Hypertensive Disorder in Pregnancy

dr. Valleria, SpOG

Hypertensive Disorder in Pregnancy

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2. 3. 4. 5.

Gestational hypertension ( Hipertensi dalam Kehamilan ) Preeclampsia Eclampsia Superimposed Preeclampsia Chronic Hypertension

Hypertensive Disorder in Pregnancy

One of the deadly triad (hemorrhage, infection) 3,7 % of all pregnancy

Gestasional hypertension
BP > 140/90 mmHg for first time during pregnancy No proteinuria BP return to normal < 12 weeks post partum May have other signs for preeclampsia (epigastric discomfort, thrombpcytopenia)

Preeclampsia

Mild : BP > 140/90 mmHg after 20 weeks gestation Proteinuria > 300 mg/24 hours or > 1+ dipstick

Preeclampsia

Severe
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BP > 160/110 mm Hg Proteinuria 2 g/24 hours or > 2+ dipstick Serum Creatinin > 1,2 mg/dL Platelets < 100.000/mm3 Increase LDH Elevated AST/ALT Persistent headache or other cerebral or visual disturbance Persistent epigastric pain

Eclampsia
Seizures that cannot be attributed to other causes in women with preeclampsia Coma

Superimposed preeclampsia
New onset proteinuria > 300mg/24 hours in hypertensive women but no proteinuria before 20 weeks gestasion Sign and symptoms severe preeclampsia

Chronic Hypertension

BP > 140 mmHg before pregnancy or diagnosed before 20 weeks gestation

Risk Factor Preeclampsia

Nulliparous Multiple pregnancy History of chronic hypertension Maternal age over 35 years Obesity

Patophyisiology Preeclampsia
Maternal vascular desease Faulty placentation Excessive trophoblast

Reduced uteroplacental perfusion

Endothelial activation

Endothelial activation Vasospasme -Hypertension -Seizure -Oliguria -Abruption -Liver ischemia

Capillary leak

Activation of coagulation

Thrombocytopenia Edema Proteinuria Hemoconcentration

Mild Preeclampsia
> 37 weeks gestasion : induction of labour < 37 weeks gestasion :

No medication No diuretik Limitation activity ANC 2x/weeks : Blood Pressure, proteinuria, refleks, fetal surveillance

Management
1.

Delivery is the cure for preeclampsia > 35 weeks gestation : induction of labor < 35 weeks gestation, no complication: expectant ( the hope that few more weeks in utero will reduce the risk of neonatal mortality and morbidity )
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Anti hypertension Lung maturation : dexametason 12 mg/day, 2 days Observation : Blood pressure, symptom impanding eclampsia, lab., fetal surveillance any disturbance termination

Management
2. Anti hypertensive Drug -blocking agent : labetolol Calcium channel blocker : nifedipine ACE inhibitor (Angiotensin-converting-enzyme): should be avoided : oligohidramnios, IUGR, limb contractur, Persistent PDA, pulmonary hypoplasia, etc Methyldopa : delayed onset (long-acting)

Management
3. Preventive and control convulsion - MgSO4 : control convulsion without central nervous system depression - i.v : 4-6 g loading dose diluted in 100 ml of iv fluid 15-20 min, maintenance 1-2 g/ hour in 100 ml - i.m : 4 g loading dose, 5 g i.m in both buttock / 4 hour

Management

Before giving MgSO4 :

1. 2. 3.

The patellar refleks is present Respiration are not depressed ( RR>16/min) Urin output > 100ml/4 hour

MgSo4 is discontinued 24 h after delivery MgSO4 toxicity : respiratory depression, paralysis, and arrest Antidotum MgSO4 : calcium gluconate

Complication
1.

Eclampsia Generalized tonic-clonic seizures Coma without convulsion Antepartum, intrapartum, postpartum Cerebral edema ICU

Complication
2. HELLP Syndrome
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Hemolysis : fragmented erythrocyte, bilirubun > 1,2 ml/dL Elevated Lever enzymes : SGOT > 72 IU/L, LDH > 600IU/L Low Platelet count : < 100.000/mm3 DIC Tx : dexamethason 2 x 10 mg, then 2 x 5 mg

Complication
3. Pulmonary edema
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Tachypneu/dyspnea Respiratory distress Severe hypoxemia Diffuse rales in both lung ICU, ventilator Furosemid

Complication
4. Acut Renal Failure 5. Hepatic rupture 6. Abruptio placentae 7. Cerebral hemorrhage 8. Visual disturbances

Prevention
Low dose aspirin ? Calcium? Anti oxidant?