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OB24 Obstetrics
Ominous Symptoms of HTN in Pregnancy
RUQ pain, headache, and visual disturbances
Hypertensive Disorders of Pregnancy Toronto Notes 2019 Hypertensive Disorders of Pregnancy
Hypertension in Pregnancy
• hypertensivedisordersofpregnancyareclassifiedaseitherpre-existingorgestationalHTN.Pre- eclampsia and eclampsia are included in the spectrum of hypertensive disorders of pregnancy
PRE-EXISTING HYPERTENSION
Definition
• BP≥140/90priorto20wkGA,persisting>7wkpostpartum;BPshouldbeelevatedon≥2occasions≥6hapart • essentialHTNisassociatedwithanincreasedriskofgestationalHTN,abruptioplacentae,IUGR,and
IUFD
GESTATIONAL HTN
Definition
• sBP≥140ordBP≥90after20wkGAwithoutproteinuriainawomanknowntobenormotensive before pregnancy
PREECLAMPSIA
Definition
• pre-existingorgestationalHTNwithnewonsetproteinuriaoradverseconditions(endorgan
dysfunction)
ECLAMPSIA
Definition
• theoccurrenceof≥1generalizedconvulsionsand/orcomainthesettingofpreeclampsiaandinthe
absence of other neurologic conditions
Epidemiology of eclampsia
• aneclampticseizureoccursinapproximately0.5%ofmildlypreeclampticwomenand2-3%ofseverely preeclamptic women
Clinical Manifestation of Eclampsia
• eclampsiaisaclinicaldiagnosis
• typicallytonic-clonicandlasting60-75s
• symptomsthatmayoccurbeforetheseizureincludepersistentfrontaloroccipitalheadache,blurred
vision, photophobia, right upper quadrant or epigastric pain, and altered mental status
• inuptoonethirdofcases,thereisnoproteinuriaorbloodpressure>140/90mmHgpriortotheseizure • ingeneral,womenwithtypicaleclampticseizureswhodonothavefocalneurologicdeficitsor
prolonged coma do not require diagnostic evaluation including imaging
Risk Factors of Hypertensive Disorders in Pregnancy
• maternalfactors
■ primigravida (80-90% of gestational HTN), first conception with a new partner, PMHx or FHx of
gestational HTN or preeclampsia/eclampsia
■ DM, chronic HTN, or renal insufficiency
■ obesity
■ antiphospholipid syndrome or inherited thrombophilia ■ extremes of maternal age (<18 or >35 yr)
■ previous stillbirth or IUFD
■ vascular or connective tissue disease
• fetalfactors
■ IUGR or oligohydramnios
■ GTN
■ multiple gestation
■ etal hydrops “mirror syndrome” ■ abruptio placentae
Clinical Evaluation of Hypertensive Disorders in Pregnancy
• ingeneral,clinicalevaluationshouldincludethemotherandfetus • evaluationofmother
■ body weight
■ central nervous system
• presenceandseverityofheadache
Note
Eclampsia prior to 20 wk of gestation is rare and should raise the possibility of an underlying molar pregnancy or antiphospholipid syndrome
Hypertension in Pregnancy
Adverse Maternal Conditions
• sBP >160 mmHg
• dBP >100 mmHg
• HELLP
• Cerebral hemorrhage
• Renal dysfunction: oliguria <500 mL/d • Left ventricular failure, pulmonary edema • Placental abruption, DIC
• Symptoms
• Abdominal pain, N/V
• Headaches, visual problems • SOB, chest pain
• Eclampsia: convulsions
Adverse Fetal Conditions
• IUGR
• Oligohydramnios
• Absent/reversed umbilical artery end
diastolic flow
• Can result in:
• Fetal disability and/or death