complications of hypertensive disorders of pregnancy by dr shashwat jani

Complications Of HDP

Dr. Shashwat Jani.M. S. ( Obs – Gyn )

Diploma in Advance Laparoscopy.

Consultant Assistant Professor,Smt. N.H.L. Municipal Medical College.

Sheth V. S. General Hospital , Ahmedabad.

Mobile : 99099 44160.E-mail : drshashwatjani@gmail.com

Introduction Giving birth should be a time for celebration,

but for more than half a million women each year—one every minute—pregnancy and childbirth end in death and mourning.

Six percent (approx. 1 in 16) of preeclamptic patients develop one or more major systemic complications .

Many maternal and fetal deaths or “near-misses” are associated with substandard care.

May 1, 2023 Dr Shashwat Jani. 9909944160. 2

HDP complicates 5 to 8% of all pregnancies.

This represents 8.5 million cases a year worldwide.

This pathology remains one of the three leading causes of maternal death.

The majority of these maternal deaths are related to cerebral hemorrhage that is secondary to poorly controlled hypertension.

Objectives

Dr Shashwat Jani. 9909944160. 4

Understanding the complications of HDP Predictions and prevention of these

complications Early identification and appropriate

management Problem based learning .

May 1, 2023

Complications

Obstetric

Mother Fetus

OVERVIEW

Maternal

CNS• Seizures• Cerebral Edema• Cerebral Hemorrhage• Strokes (thrombosis)

Hepatic• Hepatic Failure• Hepatic Rupture• Subcapsular Hemorrhage

Heamatological• DIC• HELLP

Renal• Renal Failure• Oliguria• Proteinuria >> Hypoproteinemia (Glomerular

Injury)

Lungs• Pulmonary Edema

Preterm Delivery

Stillbirth (IUFD)Intrapartum Fetal Distress

Placental Abruption

Uteroplacental Insufficency• Hypoxic Neurological Injury• IUGR• Oligohydraminos

Obstetric

Increased risk for cesarean section

Placenta abruption

Premature labor

COMPLICATIONS

Acute Future Pregnancy Late

Dynamics and incidence patterns of maternal complications in early-onset hypertension of pregnancy Ganzevoort W et al PETRA investigators. Obstet Gynecol. 2000 Jun;95(6 Pt 2):1017-9

Acute Complications of HDP CNS Complications including eclampsia Acute Respiratory Failure HELLP Syndrome Uteroplacental Complications CVS Complications Acute Kidney Injury Hematological Complications Hepatic Complications

CNS Complications

Dr Shashwat Jani. 9909944160. 11May 1, 2023

• Eclampsia is the most common, easily identifiable complication.

• Antepartum is the most common type (38-53%)intrapartum (18-36%)

postpartum (11-44%)• Atypical eclampsia

- < 20 weeks - Convulsions despite adequate MgSo4 . - 48 hours post partum (also called as late post

partum eclampsia)

Intracranial hemorrhage Infarcts Cerebral edema PRES Blindness

SEIZURES

Focal neurological signs

Prolonged coma

Atypical or recurrent convulsions

Seizures even after delivery

Posterior Reversible Encephalopathy Syndrome (PRES)

• A clinical neuroradiologic syndrome of heterogenous etiologies , that are grouped together because of similar findings on neuroimaging studies.

Pathophysiology

• Likely due to vasogenic edema secondary to an acute increase in arterial blood pressure, which overwhelms the autoregulatory capacity of the cerebral vasculature, causing arteriolar vasodilation and endothelial dysfunction, leading to extravasation of fluid (i.e preeclampsia) .

(Thackeray and Tielborg, 2007)

• OR an acute and significant episode of hypertension that causes cerebral vasoconstriction with subsequent ischemia and edema .

(Thackeray and Tielborg, 2007)

Autoregulatory failure

Normal autoregulation maintains constant cerebral blood flow over a range of systemic blood pressures .

When the upper limit is exceeded, the arterioles dilate, allowing breakdown of the blood-brain barrier, thus allowing extravasation of fluid and blood into the brain parenchyma.

PRES : Clinical manifestation and Etiopathogenesis• Postulations • Vasogenic cerebral oedema• ischaemia of brain tissue

• Posterior circulation – more susceptible – less sympathetic innervation

of the vertebro-basilar vasculature to protect the parenchyma from rapid increases in arterial blood pressure

Headache, nausea, vomiting Confusion, behavioral changes Changes of consciousness (from

somnolence to stupor) Vision disturbances (blurred vision,

hemianopia, cortical blindness) Epileptic manifestations (mostly

focal attacks with secondary generalization)

Mental functions are characterized with decreased activity and reactivity, confusion, loss of concentration and mild type of amnesia.

Management Clinical symptoms and radiologic evidence

support the diagnosis . Should be recognized promptly so

treatment can be initiated In our patient population with

preeclampsia/eclampsia, this typically means delivery and treatment of Convulsions & Hypertension .

The immediate issues in caring for an eclamptic woman include …• Maintenance of maternal vital

functions, • Control of convulsions and blood

pressure, • Prevention of recurrent seizures, and

evaluation for delivery.

Prognosis

Most cases of PRES are reversible in days to weeks with removal of the inciting factor and treatment of the blood pressure .

ACUTE RESPIRATORY FAILURE / Pulmonary edema Pulmonary edema refers

to an excessive accumulation of fluid in the pulmonary interstitial and alveolar spaces.

It complicates around 0.05% of low-risk pregnancies but may develop in up to 2.9% of pregnancies complicated by preeclampsia.

Only 30 % Antepartum

•Mainly,

- Post Partum,- Mulatiparity- Advance Maternal Age - Associated Medical Disorders

DiagnosisDyspneaOrthopneaTachypneaAuditory crackles and ralesHypoxemia

ABGA, CHEST X RAY , ECG , CT SCAN , VQ SCAN May 1, 2023 Dr Shashwat Jani.

9909944160. 23

Pulmonary Edema ARDS Pleural Effusion

B/L Air bronchogramCentral bat wing patternRight side pleural effusion

Diffuse B/L Coalescent opacities

Left hemithoraxObliteration of right costophrenic angle.Mediastinal shift to right

TreatmentOxygenPropped up positionI v lasixFluid restrictionInput – output chartingI v antibioticsIn refractory cases,Pulmonary artery catherisation and ventilation .May 1, 2023 Dr Shashwat Jani.

9909944160. 25

HELLP Syndrome• HELLP stands for: Hemolysis (abnormal smear), Elevated liver enzymes (serum SGOT >70 U/L

serum LDH >600 U/L, Low Platelets (< 100000)

6 % - one abnormalities 12 % - two abnormalities 10 % - three abnormalitiesMay 1, 2023 Dr Shashwat Jani.

9909944160. 26

Occurs in approximately 10% of pregnant women with pre-eclampsia or eclampsia.

One third of all cases of HELLP syndrome occur postpartum, and only 80% of such patients were diagnosed with preeclampsia before delivery.

CAUSE :

It is thought to arise as a consequence of endothelial and microvascular injury, increased vascular tone and platelet aggregation.

Spectrum of presentation Severity ranges from a mild and self-limited

course to a fulminant process leading to multiple organ failure.

In rare cases, occurs in normotensive pregnancy, only with epigastric pain and tenderness on palpation at the right hypochondrium as initial symptoms.

In most cases, resolves spontaneously within 48 hours of delivery.

Esan K, Moneim T, Page IJ. Postpartum HELLP syndrome after a normotensive pregnancy. Br J Gen Pract 1997;47:441−2.May 1, 2023 Dr Shashwat Jani.

9909944160. 29

HELLP post partum• Decreasing LDH and increasing PLT count

should be routinely observed on 4th postpartum day.

• Women not showing significant recovery should be suspected of TTP…- Normal coagulogram- Greatly elevated LDH 20,000 IU/L

- Neurological signs and symptoms

Beware of Postpartum HELLP :

30% cases occur postpartum Majority within 48 hrs Risk of renal failure and pulmonary edema

is significantly increased compared to antenatal onset HELLP.

Clin Perinatol 2004,31:807-33Am J Obstet Gynecol 1993,168

Management Stabilization of pt. Rx of HTN Termination of pregnancy ( Depends on

Gest. Age & maternal condition ) Role of steroids ?????

With or without corticosteroids, the vast majority of women with HELLP syndrome will

recover within 96 hours of delivery. May 1, 2023 Dr Shashwat Jani.

9909944160. 33

FUTURE PREGNANCIES The reported risk of Recurrent HELLP

syndrome in a subsequent pregnancy ranges from 3% to 27%.

Future pregnancies are also at increased risk of other adverse events, including other manifestations of preeclampsia, preterm delivery, fetal growth restriction, placental abruption, and cesarean delivery.

The overall risk of such complications is 19–43%.

Acute Kidney Injury AKI may occur in the context of severe

preeclampsia. In preeclampsia , due to the underlying

endothelial dysfunction the predominant abnormalities seen on renal histology are to the endothelium and glomeruli.

Diagnostic Criteria : Creatinine clearance by measuring 24 hr urine creatinine remains the gold standard of GFR estimation in pregnancy.

Any Sustained Fall In Output < 0.5ml/Kg/Hr OR Rising Serum Creatinine Should Alert The Clinician Of Likelihood Of AKI.

Management Supportive therapy includes blood

pressure control, positioning patients so as to improve renal blood flow, correcting fluid and electrolyte imbalance, and maintaining adequate nutrition.

If dialysis is required in pregnancy, hemodialysis is preferred over peritoneal dialysis.

CVS COMPLICATIONSLow filling pressures and a hyperdynamic circulation• Cardiomyopathy Rare complication Treatment similar to other types of CCF HDP patient with pulmonary may wrongly labeled as a case of

peripartum cardiomyopathy. HTN CMP shows good recovery and regain cardiac function on follow up.

Acute MI Enhanced vascular reactivity to angiotensin II & norepinephrine

Endothelial dysfunction Decreased uterine perfusion leading to renin release Use of ergot alkaloids – Acute MI• Malignant Ventricular Arrhythmias 38

HEPATIC COMPLICATIONS Transaminases frequently elevated Epigastric/Subcostal pain (distension of liver

capsule by edema or subcapsular bleeding) Coagulopathy (high INR) Acute fatty liver Deficiency of the long chain 3-hydroxyacyl

coenzyme A dehydrogenase

Serum bilirubin - Important factor in predicting Maternal mortalityMay 1, 2023 Dr Shashwat Jani.

9909944160. 39

Jaundice High colored Urine

Liver Hematoma

Hepatic complications

Liver Rupture / Hematoma• Mortality Is high.• First stabilize hemodynamically.• Then Exploratory Laparotomy with C.S.• Simple suturing is rarely effective because the entire

liver is edematous and friable and the hepatic parenchyma does not have the tensile strength to retain the sutures.

• Other surgical options include packing with gauze, topical coagulant agents or collagen fleeces coated with fibrin glue, incorporation of omental pedicles or surgical mesh into the liver, ligation of the hepatic artery, radiologic embolization of the hepatic artery, or hepatic lobectomy.

Hematological Complications :

Hemolysis / Anemia

Bleeding as the incision is being closed & Incision site bleeding

Target cells, schistocytes & paucity of platelets

Associated with increased LDH

(In preeclampsia there is vasoconstriction which affects blood flow to the liver. Liver releases coagulation factors.)

DIC• DIC is a hematologic disorder characterized

by a generalized increase in both fibrin formation and fibrinolysis, leading to excessive consumption of clotting factors, which presents clinically as a bleeding diathesis.

• The most common causes of DIC in pregnancy : are excessive blood loss with inadequate blood component replacement, placental abruption, amniotic fluid embolism, and severe preeclampsia / HELLP syndrome.

Management Evidence of DIC in the setting of severe

preeclampsia / HELLP syndrome should prompt immediate delivery.

The decision of whether to proceed with induction of labor or cesarean delivery depends on such factors as gestational age, parity, cervical Bishop score, motivation of the patient, and the severity of DIC .

A rapidly falling platelet count may make cesarean delivery a more appropriate choice.

Maintenance of intravascular volume and replacement of blood components and/or coagulation factors, as indicated by laboratory parameters.

Ocular ManifestationsOcular involvement includes : Conjunctival vascular anomalies, Hypertensive retinopathy, Exudative retinal detachment, Vitreous and pre-retinal haemorrhages, Ischemic optic neuropathy , Hypertensive choroidopathy

UTEROPLACENTAL COMPLICATIONSPLACENTAL ABRUPTION

BE ON GUARD

IUGR/ OLIGOHYDRAMNIOS

PRETERM DELIVERY (Iatrogenic)

COMPLICATIONS DUE TO DRUGS Antihypertensive use : Maternal hypotension

& placental abruption Fluid overload and Betamimetics – pulmonary

edema Diuretics can cause pancreatitis especially in

patients with ARF Marcovici et al,Am J Perinatol 2002

Sublingual Nifedipine can lead to Sudden Hypotension & myocardial infarction and hence not to be used.

Treatment :• Management of maternal hemodynamics &

prevention of eclampsia are key to a favorable outcome

• MgSO4 - Rx of choice for preeclampsia. • Goals

• Control BP• Prevent seizures• Deliver the fetus

TAKE HOME MESSAGE Look for complications at Primary evaluation of

the patient. Ongoing risk assessment, continued surveillance

and interventions must be offered through comprehensive critical care.

Avoid Iatrogenic complications- drugs, fluids Tertiary care management and Multidisciplinary

Team approach.

Thank you

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