Mishell Kris Sorongon

OB Case Presentation

ObjectivesTo diagnose hypertension in pregnancyTo differentiate the classification of hypertension in

pregnancyTo discuss the pathophysiology of hypertension in

pregnancyTo apply appropriate management for the case

General DataM. M. G.37 y/oMarriedG2P1 (1001) FilipinoFairview Quezon CitySSS Specialist

Past Medical History(-) Diabetes Mellitus(+) Hypertension (2008) – was started on Atenolol 20

mg once a day but stopped when she became pregnant. UBP 120/80 mmHg HBP 140/100 mmHg

(+) Bronchial asthma – last attack on July 2010 was given Prednisone 5 mg twice a day for 5 days

(-) Thyroid disorders(-) known allergies to food and drugs

Family History(+) Diabetes Mellitus - mother(+) Hypertension – Grandmother(+) Asthma – aunt (-) Heart disease (-) Cancer

Personal and Social HistoryNon-smokerNon-drinker of alcoholic beveragesWorks in SSS

Menstrual HistoryMenarche at 14 years of ageRegular monthly intervalsDuration of 5 days3-4 pads per dayDysmenorrhea on D1LMP: January 17, 2010PMP: December 2009

Obstetric HistoryG2P1 (1001)G1 (1999) 39 weeks AOG delivered 6.6 lbs male via

LTCS due to breech in SLMC. No lengthened hospital stay

G2 Present pregnancy

Gyne History(-) OCP use(+) Papsmear (March, 2009) normal results(+) sexually active(-) vaginal bleeding(-) vaginal discharge

Reason for AdmissionEpigastric pain

LMP: January 17, 2010EDC by LMP: October 24, 2010G2P1 (1001) 30 1/7 weeks AOG

First Trimester Second Trimester Third Trimester

• First prenatal check-up at 8 weeks AOG• Started taking multivitamins, iron, and calcium once a day• No maternal illness

•URTI - given Cefalexin 500 mg three times a day for 7 days• Episode of vaginal spotting - given Duvadillan once a day for 20 days then as needed• OGCT showed normal results

•UTI – Amoxicillin three times a day for 7 days. •Proteinuria +2•Repeat urinalysis not done

History of Present IllnessFew hours prior to

admission

Epigastric pain, severe, burning in

character, no radiation. No changes in

bowel habits.

Sought consult with attending physician

Blood pressure :160/100 mmHg.

(-) watery or bloody vaginal discharge (+)

good fetal movement

(+) bipedal edema

(-) headache or blurring of vision.

Patient claimed that urinalysis done last

week showed proteinuria 2+

Review of Systems General: no weigbt loss, anorexia, fever Skin: no skin changes Eyes: no blurring of vision, redness, itchiness, discharge, pain Nose: No discharge, epistaxis, anosmia Mouth & Throat: No bleeding, circumoral cyanosis, hoarseness, soreness,

difficulty of swallowing Pulmonary: no difficulty of breathing, cough, hemoptysis, chest wall

abnormalities Heart: No palpitations, chest pain, chest heaviness Abdomen: (+) epigastric pain, no constipation, diarrhea, hematochezia,

melena, hearburn, belching Genitourinary: no hematuria, frequency, urgency, flank pain Vascular: no excessive bleeding, easy bruisability Neurologic: no headache, seizure episode, one-sided weakness or numbness

Physical ExaminationConscious, coherent, not in cardiorespiratory distress,

VAS 9/10BP 140/100 mmHgCardiac rate 76 bpmRespiratory rate 16 cpmTemp: 37.2 CWeight 66 kgHeight 155 cmBMI: 27.5

Physical ExaminationMoist skin, no active dermatosis, (+) linea nigra , (+)

striae gravidarumNo facial involuntary movement, edema, massesPink palpebral conjunctivae, anicteric sclerae, patent

external auditory canal, non-congested turbinates, no nasal discharge, supple neck, no lymphadenopathies, no palpable anterior neck mass

Symmetrical chest expansions, clear breath sounds in all lung fields, no retractions

Adynamic precordium, normal rate, regular rhythm, S1>S2 apex, S2>S1 base, PMI at 5th LICS, no murmurs

Globular abdomenFundic Height: 29 cm EFW 2635 gmL1 breechL2 maternal rightL3 not engagedFHT 140s, RLQPelvic exam: normal looking external genitaliaInternal exam: admits 2 fingers with ease, Cervix

closed, uterus enlarged to age of gestationSE: not done

Rectovaginal exam: not done(+) Grade 2 bipedal edema, pulses full and equalConscious, coherent, oriented to 3 spheresNo sensorimotor deficitsDeep tendon reflexes of upper and lower extremities:

++

Admitting Diagnosis37 year old G2P1 (1001) Pregnancy uterine 30 1/7

weeks AOGchronic hypertensive vascular disease with

superimposed preeclampsia, mild

Problem ListEpigastric painBipedal edemaBP: 140/100 mmHgHypertensionPregnancy at 30 1/7 weeks AOG

Salient FeaturesSubjective Objective

37 year old G2P1 (1001) 30 1/7 w AOGPrevious LTCS due to breech (1999)Hypertensive since 2008 maintained on Atenolol OD but stopped since JanuaryEpigastric pain, burning, nonradiating, severeElevated BP: 160/100 mmHgNo blurring of vision, headache, seizure episodeBipedal edema

Conscious, coherent, not in cardio respiratory distressBP: 140/100 mmHg HR: 76 bpmDeep tendon reflexes intactGlobular abdomen, FHT 140s at RLQCervix closedBipedal edema grade 2No sensorimotor deficitsDeep tendon reflexes: ++

Laboratory Work-upsCBC13.2/38.5/4.12/10 700/N81L14E1M4/160 000MCV 94 MCH 32 MCHC 34

UrinalysisLight yellow, hazy, glucose 100 mg/dl (2+), negative

bilirubin, ketone 15 mg/dl (1+), specific gravity 1.015, pH 6.5 protein 100 mg/dl (2+), urobilinogen 0.2, nitrites negative, blood trace – intact, leukocytes moderate (2+)

RBC 3 WBC 29 Epithelial cells 11 casts 2 bacteria 15

Hypertension in Pregnancythe most common medical problem encountered in

pregnancy WHO (2006) – 16% of maternal deaths in developed

countriesremains an important cause of morbidity and

mortality

Risk FactorsYoung age and nulliparitymultiple pregnancyBMI > 35 African American ethnicityMaternal age > 35 years oldHistory of chronic hypertensionFamily history

Definitionsystolic BP (SBP) ≥ 140mmHg

and/or diastolic BP (DBP) ≥ 90mmHg

confirmed by readings over several hours apart

Categories of Hypertensive DiseasesGestational HypertensionPreeclampsiaEclampsiaPreeclampsia superimposed on Chronic HypertensionChronic Hypertension

Gestational HypertensionDescribes any form of new-onset pregnancy-related

hypertension – Transient HypertensionBP ≥ 140/90 mm Hg for first time during pregnancyNo proteinuriaBP returns to normal < 12 weeks postpartumFinal diagnosis is made only postpartumMay have other signs or symptoms of preeclampsia

(e.g. Epigastric discomfort, thrombocytopenia)

Preeclampsiagestational HPN with proteinuria

Minimum Criteria: BP ≥ 140/90 mm Hg after 20 weeks gestationProteinuria ≥ 300 mg/24 hours or ≥ 1+ dipstick* edema is abandoned as a marker because it occurs in

normal pregnant woman

EclampsiaPreeclampsia complicated by generalized tonic clonic

convulsions – cannot be attributed to other causesOne of the most dangerous conditions in pregnancyMost common in the last trimester and becomes

increasingly more frequent as term approachesPrognosis is always serious

Superimposed Preeclampsia on Chronic HypertensionNew onset proteinuria > 300 mg/24 hours in

hypertensive women but no proteinuria before 20 weeks’ gestation

Sudden increase in proteinuria/ Blood Pressure/ platelet count <100,000/mm3 before 20 wks AOG (on a chronic hypertensive patient)

Chronic Hypertensiondetection prior to 20 weeks AOG and persistence

beyond 12 weeks postpartum

Preeclampsia

Increased CertaintyBP ≥ 160/110 mm HgProteinuriaSerum creatinine > 1.2mg/dl unless known to be

previously elevatedPlatelets < 100,000/mm3increased LDH (Microangiopathic hemolysis)Elevated ALT or ASTPersistent headache or other cerebral or visual

disturbancePersistent epigastric pain

Indications on Severity of PreeclampsiaAbnormality Mild Severe

Diastolic BP <100 mmHg > 110 mmHg

Proteinuria Traces to +1 Persistent > +2

Headache Absent Present

Visual disturbance Absent Present

RUQ pain Absent Present

Oliguria Absent Present

Convulsion Absent Present

Serum Creatinine Normal Elevated

Thrombocytopenia <100, 000

Absent Present

Liver enzyme elevation Minimal Marked

Fetal growth restriction Absent Obvious

Pulmonary Edema Absent Present

Abnormal Placentation in PreeclampsiaPseudovasculogenesis• Cytotrophoblasts fail to

adopt an invasive endothelial phenotype

• Invasion of the spiral arteries is shallow – remains small caliber, resistance vessels

• Placental Ischemia

Pathophysiology

Normotensive gravidasDecreased pressor responsiveness to several vasoactive

peptides and amines, esp Angiotensin IIPreeclampsia

Hyperresponsiveness to angiotensin II and endothelin

Basic Management GuidelinesTermination of pregnancy with least possible trauma

to the mother and the fetusBirth of an infant who subsequently thrivesComplete restoration of the health to themother

Preeclampsia ManagementGoal of Management: early identification of worsening

preeclampsia and development of a management scheme that includes a plan for timely delivery

Hospitalization Evaluate:

maternal weight and maternal statusBP monitoring q4creatinine, hematocrit, platelet count, Liver

transaminasesUrinalysis every 2 daysFetal BPS, doppler velocimetry

Termination of PregnancyHeadache, visual disturbances, epigastric pain or

oliguria are indicative that convulsions may be imminent

Delivery is usually advisable for severe preeclampsia that does not improve after hospitalization

Labor should be induced by intravenous oxytocinCesarian delivery is indicated for cases of failed

induction

Some Indications for Delivery in Early-Onset Severe Preeclampsia

MaternalPersistent severe headache or visual changes; eclampsiaShortness of breath; chest tightness with rales and/or SaO2

< 94 percent breathing room air; pulmonary edemaUncontrolled severe hypertension despite treatmentOliguria < 500 mL/24 hr or serum creatinine 1.5 mg/dLPersistent platelet counts < 100,000/LSuspected abruption, progressive labor, and/or ruptured

membranes

FetalSevere growth restriction—< 5th percentile for EGAPersistent severe oligohydramnios—AFI < 5 cmBiophysical profile 4 done 6 hr apartReversed end-diastolic umbilical artery flowFetal death

Effects of Expectant Management for Severe preeclampsiaMaternal: placental abruption (20%), HELLP

syndrome, pulmonary edema (4%), renal failure, and eclampsia

Perinatal mortality rates averaged from 39 to 133 per 1000 - Fetal-growth restriction and perinatal mortality

Risks for eclampsia, cerebrovascular hemorrhage, and maternal death.

Intrapartum ManagementMagnesium SO4 - used to arrest and prevent

convulsions w/o producing generalized CNS depressionLoading dose: 4 gms IV, 10 gms IMMaintenance dose: 5 gms q 4 hrs

Therapeutic level: 4-7 mEq/LLoss of patellar reflex: 8-10mEq/LRespiratory depression: 10mEq/L Respiratory arrest: 12 mEq/L

Treatment MgSO4 toxicity: calcium gluconate, 1 gm IV, Oxygenation

MOA: Anti-convulsant Acts by:1. Neuronal calcium-channel blockade through N

methyl- d-aspartate receptors2. Reversal of cerebral arterial vasoconstriction distal to

the middle cerebral arteries3. Release of endothelial prostacyclin and inhibition of

platelet clumping

Intermittent intramural injectionsEvery 4 hours thereafter, give 5 g of a 50% solution of

magnesium sulfate injected deeply in the upper outer quadrant of alternate buttocks, but only after ensuring thata. the patellar reflex is presentb. respirations are not depressedc. urine output the previous 4 hours exceeded 100ml

Magnesium sulfate is discontinued 24 hours after delivery

Anti-hypertensive TherapyHydralazine - Causes direct relaxation of arteriolarvascular smooth muscle

Drug of choice for rapid control of acute hypertension5 mg initial dose, 5-10 mg q 15-20 m IV until there’s

satisfactory response (DBP 90-100 mmHg)Side-effects: palpitations, tachycardia, headaches,

flushing

Labetalola1- and nonselective -blocker. fewer side effects (maternal hypotension and

bradycardia)Initial: 10 mg IV

q10 – 20 mg, then 40 mg, 40 mg, 80 mg maximum dose of 220 mg per treatment cycleNifedipine - 10 mg PO q30 min.

third line drug that acts by limiting calcium channel causing relaxation of smooth muscle

ProphylaxisAspirin, 60-80 mg OD

suppression of thromboxane synthesis by platelets and promoting prostacyclin production

Antioxidantssignificantly reduces endothelical cell activation

Thank you!

Fetal Monitoring in Gestational Hypertension and PreeclampsiaGestational Hypertension(hypertension only without proteinuria, with normal

laboratory results, and without symptoms)Estimation of fetal growth and amniotic fluid status

should be performed at diagnosis. If results are normal, repeat testing only if there is significant change in maternal condition

Nonstress test (NST) should be performed at diagnosis. If NST is nonreactive, perform biophysical profile (BPP). If BPP value is eight or if NST is reactive, repeat testing only if there is significant change in maternal condition

Anti-hypertensive Therapy1. Methyldopa - First line anti-hypertensive agentMOA: stimulation of central alpha-adrenergic

receptors by a false transmitter that results in a decreased sympathetic outflow to the organ systems.

200-500mg tab Q6Lowers BP by reducing sympathetic outflow from

brainstemSuited for long-term use

Patient admitted to HRPUD5LR 1 liter to run for 8 hoursDemerol 50 mg IV nowHydralazine 4 mg IV statMagnesium sulfate 5 mg IM buttocks