hypertension in pregnancy
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Hypertension in Pregnancy. Ramon M. Gonzalez, MD Professor UST Medicine and Surgery. A 26y/o G1 21-22 weeks known hypertensive for 6 years was admitted because of severe hypertension VS- BP-200/100mmHg, - PowerPoint PPT PresentationTRANSCRIPT
Hypertension in
PregnancyRamon M. Gonzalez, MD
ProfessorUST Medicine and Surgery
A 26y/o G1 21-22 weeks known hypertensive for 6 years was admitted because of severe
hypertension VS- BP-200/100mmHg, PR- 76/min, RR-20/min, T-36.5C. She was
taking calcium channel blockers for her HPN which she was taking regularly.
Hypertensive Disorders Complicating Pregnancy
• Gestational Hypertension– Systolic BP≥ 140 or diastolic ≥ 90 mmHg for the
first time after 20 weeks gestation– No proteinuria– BP returns to normal before 12 weeks postpartum– Final diagnosis made only postpartum– May have other signs or symptoms of
preeclampsia
Hypertensive Disorders Complicating Pregnancy
• Preeclampsia– Minimum criteria
• BP ≥ 140/90 mmHg after 20 weeks gestation• Proteinuria ≥ 300mg/24 hours or ≥ 1+ dipstick
– Severe preeclampsia• BP ≥ 160/110 mmHg• Proteiunuria 2.0gms/24 hrs or ≥ 2+ dipstick• Serum creatinine > 1.2mg/dl• Platelets < 100,00/ul• Elevated LDH, ALT or AST
Hypertensive Disorders Complicating Pregnancy
• Eclampsia– Seizures that cannot be attributed to other causes
in women with preeclampsia
• Chronic Hypertension– BP ≥ 140/90 mmHg before pregnancy or diagnosed
before 20 weeks gestation– Hypertension first diagnosed after 20 weeks
gestation and persistent after 12 weeks postpartum
Hypertensive Disorders Complicating Pregnancy
• Superimposed Preeclampsia – New onset proteinuria ≥ 300mg/24 hrs in
hypertensive women but no proteinuria before 20 weeks gestation
Pregnancy 20-21 weeks, Chronic
Hypertension
Maternal Assessment
• Duration of hypertension
• Current therapy• Degree of BP
control• Other medical
complications
Maternal Assessment
• Serum creatinine• Quantification of
urine proteins• ECG • Echocardiography• Blood chemistry
1. What are the effects of chronic hypertension on pregnancy?
2. What is the management of chronic hypertension during pregnancy?
3. Can we prevent superimposition of preeclampsia ?
4. What is the management of chronic hypertension with superimposed preeclampsia?
What are the effects of chronic hypertension on pregnancy?
ORs for Fetal Complications: 1995-2008
Pregestational Diabetes-------------------------------------------------------------------------------------------Variable With Chronic HPN W/O Chronic HPN_______________________________________________________
_
Stillbirth 4.30(3.81-4.85) 3.05(2.88-3.23)
Poor fetal growth 2.66(2.40-2.94) 1.20(1.14-1.27)
Spontaneous delivery 4.88(4.63-5.15) 2.90(2.83-2.90)<37weeks
ORs for Maternal Complications: 1995-2008
Pregestational Diabetes--------------------------------------------------------------------------------------------Variable With Chronic HPN W/O Chronic HPN__________________________________________________________Preeclampsia 13.96 (13.29-14.66) 3.80 (3.69-3.91)
CVA 7.14 (4.90-10.40 ) 1.85 (1.41-2.44)
Acute renal failure 35.41 (28.39-44.16) 4.43 (3.57-5.48)
Pulmonary edema 11.97 (7.86-18.24) 4.01 (3.07-5.25)
Ventilation 11.87 (9.22-15.26) 3.34 (2.89-4.00)
Cesarean delivery 5.75 (5.46-6.05) 3.33 (3.26-3.41)
In- hospital mortality 6.02 (2.71-13.40) 2.58 (1.59-4.17)
ORs for Fetal Complications: 1995-2008
Chronic Renal Disease-------------------------------------------------------------------------------------------Variable With Chronic HPN W/O Chronic HPN________________________________________________________
Stillbirth 7.29(5.59-9.52) 1.74(1.51-2.02)
Poor fetal growth 7.94(6.67-9.44) 2.29(2.12-2.49)
Spontaneous delivery 8.60(7.64-9.67) 2.25(2.15-2.35)<37weeks
ORs for Maternal Complications: 1995-2008
Chronic Renal Disease---------------------------------------------------------------------------------------------Variable With Chronic HPN W/O Chronic HPN__________________________________________________________Preeclampsia 27.87(24.85-31.25) 3.28(3.10-3.47)
CVA 13.73(6.63-28.44) 3.53(2.34-5.31)
Acute renal failure 253.4(199.5-321.9) 62.40(54.37-71.63)
Pulmonary edema 23.29(10.32-52.56) 9.06(5.84-14.06)
Ventilation 19.29(11.36-32.76) 8.25(6.43-10.60)
Cesarean delivery 5.73(5.03-6.53) 1.74(1.68-1.81)
In- hospital mortality 27.02(8.72-83.73) 6.88(3.56-13.29)
ORs for Fetal Complications: 1995-2008
Collagen Vascular Disease-------------------------------------------------------------------------------------------Variable With Chronic HPN W/O Chronic HPN________________________________________________________
Stillbirth 7.42(5.37-10.25) 2.74(2.35-3.20)
Poor fetal growth 7.99(6.44-9.91) 3.87(3.55-4.22)
Spontaneous delivery 7.19(6.22-6.30) 3.15(2.98-3.33)<37weeks
ORs for Maternal Complications: 1995-2008
Collagen Vascular Disease---------------------------------------------------------------------------------------------Variable With Chronic HPN W/O Chronic HPN__________________________________________________________Preeclampsia 17.41 (15.09-20.09) 2.96 (2.76-3.18)
CVA 23.00 (11.47-46.14) 7.60 (5.26-10.97)
Acute renal failure 191.5 (141.4-259.4) 12.60 (8.88-17.88)
Pulmonary edema 15.52 (4.92-48.90) 6.08 (3.46-10.69)
Ventilation 26.29 (15.04-45.63) 11.09 (8.46-14.52)
Cesarean delivery 4.38 (3.74-5.12) 1.89 (1.80-1.98)
In- hospital mortality 88.81 (41.90-188.2) 23.81 (14.67-38.66)
What is the management of chronic hypertension during pregnancy?
Management
• Blood pressure control
• Fetal antepartum surveillance
• Prevention of preeclampsia
• Detection of preeclampsia
Blood Pressure Control
• Ca Channel Blockers• Adrenergic Blocking
Agents• Vasodilators• Diuretics• ACE Inhibitors/ARB
– contraindicated
• El Guindy, A.A. and Nabhan, A.F. (2008) • Journal of Perinatal Medicine• Women in the tight control group
– Were less likely to develop severe hypertension (RR 0.32, 95% CI 0.14 to 0.74)
– Delivered babies with older gestational ages (36.6 ±2.2 weeks vs 35.8 ± 2.2 weeks: P<0.05)
– Fewer preterm deliveries (RR 0.52, 95%CI 0.28 to 0.99)– No significant differences between groups regarding
stillbirth or IUGR
A randomized trial of tight vs. less tight control of mild essential and gestational hypertension in pregnancy
Fetal Antepartum Surveillance
• Fetal biometry
• Nonstress test
• Contraction stress test
• Biophysical profile
• Doppler velocimetry
Can we prevent superimposition of preeclampsia?
Preeclampsia
• Pregnancy specific syndrome that can affect virtually every organ system.
• Disorder of unknown etiology affecting 5-10% of all pregnancies.
• In developed countries 16% of maternal deaths were due to hypertensive disorder.
• POGS (2006)- 26.24% maternal deaths were due to hypertensive disorder.
Pathogenesis
• Vasospam– Increased resistance → hypertension– Endothelial cell damage → leakage of blood
constituents, including platelets and fibrinogen
– Decreased blood flow → ischemia of tissues → necrosis, hemorrhage and other end organ disturbances
Pathogenesis
• Endothelial cell activation– Increased pressor responses
• Increased sensitivity to angiotensin II
– Prostaglandin• Prostacyclin: thromboxane A2 ratio decreases
– Nitric oxide• Decreased nitric oxide synthase expression
– Endothelins• Potent vasoconstrictor which is increased in preeclampsia
Cardiovascular System
• ↑ Cardiac afterload – hypertension
• ↑Cardiac preload – Diminished hypervolemia– ↑ intravenous crystalloids
• Extravasation of intravascular fluid into the extracellular space– Pulmonary edema
Blood Volume and Coagulation
• Hemoconcentration– Hallmark of preeclampsia– Vasospasm and endothelial
leakage• Thrombocytopenia • Hemolysis
– Endothelial disruption• HELLP syndrome
Kidneys
• ↓ Glomerular filtration rate and renal plasma flow
• ↑ Serum creatinine• ↑ Uric acid• Proteinuria • Oliguria • “Glomerular capillary
endotheliosis”• Acute renal failure
Liver• Hepatic infarction
• Periportal hemorrhage
• Hepatocellular necrosis
• Elevations of AST/ALT
• Hepatic hematoma
• HELLP syndrome
Brain
• Headaches, visual symptoms
• Convulsions• Intracerebral
hemorrhage• Cortical and subcortical
petechial hemorrhages• Subcortical edema
Uteroplacental Perfusion
Vasospasm↓
Decreased uteroplacental perfusion
↓Increased perinatal
morbidity and mortality
Prevention of Superimposed Preeclampsia
• Systematic Review by Duley et al • 59 trials with 37,560 women given Aspirin
– 17% reduction in the risk of preeclampsia (RR 0.83, 077-0.89), especially in high risk patients
– 8% reduction in the relative risk of preterm birth (RR 0.92, 0.88-0.97)
– 14% reduction in fetal and neonatal deaths (RR 0.86, 0.76-0.98)
– 10% reduction in SGA babies (0.90, 0.83-0.98)
Detection of Preeclampsia
• BP monitoring
• 24 hour urine proteins
What is the management of chronic hypertension with superimposed preeclampsia?
Management
• Termination of pregnancy with the least possible trauma to mother and baby
• Birth of an infant who subsequently thrives
• Complete restoration of health to the mother
Severe Preeclampsia
• Clinical course is progressive deterioration in both maternal and fetal condition
• Associated with high rates of maternal and perinatal morbidity and mortality
Management of Severe Preeclampsia
• Aggressive - High neonatal mortality
and morbidity due to prematurity
- Prolonged NICU stay
- Long term disability
• Expectant - Fetal death
- Asphyxial damage in utero
- Increased maternal morbidity
Odendaal and associates
• Aggressive vs expectant management• 58 patients, 20 were delivered w/in 48 hours• 20 aggressive, 18 expectant• 28-34 weeks• Betamethasone, MgSO4, Antihypertensive
drugs• Maternal and fetal testing
Sibai and colleagues
• Aggressive vs expectant management• 28-32 weeks• 95 patients• Aggressive (n=46); expectant (n=49)• Bed rest, antihypertensives, MgSO4,
betamethasone, maternal and fetal testing, laboratory exams
Expectant Management• Prolongs pregnancy• Higher gestational age• Higher birth weight• Lower incidence of admission to NICU• Lower incidence of neonatal complication• No difference in the incidence of CS,
abruptio placenta, HELLP syndrome and postpartum stay
Guidelines for Expectant Management
• Hospitalization in a tertiary hospital- Good facilities to monitor the mother and fetus- NICU facilities- Trained personnels
• MgSO4• Antihypertensives• Corticosteroids
Maternal Assessment
Maternal Assessment
• Blood pressure measurement- Systolic – 140 – 155 mmHG- Diastolic – 90 – 105 mmHG
• Daily 24 hour urine volume • Maternal symptoms• Search for imminent signs of eclampsia Sibai et al AmJOG 2007
Maternal Assessment
• CBC with platelet counts• Serum creatinine • Liver function test
– AST/ALT– Lactate dehydrogenase
Sibai et al AmJOG 2007
Fetal Assessment
Fetal Assessment• Fetal kick counts• NST • Biophysical profile
scoring• Umbilical artery
Doppler studies• Assessment of fetal
growth
Maternal Indications for Delivery in Women With Severe Preeclampsia
• Persistent severe headache or visual changes; eclampsia
• Pulmonary edema• Uncontrolled severe HPN• Epigastric pain/RUQ pain with AST or ALT >2
times the upper limit of normal
Sibai et al AmJOG 2007
Maternal Indications for Delivery in Women With Severe Preeclampsia
• Oliguria (<500ml/24hr)• HELLP syndrome• Platelet counts <100,000/mm3• Deterioration of renal function (serum creatinine >/=1.5 mg/dl)• Suspected abruptio placenta, progressive labor,
and/or rupture of membranes
Sibai et al AmJOG 2007
Fetal Indications For Delivery In Women With Severe Preeclampsia
• Repetitive late or severe variable deceleration• Biophysical profile </=4 on 2 occasions at 6 hours
apart• IUGR (Estimated fetal weight <5th percentile)• Umbilical artery Doppler with reverse end diastolic
flow• Severe oligohydramnios
Sibai et al AmJOG 2007
Mode of Delivery
• Vaginal delivery- Inducible cervix- No fetal distress
• Cesarean section
Thank You