hypertensive emergencies in pregnancy

SUMC | Nikita Joshi, MD (njoshi8@gmail.com) Slide 1 of 18

Hypertensive Emergencies in Pregnancy

Nikita K Joshi MDClinical Instructor of SurgeryEmergency MedicineStanford University Medical Center

njoshi8@gmail.com

@njoshi8

SUMC | Nikita Joshi, MD (njoshi8@gmail.com) Slide 2 of 18

Objectives

Diagnostic Criteria

End Organ Consequences

Medical Management

SUMC | Nikita Joshi, MD (njoshi8@gmail.com) Slide 3 of 18

Chronic (Preexisting)

HTN

Gestational HTN Preeclampsia Severe

Preeclampsia Eclampsia

Diagnostic Criteria

SUMC | Nikita Joshi, MD (njoshi8@gmail.com) Slide 4 of 18

Epidemiology

HTN disorders complicates 5-10% of

all pregnancies

Preeclampsia complicates 3-9% of

pregnancies in developed countries

Accountable for 10-15% of maternal

death in developed countries

Lo JO. Hypertensive disease of pregnancy and maternal mortality. Curr Opin Obstet Gynecol. 2013 Apr;25(2):124-32. PMID: 23403779.

SUMC | Nikita Joshi, MD (njoshi8@gmail.com) Slide 5 of 18

Morbidity and Mortality

HTNCADCVA

ESRD

IUGRSGAHTNCAD

Maternal Neonatal

SUMC | Nikita Joshi, MD (njoshi8@gmail.com) Slide 6 of 18

Maternal History Family History Fetus

Primipaternity Smoking

Risk Factors

Uzan J. Pre-eclampsia: pathophysiology, diagnosis, and management. Vasc Health Risk Manag. 2011;7:467-74. PMID: 21822394.

SUMC | Nikita Joshi, MD (njoshi8@gmail.com) Slide 7 of 18

Preeclampsia

Unknown Etiology

Challenges in Prevention, Screening, Diagnosis, Treatment

Disease of Multiple Theories

Lack of animal model

Roberts JM. If we know so much about preeclampsia, why haven’t we cured the disease? J Reprod Immuol. 2013 Sep;99(1-2):1-9. PMID 23890710.

SUMC | Nikita Joshi, MD (njoshi8@gmail.com) Slide 8 of 18

Current TheoryAbnormal Placentation

Fetal Cytotrophoblasts fail to adopt invasive

endothelial phenotype

Invasion of spiral arteries is shallow

Remain small-caliber resistance vessels

Vikse BE. Preeclampsia and the Risk of End-Stage Renal Disease. NEJM. 2008. Aug 21;359(8):800-9. PMID: 18716297.

SUMC | Nikita Joshi, MD (njoshi8@gmail.com) Slide 9 of 18

Abnormal Placentation Endothelial Dysfunction

VasoconstrictionActivation of coagulation cascade

Loss of fluid from intravascular space

Decreased organ perfusionInflammationHemorrhage

Ischemia

Pathophysiology

SUMC | Nikita Joshi, MD (njoshi8@gmail.com) Slide 10 of 18

End Organ Consequence

Liverreduced hepatic

blood flow leads to ischemia and

periportal hemorrhage

CardiopulmCapillary leakage

leading to nondependent edema, pulm

edema

KidneyGlomerular

capillary endotheliosis and vasospasm reduce

GFR

CranialVasospasm leading

to headache, seizures, CVA

PlacentaPlacental abruption

FetusGrowth

restriction, oligohydramnios

HemePlatelet level

proportional to severity of disease

VisionRetina artery

constriction,visual changes

SUMC | Nikita Joshi, MD (njoshi8@gmail.com) Slide 11 of 18

Intubation

Magnesium

BP Control

Medical Management

Delivery

SUMC | Nikita Joshi, MD (njoshi8@gmail.com) Slide 12 of 18

Hypertensive Therapy

LabetalolBeta > Alpha Blocker

Vasodilation10-20 mg IVP

1-2 mg/min up to 300 mg

HydralazineVascular smooth muscle

relaxer5 mg IVP

0.5-10 mg/hr

SUMC | Nikita Joshi, MD (njoshi8@gmail.com) Slide 13 of 18

Evidence Review

Cochrane Review 2013

35 Randomized Control Trials3573 Women included

Not enough evidence to show which drug is most effective

SUMC | Nikita Joshi, MD (njoshi8@gmail.com) Slide 14 of 18

Treatment Algorithm

Uzan J. Pre-eclampsia: pathophysiology, diagnosis, and management. Vasc Health Risk Manag. 2011;7:467-74. PMID: 21822394.

SUMC | Nikita Joshi, MD (njoshi8@gmail.com) Slide 15 of 18

Magnesium

Prevention & Treatment of

Seizures

Fetal neural protection for

preterm delivery

Short-term prolongation of pregnancy

(48 hrs)

2013 Committee Opinion

SUMC | Nikita Joshi, MD (njoshi8@gmail.com) Slide 16 of 18

Mechanism of Action

VasculatureCa2+ Antagonist

Smooth muscle relaxationVasodilation

Relieve vasospamDecreased vascular

resistance

Anticonvulsant NMDA AntagonistDecreases effect of

glutamateLimits neuronal depolarization

Increases seizure threshold

Cerebral EndotheliumCa Antagonist

Decrease stress fiber contraction

Decrease paracellular BBB permeability

Limits cerebral edema

Euser AG. Magnesium sulfate for the treatment of eclampsia: a brief review. Stroke. 2009. Apr;40(4):1169-75. PMID: 19211496.

SUMC | Nikita Joshi, MD (njoshi8@gmail.com) Slide 17 of 18

Future Directions

Medical Management

Warrington JP. Recent advances in the understanding of the pathophysiology of preeclampsia. Hypertension. 2013 Oct;62(4):666-73. PMID: 23897068.

End Organ Consequences

Diagnostic Criteria

SUMC | Nikita Joshi, MD (njoshi8@gmail.com) Slide 18 of 18

References• Abalos E. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database of Systematic

Reviews. 2007 (1), CD0002252.• Berg CJ. Pregnancy-Related mortality in the United States, 1998-2005. Obstet Gynecol. 2010. Dec;116(6):1302-1309.• Duley L. Magnesium sulphate and other anticonvulsants for women with pre-eclampsia. Cochrane Database Syst Rev. 2010 Nov 10;

(11):CD000025.• Duley L. Magnesium sulphate versus phenytoin for eclampsia. Cochrane Database Syst Rev. 2010 Oct 6;(10):CD000128.• Duley L. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database Syst Rev. 2013 Jul31;7:CD001449.• Euser AG. Magnesium sulfate for the treatment of eclampsia: a brief review. Stroke. 2009. Apr;40(4):1169-75. PMID: 19211496.• Lo JO. Hypertensive disease of pregnancy and maternal mortality. Curr Opin Obstet Gynecol. 2013 Apr;25(2):124-32. PMID: 23403779.• Roberts JM. If we know so much about preeclampsia, why haven’t we cured the disease? J Reprod Immuol. 2013 Sep;99(1-2):1-9.

PMID 23890710.• Rosser ML. Preeclampsia: an obstetrician’s perspective. Adv Chronic Kidney Dis. 2013 May;20(3):287-96. PMID: 23929395.• Samadi AR. Maternal hypertension and associated pregnancy complications among african-american and other women in the United

States. Obstet Gynecol. 1996. Apr;87(4):557-63. PMID: 8602308.• Uzan J. Pre-eclampsia: pathophysiology, diagnosis, and management. Vasc Health Risk Manag. 2011;7:467-74. PMID: 21822394.• Vikse BE. Preeclampsia and the Risk of End-Stage Renal Disease. NEJM. 2008. Aug 21;359(8):800-9. PMID: 18716297.• Warrington JP. Recent advances in the understanding of the pathophysiology of preeclampsia. Hypertension. 2013 Oct;62(4):666-73.

PMID: 23897068.