Hypertensive Disorders in Hypertensive Disorders in PregnancyPregnancy

Selly Septina, SpOGSelly Septina, SpOG

ClassificationClassificationby the working group of the by the working group of the

NHBPEP (2000)NHBPEP (2000)

1. Gestational hypertension1. Gestational hypertension

2. Chronic hypertension2. Chronic hypertension

3. Preeclampsia3. Preeclampsia

4. Eclampsia4. Eclampsia

5. Preeclampsia superimposed on chronic 5. Preeclampsia superimposed on chronic hypertension (superimposed preeclampsia)hypertension (superimposed preeclampsia)

I. Gestational hypertensionI. Gestational hypertension

BP >= 140/90 mmHg for first time during BP >= 140/90 mmHg for first time during pregnancypregnancy

No proteinuriaNo proteinuria BP returns to normal < 12 wk postpartumBP returns to normal < 12 wk postpartum Final diagnosis made only postpartumFinal diagnosis made only postpartum May have other signs & symptoms of May have other signs & symptoms of

preeclampsia , eg. epigastric discomfort or preeclampsia , eg. epigastric discomfort or thrombocytopeniathrombocytopenia

II. Chronic hypertensionII. Chronic hypertension

BP >= 140/90 mmHg before pregnancy or BP >= 140/90 mmHg before pregnancy or diagnosed before 20 wk , not attributable diagnosed before 20 wk , not attributable to GTD orto GTD or

Hypertension first diagnosed after 20 wk Hypertension first diagnosed after 20 wk and persistent after 12 wk postpartumand persistent after 12 wk postpartum

Underlying causes of Underlying causes of Chronic HypertensionChronic Hypertension

Essential familial hypertensionEssential familial hypertension ObesityObesity Arterial abnormalitiesArterial abnormalities Endocrine disordersEndocrine disorders GlomerulonephritisGlomerulonephritis Renoprival hypertensionRenoprival hypertension Connective tissue diseaseConnective tissue disease PCKDPCKD ARFARF

III. PreeclampsiaIII. Preeclampsia

PreeclampsiaPreeclampsia

Mild preeclampsiaMild preeclampsia

BP >= 140/90 mmHg after 20 wk gestationBP >= 140/90 mmHg after 20 wk gestation

Proteinuria >= 300 mg/24hr or >=1+ dipstickProteinuria >= 300 mg/24hr or >=1+ dipstick

Severe preeclampsiaSevere preeclampsiaAnyone who meets at least two of the Anyone who meets at least two of the

following signs:following signs:

BP >= 160/110 mmHgBP >= 160/110 mmHg Proteinuria 5 g/24hr or >= 2+ dipstick (persistent)Proteinuria 5 g/24hr or >= 2+ dipstick (persistent) Cr > 1.2 mg/dlCr > 1.2 mg/dl Platelets < 100,000 /mm3Platelets < 100,000 /mm3 Microangiopathic hemolysis Microangiopathic hemolysis Elevated ALT or ASTElevated ALT or AST Persistent headache , visual disturbance , Persistent headache , visual disturbance ,

epigastric painepigastric pain

IV. EclampsiaIV. Eclampsia

Seizures that cannot be attributed to other Seizures that cannot be attributed to other causes in a woman with preeclampsiacauses in a woman with preeclampsia

Seizures are generalized Seizures are generalized May appear before , during or after laborMay appear before , during or after labor 10% develop after 48 hr postpartum10% develop after 48 hr postpartum

V. Superimposed preeclampsiaV. Superimposed preeclampsia

New onset proteinuria >= 300mg/24 hr in New onset proteinuria >= 300mg/24 hr in hypertensive women but no proteinuria hypertensive women but no proteinuria before 20 wkbefore 20 wk

A sudden increase in proteinuria or BP or A sudden increase in proteinuria or BP or platelet count < 100,000 in women with platelet count < 100,000 in women with hypertension and proteinuria before 20 wk hypertension and proteinuria before 20 wk

DiagnosisDiagnosis

Gestational HTGestational HT Also called transient HTAlso called transient HT Final Dx : after delivery , by exclusionFinal Dx : after delivery , by exclusion BP : resting BP , Korotkoff phase V is BP : resting BP , Korotkoff phase V is

used to defined diastolic pressureused to defined diastolic pressure GHT may later develop preeclampsiaGHT may later develop preeclampsia 10% of eclamptic seizures develop before 10% of eclamptic seizures develop before

overt proteinuria is identifiedovert proteinuria is identified BP rise , increase both mother and fetus BP rise , increase both mother and fetus

risksrisks

PreeclampsiaPreeclampsia

Diastolic hypertension >= 95 , increase fetal Diastolic hypertension >= 95 , increase fetal death rate 3 folddeath rate 3 fold

Worsening proteinuria resulted in increasing Worsening proteinuria resulted in increasing preterm deliverypreterm delivery

Epigastric pain from hepatocellular necrosis , Epigastric pain from hepatocellular necrosis , ischemia and edema that stretches Glisson ischemia and edema that stretches Glisson capsulecapsule

Thrombocytopenia from platelet activation & Thrombocytopenia from platelet activation & aggregation , microangiopathic hemolysis aggregation , microangiopathic hemolysis induced by severe vasospasminduced by severe vasospasm

Risk factorsRisk factors for preeclampsiafor preeclampsia

NulliparousNulliparous Advanced maternal ageAdvanced maternal age Race and ethnicity (genetic predisposition Race and ethnicity (genetic predisposition

& envoronmental factor)& envoronmental factor) Multifetal gestationMultifetal gestation ObesityObesity BMI > 35 kg/mBMI > 35 kg/m22

Superimposed preeclampsiaSuperimposed preeclampsia

1. Hypertension (>=140/90) is documented 1. Hypertension (>=140/90) is documented antecedent to pregnancyantecedent to pregnancy

2. Hypertension is detected before 20 wk , 2. Hypertension is detected before 20 wk , unless there is GTDunless there is GTD

3. Hypertension persists long after delivery3. Hypertension persists long after delivery

Additional previous Hx or family Hx of HTAdditional previous Hx or family Hx of HT

End organ damage : LVH , retinal changeEnd organ damage : LVH , retinal change

Risk abruption , IUGR , preterm & deathRisk abruption , IUGR , preterm & death

Etiology?Etiology?

EtiologyEtiology1. Abnormal trophoblastic invasion of uterine 1. Abnormal trophoblastic invasion of uterine

vesselsvessels

2. Immunological intolerance between 2. Immunological intolerance between maternal and fetoplacental tissuesmaternal and fetoplacental tissues

3. Maternal maladaptation to cardiovascular 3. Maternal maladaptation to cardiovascular or inflammatory changes of normal or inflammatory changes of normal pregnancy (vasculopathy)pregnancy (vasculopathy)

4. Dietary deficiencies4. Dietary deficiencies

5. Genetic influences5. Genetic influences

ComplicationsComplications

Cardiovascular systemCardiovascular system

Increase after loadIncrease after load Preload diminishPreload diminish Endothelial activation with extravasationEndothelial activation with extravasation Decreased cardiac outputDecreased cardiac output Hemoconcentration from generalized Hemoconcentration from generalized

vasoconstriction and endothelial vasoconstriction and endothelial dysfynctiondysfynction

Decreased blood volumeDecreased blood volume

Blood and coagulationBlood and coagulation

Thrombocytopenia from platelet activation, Thrombocytopenia from platelet activation, aggregation & consumptionaggregation & consumption

Increased platelets activating factor & Increased platelets activating factor & thrombopoietinthrombopoietin

Clotting factors decreaseClotting factors decrease Erythrocytes rapid hemolysis (increase Erythrocytes rapid hemolysis (increase

LDH , schizocyte , MAHA)LDH , schizocyte , MAHA)

KidneyKidney

RPF & GFR reducedRPF & GFR reduced Uric acid elevatedUric acid elevated Creatinine clearance reduced , oliguriaCreatinine clearance reduced , oliguria Diminished urinary Ca due to increased Diminished urinary Ca due to increased

tubular reabsorptiontubular reabsorption Urine sodium elevatedUrine sodium elevated Urine osmolality , U:P Cr , FE Na : Urine osmolality , U:P Cr , FE Na :

prerenal mechanismprerenal mechanism

LiverLiver

Periportal hemorrhage in liver peripheryPeriportal hemorrhage in liver periphery Elevated transaminaseElevated transaminase HELLP syndrome HELLP syndrome Bleeding cause hepatic rupture(mortality Bleeding cause hepatic rupture(mortality

30%) , subcapsular hematoma30%) , subcapsular hematoma Conservative treatment Conservative treatment Recombinant factor VIIaRecombinant factor VIIa

HELLP syndromeHELLP syndrome

No strict definitionNo strict definition Incidence 20% of severe preeclampsia or Incidence 20% of severe preeclampsia or

eclampsiaeclampsia Factors contributing to death : include Factors contributing to death : include

stroke , coagulopathy , ARDS , ARF , stroke , coagulopathy , ARDS , ARF , sepsissepsis

Insufficient evidence : adjunctive steroidInsufficient evidence : adjunctive steroid

BrainBrain

Headache & visual symptoms associated Headache & visual symptoms associated with eclampsiawith eclampsia

Two cerebral pathology relatedTwo cerebral pathology related

1. gross hemorrhage due to ruptured a. 1. gross hemorrhage due to ruptured a. caused by severe HTcaused by severe HT

2. more widespread , edema hyperemia , 2. more widespread , edema hyperemia , ischemia , thrombosis & hemorrhageischemia , thrombosis & hemorrhage caused by preeclampsiacaused by preeclampsia

Can we predict preeclampsia?Can we predict preeclampsia?

PredictionPrediction

Biological , biochemical & biophysical Biological , biochemical & biophysical markers markers

To identify markers of To identify markers of faulty placentation faulty placentation reduced placental perfusion , reduced placental perfusion , endothelial cell activation & dysfunction , endothelial cell activation & dysfunction , activation of coagulationactivation of coagulation

HOW?

Uric acidUric acid

Decreased renal urate excretion in Decreased renal urate excretion in preeclampsiapreeclampsia

Serum uric acid exceeding 5.9 at 24 wk Serum uric acid exceeding 5.9 at 24 wk (PPV 33%)(PPV 33%)

Not useful in differentiating GHT from Not useful in differentiating GHT from preeclampsiapreeclampsia

FibronectinFibronectin

Endothelial cell activationEndothelial cell activation Low sensitivity 69%Low sensitivity 69% Positive predictive vaules 12%Positive predictive vaules 12% Higher levels by 12 wks (PPV 29% NPV Higher levels by 12 wks (PPV 29% NPV

98%)98%)

Coagulation activationCoagulation activation

Thrombocytopenia and platelet Thrombocytopenia and platelet dysfunctiondysfunction

Increased destruction cause platelet Increased destruction cause platelet volumes increase (younger platelet)volumes increase (younger platelet)

Preeclampsia : PAI-1 increase increased Preeclampsia : PAI-1 increase increased relative to PAI-2 because of endothelial relative to PAI-2 because of endothelial cell dysfunctioncell dysfunction

CytokinesCytokines

Released by vascular endothelium & Released by vascular endothelium & leukocytes , and macrophages & leukocytes , and macrophages & lymphocytes at decidualymphocytes at decidua

Interleukin , TNF Interleukin , TNF αα , CRP : inflammatory , CRP : inflammatory responseresponse

Possibly predictive preeclampsiaPossibly predictive preeclampsia

Fetal DNAFetal DNA

Fetal DNA in maternal serumFetal DNA in maternal serum At the time endothelial activation , fetal At the time endothelial activation , fetal

cells released into maternal circulationcells released into maternal circulation Elevations after 28 wk indicate impending Elevations after 28 wk indicate impending

diseasedisease

Uterine artery dopplerUterine artery doppler

Impaired trophoblastic invasion of spiral Impaired trophoblastic invasion of spiral arteries , leading to reduction in arteries , leading to reduction in uteroplacental blood flowuteroplacental blood flow

8-22 wk , sensitivity 78% , PPV 28% , 8-22 wk , sensitivity 78% , PPV 28% , unreliable in low risk pregnanciesunreliable in low risk pregnancies

Combined inhibin A & activin A , sensitivity Combined inhibin A & activin A , sensitivity 86%86%

Combined hCG & AFP , sensitivity 2-40%Combined hCG & AFP , sensitivity 2-40%

Can we prevent preeclampsia?Can we prevent preeclampsia?

PreventionPrevention

Salt restriction : ineffectiveSalt restriction : ineffective Inappropriate diuretic therapyInappropriate diuretic therapy Low dietary calcium increased risk GHTLow dietary calcium increased risk GHT Fish oil capsules : modify abnormal PG Fish oil capsules : modify abnormal PG

balance : ineffectivebalance : ineffective Low dose aspirin (60mg) : ineffectiveLow dose aspirin (60mg) : ineffective Antioxidants : vitamin C & E : reduced Antioxidants : vitamin C & E : reduced

endothelial cell activation , reduction in endothelial cell activation , reduction in preeclampsiapreeclampsia

AntioxidantAntioxidant

39% reduction in risk of preeclampsia (RR 39% reduction in risk of preeclampsia (RR 0.61)0.61)

Reduced risk of SGA infant (RR 0.64)Reduced risk of SGA infant (RR 0.64) More preterm birth (RR 1.38)More preterm birth (RR 1.38) No difference in develop preeclampsia No difference in develop preeclampsia

among low & high risk (RR 0.66 & 0.44)among low & high risk (RR 0.66 & 0.44) GA : no diff (<20wk VS before & after GA : no diff (<20wk VS before & after

20wk)20wk) The Cochrane Database of systematic Reviews 2005The Cochrane Database of systematic Reviews 2005

Dietary saltDietary salt

Reduce dietary salt intake vs continue a Reduce dietary salt intake vs continue a normal dietnormal diet

No effect in preeclampsia (RR 1.11)No effect in preeclampsia (RR 1.11) Insuffient evidence for reliable conclusions Insuffient evidence for reliable conclusions

about effect of advice to reduce diet saltabout effect of advice to reduce diet salt

The Cochrane Database of Systematic reviews 2005The Cochrane Database of Systematic reviews 2005

Folic acid supplementFolic acid supplement

Reduction in risk of preeclampsia in Reduction in risk of preeclampsia in supplemented groups ( 200 ug & 5 mg/d)supplemented groups ( 200 ug & 5 mg/d)

In low serum folate pregnancy & women In low serum folate pregnancy & women with Hx preeclampsiawith Hx preeclampsia

Odd ratios of preeclampsia no diff Odd ratios of preeclampsia no diff between receive folic 200 ug VS 5 mg/d between receive folic 200 ug VS 5 mg/d (0.46 VS 0.59)(0.46 VS 0.59)

Ped & Perinatal Epid 2005: 19 : 112-124Ped & Perinatal Epid 2005: 19 : 112-124

ManagementManagement

ManagementManagement

Early prenatal detectionEarly prenatal detection Antepartum hospital managementAntepartum hospital management Termination of pregnancyTermination of pregnancy Antihypertensive drug therapyAntihypertensive drug therapy

1. Early prenatal detection1. Early prenatal detection

Early preeclampsia without overt HT : Early preeclampsia without overt HT : increased surveillanceincreased surveillance

New-onset diastolic BP 81-89 mmHg or New-onset diastolic BP 81-89 mmHg or sudden abnormal wt gain (> 2 lb/wk during sudden abnormal wt gain (> 2 lb/wk during 33rdrd trimester) trimester)

OPD surveillance unless overt HT , OPD surveillance unless overt HT , proteinuria , visual disturbances or proteinuria , visual disturbances or epigastric discomfortepigastric discomfort

2. Antepartum management2. Antepartum management

Admit if new onset HT , esp persistent or Admit if new onset HT , esp persistent or worsening HT or develop proteinuriaworsening HT or develop proteinuria

Detail examine : headache , visual Detail examine : headache , visual disturbances , epigastric pain , weight gaindisturbances , epigastric pain , weight gain

Proteinuria at least every 2 dProteinuria at least every 2 d BP q 4 hr , except midnight & morningBP q 4 hr , except midnight & morning Creatinine , hematocrit , platelets , liver Creatinine , hematocrit , platelets , liver

enzymes.enzymes.

Antepartum managementAntepartum management

Evaluate fetal size , AFEvaluate fetal size , AF Reduced physical activityReduced physical activity Sedative not prescribedSedative not prescribed Ample, not excess, protein & calories dietAmple, not excess, protein & calories diet Sodium & fluid intake not limit or forcedSodium & fluid intake not limit or forced Further Mg depend on : severity , Further Mg depend on : severity ,

Gestational Age , condition of cervixGestational Age , condition of cervix

Preeclampsia-Initial EvaluationPreeclampsia-Initial EvaluationPreeclampsia-Initial EvaluationPreeclampsia-Initial Evaluation

Serial blood pressure measurementsSerial blood pressure measurements Urine protein excretionUrine protein excretion Fetal monitoringFetal monitoring Tests to rule out HELLP and other Tests to rule out HELLP and other

complications: Hematocrit, platelets, uric complications: Hematocrit, platelets, uric acid, alanine aminotransferase (ALT), acid, alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactic aspartate aminotransferase (AST), lactic dehydrogenase (LDH)dehydrogenase (LDH)

Chronic Hypertension - Chronic Hypertension - ManagementManagement

Generally, deliver at term, unless Generally, deliver at term, unless superimposed preeclampsia, HELLP superimposed preeclampsia, HELLP syndromesyndrome

Avoid ACE inhibitors (renal failure, Avoid ACE inhibitors (renal failure, oligohydramnios, pulmonary hypoplasia, oligohydramnios, pulmonary hypoplasia, IUGR) and atenolol (IUGR)IUGR) and atenolol (IUGR)

Severe Preeclampsia-Severe Preeclampsia-ManagementManagement

Severe Preeclampsia-Severe Preeclampsia-ManagementManagement

Seizure prophylaxisSeizure prophylaxis Blood pressure controlBlood pressure control DeliveryDelivery

Preeclampsia-Term PregnancyPreeclampsia-Term PregnancyPreeclampsia-Term PregnancyPreeclampsia-Term Pregnancy

Delivery is a short-term goalDelivery is a short-term goal Induction of labor is appropriate after Induction of labor is appropriate after

maternal-fetal observation/stabilizationmaternal-fetal observation/stabilization Cesarean reserved for standard obstetric Cesarean reserved for standard obstetric

indicationsindications Cesarean may be recommended in cases Cesarean may be recommended in cases

of severe preeclampsia where delivery is of severe preeclampsia where delivery is remoteremote

Preeclampsia-Preterm Preeclampsia-Preterm PregnancyPregnancy

Preeclampsia-Preterm Preeclampsia-Preterm PregnancyPregnancy

Mild preeclampsia - expectant Mild preeclampsia - expectant management is acceptable under certain management is acceptable under certain conditionsconditions

Close maternal-fetal surveillanceClose maternal-fetal surveillance Ability to intervene either if conditions Ability to intervene either if conditions

worsen or if acceptable gestational age worsen or if acceptable gestational age reachedreached

In-hospital vs. home care?In-hospital vs. home care?

Preeclampsia-Preterm Preeclampsia-Preterm PregnancyPregnancy

Preeclampsia-Preterm Preeclampsia-Preterm PregnancyPregnancy

Severe preeclampsia - controversialSevere preeclampsia - controversial Delivery for poor maternal condition is Delivery for poor maternal condition is

likely to be necessary over the short termlikely to be necessary over the short term Sibai has advocated expectant Sibai has advocated expectant

management for selected patients to management for selected patients to attempt to reduce perinatal morbidity and attempt to reduce perinatal morbidity and mortality due to prematuritymortality due to prematurity

Preeclampsia-Preterm Preeclampsia-Preterm PregnancyPregnancy

Expectant management of severe Expectant management of severe preeclampsia at preterm gestational age:preeclampsia at preterm gestational age: HospitalizationHospitalization Magnesium sulfate for seizure prophylaxis, at Magnesium sulfate for seizure prophylaxis, at

least during initial observation periodleast during initial observation period Blood pressure control to range of 140-Blood pressure control to range of 140-

155/90-105 (labetalol or nifedipine)155/90-105 (labetalol or nifedipine) Daily assessment of maternal-fetal conditionDaily assessment of maternal-fetal condition

Preeclampsia-Preterm Preeclampsia-Preterm PregnancyPregnancy

24-34 weeks – corticosteroids for fetal 24-34 weeks – corticosteroids for fetal lung maturationlung maturation 24-32 weeks – ongoing daily surveillance if 24-32 weeks – ongoing daily surveillance if

stablestable 33-34 weeks – deliver after 48 hours33-34 weeks – deliver after 48 hours

Deliver for HELLP syndrome, severe Deliver for HELLP syndrome, severe headache, uncontrolled hypertension, headache, uncontrolled hypertension, eclampsiaeclampsia

3. Termination of pregnancy3. Termination of pregnancy

Delivery is the cure for preeclampsiaDelivery is the cure for preeclampsia Headache , visual disturbances or Headache , visual disturbances or

epigastric pain : indicative convulsions epigastric pain : indicative convulsions (imminent eclampsia)(imminent eclampsia)

Oliguria : ominous signOliguria : ominous sign SPE : objectives to forestall convulsions , SPE : objectives to forestall convulsions ,

prevent intracranial hemorrhage , & prevent intracranial hemorrhage , & serious vital organ damageserious vital organ damage

Termination of pregnancyTermination of pregnancy

Preterm : conservative justified in mild Preterm : conservative justified in mild preeclampsia, closed observation and preeclampsia, closed observation and monitoring to complicationsmonitoring to complications

severe preeclampsia : prompt deliverysevere preeclampsia : prompt delivery vaginal delivery vaginal delivery c-section if indicatedc-section if indicated

Induction of labor not harmful to infants , Induction of labor not harmful to infants , but unsuccessful 35%but unsuccessful 35%

4. Antihypertensive drug4. Antihypertensive drug

To prolong pregnancy , or modify perinatal To prolong pregnancy , or modify perinatal outcomesoutcomes

Antihypertensive drugAntihypertensive drug

ββ blocker (Labetolol) , calcium channel blocker (Labetolol) , calcium channel blockers (Nifedipine , Isradipine) no blockers (Nifedipine , Isradipine) no benefitbenefit

5. Delayed delivery with 5. Delayed delivery with Superimposed Pre Eclampsia (SPE)Superimposed Pre Eclampsia (SPE)

SPE remote from termSPE remote from term Conservative or expectant management in Conservative or expectant management in

selected groupselected group Sibai 1985 : SPE 18-27 wk : perinatal Sibai 1985 : SPE 18-27 wk : perinatal

mortality 87% , no mothers died , placental mortality 87% , no mothers died , placental abruption eclampsia , consumptive abruption eclampsia , consumptive coagulopathy , RF , encephalopathy , coagulopathy , RF , encephalopathy , intracerebral hemorrhage , ruptured intracerebral hemorrhage , ruptured hepatic hematomahepatic hematoma

Delayed delivery with SPEDelayed delivery with SPE

Indications for delivery : uncontrollable BP, Indications for delivery : uncontrollable BP, fetal distress , placental abruption , renal fetal distress , placental abruption , renal failure, HELLP synd , persistent symptomfailure, HELLP synd , persistent symptom

Average pregnancy prolong 8dAverage pregnancy prolong 8d

GlucocorticoidsGlucocorticoids

Not worsen maternal HTNot worsen maternal HT Decrease RDS , improve fetal survivalDecrease RDS , improve fetal survival No evidence : benefit to ameliorate No evidence : benefit to ameliorate

severity of HELLP syndromeseverity of HELLP syndrome Transient improve hematological lab : Transient improve hematological lab :

platelet countsplatelet counts 2 Maternal death , 18 stillbirth2 Maternal death , 18 stillbirth

Eclampsia-ManagementEclampsia-Management

Preeclampsia complicated by generalized Preeclampsia complicated by generalized tonic-clonic convulsions ORtonic-clonic convulsions OR

Fatal coma without convulsions also Fatal coma without convulsions also

Major complications included placental Major complications included placental abruption (10%) , neuro deficit (7%) , abruption (10%) , neuro deficit (7%) , aspiration pneumonia (7%) , pulm edema aspiration pneumonia (7%) , pulm edema (5%) , arrest (4%) , ARF (4%) , death (1%)(5%) , arrest (4%) , ARF (4%) , death (1%)

EclampsiaEclampsia

Duration of coma variableDuration of coma variable Hypercarbia , lactic acidemia , fetal brady Hypercarbia , lactic acidemia , fetal brady

cardiacardia High feverHigh fever ProteinuriaProteinuria Diminished urine output , hemoglobinuriaDiminished urine output , hemoglobinuria Pronounced edemaPronounced edema Proteinuria & edema disappear within 1 wkProteinuria & edema disappear within 1 wk BP return within a few days to 2 wk PPBP return within a few days to 2 wk PP

EclampsiaEclampsia

Differential diagnosis : epilepsy , Differential diagnosis : epilepsy , encephalitis , meningitis , cerebral tumor , encephalitis , meningitis , cerebral tumor , cysticercosis , ruptured cerebral aneurysmcysticercosis , ruptured cerebral aneurysm

Prognosis always seriousPrognosis always serious 6% of Maternal death relate to eclampsia6% of Maternal death relate to eclampsia Among PIH patient , maternal death 16%Among PIH patient , maternal death 16%

TreatmentTreatment

1. control of convulsions using IV MgSO41. control of convulsions using IV MgSO4

2. Intermittent IV or oral of antihypertensive 2. Intermittent IV or oral of antihypertensive drug to lower Diastolic BP <100drug to lower Diastolic BP <100

3. Avoidance of diuretics , limit IV fluid 3. Avoidance of diuretics , limit IV fluid adminstration , avoid hyperosmotic agentsadminstration , avoid hyperosmotic agents

4. Delivery4. Delivery

Continuous IV regimenContinuous IV regimen

4-6 gm MgSO4 dilute in 100 ml fluid , admin 4-6 gm MgSO4 dilute in 100 ml fluid , admin over 15-20 minover 15-20 min

Begin 2 g/hr in 100 ml IV maintenanceBegin 2 g/hr in 100 ml IV maintenance

Measure Mg level at 4-6 hr , adjust level Measure Mg level at 4-6 hr , adjust level between 4-7 mEq/Lbetween 4-7 mEq/L

MgSO4 discontinued 24 hr after deliveryMgSO4 discontinued 24 hr after delivery

Intermittent intramuscularIntermittent intramuscular

Give 4 g MgSO4 IV , rate not exceed 1 Give 4 g MgSO4 IV , rate not exceed 1 g/ming/min

Follow with 10 g MgSO4 : 5 g injected Follow with 10 g MgSO4 : 5 g injected each buttock through 3 inch long , 20 each buttock through 3 inch long , 20 gauge needle , (add 1 ml of 2% lidocaine)gauge needle , (add 1 ml of 2% lidocaine)

If convulsions persist after 15 min , give 2 If convulsions persist after 15 min , give 2 g more IV slowlyg more IV slowly

Give 5 g MgSO4 IM q 4 hrGive 5 g MgSO4 IM q 4 hr MgSO4 discontinue 24 hr after deliveryMgSO4 discontinue 24 hr after delivery

MgSO4MgSO4

Effective anticonvulsant without producing Effective anticonvulsant without producing CNS depression in either mother or infantCNS depression in either mother or infant

Not given to treat HTNot given to treat HT Exert specific on cerebral cortexExert specific on cerebral cortex 10-15% after MgSO4 : subsequent 10-15% after MgSO4 : subsequent

convulsionconvulsion Sodium amobarbital & thiopental , if Sodium amobarbital & thiopental , if

excessive agitate in postconvulsion stateexcessive agitate in postconvulsion state In Eclampsia , admin for 24 hr after onset In Eclampsia , admin for 24 hr after onset

of convulsionof convulsion

MgSO4MgSO4

Almost totally cleared by renal excretionAlmost totally cleared by renal excretion Monitor urine output , DTR , RRMonitor urine output , DTR , RR Maintained level 4-7 mEq/LMaintained level 4-7 mEq/L IM & IV regimen , no significant difference IM & IV regimen , no significant difference

Mg levelMg level Mg 10 mEq/L : patellar reflex disappearMg 10 mEq/L : patellar reflex disappear > 10 mEq/L : respiratory depression> 10 mEq/L : respiratory depression > 12 mEq/L : respiratory paralysis & arrest> 12 mEq/L : respiratory paralysis & arrest Cr >1.3 : half dose MgSO4Cr >1.3 : half dose MgSO4

MgSO4MgSO4

Fetal effectsFetal effects Promptly cross placentaPromptly cross placenta Neonatal depression occurs only if severe Neonatal depression occurs only if severe

hypermagnesemia at deliveryhypermagnesemia at delivery Decrease in beat-to-beat variabilityDecrease in beat-to-beat variability Possible protective effect against cerebral palsy Possible protective effect against cerebral palsy

in VLBW infantsin VLBW infants Substantial gross motor dysfunction reducedSubstantial gross motor dysfunction reduced No serious harmful effectsNo serious harmful effects

Compared with anticonvulsantsCompared with anticonvulsants

MgSO4 reduce recurrent sz 50% MgSO4 reduce recurrent sz 50% compared to diazepam , reduce maternal compared to diazepam , reduce maternal & perinatal morbidity (not sig)& perinatal morbidity (not sig)

Maternal mortality reduced compared to Maternal mortality reduced compared to phenytoin (not sig) , less neonatal phenytoin (not sig) , less neonatal intubation & NICU admissionintubation & NICU admission

Prevent eclamptic sz superior to phenytoinPrevent eclamptic sz superior to phenytoin Lower risk placental abruptionLower risk placental abruption

AntihypertensiveAntihypertensive

Hydralazine suggested if persistent Hydralazine suggested if persistent systolic > 160 , or diastolic > 105 mmHg systolic > 160 , or diastolic > 105 mmHg (NHBPEP2000)(NHBPEP2000)

5-10 mg doses at 15-20 min inervals5-10 mg doses at 15-20 min inervals Satisfactory response ante or intrapartum : Satisfactory response ante or intrapartum :

diastolic 90-100diastolic 90-100 Seldom another antihypertensive neededSeldom another antihypertensive needed FHR deceleration when BP fell to 110/80FHR deceleration when BP fell to 110/80

AntihypertensivesAntihypertensives

Labetolol : IV Labetolol : IV αα11& nonselective & nonselective ββ-blocker-blocker

Lower BP more rapidly , associated Lower BP more rapidly , associated tachycardiatachycardia

NHBPEP(2000) : recommends 20 mg IV NHBPEP(2000) : recommends 20 mg IV bolus , if not effective within 10 min , bolus , if not effective within 10 min , followed by 40 mg , then 80 mg q 10 min followed by 40 mg , then 80 mg q 10 min but not exceed 220 mg total dose per but not exceed 220 mg total dose per episode treatedepisode treated

AntihypertensivesAntihypertensives

Nifedipine 10 mg Oral , repeated in 30 min Nifedipine 10 mg Oral , repeated in 30 min , if necessary (NHBPEP 2000), if necessary (NHBPEP 2000)

Fewer dose required to achieve BP control Fewer dose required to achieve BP control without increased adverse effectswithout increased adverse effects

Sublingual : potent & rapid : Sublingual : potent & rapid : cerebrovascular ischemia , MI , conduction cerebrovascular ischemia , MI , conduction disturbance , deathdisturbance , death

Not superior to other hypertensivesNot superior to other hypertensives

Persistent postpartum HTPersistent postpartum HT

Hydralazine 10-25 mg IM q 4-6 hrHydralazine 10-25 mg IM q 4-6 hr If HT persists or recur : oral labetolol or If HT persists or recur : oral labetolol or

thiazide diuretic are giventhiazide diuretic are given Two mechanisms : Two mechanisms :

1. Underlying chronic hypertension , 1. Underlying chronic hypertension , 2. Mobilization of edema fluid 2. Mobilization of edema fluid

Diuretics & hyperosmotic agentsDiuretics & hyperosmotic agents

Diuretics : deplete intravascular volume , Diuretics : deplete intravascular volume , compromise placental perfusion , limited compromise placental perfusion , limited used to pulmonary edemaused to pulmonary edema

Hyperosmotic agents : leaks of agents Hyperosmotic agents : leaks of agents through capillaries into lungs & brain through capillaries into lungs & brain promote accumulation of edemapromote accumulation of edema

Fluid therapyFluid therapy

Lactate Ringers Solution , rate 60 ml to Lactate Ringers Solution , rate 60 ml to 125 ml/hr125 ml/hr

Unless unusual fluid loss : N/V , diarrhea , Unless unusual fluid loss : N/V , diarrhea , excessive blood lossexcessive blood loss

Oliguria : maternal blood volume Oliguria : maternal blood volume constricted, admin IV fluid more vigorouslyconstricted, admin IV fluid more vigorously

Women with eclampsia already has Women with eclampsia already has excessive extracelular fluidexcessive extracelular fluid

Pulmonary edemaPulmonary edema

Most often do so postpartumMost often do so postpartum Aspiration should be excludeAspiration should be exclude Majority have cardiac failureMajority have cardiac failure Decrease plasma oncotic pressure , increase Decrease plasma oncotic pressure , increase

extravascular oncotic pressure , increase extravascular oncotic pressure , increase capillary permeability , hemoconcentration , capillary permeability , hemoconcentration , reduced CVP , PCWPreduced CVP , PCWP

Excessive colloid & cyrstalloid cause pulm Excessive colloid & cyrstalloid cause pulm edemaedema

Invasive monitoringInvasive monitoring

Use of pulmonary artery catheterizationUse of pulmonary artery catheterization Reserved for women with severe cardiac Reserved for women with severe cardiac

disease , renal disease , refractory disease , renal disease , refractory hypertension , oliguria , pulmonary edemahypertension , oliguria , pulmonary edema

Pulmonary edema by more than one Pulmonary edema by more than one mechanismmechanism

If questionable pulmonary edema : If questionable pulmonary edema : furosemide IV , hydralazine IVfurosemide IV , hydralazine IV

DeliveryDelivery

After eclamptic sz , labor often ensues After eclamptic sz , labor often ensues spontaneously or can be induced spontaneously or can be induced successfully even in remote from termsuccessfully even in remote from term

Because lack of normal pregnancy Because lack of normal pregnancy hypervolemia , so less tolerant of blood hypervolemia , so less tolerant of blood loss at deliveryloss at delivery

Analgesia & anesthesiaAnalgesia & anesthesia

GA caused by tracheal intubation, sudden GA caused by tracheal intubation, sudden HT ,pulm edema , intracranial hgeHT ,pulm edema , intracranial hge

Epidural preferred : no serious maternal or Epidural preferred : no serious maternal or fetal complication , lower MAP , Cardiac fetal complication , lower MAP , Cardiac output not falloutput not fall

Thank you for your attentionThank you for your attention