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1、HYPERTENSIVE DISORDERS IN PREGNANCY,Prof of Gyn&Obst. Mansoura Faculty of Medicine Egypt 2009,Prof.Mohammad Emam,Introduction,Hypertensive disorders of pregnancy are leading causes of maternal mortality. Worldwide: 50,000 women die each year. Egypt: 18% of maternal mortality.,Introduction,Homeostasi
2、s during normal pregnancy: is an example of the principle of priorities, where the pregnant women must alter her entire physiological and biochemical environment to provide conditions best suited for the fetus to whom she is hostess, that is the price of viviparity.,Introduction,In hypertension: man
3、y complex homeostatic modifications occur, some are harmful to the mother and fetus, while others are beneficial.,Definitions,Hypertension in pregnancy: Bl/P of 140/90 or more is abnormal. If there is a rise of 30 mmHg or more in the systolic blood pressure or 15 mmHg or more in the diastolic blood
4、pressure In 2 occasions 6 hours apart. Mean arterial BP 105 mmHg . Systolic + 2 Diastolic Mean arterial BP = - 3,Classifications,National High Blood Pressure Education Program Classification ( NHEP) 2000,Gestational hypertension. Preeclampsia (mild, severe). Eclampsia. Superimposed preeclampsia upon
5、 chronic hypertension. Chronic hypertension with pregnancy.,Definitions,Gestational hypertension: Hypertension for first time after 20 w, without Proteinuria. BP returns to normal before 12 weeks postpartum. Chronic hypertension with pregnancy: Hypertension antedates pregnancy and detected before 20
6、 w, & lasts more than 12 weeks postpartum.,Definitions,Preeclampsia: The development of hypertension and Proteinuria after 20 w May occur earlier in vesicular mole or twins. Eclampsia (in Greek= Flash of light): The occurrence of tonic-clonic convulsions (without any neurological disease) in a woman
7、 with pre-eclampsia.,Definitions,Superimposed pre-eclampsia: It is the new development of Proteinuria after 20 weeks gestation in a patient with chronic hypertension,Definitions,Proteinuria: 300mg/24 hours urine. +1 dipstick. Heavy Proteinuria : = 2gm/24 hours or +2 in dipstick.,Preeclampsia,Epidemi
8、ology of preeclampsia,Incidence: Is a disease of humans only. Is the most common medical disorder complicating pregnancy 5-15% Is the most common hypertensive disorder in pregnancy. More common in primigravidas and elderly multipara. More common in winter. More in black races.,Epidemiology,Risk fact
9、ors: Chronic hypertension. Chronic nephritis. Past history . Family history. Obesity. Multiple pregnancy.,Epidemiology ( risks),Polyhydramnios. Vesicular mole. Diabetes mellitus. Nulliparity. Teenage Pregnancy. Smoking. Stress,Etiology= theories,Genetic Predisposition. Free Radicals Theory In pre-ec
10、lampsia the levels of free radicals are higher than normotensive women leading to endothelial damage.,Oxidative stress,Antioxidant capacity,ROS synthesis,O2._ H2O2 ONOO_,Vitamin C SOD,Etiology= theories,Endothelial injury: Endothelin 1(potent vasoconstrictors). Nitric Oxide ( vasodilator action). Va
11、scular Endothelial Growth Factor (VEGF).,Etiology= theories,Prostaglandins: There is decrease in prostacyclin /TX A2 ratio leading to : vasoconstriction and tendency to thrombosis.,Etiology= theories,Inflammatory Factors: Pre-eclampsia is considered an inflammatory disease due to increased number of
12、 activated leukocytes in the maternal circulation. Immunological Factor: primigravidas Multipara with 1st pregnancy from a new husband. Abundant trophoblast ( vesicular mole and multiple pregnancy.,The Central Players (Hemostats) in PET,The Endothelium Neutrophils 3. Platelets 4. Coagulation system.
13、 Once one is triggered Co- Workers are released (NO, PGs, ROS, Homosystein, etc),Triggers for PET,Genetic Modulators Pre-existing Vascular Pathology,Central players,Cytokines Ros,The Constant Pathophysiological Changes,Is Vascular endothelial: Damage +Dysfunction + Spasm,Pathology,PET is the clinica
14、l ice-berg tip manifestation of the disturbances in the maternal homeostasis, involving many systems and organs.,Multisystem Features Of Preeclampsia,Diagnosis,1) Prediction. 2)CL/P & Severity 3)Eclampsia,Diagnosis,I. Prediction: High risk factors. Rapid weight gain during the 2nd half of pregnancy
15、(due to occult edema). Any increase above 3/4 kg/week in late pregnancy is abnormal.,Tests for Prediction,Roll over test is positive (rise of diastolic blood pressure 20 mmHg or more after turning from left lateral to dorsal position). Increased pressor response. Uric acid: is elevated. Hypercalciur
16、ia. Doppler velocimetry to detect Uteroplacental hypo perfusion.,Diagnosis Of PET,Hypertension + Proteinuria = Two facets of a complex pathophysiological process,A): Signs: :,it is a disease of signs : 2 cardinal signs + or - Edema: Hypertension: usually precedes Proteinuria, Proteinuria: detected by Boiling test. Quantitative assay. Dipstick test.,+ or - Edema,occult or manifest: The lower extremities. Abdominal wall, vulva or may be generalized anasarca. usually after hypertension.,
