HYPERTENSION DURING HYPERTENSION DURING PREGNANCYPREGNANCY
Gestational Gestational HYPERTENSIONHYPERTENSION
HYPERTENSION DURING HYPERTENSION DURING PREGNANCYPREGNANCY
Gestational Gestational HYPERTENSIONHYPERTENSION
Sarreshtedar.A.MD.AFSASarreshtedar.A.MD.AFSA
Hypertension complicationscomplications in pregnant
womenwomen(10%)
Maternal mortality & morbidity.
Abruptio placenta
Pulmonary edema
Respiratory failure
Cerebral hemorrhage
Hepatic failure
Acute renal failure.
DIC
Hypertension complicationcomplication
In
pregnancy (BABY)(BABY)
Fetal prematurely
Intrauterine growth retardation
Stillbirth
Neonatal death
PREGNANCYPREGNANCY::
HYPERTENSION DISORDERSHYPERTENSION DISORDERS
Chronic hypertensionChronic hypertension
Gestational hypertensionGestational hypertension
Preecampsia-EclampsiaPreecampsia-Eclampsia
Chronic Hypertension
DEFINED:
Precedes pregnancy
Before 20th gestational week
Fails to normal 12 week after delivery.
Chronic hypertension
1%-5% of pregnancies
15% with increased complications
Most complications occur in those more than 30y/o
Chronic Hypertension Complications in PREGNANCYChronic Hypertension Complications in PREGNANCY::
))15%15%((
Fetal growth retardation
Premature delivery
Abruptio-placenta
Acute renal failure
Hypertension crisis
Most of these complications occurMost of these complications occur::
In patients older than 30 y/o
Longer duration of hypertension
Superimposed preeclampsia.
25% of pregnancies (most) associated with chronic hypertension occurs in the setting of
superimposed preeclampsia
CHRONIC HYPERTENSION & PREGNANCYCHRONIC HYPERTENSION & PREGNANCY::
LOW-RISK LOW-RISK patientspatients::
SBP=140-160 mmHg
DBP=90-110 mmHg
Normal physical examination
Normal EKG
No proteinuria.
CHRONIC HYPERTENSION & PREGNANCYCHRONIC HYPERTENSION & PREGNANCY::
HIGH- RISKHIGH- RISK patients patients::
SBP=more than 160 mmHg
DBP=more than 110 mmHg
Signs of preeclampsia.
Signs of end organend organ Involvement
Renal insufficiency
Diabetes mellitus
Collagen vascular disease.
CHRONIC HYPERTENSIONCHRONIC HYPERTENSION::
Incidence of prenatal mortality is high.
Fetal growth-Retardation is high.
Definition:
Rise in pressure of 30/1530/15 mmHg .
Or
Greater than 140/90 mmHg.
GESTETIONAL HYPERTENSIONGESTETIONAL HYPERTENSION: :
GESTATIONAL HYPERTENSIONGESTATIONAL HYPERTENSION::
Induced by pregnancy
Beginning after 20 weeks
Resolving by the sixth postpartum week.
GESTATIONAL HYPERTENSIONGESTATIONAL HYPERTENSION::
Transient hypertension.
Preeclampsia.
GESTATIONAL HYPERTENSIONGESTATIONAL HYPERTENSION
))TRANSIENTTRANSIENT((
Without proteinuria.
In the late third trimester.
Return to normal by 10th post partum day.
GESTATIONAL HYPERTENSIONGESTATIONAL HYPERTENSION::
))PREECLAMPSIAPREECLAMPSIA((
With proteinuria
Edema
SBP greater than 160 mmHg160 mmHg
DBP greater than 110 mmHg110 mmHg
Gestational hypertension
is
Self-limited and less commonly in next pregnanciespregnancies.
BUT
• Chronic hypertension
progresses and complicates in subsequent pregnanciespregnancies.
PreeclampsiaPreeclampsia Chronic HypertensionChronic Hypertension
Age Young<20( ( Older>30( (
Parity Primigravide Multipara
Onset After 20 weeks of pregnancy
Before 20 weeks of pregnancy
Weight gain and edema Sudden Gradual
Systolic blood pressure > >160160 < <160160
Funduscopic findings Spasm,edema
Arteriovenous nicking, exudates
Proteinuria Present Absent
Plasma uric acid Increased Normal
Blood pressure after deliveryNormal Elevated
Difference Between Preeclampsia And Chronic HypertensionDifference Between Preeclampsia And Chronic Hypertension: :
PREECLAMPSIA-ECLAMPSIAPREECLAMPSIA-ECLAMPSIA::
DefinitionDefinition::
BP more than 140/90 mmHg140/90 mmHg
After 20 weeks
Edema
Proteinuria
convulsion
Hypertension appears in 12%12% of first pregnancies after 20 weeks
50%50% of these 12%12% will progress to
preeclampsia.
PREECLAMPSIA-ECLAMPSIAPREECLAMPSIA-ECLAMPSIA::Pregnancy specific syndrome
Proteinuria more than 300 mg/24h
Regresses within 24h 48h After delivery
PREECLAMPSIA-ECLAMPSIAPREECLAMPSIA-ECLAMPSIA
PRESENTATIONPRESENTATION::
Blurred vision
Pulmonary edema
Abdominal pain
Abnormal laboratory tests :liver enzymes – low platelet ……
Mechanism
unknown
But
Hypothesis are:
Profound vasoconstriction
High cardiac output.
Decreased Prostaglandin SynthesisDecreased Prostaglandin Synthesis
Vascular prostacyclin uterine PGE 2Vascular prostacyclin uterine PGE 2
platelet platelet aggregationaggregation
angiotensionangiotension sensitivitysensitivity
Fibrin deposition in Fibrin deposition in glomeruliglomeruli
vasoconstrictionvasoconstriction
uteroplacental blood uteroplacental blood flowflow
uterine reninuterine renin
PROTEINURIAPROTEINURIA GFRGFR
Sodium retentionSodium retention
EDEMAEDEMAHYPERTENSIONHYPERTENSION
POST PARTUM ECLAMPSIAPOST PARTUM ECLAMPSIAUsually occurs within 1010 days after delivery
with:
Hypertension
Proteinuria
Convulsion
MANAGEMENTMANAGEMENTPrimary goalPrimary goal::
Prevent maternal cerebral complications
Secondary goalSecondary goal: :
Reduction of:
SBP below 126mmHg
DBS between 90-100mmHg
NOTICENOTICE::Gestation hypertension is self- limited
Delivery is the only definitive treatment for preeclampsia
MANAGEMENTMANAGEMENT
INDICATION FOR INDICATION FOR DrugsDrugs::
SBP more than 150 mmHg150 mmHg
DBS more than 100 mmHg
Target organ damage
LV hypertrophy
Renal insufficiency
DRUGDRUG SELECTION SELECTION::1)For acute treatment of sever hypertension
2)For long term treatment of hypertension
ClassClass DrugDrug DoseDose
Arterial dilator Hydralazine 5-10 mg IV q 15-30 min
diazohide 30-60mg IV q 10-15 min
Calcium channel blocker
Nifedipine 10-20mg PO q 30 min
Alpha/beta-adrenergic blocker
Labetalol 20-40-80mg IV q 10-20 min
)up to 300 mg(
Arterial /venous dilator
Sodium
nitroprusside )50 mg/250 ml saline:(0.5-5.0
kg/min
Drugs for Acute treatment of Sever HypertensionDrugs for Acute treatment of Sever Hypertension::
METHOD OF TREATMENT IN SEVER HYPERTENSIONMETHOD OF TREATMENT IN SEVER HYPERTENSION::
11::HydralazinHydralazin: (: (Initial DrugInitial Drug))
5 mg bolus iv over 2 minutes
After 20 minutes repeat
And repeated as necessary
22 : :LabetalolLabetalol: (: (second drugsecond drug))
If hydralazin not effective or
Maternal side effects:
•Tachycardia
•Headache
•nausea
Labetalol usingLabetalol using: :
2020 mg iv
After 10 minutes 4040 mg iv
After 3 doses 8080 mg in interval of 10-20 minutes
After 1-21-2 mg/min in continuous infusion
CLASSCLASS DRUGDRUG Starting Starting
DoseDoseMaximum DoseMaximum Dose
Central alpha-agonist Methyldopa 250250 mg tidmg tid44 g/dg/d
clonidin 0.1-0.30.1-0.3 mg mg bidbid1.21.2 mg/dmg/d
Alpha-adrenergic blocker Prazosin 11 mg bidmg bid2020 mg/dmg/d
Calcium chanel blocker Nifedipine 1010 mg qidmg qid120mg/d120mg/d
Beta-adrenergic blocker Atenolol 100100 mg qdmg qd100100 mg/bidmg/bid
Alpha/beta-adrenergic blocker
Labetalol 100100 mg tidmg tid24002400 mg/dmg/d
Diuretics Hydrochlorothiazide 2525 mg qdmg qd5050 mg/dmg/d
Drugs for long-term treatment of hypertensionDrugs for long-term treatment of hypertension::
NOTICENOTICE::PREFERRED THERAPY:METHYL-DOPAMETHYL-DOPA
ACE inhibitors and angiotensin II receptor blockers are:
Contraindication
because induce neonatal renal failureneonatal renal failure.
بسم الله دواءبسم الله دواء
وااحمدلله شفاء وااحمدلله شفاء
هو الشافی هو الشافی شفاءشفاء
Clinical features:
Chronic hypertension
Gestational hypertension
Preeclampsia - Eclampsia
RISK
HIGH: 160/110
LOW:
SBS=140-160
DBS=90-110
NORMAL EKG
NORMAL ECHO/
NO PROTEINURIA
Gestational hypertension
DEFINED:
Induced by pregnancy
Beginning after 2020 weeks
Resolving by the sixthsixth postpartum week
Gestational hypertension
Divided by:
Hypertension without proteinuria (transient )
Hypertension with proteinuria
CHRACTRISTICS OF PREECLAMPSIA-ECLAMPSIA
BP more than 160/90 mmHg
Headache
Blurred vision
Pulmonary edema
Abdominal pain
Low platelets
Abnormal liver tests
Usually regresses within 24-48 hr24-48 hr after delivery.
TreatmentTreatment::
Primary goal is to prevent maternal complications.
Recommended goal of therapy is reduction of mean SBP below 126 mmHgSBP below 126 mmHg & DBP between 90-105 DBP between 90-105 mmHgmmHg