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Hypertensive Disorders of PregnancyAka: Pregnancy Induced Hypertension, Gestational Hypertension-Preeclampsia, Preeclampsia, PIH, EPH gestosis

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  1. Definition
    1. EPH gestosis: Edema, Proteinuria, Hypertension
  2. Epidemiology
    1. Incidence
      1. All pregnancies: 6-8%
      2. Preterm births: 20%
    2. Mortality: 100,000 maternal deaths per year worldwide
      1. Accounts for 10-30% of all maternal deaths yearly
  3. Pathophysiology
    1. Decreased Intravascular volume
      1. Hemoconcentrated
      2. Increased Hemoglobin
    2. Increased Vascular Resistance
    3. Endothelial Cell dysfunction
      1. Very active organ system (not just vessel lining)
      2. Surface Area >6300 square meters over 100g of tissue
      3. Associated findings
        1. Edema
        2. Proteinuria
    4. Coagulation abnormalities
    5. Multiple system effects by oxygen free radicals
      1. Perfusion and re-perfusion injury
      2. Lipid peroxidation
      3. Antioxidant mechanisms are protective
    6. Trophoblastic Invasion
      1. Two phases
        1. First: Decidua
        2. Second: 12-18 weeks gestation
      2. Effects of PIH are reversed with Trophoblast delivery
    7. Model System
      1. Pregnant ewes
      2. Used to study prostaglandin synthesis inhibitor
    8. Hypertension is a major mental roadblock
      1. Prevents understanding and treatment of toxemia
      2. Hypertension is an effect of PIH, not a cause
  4. Classification
    1. Pregnancy Induced Hypertension (PIH)
      1. Hypertension without Proteinuria or pathologic edema
      2. Preeclampsia with Proteinuria or pathologic edema
        1. Mild Preeclampsia
        2. Severe Preeclampsia
      3. Eclampsia
        1. Convulsions
        2. Proteinuria
        3. Edema
      4. HELLP Syndrome
        1. Hemolysis
        2. Elevated Liver Function Tests
        3. Low platelets
    2. Pregnancy Aggravated Chronic Hypertension
      1. Superimposed preeclampsia
      2. Superimposed Eclampsia
    3. Coincidental Hypertension (Chronic Hypertension)
      1. Increased associated risks
        1. Superimposed preeclampsia
        2. Placental Abruption
        3. Intrauterine Growth Retardation
      2. High risk criteria
        1. Age 35 years or higher
        2. Antihypertensive needed for Blood Pressure control
        3. History of prior pregnancy complications
          1. Preeclampsia
          2. Untrauterine growth retardation
          3. Intrauterine Fetal Demise
        4. Comorbid conditions
          1. Diabetes Melllitus
          2. Systemic Lupus Erythematosus
          3. Chronic cardiopulmonary disease
          4. Renal disease
        5. Abnormal labs
          1. Serum Creatinine >1.0 mg/dl
          2. Proteinuria >300 mg/24 hours
          3. Phopholipid Antibody positive
  5. Risk Factors
    1. Primigravid or new paternity
    2. Family History of preeclampsia (25%)
    3. Diabetes Mellitus
    4. Multiple Gestation
    5. Obesity
    6. Maternal age >40 years
    7. Preexisting Hypertension
    8. Angiotensin gene T235
    9. Antiphospholipid Syndrome
    10. Hydatiform mole
    11. Fetal hydrops
  6. Symptoms (onset after 20 weeks gestation)
    1. Hand and face edema
      1. Least reliable PIH indicator
      2. Absent in 33% of PIH cases
      3. Often present in healthy third trimester pregnancies
    2. Headache
    3. Visual disturbance
    4. Epigastric Pain
  7. Signs: General
    1. Excessive weight gain
    2. Hyperreflexia and clonus
    3. Blood Pressure
      1. Assumes normal Blood Pressure before pregnancy
      2. Based on two supine Blood Pressures, 6 hours apart
      3. Mild Preeclampsia
        1. Blood Pressure exceeds 140/90
        2. Prior guideline: Relative BP increase 30/15
          1. NHLBI Working Group does not recommend using
          2. Use 140/90 cutoff for all pregnant patients
      4. Severe Preeclampsia
        1. Blood Pressure exceeds 160/110
  8. Signs: Severe Preeclampsia
    1. Blood Pressure exceeds 160/110
    2. Proteinuria >5 grams per 24 hours (see labs below)
    3. Urine Output decreased
      1. Urine output less than 500 ml in 24 hours
    4. Increased Serum Creatinine
    5. Thrombocytopenia
    6. Pulmonary edema
  9. Labs
    1. Proteinuria is not a useful screening measure
      1. Proteinuria is a late finding
      2. Rely on BP and other measures for screening
      3. Proteinuria assesses degree of pre-Eclampsia
    2. Urine Protein and 24 Hour Urine Protein
      1. Non-proteinuric Hypertension in Pregnancy
        1. Trace or no Urine Protein present
      2. Mild Preeclampsia
        1. Urine chemstrip exceeds 1+ protein (>0.3 g/liter)
          1. Based on 2 random urines >6 hours apart
        2. Urine Protein exceeds 300 mg in 24 hours
      3. Severe Preeclampsia
        1. Urine chemstrip exceeds 3+ protein
          1. Based on 2 random urines >6 hours apart
        2. Urine Protein exceeds 5 grams in 24 hours
    3. Urine for single Specimen protein to Creatinine ratio
      1. Correlates with 24 Hour Urine Protein
      2. PIH unlikely if protein to Creatinine ratio < 0.15
      3. Needs confirmation by larger study
      4. Reference
        1. Young (1996) J Fam Pract 42:385
    4. Complete Blood Count with platelets
      1. Thrombocytopenia seen in Severe Preeclampsia
    5. Serum Electrolytes
    6. Renal Function testing
      1. Blood Urea Nitrogen (BUN)
      2. Creatinine (increased in Severe Preeclampsia)
    7. Uric Acid
    8. Liver Function Tests
      1. Aspartate Aminotransferase
      2. Alanine Aminotransferase
      3. Serum Bilirubin
      4. Serum Albumin
      5. Lactic Acid dehydrogenase
    9. Coagulation Studies for Severe Preeclampsia or HELLP
      1. ProTime (PT)
      2. Partial Thromboplastin Time (aPTT)
      3. Fibrin split products (Fibrin Degradation Products)
      4. Fibrinogen
  10. Diagnostic studies: fetus
    1. Fetal Nonstress Test
    2. Obstetric Ultrasound
      1. Biophysical Profile
      2. Amniocentesis for Fetal Lung Maturity when indicated
  11. Monitoring
    1. See Gestational Hypertension (chronic Hypertension)
    2. See Mild Preeclampsia
    3. See Severe Preeclampsia
    4. See HELLP Syndrome
  12. Management
    1. See Delivery Indications in PIH
    2. See Gestational Hypertension Management
    3. See Mild PIH Management
    4. See Severe PIH Management
    5. See Eclampsia
    6. See HELLP Syndrome
    7. See PIH Blood Pressure Management
    8. See PIH Seizure Prophylaxis
  13. Management: Chronic Hypertension
    1. Therapy during pregnancy does not reduce complication
      1. Antihypertensives benefit mother only
        1. Does not reduce pregnancy complications
        2. van Dadelszen (2000) :
      2. Aspirin does not lower preeclampsia risk
        1. Caritis (1998) :
      3. Low sodium diet shows no benefit
      4. Minimizing weight gain shows no benefit
      5. Exercise restriction offers no benefit
    2. Antihypertensive used in pregnancy
      1. Alpha methyldopa 500 mg PO bid (up to 2 grams bid)
      2. Labetolol 200 mg PO bid (up to 1200 mg bid)
      3. Felodipine 5 mg PO daily (up to 20 mg daily)
      4. Hydrochlorothiazide
        1. Not usually initiated in pregnancy
        2. May be continued if on pre-pregnancy
      5. Nifedipine XL 30 mg PO bid (up to 120 mg daily)
      6. Hydralazine 10 mg PO tid (up to 25 mg tid)
  14. Prevention
    1. See PIH Prophylaxis
  15. Complications: Maternal
    1. Eclampsia
  16. Complications: Fetus
    1. Neonatal Asphyxia
    2. Neonatal Hypoglycemia
    3. Intrauterine Growth Retardation
  17. Course: Postpartum
    1. Most PIH cases improve in first 1-2 days after delivery
      1. Blood Pressure decreases
      2. Diuresis
    2. Eclampsia may occur after delivery (usually <24 hours)
      1. Consider continuing Magnesium Sulfate for 24 hours
      2. Continue to follow Blood Pressure and urine output
      3. Observe for signs of HELLP Syndrome
    3. Hypertension remits by 6-12 weeks postpartum
  18. Prognosis
    1. Isolated preeclampsia risks outside of pregnancy
      1. Confers future risk of Hypertension, vascular disease
      2. Wilson (2003) BMJ 326:845
    2. Increased risk of preeclampsia in future pregnancies
      1. All women with history of preeclampsia
      2. Onset before 30 weeks gestation (40% recurrence risk)
      3. Black race
      4. Different father than prior gestation
      5. Preeclampsia previously in multiparous patient
  19. References
    1. (2000) Am J Obstet Gynecol 183(1):S1
    2. Sibai (2003) Obstet Gynecol 102:181
    3. Zamorski (2001) Am Fam Physician 64(2):263

Pre-Eclampsia (C0032914)

Definition (MSH)A complication of PREGNANCY, characterized by a complex of symptoms including maternal HYPERTENSION and PROTEINURIA with or without pathological EDEMA. Symptoms may range between mild and severe. Pre-eclampsia usually occurs after the 20th week of gestation, but may develop before this time in the presence of trophoblastic disease.
Definition (CSP)toxemia occurring in women in the second half of their pregnancy, characterized by hypertension, and usually by edema and proteinuria, but without the convulsions and coma associated with eclampsia.
Definition (CSP)pregnancy induced hypertensive states, including EPH gestosis when edema and proteinuria accompany hypertension; other hypertensive disorders that develop during pregnancy or the puerperium are preeclampsia and eclampsia, either of which may be superimposed upon chronic hypertensive vascular or renal disease.
ConceptsDisease or Syndrome (T047)
ICD9642.4
DanishSvangerskabsforgiftning
EnglishEdema Proteinuria Hypertension Gestosis, EPH Complex, EPH Gestosis, EPH Toxemia, EPH Toxemias, Hypertension Edema Proteinuria Gestosis, MATERNAL TOXEMIA, PEE, PEE1, Pre Eclampsia, Preeclampsia, PREECLAMPSIA/ECLAMPSIA 1, PREG1, PREGN TOXEMIAS, pregnancy toxemia, pregnancy toxemia/hypertension, Pregnancy Toxemias, Proteinuria Edema Hypertension Gestosis, Proteinuric hypertension of pregnancy, Toxaemia of pregnancy, Toxemia of Pregnancy
FrenchToxemie/preeclampsie
NorwegianSVANGERSKAPSFORGIFTNING
Spanishpreeclampsia, preeclamsia, toxemia del embarazo, toxemia gravídica, toxemia gravidica, toxemia preeclámpsica, toxemia preeclampsica
CreditsDerived from the NIH UMLS (Unified Medical Language System)


Prolactin Release-Inhibiting Hormone (C0033373)

Definition (MSH)A number of peptides with inhibitory activities on PROLACTIN release have been isolated from the HYPOTHALAMUS, the peripheral nervous system, and the gut. These include SOMATOSTATIN, and peptides derived from POMC and precursor for VASOPRESSIN-ASSOCIATED NEUROPHYSIN. Biogenic amine DOPAMINE is also a potent PIF.
ConceptsAmino Acid, Peptide, or Protein (T116) , Pharmacologic Substance (T121) , Hormone (T125)
EnglishPIF, PIF preparation, PIH, PRIH, prolactin IH, Prolactin inhibiting factor, Prolactin inhibiting factor preparation, PROLACTIN RELEASE INHIB HORMONE, Prolactin Release Inhibiting Factors, Prolactin Release Inhibiting Hormone, Prolactin Release Inhibitory Factor
Spanishfactor inhibidor de prolactina, FIP, preparado de factor inhibidor de prolactina, preparado de PIF
CreditsDerived from the NIH UMLS (Unified Medical Language System)



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