pregnancy hypertension
DESCRIPTION
Presented on February 23, 2014 @ VMMC OB-GYN Department office, PhilippinesTRANSCRIPT
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