERTENSIVE DISEASE IN PREGNANCY
Hypertensive Disease
BP ≥ 140/90 mmHg
Risk Factors
• Renal disease
• Collagen vascular disease
• APS
• Hyperaldostreronisem,
pheochromocytoma
Management
similar with preeclampsia
Gestational Hypertension
Definition
GHTN : BP ≥ 140/90 after 20 weeks, without
proteinuria, other signs or symptoms of pre-
eclampsia, or a prior history of HTN. Severe
GHTN is defined similarly except that the
cutoffs are ≥ 160/110 mmHg.
Incidence : about 6% to 17% healthy nuliparous
women.
Cont
Preeclampsia
Proteinuria Multi organ
BP ≥ 140/90
mmHg involvement
Genetic factors
ABNORMAL
TROPHOBLASTIC INVASION
Normal Implantation Preeclampsia
- Extensive remodeling of - Incomplete trophoblastic
spiral arterioles within invasion
decidua basalis - Decidual vessels become lined
- Endovascular trophoblasts with endovascular
replace vascular endothelial trophoblasts
and muscular linings - Deeper myometrial arterioles
enlarge vessel diameter do not lose endothelial lining
and musculoelastic tissue
- Mean external diameter ½ of
normal placenta vessels
SPOT THE DIFFERENCES!
Vessel
diameter
larger
Vessel
diameter
smaller
Endothelial
Endothelial lining (+)
lining (-)
IMMUNOLOGICAL
MALADAPTIVE TOLERANCE
Loss of maternal immune tolerance to paternally-
derived placental and fetal antigens
“Immunization” from previous pregnancy with the
same partner decreased risk of preeclampsia
First pregnancy, molar pregnancies, women with
trisomy-13 fetus higher risk of preeclampsia
OTHER FACTORS
Nutritional factors
• Diet high of antioxidant
decreased blood pressure
Genetic factors
• Result of interaction of
hundreds of inherited genes
PATHOPHYSIOLOGY
PREVENTION
• Low salt diet
• Calcium
supplementation
• Fish oil
• Exercise
Dietary & Anti
lifestyle hypertensive Anti oxidants
modification drug
• Aspirin 50-150
mg/day
• Heparin
Anti
thrombotic
agents
MANAGEMENT GOALS
Termination of
pregnancy with
minimal trauma
Complete
Birth of
restoration
infant who
of maternal
thrives
health
Severe Preeclampsia
Delivery of fetus
OR NOT?
- > 37 wks, OR
- > 34 wks with:
- In labor or PROM Terminate
Yes
- Maternal or fetal distress pregnancy
- IUGR
- Placental abruption
No Yes
- < 37 wks
- > 37 wks
- Outpatient
- Maternal or fetal distress
- Maternal and fetal evaluation
- In labor or PROM
2x/wk
EXPECTANT
Severe preeclampsia
MANAGEMENT
- Evaluation in delivery room for 24-
48 hrs
Non severe preeclampsia - Corticosteroid for lung maturation,
prophylaxis MgSO4, anti HT
- Ultrasound, BPP, lab examination
- Expectant management
- Outpatient
- Close evaluation: Contraindication for expectant
- 2x/wk Blood pressure, management:
ultrasound Yes:
- Eclampsia - Fetal distress
- 1x/wk thrombocyte, - Lung edema - Abruptio placenta
Deliver after
liver function - DIC - IUFD stabilization
- Uncontrolled HT - Unviable fetus
Expectant management
- Available ICU & NICU
- Viable fetus Yes:
Complications:
- Hospitalization - Corticosteroid
- Stop MgSO4 in 24 hrs - Persistent symptoms - HELLP
for lung
- Evaluate mom & baby every day - Severe renal dysfunction - In labor
maturation
- Reversed end diastolic flow - PROM
- Deliver after
- Severe oligohydramnios - IUGR
48 hrs
- > 34 wks
- In labor or PROM
Yes:
- Maternal/fetal distress
- > 1 contraindication for expectant Terminate pregnancy
management
MANAGEMENT
Clinical management algorithm
for suspected severe
preeclampsia at <34 weeks
Note:
HELLP = Hemolysis, elevated liver
enzyme levels, low platelet count
L&D = Labor & delivery
UOP = Urine output
MANAGEMENT
Indications for delivery in women <34 weeks’ gestation managed
expectantly