Hypertensive Disorders in Pregnancy-II

Women with elevated BP during pregnancy are associated with significant maternal & fetal morbidity and mortality .

Morbidity will remain high in our environment until there is general improvement in maternity services.

Blood pressure>150/100 / < 150/100with proteinuria

<150/100

Inv for High-risk factors

Negative Positive Admit to Hospital

Out-Patient care.

24-hour urine for Protein/wklyCBC,U R/M,LDH, Liver enzymesS. urea, creatinine, uric acidAntihypertensive treatmentBetamethasone if <34wksUmbilical & MCA dopplerDFMCRepeat laboratory 2-3times/wkly

Assesments remainswithin normal limits Worsening of situation

Out-patient care

Delivery at term Delivery

Gest.hypertension

Assesment remains normal

Self monitoring of B.P. at homeRest at homeFrequent hospital visitsUltrasound for fetal growth/3-4wkUterine, umbilical and MCA doppler/wkly or biwklyWeekly liquor status

Gestational hypertension with risk factors :

Objectives of care are-

pharmacological control of their BPearly detection of Pre-eclampsia, end organ damage & fetal decompensation.

Labetalol 1st line of antihypertensive

IV bolus of 20 mg

if not decrease to Diastolic 80 -110 mm Hg in 10 mins2nd dose of IV bolus of 40 mg

if not controlled 3rd IV bolus of 80 mg

When controlled oral labetalol200 – 400 mg of 12 hrly(if we give by continuous IV then 20mg / hr , max up to 200 mg / hr)

once BP stabilized 100 – 400 mg orally every 6 – 12 hrs

Nifedipine should be given orally not sublingually. 5-10 mg cap start BP monitored every 15 min Repeat 10 mg every 30-60 mins till adequate response

Methyl dopa

Hydralazine

Na nitroprusside

Nitroglycerine

Expectant management is terminated

• When hypertension cannot be controlled or there is evidence of end organ damage.

• Abruptio-placentae• Arrest of fetal growth.• Absent or reversed umbilical artery diastolic

flow• Non reassuring test of fetal wellbeing

Mild preeclampsia Gest.age

<32 wks 32-36 wks ≥37wks

Continuous assessmentDaily BP, Wt. ,urine dipstick, DFMCQuestioning ?,sr. uric acidPlatelets ,LFT, RFT wklyGravidogram , USG for fetal growth, Doppler study every wkFundoscopy

Stable

Continue expectancyDeliver at 37 wks

Delivery

Delivery

UncontrolledBP > 160/110Proteinuria >5gm/24 hrsPlatelets<100,000/cmmAST > 70IU/L OR ALT >70IU/LLDH > 600 U/Lsr. uric acid ≥ 6mg %Minimal or no fetal growth by USGAbsent or reversed UA DopplerOligohydramnios (AFI<5cm)Progressive increase in serum creatinine

Severe preeclampsia Gest. Age

<24 wks 24-34 wks

>34wks

MgSO4 BP control immediate delivery

MgSO4 BP control immediate delivery

continuous assessment BP ≥160/110 despite of treatmentUrine output < 400ml/24hrsCBC ,Urine R/M,TPC<100,000Elevated LFT , RFT, serum uric acidSevere symptoms, HELLP, Absent or reversed diastolic flow UA D.Oligohydramnious, IUGRNonreassuring FHR, fundoscopy

YESNO

Bed rest , DFMC ,BP 4hrly,daily wt.& I/O,Daily CBC,LFT,RFT if normal 12hrly urinary protein ,steroidsUA & MCA Doppler ,Liquor status twice wklyGravidogram, USG for fetal growth every 2wks

Unstable MgSO4 & Immediate delivery

Stable Continue expectancy

MgSO4 BP controlSteroids ?immediate delivery

Do not1. Do not attempt to normal Blood pressure.

( Rapid lowering of BP will cause Blood flow to renal, cerebral ,coronary, placental pressure flow).

2. Do not give diuretics before delivery. Give diuretics after delivery.

3. Do not give diazepam or phenytoin to stop an eclamptic seizure. Mgt of seizure O2 , avoid trauma to tongue and other organs and waiting for spontaneous resolution.

4. Do not push the padded tongue blade to the back of the throat ( will stimulate gag reflex and vomit)

Eclampsia Pre-eclampsia when complicated with convulsion and / or coma is called eclampsia.

DiagnosisWhen a pregnant woman present with seizeres, hypertension and protienuria.

Approximately 15% of the cases hypertension and proteinuria are absent.

Treatment of eclamptic seizuresAirway Assess Maintain patency Apply oxygenBreathing Assess Protect airway Ventilate as requiredCirculation Evaluate pulse & BP if absent,

initiate CPR & call arrest team Secure IV access

Diurectis : • Diuretics contraindicated in

preeclampsia & eclampsia before delivery except those with ….. Pulmonary edema, severe edema or renal failure.

• Furosemide 20 – 40 mg IV / 6 – 12 hrly should be initiated shortly after delivery ( VD/CS) then orally when patient able to.

Intermittent i.m injections (pritchard)

4g of 20% magnesium sulfate i.v @ not exceeding 1g/min.

Followed by 10g of 50% magnesium sulfate 5g each in both the buttocks through a 3 inch long, 20 G needle(1 ml of 2% lidocaine minimises discomfort).

If convulsions persists after 15 min. give upto 2 g more in i.v 20% magnesium sulfate @ not exceeding 1 g /min

If the women is large upto 4g may be given. Thereafter give 5gm of 50% solution of magnesium

sulphate every 4hr in alternate buttock Magnesium sulfate is to be continued 24 hrs after

delivery or if eclampsia develops post-partum , 24hrs after the last seizure .

Monitoring of magnesium toxicity Urine output should be at least 30ml/hr or 100ml

in last 4 hr. Deep tendon reflexes should be present

(disappearance of the patellar reflex is the first sign of impending toxicity , in this case the drug must be discontinued until the patellar reflex is present)

Respiration rate should be greater than 14 breaths/min (if there is respiratory depression due to hyper-magnesemia O2, i.v calcium gluconate (1g) 10ml of a 10 % solution to be given over 10 min. withholding the magnesium sulfate)

Pulse oximetry ≥ 96%

What is the therapeutic plasma level & describe the toxicity according to the plasma level of MgSO4?

Plasma Level of magnesium (mEq/lit) Signs of Toxicity

4 -7 Nil -this is a required level for prevention of eclampsia

8-10 Uterine relaxation 10 Patellar reflex disappears

10-12 Respiratory depression >12 Respiratory paralysis

Eclampsia ABCPlace the patient in lt. lat positionInsert padded tongue blade ,avoiding gag reflex Suction oral secretionsGive O2 mask at 8-10L/min.Elevate bed side rails & pad them to avoid injury Use physical restrains if necessary IVF (80 ml/hr or 1ml /kg/hr)

Indications for C.S. •Unripe cervix•GA < 32wks•Inadequate BP control•Obstetric indication for C.S.•Fetal distress, Status eclampticus

Loading dose of MgSO4 & then maintenance (if referred with MgSO4 then only maintenance )

Antihypertensive , if DBP ≥ 110 mm Hg after MgSO4

Delivery :

In eclampsia the definitive treatment is delivery.However it is inappropriate to deliver an unstable

mother even if there is fetal distress.Once seizures are controlled ,severe hypertension

treated & hypoxia corrected, delivery can be expedited.

In 3rd stage of labour oxytocin 10U IV/IM, prostaglandin 125or250mg IM, misoprostol given . Ergometrine is avoided.

In caesarean section : antibiotic prophylaxis. RCOG 2006