Pregnancy Induced
Hypertension
Prof,Duan Tao,M.D.
Shanghai 1st Maternity and
Infant Hospital
Pregnancy Induced
Hypertension
Definition：
Toxemia
Gestosis
Preeclampsia-Eclampsia
Pregnancy Induced Hypertension
EPH Syndrome
Theories about causes
Still Unknown:
Utero-placental ischemia:
Neuro-endocrinology,PGI2/TXA2
Immunology-hereditary：
Chronic DIC：
Theory
Primipaternity:
Robillard PY,Eur J Obstet Gynecol
Reprod Biol,1999.
Dekker,392 multiparous PIH women,
22-25% have new partners,3.4% in
control group.
My Theory
Trigger off theory,
The open Shield in Chicago
Lying –In Hospital
Diagnosis
Hypertension of pregnancy,
BP ? 140 / 90 mmHg ALONE
or WITH mild oedema (after 20wks
of gestation)
Diagnosis
American Way
Preeclampsia
I) Mild preeclampsia
BP, ? 140/90mmHg,but <160/110mmHg,
Edema,mild
Proteinuria,Trace / 1+
Diagnosis
II) Severe preeclampsia
BP,? 160/110 mmHg
Edema,marked
Proteinuria,2+ or more
Diagnosis
With headache,visual disturbances,
abdominal pain,oliguria,thrombocytopenia,
bilirubin,liver enzymes,creatinine,foetal
growth retardation,pulmonary oedema
Eclampsia
Severe preeclamsia with CONVULSION
Diagnosis
Chinese way:
Mild preeclampsia
BP, ? 140/90mmHg,but <150/100mmHg,
or with an elevation of 30/15 mmHg
Edema,and/or
Proteinuria,Trace
Diagnosis
Moderate preeclampsia
BP, ? 150/100mmHg,but <160/110mmHg,
Edema,and/or
Proteinuria,1+
Diagnosis
Severe preeclampsia
BP, ? 160/110mmHg
Edema,and/or
Proteinuria,2+~4+
Pathophysiology
Vasospasm,haemorrage & necrosis” end
organ changes
Reduced placental perfusion? IUGR
& foetal death
Increased cardiac output
Increased extra cellular fluid volume
Pathophysiology
Haemoconcentration
Hypercoagulability-DIC - reduced
clotting factors - bleeding
Reduced GFR oligouria - anuria
No electrolytic imbalance
Pathophisiology
Serious Complications:
Hellp syndrome
Abruptio placentae
Pulmonary oedema
Acute renal failure
Pathophysiology
Serious Complications:
Cerebral haemorrhage
Visual disturbances & blindness
Hepatic rupture
Electrolytic imbalance
Postpartum collapse
Differential Diagnosis
Chronic hypertension essential / renal /
others
Mostly obese,elderly,parous & likely to
be on antihypertensive drugs
Usually preexists / appears early (<20wks)
& persists postpartum
End organ damage maybe present
Differential Diagnosis
Diagnostic confusion:
10 of 24(42%) women initially thought to
have had eclampsia were later found to have
had other cerebro-vascular pathology-
hypertensive encephalopathy,cerebral
hemorrhage,or cerebral infarction.
Suspected eclampsia,unresponsive to Mgso4
therapy warrants a prompt neuroimaging
study.
Am J Obstet Gynecol,1997;176:1139-1148
Cure / prevent progression -
Close monitoring
Reduce blood pressure -tatrget- 140/90mmHg
Promote foetal maturity
Prolong pregnancy (34 - 36 weeks)
To achieve foetal maturity ? termination
Delivery- best day,best way & best place
Prevent / manage complications
OBJECTIVES OF MANAGEMENT
Look for appearance of ominous features
Daily- record b.P 4 times,monitor urine output
& test for proteinuria quali,/ Quant
Alt.Day- body weight
Every 4th day- uric acid,platelet count,liver
function
Weekly- creatinine
MATERNAL MONITORING
Daily - clinical foetal monitoring - fhs,fundal
ht,Abdominal girth,amniotic fluid,foetal
movement count,C.T.G
Ultrasound - on admission & then 3 weekly for
foetal biophysical parameters,placenta and
amniotic fluid volume
Dopller ultrasonography for placental blood
flow velocity every 4th day
L/s ratio for maturity
FOETAL MONITORING
Anticonvulsion
The history of MgSO4：
Magnesium sulfate in the treatment of
eclamptic convulsion:
1)It was first used to control tetanic
convulsions in early 1900s,The modern
obstetric use of Mgso4 was first
popularized by Pritchard,IM 10 g load,
then 5g/4hrs (1955)
Anticonvulsion
2)Zuspan recommended continuous intravenous
infusion,4g load,then 1g/hr (1966)
( This regimen was used in the United
States before 1980s,and is currently used in
Europe and South Africa,it was found to
produce levels less than 4.8mg/dl in the
majority of women treated).
Anticonvulsion
3)Sibai modified IV infusion,6g load,then
2g/hr (1981)
4)Pritchard recommended that the
appropriate serum levels of Mgso4 for
treatment of eclamptic convulsions were
3.5-7 Meq /L(or 4.2-8.4mg/dl)(1979)
Anticonvulsion
5)Magnesium level mg/dl= 1.2x magnesium level
Meq/L
6)If the patients were treated according to the
recommended regimen,10% of the eclamptic
seizures will recur
Anticonvulsion
The usage of MgSO4：
1)15-22.5g/d 1.5-2g/hr
2)I.M.Vs I.V.
3)I.V./day,I.M./night
25% MgSO420ml+2%Lidocaine 2ml
4)The effect of MgSO4, BP/ Proteinuria
/Edema
Attentions,patellar reflex /respiratory/ urine
output
Sedatives
Diazepam,10mg IV
Pethedine:100mg
Chloropramazine:50mg
Antihypertensives
Apresoline,α blocker/25mg+5%GS 500ml
Captopril,ACE II blocker,banned because of
fetal damage.
Nifedipine,Calcium channel blocker,
quick/short lasting,10mg q6h.
Antihypertensives
Labetalol,αandβ blocker,
50-100mg+5%GS 500ml
Nitroprusside sodium,Very potent,but
with toxic effect.
50mg+5%GS 500ml
Rigitine,α-blocker,first choice for PIH
patients with cardiac disease.
10-40mg+5%GS 500ml
Caveats for antihypertensive
therapy
1 ) There is great individual variability in
response to these drugs,and they do not
lower blood pressure predictably,precisely,
or smoothly.
2)Lowering blood pressure too rapidly or
excessively may produce fetal distress,
particularly in the setting of IUGR or an
abnormal fetal heart rate tracing.
Caveats for antihypertensive
therapy
3)Epidural anesthesia will lower the blood
pressure approximately 15%,frequently
abrogating the need for antihypertensive
medication.
4)The gravida with chronic renal
insufficiency has hypertension that is more
difficult to control,in part due to volume
expansion.
Caveats for antihypertensive
therapy
5 ) Severe hypertension without
proteinuria should prompt a urine
screen for cocaine.
6)With prolonged unconsciousness,
papilledema,lateralizing signs,seizures
on magnesium sulfate,or seizures more
than 48 hours after delivery,a CT scan
should be performed to rule out
intracranial hemorrhage.
Volume Expansion
Choice between crystalloid and colloid.
Diuresis
Furosemide:10-20mg/iv
Mannitol,20% 250ml,within 15’-20’
Management of Eclampsia
Mafia Look
protocol for managing eclampsia
1） Convulsions are controlled or prevented with
a loading dose of 6 g Mgso4 in 100ml
5%dextrose in Ringer’s lactated solution,given
over 15 minutes,followed by a maintenance dose
of 2g/hr,the dose is adjusted according to
patellar reflexes and urine output in the
previous 4-hour period.
Management of Eclampsia
2 ) Diuretics,plasma volume expanders,and
invasive hemodymnamic monitoring are not
used.
3)Induction and/or delivery is initiated within 4
hours after maternal stabilization.
Management of Eclampsia
4)Mgso4 is continued for 24 hrs after delivery or,
if postpartum,24 hrs after the last convulsion.
In some cases,the infusion may be continued
for longer.
* Witlin and Sibai,Hypertensive diseases in
pregnancy,In,Medicine of the fetus and
mother,2nd ed,Reece EA,Hobbins J (eds).
Philadelphia,PA,Lippincott-Raven,1998,997-
1020.
Hint
DAMMCALD
D, Diazepam A, Apresoline
M, MgSO4 M, Mannitol
C, Chlorpremazine A, Antibiotics
L, Lasix D,Digitalis
1 ) at 36 weeks,- in all controlled cases
2 ) after 32 weeks,- for foetal salvage
Decreased foetal movement
Severe IUGR with oligohydramnios
Late deceleration with poor variability
Reversed umbilical diastolic blood flow
DELIVERYTREATMENT
BEST DAY - WHEN?
DELIVERYTREATMENT
BEST DAY - WHEN?
3) any time, - if progressive in spite of
treatment,when -
Bp >160 /100 mmHg
Urine output < 400 ml / 24 hours
Platelet count < 50,000 / cmm
Serum creatinine increases
progressively
Ldh >1000 iu / l
1 ) Induction with oxytocin,-after 36 weeks
If foetal condition is good
Cervix is favourable / cerviprime
Application of forceps / ventouse
DELIVERYTREATMENT
BEST WAY - HOW?
DELIVERYTREATMENT
BEST WAY - HOW?
2 ) By C-S:
If termination before 36 weeks
In cases of maternal / fotal jeopardy
Anaesthesia - general / epidural / spinal –
better left to anaesthetist
DELIVERYTREATMENT
Best place - where?
High-risk pregnancy unit / tertiary hospital
/ well equipped hospital
2 ) neonatal care,-
Presence of paediatrician is a must
Incubator is helpful
POSTPARTUMTREATMENT
1 ) PPH,- be prepared to face it
Uterine atony / DIC - FDP/bleeding disorder
Oxytocics / uterine massage / packing /
uterine artery ligation / internal iliac artery
ligation / hysterectomy
POSTPARTUMTREATMENT
3 ) Drugs,-
Judicious use of antihypertensives,iv fluids,
diuretics,& diazepam in the first 48 hours
4) Follow up for 6 weeks
TORCH Syndrome
Why TORCH?
T,Toxoplasma
O,Others(Treponema pallidum,syphilis)
R,Rubella Virus
C,Cytomegalo Virus
H,Herpes Simplex Virus
TORCH Syndrome
Characteristics:
Mother---Minimal/Flu-like
Fetus---Fatal/malformatiom
Risk Population:
Way of fetal Infection:
1.Intrauterine infection
2.Birth canal infection
3.Postpartum infection
TORCH Syndrome
Effect on the mother,minimal
Effect on the fetus:
1,Toxoplasma:
Abortion,fetal death,cranial
malformation,neural dysfunction.
2,Others(Treponema pallidum,
syphilis):
Abortion,fetal death,congenital
syphilis
TORCH Syndrome
3,Rubella Virus:
Congenital rubella syndrome(CRS),
CRS triade,cardiovascular malformation,
congenital cataract,deaf.
4,Cytomegalo Virus:
Abortion,fetal death,neural and
cardiovascular malformation.
TORCH Syndrome
5,Herpes Simplex Virus:
IUGR,cranial malformation,neonatal
infection
Diagnosis:
1.History and Symptoms
2.Lab Test,antibodies/PCR
TORCH Syndrome
Management:
1.Therapeutic abortion
2.Drugs:
The existing problems:
HELLP SYNDROME
What is HELLP?
H,hemolysis
EL,elevated liver enzyme
LP,low platelet count
Severe complication of PIH
HELLP SYNDROME
Effect on the mother:
Effect on the fetus:
Clinical manifestation:
Diagnosis and differential diagnosis:
Management:
Antiphospholipid Syndrome
Characteristics:
1,anticardiolipin antibody (+)
lupus coagulant (+)
2.Symptoms like,thrombosis,recurrent
spontaneous abortion,thrombocytopenia
Antiphospholipid Syndrome
Clinical manifestation:
Diagnosis:
Management:
1.aspirin
2.heparin
3.steroids
Thank U !
Prof,Duan Tao,M.D.
Hypertension
Prof,Duan Tao,M.D.
Shanghai 1st Maternity and
Infant Hospital
Pregnancy Induced
Hypertension
Definition：
Toxemia
Gestosis
Preeclampsia-Eclampsia
Pregnancy Induced Hypertension
EPH Syndrome
Theories about causes
Still Unknown:
Utero-placental ischemia:
Neuro-endocrinology,PGI2/TXA2
Immunology-hereditary：
Chronic DIC：
Theory
Primipaternity:
Robillard PY,Eur J Obstet Gynecol
Reprod Biol,1999.
Dekker,392 multiparous PIH women,
22-25% have new partners,3.4% in
control group.
My Theory
Trigger off theory,
The open Shield in Chicago
Lying –In Hospital
Diagnosis
Hypertension of pregnancy,
BP ? 140 / 90 mmHg ALONE
or WITH mild oedema (after 20wks
of gestation)
Diagnosis
American Way
Preeclampsia
I) Mild preeclampsia
BP, ? 140/90mmHg,but <160/110mmHg,
Edema,mild
Proteinuria,Trace / 1+
Diagnosis
II) Severe preeclampsia
BP,? 160/110 mmHg
Edema,marked
Proteinuria,2+ or more
Diagnosis
With headache,visual disturbances,
abdominal pain,oliguria,thrombocytopenia,
bilirubin,liver enzymes,creatinine,foetal
growth retardation,pulmonary oedema
Eclampsia
Severe preeclamsia with CONVULSION
Diagnosis
Chinese way:
Mild preeclampsia
BP, ? 140/90mmHg,but <150/100mmHg,
or with an elevation of 30/15 mmHg
Edema,and/or
Proteinuria,Trace
Diagnosis
Moderate preeclampsia
BP, ? 150/100mmHg,but <160/110mmHg,
Edema,and/or
Proteinuria,1+
Diagnosis
Severe preeclampsia
BP, ? 160/110mmHg
Edema,and/or
Proteinuria,2+~4+
Pathophysiology
Vasospasm,haemorrage & necrosis” end
organ changes
Reduced placental perfusion? IUGR
& foetal death
Increased cardiac output
Increased extra cellular fluid volume
Pathophysiology
Haemoconcentration
Hypercoagulability-DIC - reduced
clotting factors - bleeding
Reduced GFR oligouria - anuria
No electrolytic imbalance
Pathophisiology
Serious Complications:
Hellp syndrome
Abruptio placentae
Pulmonary oedema
Acute renal failure
Pathophysiology
Serious Complications:
Cerebral haemorrhage
Visual disturbances & blindness
Hepatic rupture
Electrolytic imbalance
Postpartum collapse
Differential Diagnosis
Chronic hypertension essential / renal /
others
Mostly obese,elderly,parous & likely to
be on antihypertensive drugs
Usually preexists / appears early (<20wks)
& persists postpartum
End organ damage maybe present
Differential Diagnosis
Diagnostic confusion:
10 of 24(42%) women initially thought to
have had eclampsia were later found to have
had other cerebro-vascular pathology-
hypertensive encephalopathy,cerebral
hemorrhage,or cerebral infarction.
Suspected eclampsia,unresponsive to Mgso4
therapy warrants a prompt neuroimaging
study.
Am J Obstet Gynecol,1997;176:1139-1148
Cure / prevent progression -
Close monitoring
Reduce blood pressure -tatrget- 140/90mmHg
Promote foetal maturity
Prolong pregnancy (34 - 36 weeks)
To achieve foetal maturity ? termination
Delivery- best day,best way & best place
Prevent / manage complications
OBJECTIVES OF MANAGEMENT
Look for appearance of ominous features
Daily- record b.P 4 times,monitor urine output
& test for proteinuria quali,/ Quant
Alt.Day- body weight
Every 4th day- uric acid,platelet count,liver
function
Weekly- creatinine
MATERNAL MONITORING
Daily - clinical foetal monitoring - fhs,fundal
ht,Abdominal girth,amniotic fluid,foetal
movement count,C.T.G
Ultrasound - on admission & then 3 weekly for
foetal biophysical parameters,placenta and
amniotic fluid volume
Dopller ultrasonography for placental blood
flow velocity every 4th day
L/s ratio for maturity
FOETAL MONITORING
Anticonvulsion
The history of MgSO4：
Magnesium sulfate in the treatment of
eclamptic convulsion:
1)It was first used to control tetanic
convulsions in early 1900s,The modern
obstetric use of Mgso4 was first
popularized by Pritchard,IM 10 g load,
then 5g/4hrs (1955)
Anticonvulsion
2)Zuspan recommended continuous intravenous
infusion,4g load,then 1g/hr (1966)
( This regimen was used in the United
States before 1980s,and is currently used in
Europe and South Africa,it was found to
produce levels less than 4.8mg/dl in the
majority of women treated).
Anticonvulsion
3)Sibai modified IV infusion,6g load,then
2g/hr (1981)
4)Pritchard recommended that the
appropriate serum levels of Mgso4 for
treatment of eclamptic convulsions were
3.5-7 Meq /L(or 4.2-8.4mg/dl)(1979)
Anticonvulsion
5)Magnesium level mg/dl= 1.2x magnesium level
Meq/L
6)If the patients were treated according to the
recommended regimen,10% of the eclamptic
seizures will recur
Anticonvulsion
The usage of MgSO4：
1)15-22.5g/d 1.5-2g/hr
2)I.M.Vs I.V.
3)I.V./day,I.M./night
25% MgSO420ml+2%Lidocaine 2ml
4)The effect of MgSO4, BP/ Proteinuria
/Edema
Attentions,patellar reflex /respiratory/ urine
output
Sedatives
Diazepam,10mg IV
Pethedine:100mg
Chloropramazine:50mg
Antihypertensives
Apresoline,α blocker/25mg+5%GS 500ml
Captopril,ACE II blocker,banned because of
fetal damage.
Nifedipine,Calcium channel blocker,
quick/short lasting,10mg q6h.
Antihypertensives
Labetalol,αandβ blocker,
50-100mg+5%GS 500ml
Nitroprusside sodium,Very potent,but
with toxic effect.
50mg+5%GS 500ml
Rigitine,α-blocker,first choice for PIH
patients with cardiac disease.
10-40mg+5%GS 500ml
Caveats for antihypertensive
therapy
1 ) There is great individual variability in
response to these drugs,and they do not
lower blood pressure predictably,precisely,
or smoothly.
2)Lowering blood pressure too rapidly or
excessively may produce fetal distress,
particularly in the setting of IUGR or an
abnormal fetal heart rate tracing.
Caveats for antihypertensive
therapy
3)Epidural anesthesia will lower the blood
pressure approximately 15%,frequently
abrogating the need for antihypertensive
medication.
4)The gravida with chronic renal
insufficiency has hypertension that is more
difficult to control,in part due to volume
expansion.
Caveats for antihypertensive
therapy
5 ) Severe hypertension without
proteinuria should prompt a urine
screen for cocaine.
6)With prolonged unconsciousness,
papilledema,lateralizing signs,seizures
on magnesium sulfate,or seizures more
than 48 hours after delivery,a CT scan
should be performed to rule out
intracranial hemorrhage.
Volume Expansion
Choice between crystalloid and colloid.
Diuresis
Furosemide:10-20mg/iv
Mannitol,20% 250ml,within 15’-20’
Management of Eclampsia
Mafia Look
protocol for managing eclampsia
1） Convulsions are controlled or prevented with
a loading dose of 6 g Mgso4 in 100ml
5%dextrose in Ringer’s lactated solution,given
over 15 minutes,followed by a maintenance dose
of 2g/hr,the dose is adjusted according to
patellar reflexes and urine output in the
previous 4-hour period.
Management of Eclampsia
2 ) Diuretics,plasma volume expanders,and
invasive hemodymnamic monitoring are not
used.
3)Induction and/or delivery is initiated within 4
hours after maternal stabilization.
Management of Eclampsia
4)Mgso4 is continued for 24 hrs after delivery or,
if postpartum,24 hrs after the last convulsion.
In some cases,the infusion may be continued
for longer.
* Witlin and Sibai,Hypertensive diseases in
pregnancy,In,Medicine of the fetus and
mother,2nd ed,Reece EA,Hobbins J (eds).
Philadelphia,PA,Lippincott-Raven,1998,997-
1020.
Hint
DAMMCALD
D, Diazepam A, Apresoline
M, MgSO4 M, Mannitol
C, Chlorpremazine A, Antibiotics
L, Lasix D,Digitalis
1 ) at 36 weeks,- in all controlled cases
2 ) after 32 weeks,- for foetal salvage
Decreased foetal movement
Severe IUGR with oligohydramnios
Late deceleration with poor variability
Reversed umbilical diastolic blood flow
DELIVERYTREATMENT
BEST DAY - WHEN?
DELIVERYTREATMENT
BEST DAY - WHEN?
3) any time, - if progressive in spite of
treatment,when -
Bp >160 /100 mmHg
Urine output < 400 ml / 24 hours
Platelet count < 50,000 / cmm
Serum creatinine increases
progressively
Ldh >1000 iu / l
1 ) Induction with oxytocin,-after 36 weeks
If foetal condition is good
Cervix is favourable / cerviprime
Application of forceps / ventouse
DELIVERYTREATMENT
BEST WAY - HOW?
DELIVERYTREATMENT
BEST WAY - HOW?
2 ) By C-S:
If termination before 36 weeks
In cases of maternal / fotal jeopardy
Anaesthesia - general / epidural / spinal –
better left to anaesthetist
DELIVERYTREATMENT
Best place - where?
High-risk pregnancy unit / tertiary hospital
/ well equipped hospital
2 ) neonatal care,-
Presence of paediatrician is a must
Incubator is helpful
POSTPARTUMTREATMENT
1 ) PPH,- be prepared to face it
Uterine atony / DIC - FDP/bleeding disorder
Oxytocics / uterine massage / packing /
uterine artery ligation / internal iliac artery
ligation / hysterectomy
POSTPARTUMTREATMENT
3 ) Drugs,-
Judicious use of antihypertensives,iv fluids,
diuretics,& diazepam in the first 48 hours
4) Follow up for 6 weeks
TORCH Syndrome
Why TORCH?
T,Toxoplasma
O,Others(Treponema pallidum,syphilis)
R,Rubella Virus
C,Cytomegalo Virus
H,Herpes Simplex Virus
TORCH Syndrome
Characteristics:
Mother---Minimal/Flu-like
Fetus---Fatal/malformatiom
Risk Population:
Way of fetal Infection:
1.Intrauterine infection
2.Birth canal infection
3.Postpartum infection
TORCH Syndrome
Effect on the mother,minimal
Effect on the fetus:
1,Toxoplasma:
Abortion,fetal death,cranial
malformation,neural dysfunction.
2,Others(Treponema pallidum,
syphilis):
Abortion,fetal death,congenital
syphilis
TORCH Syndrome
3,Rubella Virus:
Congenital rubella syndrome(CRS),
CRS triade,cardiovascular malformation,
congenital cataract,deaf.
4,Cytomegalo Virus:
Abortion,fetal death,neural and
cardiovascular malformation.
TORCH Syndrome
5,Herpes Simplex Virus:
IUGR,cranial malformation,neonatal
infection
Diagnosis:
1.History and Symptoms
2.Lab Test,antibodies/PCR
TORCH Syndrome
Management:
1.Therapeutic abortion
2.Drugs:
The existing problems:
HELLP SYNDROME
What is HELLP?
H,hemolysis
EL,elevated liver enzyme
LP,low platelet count
Severe complication of PIH
HELLP SYNDROME
Effect on the mother:
Effect on the fetus:
Clinical manifestation:
Diagnosis and differential diagnosis:
Management:
Antiphospholipid Syndrome
Characteristics:
1,anticardiolipin antibody (+)
lupus coagulant (+)
2.Symptoms like,thrombosis,recurrent
spontaneous abortion,thrombocytopenia
Antiphospholipid Syndrome
Clinical manifestation:
Diagnosis:
Management:
1.aspirin
2.heparin
3.steroids
Thank U !
Prof,Duan Tao,M.D.
