Severe HTN ( hypertention) preeclampsia

1. Emergent & urgent
Hypertension
Reference: Harrison 2012, Chapter 247
‫خدا‬ ‫نام‬ ‫به‬

2. Definitions:
• Hypertension:
• Stage I: 140-159/90-99
• Stage II: >160/100
• Hypertensive Urgency:
• Systolic BP >180 or Diastolic BP >120 in the absence of
end-organ damage
• Hypertensive Emergencies:
• SBP >180 or DBP>120 in the presence of end-organ damage

3. Hypertensive Emergencies:
 Hypertensive encephalopathy
 Malignanthypertension
 Stroke
 Myocardial infarction/unstable angina
 Acute left ventricular failure
 Aortic dissection
 Adrenergic crisis
 Postoperative hypertension
 Preeclampsia/eclampsia of pregnancy

4. Malignant hypertension
 Acute ↑ of BP (hypertensive crisis) in a patient with
underlying hypertension
 or sudden onset of HTN in a previously normotensive
individual
 with irreversible organ damage
 SBP >180 or DBP >120
 Damage :
diffuse necrotizing vasculitis
arteriolar thrombi
fibrin deposition in arteriolar walls (kidney, brain, retina, and other organs)

5. Malignant hypertension
 Damage :
 diffuse necrotizing vasculitis
 arteriolar thrombi
 fibrin deposition in arteriolar walls (kidney, brain, retina, and …)
 Fibrinoid Necrosis
 progressive retinopathy (arteriolar spasm, hemorrhages, exudates, and
papilledema)
 renal function with proteinuria
 microangiopathic hemolytic anemia
 encephalopathy
 Hx:
use of MAO inhibitors , OCP,cocaine, amphetamines ,…

6. Normal

10. Autoregulation in brain

12. s
 ↓ ↓ of BP, under the lower limit of autoregulation = cerebral ischemia (also
Renal and Coronary blood flows )

13. initial Goal
 ↓ MAP : 25% of HTN (160/100–110 mmHg)
 in minutes to 2 h
 IV nitroprusside, labetalol,nicardipine

14. preeclampsia
 5–7% of pregnant women
 after 20 weeks of gestation
new onset of hypertension (BP>140/90 mmHg)
+
proteinuria (>300 mg/24 h) (organ damage)
 Eclampsia = onset of seizures (convulsions) in a woman with pre-eclampsia

15. Severe preeclampsia
 BP >160/110 mmHg
 proteinuria >5 g/24 h
 CNS dysfunction (headaches, blurred vision, seizures, coma)
 Renal dysfunction (oliguria or creatinine > 1.5 mg/dL)
 pulmonary edema
 hepatocellular injury (ALT > 2-fold the upper limits of normal)
 hematologic dysfunction (platelet count < 100,000/L or DIC)
 placental dysfunction (oligohydramnios or severe IUGR)
 HELLP syndrome (hemolysis, elevated liver enzymes, low platelets)

16. treatment
 Mild preeclampsia  Bed rest
 Severe preeclampsia  delivery +
labetalol(IV)
Nifedipine
hydralazine
ACEI (-)
Magnesium sulfate