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Hypertension
Sustained BP elevation of 140/90 or greater
PIH Gestasional
Preeclampsia Severe
Chronic HELLP
Mild Synd
Effect
Impending
eclampsia
Eclampsia
20 Proteinuria (-)
Proteinuria (+)
Gestational Hypertension
Preeclampsia
Eclampsia
HELLP Syndrome
Hypertensive Disease Associated with
Pregnancy
Chronic Hypertension
Diagnosed before the 20th week or present before the
pregnancy
Mild hypertension
> 140-180 mmHg systolic
> 90-100 mmHg diastolic
Gestational Hypertension
Preeclampsia
Eclampsia
HELLP Syndrome
Hypertensive Disease Associated with
Pregnancy
Chronic Hypertension
Gestational Hypertension
Criteria
Develops after 20 weeks of gestation
Proteinuria is absent
Blood pressures return to normal postpartum
Morbidity is directly related to the degree of hypertension
Preeclampsia
Eclampsia
HELLP Syndrome
Overlap/Disease Progression
Patient with Hypertension
Gestational Hypertension
Preeclampsia
Criteria
Develops after 20 weeks
Blood pressure elevated on two occasions at least 6 hours
apart
Associated with proteinuria and edema
May occur less than 20 weeks with gestational
trophoblastic neoplasia
Eclampsia
HELLP Syndrome
Preeclampsia vs. Severe Preeclampsia
Criteria for Preeclampsia
Previously normotensive
woman
Nondependent edema
Criteria for Severe Preclampsia
BP > 160 systolic or >110 diastolic
Thrombocytopenia
Chronic hypertension
Pregestational diabetes
Hypertensive Disease Associated with
Pregnancy
Chronic Hypertension
Gestational Hypertension
Preeclampsia
Eclampsia
Diagnosis of preeclampsia
Presence of convulsions not explained by a neurologic
disorder
Grand mal seizure activity
Occurs in 0.5 to 4% or patients with preeclampsia
HELLP Syndrome
Hypertensive Disease Associated with
Pregnancy
Chronic Hypertension
Gestational Hypertension
Preeclampsia
Eclampsia
HELLP Syndrome
◦ A distinct clinical entity with:
Hemolysis, Elevated Liver enzymes, Low Platelets
◦ Occurs in 4 to 12 % of patients with severe preeclampsia
Microangiopathic hemolysis
Thrombocytopenia
Hepatocellular dysfunction
Morbidity and Mortality from
Hypertensive Disease
Hypertension affects 12 to 22% of pregnant patients
Uterine vessels
Hemostasis
Prostanoid balance
Endothelium-derived factors
Uterine vessels
Hemostasis
Prostanoid balance
Endothelium-derived factors
Uterine vessels
◦ Inadequate maternal vascular response to trophoblastic
mediated vascular changes
◦ Endothelial damage
Hemostasis
Prostanoid balance
Endothelium-derived factors
Uterine vessels
Hemostasis
Increase platelet activation resulting in consumption
Increased endothelial fibronectin levels
Decreased antithrombin III and α2-antiplasmin levels
Allows for microthrombi development with resultant
increase in endothelial damage
Prostanoid balance
Endothelium-derived factors
Uterine vessels
Hemostasis
Prostanoid balance
◦ Prostacyclin (PGI2):Thromboxane (TXA2) balance shifted to
favor TXA2
◦ TXA2 promotes:
Vasoconstriction
Platelet aggregation
Endothelium-derived factors
Uterine vessels
Hemostasis
Prostanoid balance
Endothelium-derived factors
◦ Nitric oxide is decreased in patients with preeclampsia
As this is a vasodilator, this may result in vasoconstriction
Uterine vessels
Hemostasis
Prostanoid balance
Endothelium-derived factors
Hematologic effects
Neurologic effects
Pulmonary effects
Renal effects
Fetal effects
Pathophysiologic Changes
Cardiovascular effects
◦ Hypertension
◦ Increased cardiac output
◦ Increased systemic vascular resistance
Hematologic effects
Neurologic effects
Pulmonary effects
Renal effects
Fetal effects
Pathophysiologic Changes
Cardiovascular effects
Hematologic effects
◦ Volume contraction/Hypovolemia
◦ Elevated hematocrit
◦ Thrombocytopeniz
◦ Microangiopathic hemolytic anemia
◦ Third spacing of fluid
◦ Low oncotic pressure
Neurologic effects
Pulmonary effects
Renal effects
Fetal effects
Pathophysiologic Changes
Cardiovascular effects
Hematologic effects
Neurologic effects
◦ Hyperreflexia
◦ Headache
◦ Cerebral edema
◦ Seizures
Pulmonary effects
Renal effects
Fetal effects
Pathophysiologic Changes
Cardiovascular effects
Hematologic effects
Neurologic effects
Pulmonary effects
◦ Capillary leak
◦ Reduced colloid osmotic pressure
◦ Pulmonary edema
Renal effects
Fetal effects
Pathophysiologic Changes
Cardiovascular effects
Hematologic effects
Neurologic effects
Pulmonary effects
Renal effects
◦ Decreased glomerular filtration rate
◦ Glomerular endotheliosis
◦ Proteinuria
◦ Oliguria
◦ Acute tubular necrosis
Fetal effects
Renal Effects
Decreased glomerular filtration rate
Glomerular endotheliosis
Proteinuria
Oliguria
Hematologic effects
Neurologic effects
Pulmonary effects
Renal effects
Fetal effects
◦ Placental abruption
◦ Fetal growth restriction
◦ Oligohydramnios
◦ Fetal distress
◦ Increased perinatal morbidity and mortality
Management
The ultimate cure is delivery
Assess cervix
Fetal well-being
Laboratory assessment
Conservative management
Serial labs
Favorable cervix
Unfavorable Cervix
No contraindication to prostaglandin agents
IV access
IV hydration
Labetalol
Nifedipine
Nitroprusside
Diazoxide
Clonidine
Hydralazine
Dose: 5-10 mg every 20 minutes
4-6 g bolus
1-2 g/hour
Altered sensorium
Protect patient
IV access
Fetal well-being
Effect delivery
Oliguria
Persistent hypertension
DIC
Pulmonary Edema
Fluid overload
Restrict fluids
Lasix 10-20 mg IV
LP-low platelets
HELLP Syndrome
Is a variant of severe preeclampsia
LFT’s - 2 x normal
Steroids