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HYPERTENSIVE DISORDERS DURING PREGNANCY

HYPERTENSIVE DISORDERS DURING PREGNANCY. CLASSIFICATION OF HYPERTENSION IN PREGNANCY. PREGNANCY INDUCED HYPERTENSION With proteinuria and/or oedema Pre – eclampsia Eclampsia Without gross oedema or proteinuria Gestational hypertension.

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HYPERTENSIVE DISORDERS DURING PREGNANCY

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  1. HYPERTENSIVE DISORDERS DURING PREGNANCY

  2. CLASSIFICATION OF HYPERTENSION IN PREGNANCY • PREGNANCY INDUCED HYPERTENSION • With proteinuria and/or oedema Pre – eclampsia Eclampsia • Without gross oedema or proteinuria Gestational hypertension

  3. CLASSIFICATION OF HYPERTENSION IN PREGNANCY…..Contd • COINCIDENTAL HYPERTENSION • Essential hypertension • Renovascular hypertension • Pheochromocytoma • Coarctation of aorta • Thyrotoxicosis • Connective tissue disease – Systemic lupus erethematous

  4. CLASSIFICATION OF HYPERTENSION IN PREGNANCY…..Contd • HYPERTENSION WORSONED BY PREGNANCY • Superimposed pre – eclampsia • Superimposed eclampsia

  5. PREGNANCY INDUSED HYPERTENSION • The hypertension develop as a direct result of gravid uterus. • Three clinical types are there • Pre – eclampsia • Eclampsia • Gestational Hypertension

  6. PRE - ECLAMPSIA

  7. PRE – ECLAMPSIA DEFINITION Pre- eclampsia is a • multi system disorder of • unknown etiology • characterised by development of hypertension to the extent of 140/90 mm of Hg or more • with proteinuria • induced by pregnancy after 20th week • in a previously normotensive & non- proteinuric patient.

  8. CLASSIFICATION I. PRIMARY ( 70%) • Pre- eclampsia • Eclampsia(with convulsion) II. SECONDARY (30%) • Pre-eclampsia-eclampsia superimposed on chronic hypertension (25%) • Pre-eclampsia-eclampsia superimposed on chronic nephritis (5%)

  9. DIAGNOSTIC CRITERIA OF PRE ECLAMPSIA • HYPERTENSION • Absolute rise of Bp of at least 140/90 mmHg • Rise in, • systolic 30mmHG • Diastolic 15mmHg • MAP • 105mmHg • Rise of 20 mmHg over previous reading

  10. DIAGNOSTIC CRITERIA OF PRE ECLAMPSIA • OEDEMA • Pitting edema over ankles • Weight gain 1 lb a week or 5 lb a month • PROTEINURIA • 0.3 gm in 24 hrs • 1 gm per litre

  11. RISK FACTORS • PRIMIGRAVIDA • FAMILY HISTORY • PLACENTAL ABNORMALITIES • OBESITY • PRE EXISTING VASCULAR DISEASE • NEW PATERNITY • THROMBOPHILIAS

  12. ETIOPATHOGENESIS OF PRE ECLAMPSIA • Etiology of pre eclampsia is not yet known • Primary event is abnormal development of the placenta • Principal feature is an inadequate trophoblastic invasion of the spiral arterioles of the placental bed

  13. ETIOPATHOGENESIS OF PRE ECLAMPSIA

  14. ETIOPATHOGENESIS OF PRE ECLAMPSIA HYPERTENSION • Intense vasospasm • Affect almost all the vessels • Following are the possibilities; • Increased normal circulating pressor substance • Appearance of a new pressor agents • Vascular system sensitised to normal circulating pressor substance • Dimnished vascular resistance to pressor substance

  15. ETIOPATHOGENESIS OF PRE ECLAMPSIA….Contd IN NORMAL PREGNANCY • Placenta release angiotensinase Destroy ANGIOTENSIN II • Vascular system become selective to Angiotensin II • By PROSTAGLANDIN I2 and NITRIC OXIDE (vasodialator)

  16. ETIOPATHOGENESIS OF PRE ECLAMPSIA….Contd IN PRE ECLAMPSIA • Imbalance of different components of prostaglandins • PG I2 (Vasodialator) • TXA2 ( Vasoconstrictor) • Increased vascular sensitivity to Angiotensin II • Decrease in NO • Relaxes vascular smooth muscles • Inhibit platelet aggregation • Prevent intervillous thrombosis

  17. ETIOPATHOGENESIS OF PRE ECLAMPSIA….Contd Imbalance of Vasodialator Vasoconstrictor PGI2 Angiotensin II NO TXA2 Endothelin 1 Endothelial dysfunction Pre eclampsia

  18. ETIOPATHOGENESIS OF PRE ECLAMPSIA….Contd • OEDEMA • Angiotensin II Activate Corticosterone Aldosterone Na & H2O retension • Severe pre eclampsia Aldosterone level fall • OEDEMA • Renal blood flow GFR Retension of Na

  19. ETIOPATHOGENESIS OF PRE ECLAMPSIA….Contd • OEDEMA • Renal blood flow Glomerular damage Protein leak across glomerular membrane Protein loss Colloidal osmotic pressure Shift of fluid to interstitial space Edema

  20. ETIOPATHOGENESIS OF PRE ECLAMPSIA….Contd • PROTEINURIA Spasm of the afferent glomerular arterioles Anoxic damage Capillary permeability Leakage of protein Tubular reabsorption

  21. PATHOPHISIOLOGY VASOSPASM DECREASED DIAMETER OF THE VESSELS • Endothelial cell damage • Decreased endothelium derived relaxing factor(NO) • Impeded blood flow • Elevated Bp

  22. PATHOPHISIOLOGY….Contd KIDNEY • Glomerular endotheliosis • Endothelial cells swells up • Fibrin deposit occur Occlude the lumen • Interstitial cells in b/w capillary proliferate • Spasm of the afferent glomerular arterioles • Decreased blood supply • Anoxia • Damage to the tubular epithelium

  23. PATHOPHYSIOLOGY….Contd The net effects are: • Decreased renal blood flow • Decreased glomerular filtration rate • Impaired tubular reabsorption

  24. PATHOPHYSIOLOGY….Contd • Decreased renal blood flow Glomerular damage Protein leak across glomerular membrane

  25. PATHOPHYSIOLOGY….Contd • Decreased glomerular filtration rate Decreased renal perfusion Decreased GFR Rise in BUN,Creatinine and Uric acid

  26. PATHOPHYSIOLOGY….Contd • Impaired tubular reabsorption Decreased renal blood flow Glomerular damage Protein leak across glomerular membrane

  27. PATHOPHYSIOLOGY….Contd Protein leak across glomerular membrane Decreased colloidal osmotic pressure Shift of fluid to interstitial space

  28. PATHOPHYSIOLOGY….Contd Reduced intravascular volume Release of Angiotensin II Increased Aldosterone Retension of sodium and water Generalised edema

  29. PATHOPHYSIOLOGY….Contd LIVER 1.Thrombosis of the arterioles Decreased circulation to the liver Hepatic edema Subcapsular haemorrhage Hemorrhagic necrosis Elevated liver enzymes 2.Subcapsular haematoma Epigastric pain

  30. PATHOPHYSIOLOGY….Contd MANIFESTATIONS OF LIVER INVOLVMENT • Nausea • Vomiting • Epigastric or right upper quadrant pain • Biochemical or hematological changes

  31. PATHOPHISIOLOGY….Contd BRAIN Vasoconstriction of cerebral vessels Pressure induced rupture of thin walled capillaries Small cerebral haemorrhage

  32. PATHOPHISIOLOGY….Contd BRAIN Vasoconstriction of cerebral vessels Pressure induced rupture of thin walled capillaries Small cerebral haemorrhage

  33. PATHOPHYSIOLOGY….Contd MANIFESTATIONS OF BRAIN INVOLVMENT • Head ache • Visual disturbance • Blurred vision • Spots before eye • Hyperactive deep tendon reflex • Seizure • Unconsciousness

  34. PATHOPHISIOLOGY….Contd LUNGS Decreased colloidal oncotic pressure Pulmonary capillary leak Pulmonary edema Dyspnea

  35. PATHOPHISIOLOGY….Contd HEART • Sub endothelial haemorrhage • Focal necrosis and haemorrhage in the myocardium Affect conducting system of the heart WATER AND ELECTROLYTE BALANCE • Intravascular dehydration • Extravascular overhydration OTHER ORGAN • Adrenal gland – Haemorrhage and necrosis • Stomach – Hemorrhagic gastritis

  36. PATHOPHISIOLOGY….Contd HEMATOLOGICAL CHANGES • Haemoconcentration • Increased hematocrit value • Hemoglobinemia • Haemoglobinuria • Reduction in clotting factors • Thrombocytopenia HORMONES • Reduction in estrogen, progesterone and HPL • Increased chorionic gonadotrophin

  37. PATHOPHISIOLOGY….Contd BIOCHEMICAL VALUES • Increased serum urea, uric acid and creatinine • Blood chlorides increased • Lowered serum protein

  38. PATHOPHISIOLOGY….Contd PLACENTA

  39. CLINICAL TYPES

  40. CLINICAL FEATURES • ONSET • Insidious • Runs a slow course • Rarely acute • Follows a rapid course

  41. CLINICAL FEATURES • SYMPTOMS • A syndrome of signs • When symptoms appear it is usually late

  42. CLINICAL FEATURES • MILDSYMPTOMS • Slight swelling over the ankles • Tightness of the ring on the fingers • Edema

  43. CLINICAL FEATURES • ALARMING SYMPTOMS • Headache (occipital or frontal region) • Disturbed sleep • Diminished urinary out put ( 400ml in 24 hours) • Epigastric pain • Vomiting (Coffee colour) • Eye symptoms • Blurring • Dimness of vision • Complete blindness

  44. CLINICAL FEATURES • SIGNS • Abnormal weight gain • Rise of blood pressure • Edema • No manifestation of chronic renal or cardiovascular pathology • Abdominal examination • Scanty liquor • IUGR

  45. INVESTIGATIONS • URINE • Proteinuria • OPHTHALMIC EXAMINATION • Retinal edema • Constriction of arterioles • A/T of normal vein arteriole ratio • Nicking of veins

  46. INVESTIGATIONS • BLOOD VALUE • S.Uric acid  4.5 mg/dL • S.Creatinine  1 mg/dL • Thrombocytopenia • Abnormal coagulation profile • Elevated hepatic enzymes • ANTENATAL FETAL MONITORING

  47. ANTENATAL FETAL MONITORING

  48. ANTENATAL FETAL MONITORING….Contd • UMBILICAL ARTERY FLOW VELOCIMETRY

  49. COMPLICATIONS OF PRE ECLAMPSIA….Contd • IMMEDIATE MATERNAL COMPLICATIONS • During pregnancy • Eclampsia • Accidental haemorrhage • Oliguria and Anuria • Dimness of vision • Blindness • Pre term labour • HELLP syndrome

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