1. Hypertansive disorders in pregnancy
Zehra Eren,M.D.

2. LEARNING OBJECTIVES
recall hemodynamic and biochemical changes in normal pregnancy
describe preeclampsia-eclampsia
describe chronic (preexiting ) hypertension
describe preeclampsia-eclampsia superimposed upon chronic hypertension
describe gestational hypertension
explain HEELP Syndrome
manage hypertensive disorders during pregnancy

3. Hemodynamic and biochemical changes in normal pregnancy

4. Cardiovascular and Renal Physiology
Blood Presure (BP) Regulation:
BP fall shortly after conception and return to normal at term
- peripheral vasodilatation and resistance to angiotensin II (prostacyclin and prolactin levels↑)
-Nitric oxide synthesis ↑
Renin-angiotensin-aldosterone system(RAAS) is stimulated, aldosterone is critical in maintaining sodium balance

5. Volume Regulation Circulating blood volume ↑ 50%
Red blood cell mass ↑20-30%
Cumulative sodium retention ( mEq)
→ extrasellular fluid volume ↑
→ weight gain
→ ‘’benign ‘’ edema of lower extremities

6. Renal Hemodynamics GFR: second trimester ↑ 50% last trimester ↑20%
return to prepartum levels within 3 monts
Normal plasma creatinine fall to 0.5 mg/dl
>0.8 mg/dl shoud be considered abnormal
Renal blood flow ↑85%
↑ cardiac output (30-40%max)
↑ renal vasodilatation (afferent and efferent)

7. Hypertensive disorders
Systolic BP >140 mm Hg /125mmHg
Diastolic BP >90 mm Hg /75mmHg
Most common (10% of pregnancies)
↑maternal and fetal mortality and morbidity
Leading to premature birth

9. Causes of Hypertansion in pregnancy

10. Chronic Hypertention
HT present before pregnancy or diagnosed before twentieth week of gestation
May include HT diagnosed during pregnancy that does not resolve after delivery
May be associated with nephrosclerosis with minimal proteinuria
İncreased risk of preeclampsia, abruptio placentae, intrauterin growth retardation and second trimester fetal death

11. Treatment

12. Treatment
İn stage 1 and 2 HT, may require less or even antihypertansives if BP is controlled
Methyldopa is preferred agent for treatment
İn women who enter pregnancy with well- controlled BP, same regimen can be continued
ACE and ARBs are contraindicated

13. Gestational Hypertantion
Essentials of Diagnosis
Maternal blood pressure elevation of ≥140 mm Hg systolic or ≥90 mm Hg diastolic on 2 occasions 6 hours apart in a previously normotensive woman ≥20 weeks' gestation
No evidence of proteinuria
Resolved after delivery ( women are at risk for chronic HT)
Risk factors: multiparity, obesity, positive family history

14. Preeclampsia-Eclampsia
Systemic syndrome unique to pregnancy
Essentials of Diagnosis
Maternal blood pressure elevation of ≥140 mm Hg systolic or ≥90 mm Hg diastolic on 2 occasions 6 hours apart
Proteinuria ≥300 mg in a 24-hour urine specimen
Resolving with delivery
Eclapsia: occurrence of sezures

15. Preeclampsia-Eclampsia
Hypertension in pregnancy: Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122:1122

16. Pathogenesis of preeclampsia

17. Risk factors

18. Risk factors

19. Renal abnormalities in preeclampsia

20. Renal Abnormalities Renal blood flow and GFR fall
Decreased urate clearence and increased calcium reabsorption→hyperuricemia and hypocalciuria
GFR can decrease by 30-40%→creatinine levels increased ( mg/dL)
Hyperuricemia may correlate with clinical severity of preeclampsia (>4.5mg/dL)

21. Clinical features
Usually begins after the thirty-second week and may seen postpartum within h after delivery
Usually resolves within 10 days after delivery
Diastolic HT is prominent, with SP<160mmHg
SBP>200mmHg suggest preeclampsia superimposed on chronic HT
When HT and proteinuria occur before 20 w, etiologies other than preeclampsia should be sought

23. Clinical features
Pulmonary edema can occur due to changes in pulmonary capillary permeability
Hyperreflexia secondary to central nervous system excitability reflects of neurologic involvement

24. Classification of Preeclampsia

26. Severe preeclampsia 2013 criteria do not include
-proteinuria >5 grams/24 hours and
-fetal growth restriction as features of severe disease
Hypertension in pregnancy: Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122:1122

27. HEELP Syndrome
HEmolysis
Elevated Liver Function Tests
Low Platelets

28. HEELP Syndrome
Commonly associated with severe HT and variable degrees of renal failure
May be associated with
-pulmonary edema
-ascites
-acute renal failure
-disseminated intravascular coagulation

30. Treatment of Preeclampsia
Prophylactic low-doze aspirin or calcium→ no evidence of significant reduction or improved outcomes
Bed rest→ therapy of choice for mild disease (BP<140/90 mmHg, proteinuria<500mg/24h, normal renal fonction,urate levels<4.5mg, normal PLT, and no evidence of hemolysis or hepatic dysfunction)
Optimal levels has not be defined

31. Treatment of Preeclampsia 2

32. Preeclampsia superimposed upon chronic hypertension
Difficult to distinguish from worsening hypertansion
Suspect in women with HT before 20 week of gestation who developt proteinuria or sudden increase in BP
More likely to occur in older patients
Hyperuricemia, proteiuria, or rise in serum creatinine suggests preeclampsia
Risk in women with some form of renal disease is between 20-40%

33. Acute Renal Failure in Pregnancy
Early pregnancy
1.Prerenal azotemia→ hyperemesis, hemorrage of spontaneus abortion
2. Acute tubular necrosis→ volume depletion secondary to hyperemesis, hemorrage of spontaneus abortion, septic abortus, Gram- negative sepsis, myoglobulinuria secondary to Clostridium induced myonecrosis of uterus
3.Renal cortical necrosis

34. Renal Cortical Necrosis
Frequently seen in older women, multigravidas, multipl gestations
Causes: abruptio placentae, septic abortion, severe preeclampsia, amniotic fluid embolism, retained fetus
Presents with gross hematuria, flank pain, severe oliguria or anuria
Renal functional recovery requires monts and is incomplete, may lead to ESRD

35. Acute Renal Failure in Pregnancy
Late pregnancy
1. Acute tubular necrosis→ preeclampsia, HEELP syndrome, bleeding in abruptio placentae
2. Acute fatty liver of pregnancy→ present after 34 week with jaundice and abdminal pain; associated with ARF

36. Acute Renal Failure in Pregnancy
3.Postpartum acute renal failure and thrombotic thrombocytopenic purpura- hemolytic uremic syndrome
-presents with severe HT, microangiopathic hemolytic anemia, thrombocytopenia and ARF days to weeks after normal pregnancy
-patients can have severe deficiency of ADAMSTS-13 activity

37. Acute Renal Failure in Pregnancy
3.Postpartum acute renal failure and thrombotic thrombocytopenic purpura- hemolytic uremic syndrome
-Retained placental fragments may play a role
-major clinical issue is to differantiate from preeclampsia and HEELP syndrome
-Treatment: plasma exchange or plasmapheresis

39. What Did We Learn?
- Cardiovascular and renal hemodynamic changes in normal pregnancy
Preaclampsia-eclampsia
Chronic hypertension
Preeclampsia-eclampsia superimposed chronic hypertension
Gestational hypertension
Maternal evaluation
Indication for treatment of hypertensive disorders
Acute therapy
Long-term oral therapy