Hypertensive disorders

in pregnancy

Zhangxi,
Department of Gynecology
and Obstetrics , the Third
Affiliated Hospital of Henan
Medical University
.
Hypertensive disorder
.
complicating pregnancy
It can be also called (HDCP)
in short and Pregnancy induced
hypertension syndrome “PIH”
 Ⅰ. Introduction
The characteristics of ≥ 95%
patients are as follows:
1.It is a syndrome peculiar to
pregnant. (the unpregnant woman
will not be affected).
2.It happens only after the 20
week’s of gestation , or the third
trimester.
3.The mainly clinical representation
is three symptoms: hypertension,
proteinuria, edema.
4.In severe cases, there may be
convulsions, coma, and
complication of important organs,
such as the heart failure and the
renal failure.
5.This disease threatens the safety of
both mothers and Infants .

In the city area of China ,It is the

first reason of maternal death . It also
is the second reason for perinatal
birth death.
6. The etiology of PIH has not been made
clear now. But we can conclude that it
must have directly relationship with the
fetus and its attachment. All symptoms
will disappear rapidly after the delivery of
fetus and its attachment.( The attachment of
fetus include placenta 、 umbilical cord 、
amniotic fluid and so on).
 Ⅱ. Etiology

As we know, the cause of PIH

is not clarified yet , but we
actually know something related
to it .
The risk factors are as follows:

① too nervous such as the pati-

ents fear the pain during the de-
livery or fear death of fetus etc .

② the incidence rate will

increase in winter or at time of
seasonal changing.
③ the history of chronic hypertension
and renal disease or diabetes.

④ malnutrition such as body type is

thin very much or anemia or protein
decreased in blood plasma.

⑤ short and fat body type.

⑥ uterine over-distension including
such conditions as twins,
hydramnios, macrosomia and so on.

⑦ have family tendency.

 The theories of etiology.
A lot of researches about PIH

have been done but several

theories have been concluded by

people.
1 、 The theory of uterine and
placental ischemia. such as twins
and macrosomia 、 hydramnios.

2 、 The theory of
neuroendocrinology. such as
increased sensitivity to renin-
angiotonin or disproportion of
prostagelandins synthesis etc.
 3 、 The theory of immunology.
Such as ABO and Rh antigen,
The changes of HLA (human
leucocyte antigen) on the placenta.
4. Placenta shallow invasion;
Vascular Endothelial damage;
Genetic factor;
Alimentary deficiency;
Insulin resistance and so on.
 5 、 The research of the
relationship
between plasma endothelin
and calcium and PIH is developing
now.
 But no final conclusion has
yet been reached now, so we’ll
not introduce the theories
above one by one in detail.
Ⅲ. Pathologic
changes
 The basic pathologic change
of PIH is the widespread arteriolar
spasm.
1. the widespread arteriolar
spasm leads to the basic
symptoms: hypertension .
proteinuria and edema .
The widespread arteriolar spasm
↓ ↓ ↓
the increased the ischemia peripheral
aldosterone and hypoxia resistance
of renal increased
↓ ↙
the reabsorption
of sodium increase
in proximal end
of renal tubules
↓
edema proteinuria hypertension
2. The spasm of small artery all over
the body
also leads to the ischemia and
hypoxia of every organ and
tissue,
then leads to the complications
of important organs such as :
brain, heart, renal ,liver, placenta
and so on .
 Finally, it can be expressed as
convulsion, coma, cerebral
hemorrhage and failure of
heart or renal etc.
 Spasm of coronary artery
of HDCP(PIH)

Normal heart

Heart ischemia and infarction

Renal flow↓ → glomerular filtration rate ↓
→glomerule swelling→glomerule infarction
 Local hemorrhage of portal vein, infarction
of hepatic cells, hematoma under liver mem-
brane
 optical fundus examination

Normal fundus Fundus bleeding Fundus edema

Artery flow of uterine and placental↓→
placental function↓→ IUGR, placental abruption
Ⅳ. Classification
and clinical
findings
Ⅰ)[Gestational hypertension]

1 、 BP≥140/90 mmHg for first time

during pregnancy ;
( millimeter mercury column)

2 、 No proteinuria ;
3 、 BP return to normal ＜ 12 weeks’
postpartum;
4 、 Final diagnosis made only
postpartum ;
5 、 May have other signs of
preeclampsia , for example ,
epigastric discomfort or
thrombocytopenia .
Ⅱ) [Preeclampsia]

[Minimum criteria] :
1 、 BP≥140/90 mmHg after 20 weeks'
gestation;
2 、 Proteinuria≥300 mg/24 hours or
≥(+) ;
[Increased certainty
of preeclampsia : ]

1 、 BP≥160/110 mmHg ;

2 、 Proteinuria≥2.0 g/24 hours or

≥(++) ;
3 、 Serum creatinine ﹥ 1.2 mg/dL
unless known to be previously
elevated ;
4 、 Platelets ﹤
100,000/mm3

(the third power of millimeter)

5 、 Microangiopathic hemolysis
(increased LDH) ;

6 、 Elevated ALT or AST ;

7 、 Persistent headache or other

cerebral or visual
disturbance ;
 Seizures
[si 了 ə] that cannot be attributed to
other causes in a woman with
preeclampsia .
Ⅳ) [Superimposed preeclampsia]
(on chronic hypertension)

1 、 New-onset proteinuria≥300 mg/24 hours

in hypertensive women but no

proteinuria before 20 weeks'
gestation ;
2 、 A sudden increase in proteinuria
or blood pressure or platelet count
﹤ 100,000/mm3 in women with
hypertension and proteinuria before 20
weeks' gestation .
(the third power of millimeter)
Ⅴ) [Chronic Hypertension]

1 、 BP≥140/90 mmHg before pregnancy

or diagnosed before 20 weeks' gestation
；
OR

2 、 Hypertension first diagnosed after 20

weeks' gestation and persistent after 12
weeks' postpartum .
 PIH: Indications of Severity
Abnormality Mild Severe
Diastolic blood pressure ﹤100 mmHg 110 mmHg or higher
Proteinuria Trace ～（ + ） Persistent(++) or more
Headache Absent Present
Visual disturbances Absent Present
Upper abdominal pain Absent Present
Oliguria Absent Present
Convulsion Absent Present (eclampsia)
Serum creatinine Normal Elevated
Thrombocytopenia Absent Present
Liver enzyme elevation Minimal Marked
Fetal growth restriction Absent Obvious
Pulmonary edema Absent Present
Ⅴ. Diagnosis
1. History
The most patients are as
follows:

1) Without history of
hypertension before pregnancy
(unless chronic hypertensive).
2) Happens after the 20 week’s
of gestation.
2.The main clinical
Feature
Hypertension
Proteinuria
Edema
Subjective Symptoms
Convulsions and coma
Complications
 [ Edema: ]

①latent edema: weight gain one

week: >0.5kg/w.
②Apparent edema:

“+” : the edema of foot and leg which

will not disappear after bed rest.
“++”: the edema extends to thigh.
“+++”: the edema extends to
abdomen and vulva.
“++++” : the edema extends to the
whole body and sometimes
with ascitic fluid.
3. Accessory examination

(1).Blood examination
(2).routine urine examination
(3).optical fundus examination.
A/V Normal:2:3
Preeclampsia 1:2 or 1:4;
(4).Electrocardiogram(ECG)
Ⅵ . The
complication of
important organs
and its affection of
mother and infant.
1.cerebrovascular accident:
Cerebral hemorrhage, cerebral
infarction.
2.heart failure

3.renal failure.
4.placental dysfunction

①Intrauterine Growth
Retardation(IUGR)
②Intrauterine fetal distress.
③Fetal death
④Dead birth.
⑤Neonatal death.
5. Placenta abruption
6. Dysfunction of blood
coagulation
( DIC:dispread intervenous
coagulation)
7. Postpartum circulatory failure:
Abuse of large amount of
antispasmodic.
 All the complications above may
lead to the death of mothers and
infants when it is severe.
Ⅶ . Treatment
Mild PIH patient

1. Bed rest throughout much

of
the day;

2. Diet : with ample protein

and
vitamin;
(without sodium
restriction
except the cases of
severe
3. Lie on the left side at rest and
sleep:

it could increase the blood

perfusion of placenta and uterus.
Because lie on the face upward,
the uterus presses artery.
4. Tranqulizer:
to assure the rest or sleep
For example:
Luminal 0.03-0.06g tid po
Diazepam 2.5mg tid po

(take a medicine three times a day)

[ take orally]
 Severe PIH patient

⑴The principia of
treatment

① The patient should be

hospitalized
② Antispasmodic
③ Antihypertensive drug
when
necessary
④ Tranquilizer
⑤ Hydration when
necessary
⑥ Diuresis when necessary
⑦ Terminate the pregnancy
in a
proper time
⑵The method of treatment

① Antispasmodic
The first step is to relieve the
widespread arteriolar spasm,
because it is the basic
pathological changes in PIH.
A. Drugs: The most common
used
agent is magnesium sulfate
B. Dosage schedule (directions)
ⅰ.Intramuscular injection (IM)
(25% Mgso4 20ml +1~2ml of
1% procaine ) IM—deeply in
the outer quadrant of both
buttocks Q6h .
ⅱ.Intravenous therapy

First step (25% Mgso4 10ml

+10% G.S 10ml), at a rate in ≥ 5
mins .
Then 25% Mgso4 60ml +5% G.S
1000ml iv drip, at a rate of 1g ／ h
At night before sleep :25% Mgso4
10ml +1% procaine 2ml), IM
Next day no need of the load
dosage

(GDW=glucose dextran
C. Toxic action
ⅰ). Patellar reflex is not
present;

ⅱ). Respiration depress;

ⅲ). Inhibition of heart beat

could cause to death.
D. Points for attention
The following is necessary for
use
of Mgso4 :

ⅰ). Patellar reflex is present;

ⅱ). Respiration frequency ≥16
per
minute;
ⅲ). Urine flow ≥ 25ml per hour.
ⅳ). Preparation of antidote –
calcium agent

10% calcium gluconate 20ml IV

immediately when the toxic
action is found.
② Anti-hypertension

A . Anti-hypertension therapy is
necessary
When the diastolic is higher than
110 mmHg(14.7kpa) or the mABP is
higher than 140mmHg.
mABP: the mean arterial blood
pressure=diastolic +1∕3(sistolic-
(minus) diastolic)
B. Hypotensor
.

ⅰ). Hydralazine:
10-20mg bid-tid po , take
orally,
Or 40mg+5%GS 500ml iv
drip
in severe cases, to
maintain the
diastolic in 90~100mmHg
(take a medicine twice a day)
ⅱ). Nifepine:
10mg tid po
ⅰ). Diazepam :
5mg tid po , take orally

ⅱ). Lytic-cocktail :

Full dosage: Dolantine

100mg
Phenergan
50mg
Wintermin
50mg
④ volume expanding
therapy

ⅰ).The indication :
hemoconcentration,
HCT ＞ 35%(hematocrit )

ⅱ). The contraindication

 heart failure
renal failure
edema of the whole body
pulmonary edema
⑤diuresis:

A .Indications:
ⅰ). edema of the whole body or
anasarca
ⅱ). pulmonary edema
ⅲ). Cerebral edema
ⅳ). heart failure
B . Drugs :
ⅰ). Furosemide :

20-40mg IV
ⅱ). mannital:

20% mannital 250ml IV

drip rapidly in 15-20 min.
Notice that the patient
with heart failure or pulmonary
edema can not use it.
⑥Termination of pregnancy
at
proper time
A.Preeclampsia patient has
not
been controled after
treated
actively 24-48 hours.
B.When the pregnancy ≥34 weeks
or the patient is in severe
conditions .
C.Eclampsia patient has achieved a
stable state more than 2 hours.
The method of delivery:

ⅰ). Adopting cesarean section when

necessary
ⅱ). Vaginal delivery:
the step to shorten the second
stage
of labor should be used (use the
lateral
episiotomy, vacuum extractor or
forceps delivery)
ⅲ). Notice the prevention of
postpartum
hemorrhage and infection
Cesarean section
⑦ The treatment of
eclampsia

ⅰ). Control convulsion

Magnesium sulfate given by IV
or IV
drip;
Use other anticonvulsant agents
if
necessary;
Add antihypertensive agents in
condition of hypertension;
ⅱ). Prevent injury
ⅲ). Reduce stimulation to
minimize
occurrence of convulsion
ⅳ).Supervise carefully
BP .pulse
.respiration.temperature and urine
volume must be watched carefully.

Perform ophthalmic ground

examination 、 hemotological
examination and ECG.
Treat pulmonary edema acute
renal failure and placenta
abruption.
ⅴ).Termination of
pregnancy:
2 h after
convulsions under control.
⑧ Prevention:

Enforce the perinatal health

care, make the prepartum test
regularly.
The early symptoms be
discovered in time and make
treatment as soon as possible.
So prevent the severe disease
developing.