A compact story of pregnancy induced hypertension pathogenesis made of flowcharts. Helps to understand the pathophysiology in detail. Sources:dr.sakshi aurora classes, dc.dutta.

1. Pathophysiology
Of PREGNANCY INDUCED HYPERTENSION

2. Key words:
● Incomplete Trophoblastic invasion
● Abnormal Vascular remodelling
● Placental ischemia
● sFlt-1
● Endoglin
● VEGF
● TGF beta
● Endothelial dysfunction
● Multi organ failure

4. Failure of second wave of endovascular
trophoblastic migration
Causes:
● Immunological intolerance:
*insufficient shift from Th-1 to Th-2 cells
*increased levels of inflammatory cytokines(TNF alpha,IL6,IL8)
*Abnormal maternal NK cells
● Genetic predisposition
● First time or excessive exposure to chorionic villi

5. Incomplete trophoblastic invasion
Abnormal Vascular remodelling
Vessels remain narrow
Increased resistance , decreased volume
Placental hypoperfusion
Placental
syndrome

6. Placental ischemia Small sized placenta
Reduced
blood flow
to fetus
Inflammatory mediators
Antiangiogenic
factors
● SFlt-1 ( soluble fms
like tyrosine kinase)
● SEng ( soluble
Endoglins)
Angiotensinase
Angiogenic
Factors
● VEGF (Vascular
endothelial growth
factor)
● PIGF (placental
growth factor)
● IL6
● IL8
● TNF alpha
Angiotensin 2

8. SFlt-1
A soluble receptor of VEGF
VEGF
PGI2 ( Prostacyclin)
Thromboxane A2
Endoglin
A soluble receptor of TGF
beta
Nitric oxide
TGF beta Oxidative stress
● Lipid peroxide
● ROS
● Superoxide radicals
Inflammatory
mediators
Angiotensin 2
Endothelial dysfunction
ADA shunt

9. Anti angiogenic factors
Vasoconstriction
Thrombosis
Oxidative stress
Inflammation
Angiogenic factors
Vasodialation
Thrombolysis
Antioxidants

10. Endothelial dysfunction
Vasoconstriction Capillary leak
Extravascular over
hydration
Hemoconcentration
Stasis of blood
Platelet activation and
aggregation
Edema
Ascites
Proteinuria
Pulmonary edema
Hypertension
Organ
hypoperfusion
● Kidney
● Liver
● Brain
● Retina
Virchows
triad
Hyper
coaguability
Multi organ failure
Fibrin thrombi

11. VEGF functions
● Angiogenesis
● Maintenance of fenestrations in capillary
endothelium
● Endothelial repair
● Increases levels of prostacyclin

12. Maternal kidney
● First and most common organ to get involved
● Highly sensitive to VEGF
⬇VEGF
⬇Perfusion
Vasospasm
⬆GFR
Capillary leak
Proteinuria
Albumin, alpha globulin
Swollen fenestrae
Glomerular endotheliosis
Oliguria
● ⬆serum
creatinine
● ⬆Serum urea
● ⬆serum uric acid
Hypercoaguability
Fibrin thrombi
Bilateral renal cortical necrosis

14. Maternal liver
● Hypercoaguability
Fibrin thrombi
in portal capillaries
Periportal hemorrhagic
Necrosis
● Subcapsular hematoma
Periportal necrosis
Subcapsular hemorrhages
Epigastric pain (stretch of glisson capsule)

15. HELLP Syndrome
● Hemolysis : RBCs get damaged as they pass through small vessels with
endothelial damage and fibrin deposits Microangiopathic hemolytic anemia
*schistocytosis,burr cells in peripheral blood smear
● Elevated liver enzymes :
* AST , ALT >70 IU/L
*LDH>600IU/L
*bilirubin >1.2mg/dL
● Low platelet count : <150 000/ mm3 due to increased consumption

16. Maternal brain
Cerebral edema, capillary thrombosis , infarction , parenchymal necrosis and
hemorrhage
PRES (posterior reversible encephalopathy syndrome)
● Bilateral symmetrical vasogenic edema in occipital and posterior parietal
lobes (T2 weighted MRI)
● Clinical features : headache , seizures , altered mental status , vision changes

17. Eclampsia (pre-eclampsia complicated with grandmal seizures)
Extensive damage to the brain
Causes:
● Anoxia
● Cerebral edema
● ⬆Glutamate
● Loss of Cerebrovascular autoregulation
● Cerebral dysrhythmia
Endothelial dysfunction
Vasogenic edema
Ischemia
herniation
Fibrinoid necrosis
of vessels
Microvascular
hemorrhages
infarcts

18. Vision
● Most common visual symptom: scotoma
● Causes of blindness :
*amaurosis ( occipital cortex edema )
*retinal ischemia( purtscher’s retinopathy)
* retinal detachment
● Mostly reversible , corrected after delivery

19. Other organs
● Heart:
*subendothelial hemorrhages
*heart failure
*peripartum dilated cardiomyopathy
● Lung:
*Hemorrhagic bronchopneumonia
*ARDS

20. Effects on fetus
● IUGR
● ⬇ Renal blood flow Oliguria oligohydromnios
● Decreased fetal oxygenation
● Prematurity