Interesting case

11/24/2011

Warawut suttison , GP

• A pregnant woman , 19 yrs• History taking from patient and her husband• CC : seizure 30 min PTA

• OB-GYN Hx :– G1P0 GA 35 wks by U/S – ANC x 8 at private clinic : normal

• PH :– No underlying disease– No drug allergy

• FH :– No history of seizure

• PE :– General appearance : confusion– Vital sign : BP 140/100 mmHg , RR 22 /min ,

BT 38.1 c , PR 120 /min– HEENT : pink conjunctiva , anicteric sclera– Heart and lungs : equal breath sound , normal S1S2 ,

no murmur– Abdomen : HF - , position : ROA , FHS : 160 , uterine

contraction : can’t evaluate , EFW : 2500 gram– PV : not done

Provisional diagnosis

Hypertensive Disorders of Pregnancy

I. Introduction

• Hypertensive disorders complicate 5 to 10 percent of all pregnancies, and together they form one member of the deadly triad

• In developed countries, 16 percent of maternal deaths were due to hypertensive disorders

Ref : William obstetric 23rd edition,2009

II. Diagnosis

• Hypertension is diagnosed empirically when appropriately taken blood pressure exceeds 140 mm Hg systolic or 90 mm Hg diastolic

• women who have a rise in pressure of 30 mm Hg systolic or 15 mm Hg diastolic should be seen more frequently

Ref : William obstetric 23rd edition,2009

III. Classification and Definitions

Ref : William obstetric 23rd edition,2009

Ref : William obstetric 23rd edition,2009

III. Classification and Definitions

• Gestational Hypertension• Preeclampsia and eclampsia syndrome• superimposed Preeclampsia on chronic

hypertension• Chronic hypertension

Ref : William obstetric 23rd edition,2009

II. Classification and Definitions

• 1. Gestational Hypertension:– Systolic BP 140 or diastolic BP 90 mm Hg for first

time during pregnancy – No proteinuria – BP returns to normal before 12 weeks postpartum – Final diagnosis made only postpartum – May have other signs or symptoms of

preeclampsia, for example, epigastric discomfort or thrombocytopenia

Ref : William obstetric 23rd edition,2009

• 2. Preeclampsia and eclampsia syndrome• Preeclampsia:

Minimum criteria:– BP 140/90 mm Hg after 20 weeks' gestation – Proteinuria 300 mg/24 hours or 1+ dipstick

Ref : William obstetric 23rd edition,2009

Increased certainty of preeclampsia :– BP 160/110 mm Hg – Proteinuria 2.0 g/24 hours or 2+ dipstick – Serum creatinine >1.2 mg/dL unless known to be previously

elevated – Platelets < 100,000/L – Microangiopathic hemolysis—increased LDH – Elevated serum transaminase levels—ALT or AST – Persistent headache or other cerebral or visual disturbance – Persistent epigastric pain

Ref : William obstetric 23rd edition,2009

• Eclampsia:– Seizures that cannot be attributed to other causes

in a woman with preeclampsia

Ref : William obstetric 23rd edition,2009

Ref : William obstetric 23rd edition,2009

• 3. Superimposed Preeclampsia On Chronic Hypertension:– New-onset proteinuria 300 mg/24 hours in

hypertensive women but no proteinuria before 20 weeks' gestation

– A sudden increase in proteinuria or blood pressure or platelet count < 100,000/L in women with hypertension and proteinuria before 20 weeks' gestation

Ref : William obstetric 23rd edition,2009

• 4. Chronic Hypertension:– BP 140/90 mm Hg before pregnancy or diagnosed

before 20 weeks' gestation not attributable to gestational trophoblastic disease

or– Hypertension first diagnosed after 20 weeks'

gestation and persistent after 12 weeks postpartum

Ref : William obstetric 23rd edition,2009

Investigation

• UA (15/11)– Color : yellow– Appearance : clear– glu ,ketone– alb : neg– RBC : 2-3– WBC : 5-10– Epi : 5-10

• CBCHb 12.4 Hct 38.2 WBC 23000Plt 430000 PMN 66 Lymph 26 MCV 78

• Coagulogram PT 9(11.2) PTT 28.1(29.2)INR 0.83

• Blood chemistryBUN 5 , Cr 0.9Electrolyte : Na 136 K 2.8

HCO3 22.3 Cl 104LFT : pro 7.9 alb 3.8 glob 4.1

DB 0.06 TB 0.47 SGOT 19 SGPT 10 ALP 136

Diagnosis

• Management– Non-severe preeclampsia– severe preeclampsia– eclampsia

Non severe preeclampsia• Admit• Bed rest• Monitoring for symptoms of pre-eclampsia ; daily kick counts• Body weight once a day• Blood pressure check every 6 hours , no antihypertensive drug

not shown to improve perinatal outcome• Laboratory testing: baseline 24-hour urine protein collection

at least 3 days• Non-stress test/biophysical profile• Termination

termclinical worsing (severe PIH)

Ref : Johns Hopkins Manual of Gynecology and Obstetrics, The, 3rd Edition

Severe preeclampsia

• Principle1. Seizure prophylaxis2. Antihypertensive therapy3. Delivery

Ref : William obstetric 23rd edition,2009

Severe preeclampsia

• 1. Seizure prophylaxis

Ref : William obstetric 23rd edition,2009

Severe preeclampsia

• Seizure prophylaxis• LD : Give 4 g of magnesium sulfate diluted in 100 mL of

IV fluid administered over 15–20 min• MD :Begin 2 g/hr in 100 mL of IV maintenance infusion.• Monitor for magnesium toxicity:

The patellar reflex is present,Respirations are not depressed, andUrine output the previous 4 hr exceeded 100 mL

• Magnesium sulfate is discontinued 24 hr after deliveryRef : William obstetric 23rd edition,2009

Severe preeclampsia

• Antihypertensive therapy• The three most commonly employed in North

America and Europe are hydralazine, labetalol, and nifedipine

• 1. nifedipine Dosage :– (soft capsule) 10 mg sublingual– (film-coat tablet) 10 mg oral

Ref : William obstetric 23rd edition,2009

Severe preeclampsia

• 2. hydralazine Dosage : 5 mg IV

Ref : William obstetric 23rd edition,2009

Severe preeclampsia

• Delivery– 1. induction– 2.route of delivery

Ref : William obstetric 23rd edition,2009

Ecclampsia

• Management– Control of convulsions – Intermittent administration of an antihypertensive

medication – Avoidance of diuretics unless there is obvious

pulmonary edema– Delivery of the fetus to achieve a "cure."

Ref : William obstetric 23rd edition,2009

Thank you