hypertension during pregnancy gestational hypertension

HYPERTENSION DURING HYPERTENSION DURING PREGNANCYPREGNANCY

Gestational Gestational HYPERTENSIONHYPERTENSION

HYPERTENSION DURING HYPERTENSION DURING PREGNANCYPREGNANCY

Gestational Gestational HYPERTENSIONHYPERTENSION

Sarreshtedar.A.MD.AFSASarreshtedar.A.MD.AFSA

Hypertension complicationscomplications in pregnant

womenwomen(10%)

Maternal mortality & morbidity.

Abruptio placenta

Pulmonary edema

Respiratory failure

Cerebral hemorrhage

Hepatic failure

Acute renal failure.

DIC

Hypertension complicationcomplication

In

pregnancy (BABY)(BABY)

Fetal prematurely

Intrauterine growth retardation

Stillbirth

Neonatal death

PREGNANCYPREGNANCY::

HYPERTENSION DISORDERSHYPERTENSION DISORDERS

Chronic hypertensionChronic hypertension

Gestational hypertensionGestational hypertension

Preecampsia-EclampsiaPreecampsia-Eclampsia

Chronic Hypertension

DEFINED:

Precedes pregnancy

Before 20th gestational week

Fails to normal 12 week after delivery.

Chronic hypertension

1%-5% of pregnancies

15% with increased complications

Most complications occur in those more than 30y/o

Chronic Hypertension Complications in PREGNANCYChronic Hypertension Complications in PREGNANCY::

))15%15%((

Fetal growth retardation

Premature delivery

Abruptio-placenta

Acute renal failure

Hypertension crisis

Most of these complications occurMost of these complications occur::

In patients older than 30 y/o

Longer duration of hypertension

Superimposed preeclampsia.

25% of pregnancies (most) associated with chronic hypertension occurs in the setting of

superimposed preeclampsia

CHRONIC HYPERTENSION & PREGNANCYCHRONIC HYPERTENSION & PREGNANCY::

LOW-RISK LOW-RISK patientspatients::

SBP=140-160 mmHg

DBP=90-110 mmHg

Normal physical examination

Normal EKG

No proteinuria.

CHRONIC HYPERTENSION & PREGNANCYCHRONIC HYPERTENSION & PREGNANCY::

HIGH- RISKHIGH- RISK patients patients::

SBP=more than 160 mmHg

DBP=more than 110 mmHg

Signs of preeclampsia.

Signs of end organend organ Involvement

Renal insufficiency

Diabetes mellitus

Collagen vascular disease.

CHRONIC HYPERTENSIONCHRONIC HYPERTENSION::

Incidence of prenatal mortality is high.

Fetal growth-Retardation is high.

Definition:

Rise in pressure of 30/1530/15 mmHg .

Or

Greater than 140/90 mmHg.

GESTETIONAL HYPERTENSIONGESTETIONAL HYPERTENSION: :

GESTATIONAL HYPERTENSIONGESTATIONAL HYPERTENSION::

Induced by pregnancy

Beginning after 20 weeks

Resolving by the sixth postpartum week.

GESTATIONAL HYPERTENSIONGESTATIONAL HYPERTENSION::

Transient hypertension.

Preeclampsia.

GESTATIONAL HYPERTENSIONGESTATIONAL HYPERTENSION

))TRANSIENTTRANSIENT((

Without proteinuria.

In the late third trimester.

Return to normal by 10th post partum day.

GESTATIONAL HYPERTENSIONGESTATIONAL HYPERTENSION::

))PREECLAMPSIAPREECLAMPSIA((

With proteinuria

Edema

SBP greater than 160 mmHg160 mmHg

DBP greater than 110 mmHg110 mmHg

Gestational hypertension

is

Self-limited and less commonly in next pregnanciespregnancies.

BUT

• Chronic hypertension

progresses and complicates in subsequent pregnanciespregnancies.

  PreeclampsiaPreeclampsia  Chronic HypertensionChronic Hypertension

Age Young<20( (  Older>30( (

Parity Primigravide  Multipara

Onset After 20 weeks of pregnancy  

Before 20 weeks of pregnancy

Weight gain and edema Sudden  Gradual

Systolic blood pressure  > >160160   < <160160

Funduscopic findings Spasm,edema  

Arteriovenous nicking, exudates

Proteinuria Present  Absent

Plasma uric acid Increased  Normal

Blood pressure after deliveryNormal  Elevated

Difference Between Preeclampsia And Chronic HypertensionDifference Between Preeclampsia And Chronic Hypertension: :

PREECLAMPSIA-ECLAMPSIAPREECLAMPSIA-ECLAMPSIA::

DefinitionDefinition::

BP more than 140/90 mmHg140/90 mmHg

After 20 weeks

Edema

Proteinuria

convulsion

Hypertension appears in 12%12% of first pregnancies after 20 weeks

50%50% of these 12%12% will progress to

preeclampsia.

PREECLAMPSIA-ECLAMPSIAPREECLAMPSIA-ECLAMPSIA::Pregnancy specific syndrome

Proteinuria more than 300 mg/24h

Regresses within 24h 48h After delivery

PREECLAMPSIA-ECLAMPSIAPREECLAMPSIA-ECLAMPSIA

PRESENTATIONPRESENTATION::

Blurred vision

Pulmonary edema

Abdominal pain

Abnormal laboratory tests :liver enzymes – low platelet ……

Mechanism

unknown

But

Hypothesis are:

Profound vasoconstriction

High cardiac output.

Decreased Prostaglandin SynthesisDecreased Prostaglandin Synthesis

Vascular prostacyclin uterine PGE 2Vascular prostacyclin uterine PGE 2

platelet platelet aggregationaggregation

angiotensionangiotension sensitivitysensitivity

Fibrin deposition in Fibrin deposition in glomeruliglomeruli

vasoconstrictionvasoconstriction

uteroplacental blood uteroplacental blood flowflow

uterine reninuterine renin

PROTEINURIAPROTEINURIA GFRGFR

Sodium retentionSodium retention

EDEMAEDEMAHYPERTENSIONHYPERTENSION

POST PARTUM ECLAMPSIAPOST PARTUM ECLAMPSIAUsually occurs within 1010 days after delivery

with:

Hypertension

Proteinuria

Convulsion

MANAGEMENTMANAGEMENTPrimary goalPrimary goal::

Prevent maternal cerebral complications

Secondary goalSecondary goal: :

Reduction of:

SBP below 126mmHg

DBS between 90-100mmHg

NOTICENOTICE::Gestation hypertension is self- limited

Delivery is the only definitive treatment for preeclampsia

MANAGEMENTMANAGEMENT

INDICATION FOR INDICATION FOR DrugsDrugs::

SBP more than 150 mmHg150 mmHg

DBS more than 100 mmHg

Target organ damage

LV hypertrophy

Renal insufficiency

DRUGDRUG SELECTION SELECTION::1)For acute treatment of sever hypertension

2)For long term treatment of hypertension

ClassClass  DrugDrug  DoseDose 

Arterial dilator Hydralazine  5-10 mg IV q 15-30 min

  diazohide  30-60mg IV q 10-15 min

Calcium channel blocker

 Nifedipine 10-20mg PO q 30 min

Alpha/beta-adrenergic blocker

 Labetalol 20-40-80mg IV q 10-20 min

     )up to 300 mg(

Arterial /venous dilator

 Sodium

nitroprusside )50 mg/250 ml saline:(0.5-5.0

    kg/min 

Drugs for Acute treatment of Sever HypertensionDrugs for Acute treatment of Sever Hypertension::

METHOD OF TREATMENT IN SEVER HYPERTENSIONMETHOD OF TREATMENT IN SEVER HYPERTENSION::

11::HydralazinHydralazin: (: (Initial DrugInitial Drug))

5 mg bolus iv over 2 minutes

After 20 minutes repeat

And repeated as necessary

22 : :LabetalolLabetalol: (: (second drugsecond drug))

If hydralazin not effective or

Maternal side effects:

•Tachycardia

•Headache

•nausea

Labetalol usingLabetalol using: :

2020 mg iv

After 10 minutes 4040 mg iv

After 3 doses 8080 mg in interval of 10-20 minutes

After 1-21-2 mg/min in continuous infusion

CLASSCLASS  DRUGDRUG  Starting Starting

DoseDoseMaximum DoseMaximum Dose

Central alpha-agonist Methyldopa  250250 mg tidmg tid44 g/dg/d

  clonidin  0.1-0.30.1-0.3 mg mg bidbid1.21.2 mg/dmg/d

Alpha-adrenergic blocker Prazosin 11 mg bidmg bid2020 mg/dmg/d

Calcium chanel blocker Nifedipine 1010 mg qidmg qid120mg/d120mg/d

Beta-adrenergic blocker Atenolol 100100 mg qdmg qd100100 mg/bidmg/bid

Alpha/beta-adrenergic blocker

 Labetalol 100100 mg tidmg tid24002400 mg/dmg/d

Diuretics Hydrochlorothiazide 2525 mg qdmg qd5050 mg/dmg/d

Drugs for long-term treatment of hypertensionDrugs for long-term treatment of hypertension::

NOTICENOTICE::PREFERRED THERAPY:METHYL-DOPAMETHYL-DOPA

ACE inhibitors and angiotensin II receptor blockers are:

Contraindication

because induce neonatal renal failureneonatal renal failure.

بسم الله دواءبسم الله دواء

وااحمدلله شفاء وااحمدلله شفاء

هو الشافی هو الشافی شفاءشفاء

Clinical features:

Chronic hypertension

Gestational hypertension

Preeclampsia - Eclampsia

RISK

HIGH: 160/110

LOW:

SBS=140-160

DBS=90-110

NORMAL EKG

NORMAL ECHO/

NO PROTEINURIA

Gestational hypertension

DEFINED:

Induced by pregnancy

Beginning after 2020 weeks

Resolving by the sixthsixth postpartum week

Gestational hypertension

Divided by:

Hypertension without proteinuria (transient )

Hypertension with proteinuria

CHRACTRISTICS OF PREECLAMPSIA-ECLAMPSIA

BP more than 160/90 mmHg

Headache

Blurred vision

Pulmonary edema

Abdominal pain

Low platelets

Abnormal liver tests

Usually regresses within 24-48 hr24-48 hr after delivery.

TreatmentTreatment::

Primary goal is to prevent maternal complications.

Recommended goal of therapy is reduction of mean SBP below 126 mmHgSBP below 126 mmHg & DBP between 90-105 DBP between 90-105 mmHgmmHg