hypertension in pregnancy-latest

8/11/2019 Hypertension in Pregnancy-latest

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Jumarni Binti Abdurachman

Aizuddin Azim Bin Zainuddin


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DefinitionChronic HPT

Gestational HPT (PIH)Pre-eclampsiaEclampsia


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Raised BP; EITHER Systolic BP > 140mmHg previously

normotensive Diastolic BP > 90mmHg

An increase of 15 mmHg and 30 mmHg diastolic andsystolic BP levels above baseline BP is no longerrecognized as hypertension if absolute values are below

140/90 mmHg. Nevertheless, this warrants closeobservation, especially if proteinuria and hyperuricaemiaare also present (CPG 2008)


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Chronic hypertension - hypertension that is present at the booking visit orbefore 20 weeks or if the woman is already taking antihypertensivemedication when referred to maternity services. It can be primary orsecondary in etiology.

Eclampsia - convulsive condition associated with pre-eclampsia.

Gestational hypertension (PIH) - is new hypertension presenting after 20weeks without significant proteinuria.

Pre-eclampsia - new hypertension presenting after 20 weeks with significantproteinuria.

Severe pre-eclampsia - pre-eclampsia with severe hypertension and/or withsymptoms, and/or biochemical and/or haematological impairment.

Significant proteinuria- if the urinary protein:creatinine ratio is greater than 30mg/mmol or a validated 24-hour urine collection result shows greater than 300mg protein.


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New onset of hypertension after

20 weeks gestation


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Molar

pregnancy

Primigravida

Multiplepregnancy

DMPolyhydramnios

Hydropfetalis

Previoush/o PIH


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Maternal FetusEclampsia

Renal failure

Thrombocytopenia

Abruptio placenta

Sub-capsular hemorrhage

and liver dysfunction

-- HELLPHeart failure

Pulmonary oedema

Retinal hemorrhage

IUGR

Fetal hypoxia &

IUD


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Degree of hypertension Mild hypertension

(140/90 to 149/99

mmHg)

Moderate hypertension

(150/100 to

159/109 mmHg)

Severe hypertension

(160/110 mmHg or

higher)

Admit to hospital No Yes Yes (until blood pressure is159/109 mmHg or lower)

Treat No oral labetalol as first-linetreatment to keep:

diastolic blood pressurebetween 80100 mmHg

systolic blood pressure lessthan 150 mmHg

oral labetalol as first-linetreatment to keep:

diastolic blood pressurebetween 80100 mmHg

systolic blood pressureless than 150 mmHg

Measure blood pressure Not more than once aweek

At least twice a week At least four times a day

Test for proteinuria At each visit At each visit Daily

Blood tests Only those for routineantenatal care

Test kidney function,electrolytes, full blood count,transaminases, bilirubin

# Do not carry out further

blood tests if no proteinuria atsubsequent visits

Test at presentation andthen monitor weekly:kidney function,electrolytes, full bloodcount, transaminases,

bilirubin


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Fetal kick chartDaily CTG

U/S (detect growth restriction- fetal growth &AFI)Umbilical blood flow monitoring by doppler


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SHOULD NOT USE:

ACE inhibitors

blocker agent (propanolol) : a/w fetal growth

restriction in long term use

Diuretics : reduce plasma volume thus may cause

IUGR

DO NOT REDUCE blood pressure TOO QUICKLY. It

may compromise utero-placental blood flow


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Only CURE is

DELIVERY

Indications for delivery

Inability to control maternalblood pressure

Progressive deterioration inrenal/hepatic function

Signs/symptoms of impendingeclampsia

Progressive thrombocytopenia

Severe IUGR/signs of fetal

distress


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Hypertension that is present at the bookingvisit or before 20 weeks or if the woman is

already taking antihypertensive medicationwhen referred to maternity services. It can

be primary or secondary in etiology.


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Renal disease - Glomerulonephritis- Renal artery stenosis- Diabetic nephropathy- Polycystic kidneys

Endocrine causes - Phaechromocytoma- Conns Syndrome- Cushings

Others -Coarctation of aorta


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Women with chronic hypertension may require a

change in the type of antihypertensive agentused pre-pregnancy

The drugs of choice in pregnancy:Methyldopa labetalol

Atenolol has been shown to lead to fetal growthrestriction.

The use of ARBs & ACEIs is contraindicated inpregnancy.


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High blood pressure with proteinuria Also known as

Gestational proteinuric hypertension Preeclamptic toxemia (PET)

Affects many organs i.e. placenta, kidney,

liver, heart, brain Reduced blood flow


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Clinically diagnosed in the presence of de novo hypertension after gestationalweek 20, and one or more of the following:

i. Significant proteinuria.

ii. Renal insufficiency: serum creatinine >90 mol/l or oliguria.

iii. Liver disease: raised transaminases and/or severe right upper quadrant orepigastric pain.

iv. Neurological problems: convulsions (eclampsia), hyperreflexia with clonus orsevere headaches, persistent visual disturbances (scotoma).

v. Haematological disturbances: thrombocytopenia, coagulopathy, haemolysis.

vi. Fetal growth restriction. This is followed by normalisation of the BP by three months postpartum. Oedema is no longer part of the definition of preeclampsia. Either excessive

weight gain or failure to gain weight in pregnancy may herald the onset ofpreeclampsia.


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Moderate risk

Primigravida

Extremes of age (40) Pregnancy interval >10 years

Family history of pre-eclampsia

Multiple pregnancy


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High risk

Hypertensive disease in previous pregnancies

Chronic kidney disease Autoimmune (e.g. SLE, antiphospholipid

syndrome)

Diabetes mellitus

Chronic HPT


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Maternal Eclampsia

Renal failure

Thrombocytopenia Abruptio placenta

HELLP (hemolysis, elevated liver enzymes, lo plateletcount)

Heart failure

Pulmonary edema

Retinal hemorrhage *fundoscopy during physical

examination


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Fetal (reduced placental blood flow)

IUGR

Fetal hypoxia Intrauterine death (IUD)


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Headache Nausea, vomitting

Blurring of vision, papilloedema Hyperreflexia Epigastric pain liver involvement Sudden increase of edema (e.g. facial

puffiness) Lethargy hemolytic anemia


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Renal values

Serum creatinine >150 umol/L

Serum uric acid >5.6 mg/dL Sensitive indicator of renal damage in pre-

eclampsia

Oliguria


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Proteinuria

1. 24-hour urine protein

>300mg/ 24hr significant >5g/ 24hr impending eclampsia

2. Urine dipstick

+, ++ or +++

To rule out renal disease, UTI,contamination, etc


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Transabdominal ultrasound to look forgrowth restriction (abdominal circumference)

Doppler ultrasound to assess umbilicalartery blood flow Cardiotocography Fetal kick chart


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Cure: To deliver Same as gestational hypertension in

pregnancy


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High BP, proteinuria + convulsion Life-threatening, an obstetric emergency

Secure airway Keep patient at left lateral decubitus position

Reduce risk of aspiration

Improves uterine blood flow (relieves obstruction

of vena cava by gravid uterus)

Protect patient from injuring herself


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IV MgSO44g for 5 min

Then, 1g/hr for 24 hours

Further dose of 2-4g for 5 minif recurrent seizures


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If BP high, IV bolus Labetolol 20mg Consider delivery of baby

Do vaginal examination for possibility ofvaginal delivery If not possible, do caesarean section


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