PREGNANCY PREGNANCY INDUCED INDUCED

HYPERTENSIONHYPERTENSION

PIHPIH

Gestational HypertensionGestational Hypertension or or

pregnancy-induced hypertensionpregnancy-induced hypertension

Defined as the Defined as the Development of Development of newnew arterial hypertensionarterial hypertension in a in a

pregnantpregnant woman after 20 weeks gestation woman after 20 weeks gestation

INCIDENCEINCIDENCE

5 percent to 8 percent of all pregnancies. 5 percent to 8 percent of all pregnancies. Young womenYoung women First pregnancyFirst pregnancy Twin pregnanciesTwin pregnancies Previous pre-eclmaptic pregnancyPrevious pre-eclmaptic pregnancy Diabetese MallitusDiabetese Mallitus Chronic hypertensionChronic hypertension

TypesTypes

PIHPIH Pre-eclampsia (Toxemia of pregnancy)Pre-eclampsia (Toxemia of pregnancy)

MildMild SevereSevere

EclampsiaEclampsia HELLP syndromeHELLP syndrome

PIHPIH

MILDMILD

BP 140/90BP 140/90 SEVERESEVERE

BP 160/110 or moreBP 160/110 or more

CharacteristicsCharacteristicsof of

Pre-EclampsiaPre-Eclampsia

HypertensionHypertension ProtienuriaProtienuria EdemaEdema

PRIMARY CHARACTERISTICS PRIMARY CHARACTERISTICS

High blood pressure High blood pressure

140/90 mm Hg140/90 mm Hg

or a significant increase in or a significant increase in one or both pressures one or both pressures

Proteinuria (300 mg or >/24 hours urine)Proteinuria (300 mg or >/24 hours urine)• Or Urinolysis +++ or ++++Or Urinolysis +++ or ++++

Edema or recent rapid weight gainEdema or recent rapid weight gain

ECLAMPSIAECLAMPSIA

SevereSevere form of PIH form of PIH Women with eclampsia have Women with eclampsia have seizuresseizures Occurance one in 1,600 pregnanciesOccurance one in 1,600 pregnancies Develops near the end of pregnancy, in Develops near the end of pregnancy, in

most cases.most cases.

HELLP syndromeHELLP syndrome

Complication of severe pre-eclampsia or Complication of severe pre-eclampsia or eclampsia. eclampsia.

group of physical changes:group of physical changes:

Breakdown of RBCs, Breakdown of RBCs,

Changes in the liverChanges in the liver

Low plateletsLow platelets

HELLPHELLP

H:H: Haemolysis Haemolysis EL:EL: Elevated Liver EnzymesElevated Liver Enzymes LP:LP: Low PlateletsLow Platelets

HELLPHELLPDiagnosisDiagnosis

HemolysisHemolysis

Blood smearBlood smear

Bilirubin 1.2 mg/dl or moreBilirubin 1.2 mg/dl or more

Elevated liver enzymesElevated liver enzymes

SGOT (asperate aminotransferase) > 70 SGOT (asperate aminotransferase) > 70 U/LU/L

Lactate dehydrogenase > 600 U/LLactate dehydrogenase > 600 U/L

Low PlateletsLow Platelets

<100,000 per mm<100,000 per mm33

cause cause of PIH of PIH

unknownunknown

??????

PathophysiologyPathophysiology

Immunologic responseImmunologic response Endothelial Dysfunction Endothelial Dysfunction Abnormal Prostaglandin MetabolismAbnormal Prostaglandin Metabolism Platelet DysfunctionPlatelet Dysfunction CalciumCalcium Coagulation factorsCoagulation factors Fatty metabolismFatty metabolism Markers of angiogenesisMarkers of angiogenesis

1-Immunologic response1-Immunologic response

Abnormal Abnormal

fetal-maternal antigen-antibody responsefetal-maternal antigen-antibody response Spermatozoa cause formation antibody or Spermatozoa cause formation antibody or

prostaglandins which cause VCprostaglandins which cause VC Normally at 20 weeks, Maternal spiral arteries are Normally at 20 weeks, Maternal spiral arteries are

invaded by trophoblast causing release of PGI and invaded by trophoblast causing release of PGI and NO,NO,

this mechanism lacks in pre eclampsiathis mechanism lacks in pre eclampsia

>>>>>>>>high resistance low flow uteroplacental circulation

22 Endothelial cell dysfunctionEndothelial cell dysfunction

in response to unknown factorsin response to unknown factors Resulting in Resulting in imbalanceimbalance in the production ofin the production of :PGI :PGI2 2

and EDRF(NO)and EDRF(NO) >> >> VasodialatorVasodialator&&

:TXA:TXA22 derived from platelets & endothelaium derived from platelets & endothelaium>>>>VasoconstrictorVasoconstrictor

ET-1: chorionic plate arteries constrictor, ET-1: chorionic plate arteries constrictor, elevated in pre-eclampsia elevated in pre-eclampsia

& & pre term rupture of membranepre term rupture of membrane

33 Platelet factorPlatelet factor

Normally aggregating platelet release (serotonin) Normally aggregating platelet release (serotonin) 5HT + 5HT receptors >> release of NO &5HT + 5HT receptors >> release of NO &

Prostacyclin Prostacyclin >>>> Angiotensin II >> improve Angiotensin II >> improve uteroplacental blood flowuteroplacental blood flow

Loss of 5-HT receptor prevents stimulation Loss of 5-HT receptor prevents stimulation of angiotensin II release in pre eclampsiaof angiotensin II release in pre eclampsia

44 CALCIUMCALCIUM

Instead of normal slow rise of intracellular Calcium Instead of normal slow rise of intracellular Calcium concentration concentration

In Pre eclampsia CaIn Pre eclampsia Ca++++ increases rapidly increases rapidly

also enhanced by angiotensin IIalso enhanced by angiotensin II

(Sensitive indicator of subsequent (Sensitive indicator of subsequent development)development)

44 Other FactorsOther Factors

Coagulation factorsCoagulation factors

disturbance between plasma ratio of von disturbance between plasma ratio of von Willebrand factor and factor VIII Willebrand factor and factor VIII

Fatty metabolismFatty metabolism

increased free fatty uptake by liverincreased free fatty uptake by liver

hypertriglyceridemiahypertriglyceridemia Markers of angiogenesisMarkers of angiogenesis

FLT-I, VEGF (vascular endothelial growth FLT-I, VEGF (vascular endothelial growth factor)factor)

RISK FACTORSRISK FACTORSfor PIHfor PIH

pre-existing hypertension pre-existing hypertension kidney disease kidney disease Diabetes MallitusDiabetes Mallitus PIH with a previous pregnancy PIH with a previous pregnancy Mother's age Mother's age

younger than 20 or older than 40 younger than 20 or older than 40 multiple fetuses (twins, triplets)multiple fetuses (twins, triplets) Vascular DiseasesVascular Diseases

Why is pregnancy-induced Why is pregnancy-induced hypertension a concern?hypertension a concern?

With high blood pressure there is an increase in With high blood pressure there is an increase in the resistance of blood vessels. the resistance of blood vessels.

This may hinder blood flow in many different This may hinder blood flow in many different organ systems in the expectant mother including organ systems in the expectant mother including the the liver, kidneys, brain, uterus, and liver, kidneys, brain, uterus, and placenta.placenta.

Baby required to be Baby required to be delivered early, before 37 delivered early, before 37 weeks gestation.weeks gestation.

Complications Complications

MaternalMaternal FetalFetalDICDIC Pre-maturityPre-maturity

CCF with pulmonary edemaCCF with pulmonary edema Respiratory DistressRespiratory Distress

Placental AbruptionPlacental Abruption IUG retardationIUG retardation

PPHPPH OligohydromniosOligohydromnios

ARFARF Intracranial HemorrhageIntracranial Hemorrhage

Rupture of LiverRupture of Liver Small for ageSmall for age

CVA, SeizuresCVA, Seizures Meconium aspirationMeconium aspiration

Septic shockSeptic shock More Morbidity/MortalityMore Morbidity/Mortality

Symptoms of PIHSymptoms of PIH

NeurologicalNeurological Headach, Visual distubancesHeadach, Visual distubances

Hyperexcitability, SeizersHyperexcitability, Seizers

Intracranail hemorrhages, Cerebral edemaIntracranail hemorrhages, Cerebral edema

PulmonaryPulmonary Upper airway edemaUpper airway edema

Pulmonary edemaPulmonary edema

CardiovascularCardiovascular Decreased intravascular volumeDecreased intravascular volume

Increased arteriolar resistanceIncreased arteriolar resistance

Hypertension, Heart failureHypertension, Heart failure

HepaticHepatic Impaired function, Elevated enzymesImpaired function, Elevated enzymes

Hematoma, RuptureHematoma, Rupture

RenalRenal Protienuruia, Sodium retentionProtienuruia, Sodium retention

Decreased GFR Renal FailureDecreased GFR Renal Failure

HematologicalHematological CoagulopathyCoagulopathy

ThrombocytopniaThrombocytopnia

Platelet dysfunctionPlatelet dysfunction

Microangiopathic hemolysisMicroangiopathic hemolysis

How is pregnancy-induced How is pregnancy-induced hypertension diagnosedhypertension diagnosed

Increase in blood pressure levelsIncrease in blood pressure levelsbut other symptoms helpbut other symptoms help

Tests for pregnancy-induced hypertension may include the following:

blood pressure measurement urine testing assessment of edema frequent weight measurements eye examination (retinal changes ) Liver and Renal function tests Blood clotting tests

goal of treatmentgoal of treatment

To prevent the:To prevent the:

Condition from becoming bad to Condition from becoming bad to worse worse

Complications. Complications.

Treatment Treatment for pregnancy-induced for pregnancy-induced

Specific treatment will be determined by the Specific treatment will be determined by the physician based on:physician based on:

pregnancy, overall health, and medical pregnancy, overall health, and medical history history

extent of the disease extent of the disease Tolerance for specific medications, Tolerance for specific medications,

procedures, or therapies procedures, or therapies expectations for the course of the disease expectations for the course of the disease Patient’s opinion or preference Patient’s opinion or preference

Obstetric ManagementObstetric Management

Bedrest (either at home or in the hospital) Hospitalization (specialized personnel and equipment) Magnesium sulfate (or other antihypertensives for PIH) Fetal monitoring may include:

fetal movement counting - fetal kicks and movements change in the number/frequency: means fetus under stress. nonstress testing - measures the fetal heart rate in response to

the fetus' movements.

biophysical profile - combines nonstress test with ultrasound Doppler flow studies

Continued laboratory testing of urine and blood (for changes that may signal worsening of PIH)

Corticosteroids (help mature the lungs of the fetus) Delivery of the baby (if treatments do not control PIH or if the fetus

or mother is in danger)

What antihypertensive medication is What antihypertensive medication is used in PIH ?used in PIH ?

ANTIHYPERTENSIVESANTIHYPERTENSIVES

Diuretic Beta Blocker

ACE inhibitors

/Angiotensin II receptor antagonist

Calcium Channel Blocker

Alpha Blockers

Caution Not

in

late pregnancy

No

Adversely effect fetal and neonatal blood pressure control,

skull defects, oligohydromnios,

toxicity

No

Myocardial depressants

caution

Labetalol Arteriolar dilator

I/V Max 200 mg

2mg/min until satisfactory response

Oral 200 mg BID upto 1200mg

Hydralazine(Apresoline)

Vasodilator

Causes tachycardia fluid retention

Oral 25 mg BD

IV 10mg in 10 ml saline in 20 minutes

Nitrates Isorbid dinitrate, Glyceryl trinitrate, isorbid mono nitrate

Methyldopa(Aldomet)

250 – 500 mg 2-3 times/day

Centrally acting Alph 2 receptor agonist

Sodium Nitropruside

0.5-1.5µgm/kgmin

Cyanide toxocity if treatment exceeds 3 days

Nifedipine(ADALET)

Vasodilator

no myocardial depression

10-20mg BD

Alpha methyldopa 500 mg PO bid (up to 2 grams bid) Alpha methyldopa 500 mg PO bid (up to 2 grams bid) Labetolol 200 mg PO bid (up to 1200 mg bid) Labetolol 200 mg PO bid (up to 1200 mg bid) Felodipine 5 mg PO daily (up to 20 mg daily) Felodipine 5 mg PO daily (up to 20 mg daily) Hydrochlorothiazide Hydrochlorothiazide

Not usually initiated in pregnancy due to volume depletion Not usually initiated in pregnancy due to volume depletion May be continued if on pre-pregnancy - consult with local expert May be continued if on pre-pregnancy - consult with local expert

opinion opinion Nifedipine XL 30 mg PO bid (up to 120 mg daily) Nifedipine XL 30 mg PO bid (up to 120 mg daily) Hydralazine 10 mg PO tid (up to 25 mg tidHydralazine 10 mg PO tid (up to 25 mg tid

GOAL GOAL ofof

Antihypertensives Antihypertensives

Blood Pressure < 150/100 Blood Pressure < 150/100

(much higher than non-pregnant goal)(much higher than non-pregnant goal) Anti-hypertensives are Anti-hypertensives are not indicatednot indicated for mild to for mild to

moderate chronic Hypertension in pregnancy moderate chronic Hypertension in pregnancy BP <150/100 does not reduce risk to fetus BP <150/100 does not reduce risk to fetus

or prevent Preeclampsia or prevent Preeclampsia Antihypertensives benefit mother only Antihypertensives benefit mother only do not reduce pregnancy complicationsdo not reduce pregnancy complications

Pre-Operative EvaluationPre-Operative Evaluation

Investigations ?Investigations ?

Blood complete pictureBlood complete picture Platelet countPlatelet count Coagulation assay, PT, APTT, Fibrinogen, D - dimerCoagulation assay, PT, APTT, Fibrinogen, D - dimer Serum Urea/creatinine Electrolytes Uric AcidSerum Urea/creatinine Electrolytes Uric Acid LFTsLFTs Urinolysis, Microscopy, 24 Hours specimen for protien Urinolysis, Microscopy, 24 Hours specimen for protien

and creatinine clearenceand creatinine clearence Type and screen BloodType and screen Blood

MonitorsMonitors NIBPNIBP SaOSaO22 Hourly deep tendon reflexHourly deep tendon reflex Muscle strengthMuscle strength Serial Magnesium Sulphate levelsSerial Magnesium Sulphate levels Foleys Catheter for urine volumeFoleys Catheter for urine volume Urine concentrationUrine concentration Fetal heart RateFetal heart Rate IBPIBP CVPCVP Persistent oligouria, difficulty in fluid management Persistent oligouria, difficulty in fluid management

therapy in ante/post partum period, Pulmonary therapy in ante/post partum period, Pulmonary edemaedema

PAPASevere eclampsia Left ventricular systolic function is Severe eclampsia Left ventricular systolic function is markedly reducedmarkedly reduced

CVP 92% versus PA 8%CVP 92% versus PA 8%

What condition mandate immediate What condition mandate immediate DeliveryDelivery

Immediate DeliveryImmediate Delivery

Severe HypertensionSevere Hypertension Progressive thrombocytopeniaProgressive thrombocytopenia Liver dysfunctionLiver dysfunction Progressive Renal dysfunction Progressive Renal dysfunction Persistent headache Persistent headache Evidence of fetal jeopardyEvidence of fetal jeopardy Premonitory signs of ECLAMPSIAPremonitory signs of ECLAMPSIA

What drug therapy is the treatment What drug therapy is the treatment of choice for Seizure prophylaxisof choice for Seizure prophylaxis

DiazepamDiazepam PhenytoinPhenytoin Magnesium SulphateMagnesium Sulphate

How to use How to use Magnesium SulphateMagnesium Sulphate

4 - 6 Grams in 20 minutes4 - 6 Grams in 20 minutes

followed by 1-2 gram per hourfollowed by 1-2 gram per hour

MonitorMonitor

Urine outputUrine output

Respiratory rateRespiratory rate

Patellar reflexesPatellar reflexes

Serum levelsSerum levels 4 hourly4 hourly

Serum levels ofSerum levels of Magnesium SulphateMagnesium Sulphate

5 mEq/L5 mEq/L Therapeutic rangeTherapeutic range

10 mEq/L10 mEq/L Loss of deep tendon reflexesLoss of deep tendon reflexes

Prolonged P-Q intervalProlonged P-Q interval

Widening QRS complexesWidening QRS complexes

15 mEq/L15 mEq/L Respiratory ArrestRespiratory Arrest

20 mEq/L20 mEq/L AsystoleAsystole

Role of Magnesium SulphateRole of Magnesium Sulphate CNS depressant & Anticonvulsant CVS Mild Anti-hypertensive effect Neuromuscular Junction

Inhibits Ach releasedecrease membrane excitabilityaugment Non and depolarizing muscle relaxant

UterusMild relaxant effect on vascular & uterine

smooth muscleImprove uterine blood flow

What are fetal effects of MgSOWhat are fetal effects of MgSO44

MgSOMgSO44 crosses the placenta crosses the placenta

• Neonatal depressionNeonatal depression• Respiratory Respiratory • HyporeflexiaHyporeflexia• Decreased beat to beat variability in heart rateDecreased beat to beat variability in heart rate

Treatment of EclampsiaTreatment of Eclampsia

Stop convulsion (Thiopentone 50-100 mg)Stop convulsion (Thiopentone 50-100 mg) ABCABC Apply monitors (Pulse Oximeter, NIBP, ECG)Apply monitors (Pulse Oximeter, NIBP, ECG) I/V lineI/V line Check BP repeatedlyCheck BP repeatedly Administer MgSOAdminister MgSO44

Treat hypertensionTreat hypertension Deliver babyDeliver baby

Intraoperative ManagementIntraoperative Management

What type?What type? Analgesia/AnesthesiaAnalgesia/Anesthesia

for patient with pre-eclampsiafor patient with pre-eclampsiain labourin labour

EPIDURALEPIDURAL Superior pain reliefSuperior pain relief Attenuate the hypertensive response to painAttenuate the hypertensive response to pain Reduce circulating level of catecholamines/hormonesReduce circulating level of catecholamines/hormones Improve intervillous blood flowImprove intervillous blood flow Stable Cardiac outputStable Cardiac output Increased Risk for C-sectionIncreased Risk for C-section

Any Role of PrehydrationAny Role of Prehydration

Prehydration with crystalloidPrehydration with crystalloid compensate for decreased prelaod and after compensate for decreased prelaod and after

laod >>> ANP >> VD >>renal elimination of laod >>> ANP >> VD >>renal elimination of excess ECFexcess ECF

AVOID if there is recent excessive weight gain AVOID if there is recent excessive weight gain (overhydration)(overhydration)

Monitor for pulmonary oedemaMonitor for pulmonary oedema

Role of Bleeding time or Platelet Role of Bleeding time or Platelet count for EPIDURALcount for EPIDURAL

BT not usefulBT not useful Skin bleeding time is not predictor for pre-Skin bleeding time is not predictor for pre-

eclamptic epidural vein bleedingeclamptic epidural vein bleeding Platelet count reliablePlatelet count reliable

• 50-50-80,00080,000

Commonly used Local AnaestheticsCommonly used Local Anaesthetics BupivacainBupivacain

• 4 times potent then lignocain4 times potent then lignocain• Onset 5 times longer then lignocainOnset 5 times longer then lignocain• Fast in, slow outFast in, slow out

RopivacainRopivacain• Single levorotatory isomer rather then racemic solutionSingle levorotatory isomer rather then racemic solution• Less cardiotoxicLess cardiotoxic

LevobupivacainLevobupivacain• Single levorotatory isomerSingle levorotatory isomer• Less cardiotoxicLess cardiotoxic

LignocainLignocain• More Motor block More Motor block • More hypotensionMore hypotension• instant onsetinstant onset

• Note: with adrenaline should not be used in severe pre-Note: with adrenaline should not be used in severe pre-eclampsiaeclampsia

What type of anaesthesiaWhat type of anaesthesia for C Section for C Section

SpinalSpinal GeneralGeneral

Spinal AnaesthesiaSpinal Anaesthesia

BestBest even in severe pre-eclampsia even in severe pre-eclampsia GAGA

Severe hypertensive response to intubation Severe hypertensive response to intubation Risk of difficult intubation due to airway edemaRisk of difficult intubation due to airway edema EpiduralEpidural

Less reliable anaesthesia than spinalLess reliable anaesthesia than spinalRisk of trauma to epidural veinRisk of trauma to epidural vein

Risk of hypotension 6 times less in pre eclamptic Risk of hypotension 6 times less in pre eclamptic pregnant womanpregnant woman

.75% hyperbaric Bupivacain 11-12 mg with or without .75% hyperbaric Bupivacain 11-12 mg with or without 15-20 15-20 µgµg Fentanyl or morphine 100-200 Fentanyl or morphine 100-200 µgµg

General AnesthesiaGeneral Anesthesia Aspiration prophylaxisAspiration prophylaxis Thiopentone sodium inductionThiopentone sodium induction Suxamethonium with cricoid pressureSuxamethonium with cricoid pressure Attenute intubation response by deep anaesthesia & lignocain Attenute intubation response by deep anaesthesia & lignocain Smaller ETT 6-6.5 mm (airway edema)Smaller ETT 6-6.5 mm (airway edema) Nondepolarizing agent after recovery from suxamethonium Nondepolarizing agent after recovery from suxamethonium

Remember MgSORemember MgSO44

2/3 rd MAC for adequate depth of anaesthesia2/3 rd MAC for adequate depth of anaesthesia MgSOMgSO4 4 intra and Post op periodintra and Post op period

IBP line for continuous blood pressure monitoringIBP line for continuous blood pressure monitoring Anti HTN drugsAnti HTN drugs

The EndThe End

Pathology of pregnancy, childbirth and the perpuriumPathology of pregnancy, childbirth and the perpurium

Pregnancy Pregnancy ēē abortiveabortive outcome outcome EctopicEctopic pregnancy pregnancy - - HydatidiformHydatidiform mole mole - - MiscarriageMiscarriage

Oedema, proteinuria andOedema, proteinuria and

hypertensive disordershypertensive disorders Pregnancy-induced hypertension - Pre-eclampsia - Eclampsia - Gestational diabetes Gestational diabetes

Other, predominantlyOther, predominantlyrelated to pregnancyrelated to pregnancy

HyperemesisHyperemesis gravidarumgravidarum - - Gestational Gestational pemphigoidpemphigoid - - IntrahepaticIntrahepatic cholestasischolestasis of pregnancy of pregnancy

Maternal care related to theMaternal care related to theFFetusetus and and amniotic cavityamniotic cavity & &possible possible deliverydelivery problems problems

PolyhydramniosPolyhydramnios - - OligohydramniosOligohydramnios - - ChorioamnionitisChorioamnionitis - - Premature rupture of membranesPremature rupture of membranes - - Amniotic band syndromeAmniotic band syndrome - - Placenta Placenta praeviapraevia - - Braxton Hicks contractionsBraxton Hicks contractions - - AntepartumAntepartum haemorrhagehaemorrhage – –abruptionabruption

Complications ofComplications oflabourlabour and delivery and delivery

Premature birthPremature birth - - PostmaturePostmature birth birth - - CephalopelvicCephalopelvic disproportion disproportion - - DystociaDystocia ( (Shoulder Shoulder dystociadystocia) - ) - Fetal distressFetal distress - - VasaVasa praeviapraevia - - Uterine ruptureUterine rupture - - hemorrhagehemorrhage - - Placenta Placenta accretaaccreta - - Umbilical cord Umbilical cord prolapseprolapse - - Amniotic fluid embolismAmniotic fluid embolism

Maternal complicationsMaternal complicationsin the weeks after in the weeks after childbirthchildbirth

Puerperal feverPuerperal fever - - PeripartumPeripartum cardiomyopathycardiomyopathy - - Postpartum Postpartum thyroiditisthyroiditis - - GalactorrheaGalactorrhea - - Postpartum depressionPostpartum depression

Complications related to the Complications related to the fetusfetus

Fetal interventionFetal intervention - - Fetal surgeryFetal surgery

OtherOther Maternal deathMaternal death