pregnancy hypertension

Pregnancy HypertensionMax Angelo G. TerrenalPost-Graduate Medical Intern

Hypertensive disorders complicate 5 to 10% of all pregnancies

Hypertension

Hemorrhage Infection

Maternal Mortality

Rate in the Philippines

2000

Post-partum Hemor-rhage

8.9%

Hypertension complicating pregnancy

32.1%

18%

Pregnancy with abortive outcome

Hemorrhage in early pregnancy

41%Complications

occurring in the course of labor, delivery or

puerperium

Definition of Terms

BP > 140 / 90

Criteria for Diagnosis of HTN in Pregnancy

> 0.3g or 300mg

Proteinuria

+1 or > 30mg/mmol

24-hour urine specimen

Spot urine sample

Swelling of the hands and the face or leg edema after an overnight

rest

Edema

1. Gestational Hypertension2. Chronic Hypertension3. Pre-eclampsia

a. Mild/nonsevereb. Severe

4. Eclampsia5. Preeclampsia syndrome superimposed on

chronic hypertension

Classification

Gestational Hypertension• BP > 140 / 90 mm Hg for first time during pregnancy • No proteinuria • BP returns to normal before 12 weeks postpartum • Final diagnosis made only postpartum • (+) epigastric discomfort or thrombocytopenia

Chronic Hypertension• BP > 140/90 mm Hg prepregnancy or diagnosed

before 20 weeks' gestation not attributable to gestational trophoblastic disease

Or

• Hypertension first diagnosed after 20 weeks' gestation and persistent after 12 weeks postpartum

Gestational Hypertension

• BP > 140 / 90 mm Hg for first time during pregnancy

• BP returns to normal before 12 weeks postpartum

• BP > 140/90 mm Hg prepregnancy or diagnosed before 20 weeks gestation

• Hypertension first diagnosed after 20 weeks' gestation and persistent after 12 weeks postpartum

Chronic Hypertension

PreEClampsia• BP > 140/90 mm Hg after 20 weeks' gestation

• Proteinuria > 300 mg/24 hours or > 1+ dipstick

Mild/NonSevere

Severe PreEclampsiavs

NonSevere SevereBP 160/110

mmHg< 2+ > 3+

Normal Marked

< >Proteinuri

aSerum

CreatinineThrombocytopeni

aAbsent Present

Transaminase Elevation

MarkedMinimal

NonSevere Severe

HeadacheVisual Disturbances

Upper Abdominal PainOliguria

Pulmonary EdemaFetal-growth restriction

Eclampsia

• Seizures that cannot be attributed to other causes in a woman with preeclampsia

PreEclampsia Seizures Eclamspia

Preeclampsia syndrome superimposed on

chronic hypertension• New-onset proteinuria > 300 mg/24 hours in

hypertensive women but no proteinuria before 20 weeks' gestation

ETIOPATHOGENESIS

VasospasmPathophysiology

ETIOLOGY1. Placental implantation with abnormal trophoblastic

invasion of uterine vessels2. Immunological maladaptive tolerance between

maternal, paternal (placental), and fetal tissues3. Maternal maladaptation to cardiovascular or

inflammatory changes of normal pregnancy4. Genetic factors including inherited predisposing genes

as well as epigenetic influences.

Abnormal Trophoblastic Invasion

Maternal immune tolerance

Endothelial Cell Dysfunction

Genetic Factors

Management

Basic Management1. Termination of pregnancy with the least possible

trauma to mother and fetus2. Birth of an infant who subsequently thrives3. Complete restoration of health to the mother

Evaluation1. Weight2. Proteinuria on admittance and at least every 2 days

thereafter 3. Blood pressure readings4. Measurements of plasma or serum creatinine and liver

transaminase levels, and hemogram to include platelet quantification.

5. Evaluation of fetal size and well-being and amnionic fluid volume

Gestational Hypertension and Mild PreEclampsia

Approximately 35% of women with gestational hypertension with onset at <34 weeks develop preeclampsia

Home ManagementVS

Hospitalization

Home Management• BP <140/100 mmHg• Proteinuria < 1,000mg 24hr or <2+ on dipstick• Platelet count > 120,000/mm• Normal fetal growth and testing• No indication for delivery

Hospitalization• Gestational age > 40 weeks• Gestational age > 37 weeks if there is• Bishop score > 5• Fetal weight <10th percentile• Non-reactive non-stress test

Hospitalization• Gestational age 34 weeks and above with the presence

of• Labor• Rupture of membranes• Vaginal bleeding• Abnormal biophysical profile• Criteria for severe preeclampsia

• Expectant management should be considered for women remote from term who have mild preeclampsia

Out-Patient• BP at each visit – at least once weekly• Platelet count and liver enzymes at regular intervals• NST at regular intervals• Fetal growth every 2 to 3 weeks

Medications• Anticonvulsants are not recommended• Anti-Hypertension meds only for increase in BP from

baseline• Low dose aspirin and high dose calcium are not

recommended

Severe PreEclampsia

Hypertension

5-6%

Severe 5-10%

Pregnancies

Criteria for the diagnosis of severe preeclampsia

SymptomsCNS dysfunction Blurred vision, scotomata, altered mental status, headache

Liver capsule distention or rupture Persistent RUQ and/or epigastric pain

SignsBlood Pressure > 160/110 mmHg CVA

Pulmonary Edema Cortical blindness

Laboratory FindingsProteinuria >5g/24h or >3+ on 2 random urine samples

Oliguria and/or renal failure Urine output <500mL/24h and/or serum creatinine > 1.2mg/dL

HELLP syndrome Evidence of hemolysis (abnormal PBS, total bilirubin > 1.2mg/dL, LDH >600U/L)Elevated liver enzymes (ALT > 70U/L)Low platelets (<100,000/mm3)

Hepatocellular Injury Serum transaminase levels >2 x normal

Thrombocytopenia <100,000/mm3

Coagulopathy PT >1.4s, low platelet count and low fibrinogen (<300mg/dL)

The main objective in the management of severe preeclampsia must always be the safety of mother and the fetus

DeliveryVS

Expectant Management

> 34 weeks AOG

1.Proteinuria2.IUGR with good fetal testing3.Blood pressure

Perinatal Complications•Abruptio placenta•Uteroplacental insufficiency• Increased premature deliveries• Increased cesarean section deliveries

Maternal Complications•HELPP syndrome•Pulmonary edema•Eclampsia•Acute renal failure•DIC and thrombocytopenia•Cerebral hemorrhage

TerminationVS

Delivery24 to 26 weeks, perinatal survival at 60%

> 26 weeks almost 90%

Before 23 weeks with severe preeclampsia

Anti-Seizure Prophylaxis

Serum concentration of MgSO4 Clincal Response

4-7meq/L 4.8-8.4mg/dL 2.0-3.5mmol/L Therapeutic prophylaxis

10meq/L 12mg/dL CNS depression

12meq/L Respiratory Depression

17 Coma

20-25 Cardiac arrest

Treatment with calcium gluconate or calcium chloride, 1 g intravenously, along with withholding further magnesium sulfate,

usually reverses mild to moderate respiratory depression.

Fluid ManagementFluid restriction with 80ml/h or 1ml/kg/h

Baseline Cardiotocography

BP > 160/110mmHg

Target of 140-155/90-105mmHg

Anti-hypertensives

Drugs for Urgent Control of Severe Hypertension

Labetalol 10 to 20mg IV, then 20-80mg q20-30 minutes

Hydralazine 5mg IV or IM, then 5 to 10 every 20 to 40 minutes

Nifedipine 10 to 30mg PO, q45 minutesIV Nicardipine Start at 0.1mg/mL with maximum of

10mg/hrAtenolol, ACEi, ARBs and diuretics should be avoided

Corticosteroids• Indicated for lung maturity• Between 24-34 weeks• Betamethasone 12mg IM every 24 hours for 2 doses•Dexamethasone 6mg IM every 12 hours for 4 doses

Eclampsia

Goals of treatment for eclampsia

• Control of seizure• Correction of hypoxia and acidosis• Control of blood pressure•Delivery after control of seizure

Hospitalization

Control of Seizure

Anti-hypertensive therapy

Delivery

Chronic Hypertension

• Low dose aspirin (65-85mg) at bedtime everyday for 12 weeks until birth• ACEi and ARB are contraindicated• Anti-hypertensive therapy•Methyldopa 250-500mgPO BID-QID (max 2 g/day)• Labetalol 1000499mg PO BID0ID (max 1200mg/day)•Nifedipine 10-20mg PO BID-TID max, 120-180mg/day

HELLP•Hemolysis•Elevated liver enzymes•Low platelets

HELLP•Hemolysis•Abnormal peripheral smear• LDH > 600 IU.L•Bilirubin > 1.2mg/dL

•Elevated liver enzymes•AST > 70 IU/L

•Low platelets• Platelet count < 100,000/mL

Complete HELLP

InComplete HELLPvs

Develops suddenly in the 3rd Trimester or immediate Postpartum

• Malaise• Epigastric or RUQ

pain• Nausea and vomiting

Delivery•Beyond 34 weeks AOG•Earlier• MOD• DIC• Liver infarction• Hermorrhage• Renal Failure• Nonreassuring fetal status

•MgSO4

•Control of hypertension•Stabilization of maternal condition

Abruptio Placenta

End