neil vanes, obstetric and gynaecology uhcw. pre-eclampsia eclampsia pregnancy-induced (gestational)...

HYPERTENSION IN PREGNANCY

Neil Vanes, Obstetric and Gynaecology

UHCW

Scope of This Talk

• Pre-eclampsia• Eclampsia• Pregnancy-Induced (Gestational)

Hypertension• Essential Hypertension

PET/Eclampsia 3

Hypertensive disorders

N o p ro te in u ria -PIH

M ild an d m od era te P E T Severe PET Eclam psia HELLP

P ro te in u ria an d R a ised B PPre -eclam psia

Pregnancy induced hypertension(R a ised B P a fte r 2 0 w eeks )

Chronic hypertension(R a ised B P b e fo re 2 0 w eeks g es ta tion )

R a ised B P in p reg n an cy> o r = 1 4 0 /9 0

What you need to know.

• Definition and symptoms PET• Prevention of PET• Who is at risk of PET• History, examination and investigation of

patients with suspected PET• Management of PET (mild and severe)• Prevention of fits• When to deliver• Postnatal care

PET/EclampsiaGeorge Eliot Hospital, Nuneaton 5

Pre-Eclampsia: Definition Hypertension and proteinuria with onset

≥20 weeks Oedema from classical definition dropped as not

discriminating clinically Onset <20 weeks ONLY seen in hydatidiform mole

(triploid pregnancy) –extremely rare

• Symptoms– NOT necessary to diagnose PET– Marker of more severe disease/progression

towards eclampsia

DEFINITIONS (2)• HYPERTENSION: Diastolic ≥90mmHg on 2

occasions 4-6 hours apart OR ≥110mmHg on one occasion

• PROTEINURIA : >300mg/24 hours• 24 hour collection or (preferably) PCR (>30)

• Differentiation from PIH/renal disease• Timing• Other findings eg blood in urine, abnormal U+E

Definitions of Hypertension in Pregnancy

MILD MODERATE SEVERE

Systolic 140-149 150-159 160

Diastolic 90-99 100-109 110


Incidence (some facts and figures)• 10% women have hypertension• 5% pregnancies have PET

• 1-2% pregnancies have severe PET

• Rates eclampsia 26.8/100 000 maternities (UKOSS reporting system 2003-5)

• Worldwide every year 1.5-8 million develop PET with 150 000 deaths

• UK: 18 deaths (2006-8)• 9 cerebral haemorrhage/infarction • 5 from hypoxic arrest after fit• 7 were eclamptic, 8 had HELLP syndrome


Importance

Maternal Risks◦ DEATH◦ Blindness◦ Neurological sequelae (haemorrhage/infarction)◦ Fits (Eclampsia)◦ Renal impairment/failure◦ Hepatic failure/rupture◦ Abruption◦ DIC


Importance

Fetal Risks Death◦ Abruption-> hypoxia◦ IUGR

◦ (onset PET <28 weeks->50% babies have IUGR)◦ Hypoxia◦ Prematurity (PET is cause of >40% iatrogenic

preterm dels) respiratory complications (RDS) neurodevelopmental complications (inc.learning

difficulty/IQ in up to 60%)


Risk Factors:-Pre-Eclampsia• Primiparous• First pregnancy with

new partner• Family history (1 in 3

risk if mother had PET)• Twins/multiples• Pregestational

Diabetes• Previous PET (if

severe/ <28 weeks, 50% recurrence)

• Essential hypertension

• Renal disease• SLE• Antiphospholipid

syndrome• Thrombophilias• Age >40• Obesity


Pathophysiology “The disease of theories”

Pregnancy specific syndrome Placenta has a central role to play

◦ Reduced placental perfusion◦ Inadequate vascular remodelling at ~16 wks◦ Relative hypoperfusion◦→Oxidative stress◦→Widespread endothelial dysfunction◦→Systemic disease

Spectrum of same underlying placental pathology

Usually coexist

PET and IUGR

PET IUGR

Aspirin: Who to Treat?HIGH RISK: women with

ANY of:• hypertensive disease

during a previous pregnancy

• chronic kidney disease• autoimmune disease

such as systemic lupus erythematosis or antiphospholipid syndrome

• type 1 or type 2 diabetes• chronic hypertension.

MODERATE RISK: women with >1 of:

• first pregnancy• age 40 years or older• pregnancy interval of

more than 10 years• body mass index (BMI)

of 35 kg/m² or more at first visit

• family history of pre-eclampsia

• multiple pregnancy.

NICE : Hypertension in Pregnancy (RCOG/RCM, August 2010)• Evidence supports use of aspirin in women

at ‘high’ or ‘moderate’ risk of developing PET

• Use of 75mg per day aspirin from 12 weeks to delivery• No evidence of fetal harm at this dose• No convincing evidence increased risk APH/PPH

Clinical diagnosis

Classic triad◦ Hypertension 140/90◦ Proteinuria >300mg in 24 hours (RCOG)◦ Oedema (least reliable)

◦ BUT....◦ Proteinuria and raised BP x 2 occasions 6 hrs

apart (or once if DBP ≥110 and heavy proteinuria >2+ (=1g/24h))

CLINICAL FEATURES

Mild hypertension

Mild proteinuria

>20 weeks pregnant

= Mild pre-eclampsia

DIAGNOSIS?

What questions should you ask?• Headache (classically severe)

– Effects hypertension• Visual disturbances (‘flashing lights’)

– Sign of cerebral vasospasm/impending eclampsia• Epigastric pain

– Hepatic congestion/liver capsule stretching• Is baby moving normally?

– Fetal wellbeing


PET-Maternal Investigations• BLOOD:• FBC- platelet count

– Platelets <100 indicate progressive/worsening disease

• U+E signs renal dysfunction (late)• Urate hyperuricaemia

– ( early, doesn’t predict outcomes well )

• LFTs elevated transaminases– Can indicate worsening of disease

• Clotting X (not routinely if plts>100)

• URINARY:• MSU to exclude UTI as cause of protein• PCR quantify proteinuria


PET

• Fetal assessment– Clinical– USS for growth– CTGs

• ?cervical assessment –vaginal examination• (depending on gestation)


Mild PET Classically asymptomatic BP 140/90 (ish)-mild hypertension Maybe trace-+ proteinuria Often incidental finding at CMW clinic

attendance


Monitoring MILD PET

• Monitor BP– CMW– Day assessment or Triage Unit (outpatient Mx)

• Monitor bloods– Weekly or twice weekly (depends on sitn)

• Monitor fetus– CTG– Serial USS


Definitive treatment

• Deliver when– BP/protein or clinical condition deteriorates so

become moderate or severe PET– Reaches 41 weeks and no change in condition– Fetal condition mandates delivery even if

maternal condition stable


Moderate PET Classically asymptomatic

◦ May have odd headache or occ visual disturbances

BP 150/100 (ish)-moderate hypertension Usually + - ++proteinuria Often incidental finding at CMW clinic

attendance◦ May present with headaches


Monitoring MODERATE PET

• Monitor BP– Admit initially-4 hourly BP– Consider antihypertensives if <36 weeks to

prolong pregnancy– If 36 weeks or greater ?delivery

• Monitor bloods– Check on admission– Check 2-3x weekly (if wish to prolong pregnancy)

• Monitor fetus– CTG– Serial USS (with LV/Dopplers)


Definitive treatment

• Deliver when– Reaches 36-37 weeks or diagnosis after this

gestation– Fetal condition mandates delivery even if

maternal condition stable and below this gestation

Severe pre-eclampsia SYSTOLIC 160-180+ DIASTOLIC >110

◦ =Severe hypertension

HEAVY PROTEINURIA

May present unwell or asymptomatic



Symptoms

• Headache (BP)• Flashing lights (lightning) (cerebral oedema)• Epigastric pain (stretching of liver capsule)• Oedema (albumin/BP)• Less common:

• blindness, scotoma, oliguria, SOB

• Asymptomatic

Signs: Severe PET

CNS◦ Disorientation/ irritability◦ Hyperreflexia◦ FITS◦ Clonus◦ Blindness◦ Scotoma◦ Papilloedema

– Hepatic◦ Abnormal LFTs/dysfunction◦ Epigastric pain/tenderness

Renal◦ Elevated creatnine,

urea, urate◦ Oliguria◦ Heavy proteinuria

>5g in 24 hrs Haemtological

◦ Thrombocytopaenia◦ Haemolysis

Pulmonary◦ Shortness of

breath


Management of severe pre-eclampsia• Immediate admission to hospital

• High dependency care/LW-QUIET– Invasive monitoring (arterial line +/- CVP)– NICU for baby if early gestation

• Senior multidisciplinary involvement early-obs and anaesthetics


Aims of treatment

Aims

1. Prevent seizures2. Control hypertension (to prevent cerebral

haemorrhage)3. Deliver safely (stabilise, +/- IUT, +/- steroids)


Maternal Assessment• BP- every 15 minutes [MEOWS]• Urine output-hourly• Urinary protein dipstix• Strict fluid balance chart

• Restrict 60-80ml/hr• Bloods

– U+E, urea, creatnine, urate– FBC esp. platelets (G+S)– LFTs

• Deep tendon reflexes and presence of clonus• CTG


Control blood pressure• Antihypertensives – aim for diastolic 80-99,

systolic <150

– IV hydralazine (5mg every 15 minutes to acutely control BP)

– IV labetolol (Not good if asthmatic or already signs of pulmonary oedema-first line in many places now)

– Oral nifedipine 10mg NOT SUBLINGUAL

– Methyldopa TOO SLOW ONSET (24-48 hours) for use in acute situation

– Titrate IV antihypertensive vs. BP then infusion


KEY POINTS: Hypertension

Systolic blood pressure of 160 mm/Hg or more = anti-hypertensive treatment.

(irrespective of diastolic)

Consideration starting treatment at lower pressures if the overall clinical picture suggests likely rapid deterioration with anticipation of severe hypertension.


Prevent Fits• Magnesium sulphate

– All severe and moderate PET (MAGPIE)– 4g IV over 15 minutes– Then infusion 1g/ hour

– Monitor reflexes (present) urine OP (>30ml/hr) and respiratory rate (>12/minute)– Slows neuromuscular conduction and decreases

CNS irritability– Best anticonvulsant in these circumstances

AND IN ECLAMPSIA– No effect on BP– Tell anaesthetist if GA as potentiates effects of

muscle relaxants


Magnesium toxicity

If urine OP OK then likely not to accumulate (85% renal excretion)

If urine output falls, reduce dose to 0.5g/hour

If signs toxicity, stop Antidote = Calcium

gluconate 1g IV over 3 minutes

Magnesium levels◦ Therapeutic 2-4 mmol/l◦ Warmth, flushing, slurred

speech 3.8-5mmol/l◦ Loss of patellar reflexes >5

mmol/l◦ Respiratory depression >6

mmol/l◦ Respiratory arrest 6.3-

7mmol/l◦ Cardiac arrest, asystole >12

mmol/l


MAGPIE

MgSO4 produced 58% reduced risk of eclampsia (0.8% cf. 1.9%)-across all categories of PET

Maternal mortality lower as well RR 0.55, CI 0.26-1.14

Lancet 2002; 359: 1877-90.


Deliver Baby If severe PET, should NOT transfer Ensure SCBU aware if baby premature Give antenatal steroids if time but usually,

if require IV therapy, delivery is indicated once stabilised

If cervix favourable and patient >36 weeks, consider short trial IOL

If cervix unfavourable and/or <36 weeks, deliver by LSCS

Anaesthesia regional vs. general


DELIVERY: Key Points ◦ Risk of sharp rise of BP on intubation

This may be obtunded by large dose alfentanyl or similar

Need experienced and senior anaesthetist to give GA in these circumstances

◦ Syntometrine should not be given for the active management of the third stage if the mother is hypertensive, or if her blood pressure has not been checked. (ergometrine causes vasospasm and a sharp rise in

BP which may precipitate hypertensive crisis, fits or cerebral haemorrhage)


ECLAMPSIA• Occurrence of fits

– 44% postpartum – 38% antenatal) – ALWAYS GRAND MAL

• Due usually to cerebral vasospasm

Occurrence of fits increases risks of maternal death x10

Seizures may precipitate hypoxic cardiac arrest and maternal death

Seizures = bad news


What isn’t eclampsia? Beware known epileptics

◦ If BP normal, no protein, typical for their type of fit-may be epilepsy BUT any fit must be considered as eclampsia until proven otherwise especially of BP slightly up etc

Any FOCAL fit is not eclampsia◦ Consider SOL eg cerebral bleed/infarction due

to severe PET◦ Arrange head CT urgently


Eclampsia• Treatment is IV magnesium sulphate-4g loading

• then continue infusion at 1g/hr• i.e the same as for severe PET

• If recurrent fits or fit already on MgSO4• then further 2g IV bolus/increase infusion to 1.5g/hr

• If fits persist• check magnesium levels, • contact anaesthetists, • consider CT, • consider intubation and ventilation

• If antenatal, stabilise and Deliver


Postnatal care Watch closely on HDU/LW

◦ ¼ hourly BP, SaO2, pulse, resps◦ Hourly reflexes, urine output, fluid restriction 60-

80ml/hr◦ One to one care

Anticipate possible worsening BP or seizures in first 18-24 hours

Hence MgSO4, may need antihypertensives de novo Continue MgSO4 for 24 hours and then review

Do not need to taper off MgSO4, just stop Do not feed within 12 hours as significant risk

ileus- sips H2O only until next morning then review for bowel sounds


Disease Progression

Often improve quickly Some may deteriorate further

immediately after delivery –may continue to worsen for 24 + hours◦ Worsening BP◦ Worsening bloods◦ Oliguria/anuria◦ Increased risk fits

Consult seniors and manage with multidisciplinary team


Postnatal Management-Hypertension Hypertension may persist for some weeks Switch to oral treatment when feasible

◦ Atenolol◦ Nifedipine

Polypharmacy may be required to control BP-consult with physicians

Ensure regular BP checks arranged on discharge with review and follow-up by GP◦ Good communication is the key◦ Check BP days 1, 2, 3-5 and 7◦ If still hypertensive at 6 weeks, refer physicians


HELLP syndrome

• Haemolysis• Elevated• Liver Enzymes• Low• Platelets

• 1-12% PET (usually severe end of spectrum)

• Commoner in multips• Variable presentation

– RUQ pain, epigastric pain, nausea + vomiting

– 85% hypertensive at presentation

• Present: 2/3 antepartum, 1/3 postpartum– mid 2nd trimester to several

days postnatal

Next Pregnancy?

• If ‘straightforward’ PET– Risk PIH 13-53%– Risk PET 16%

• If severe PET, eclampsia or HELLP and birth <34 weeks– Risk PET 25%

• If severe PET/eclampsia/HELLP and delivery <28 weeks– Risk PET is 55%

Gestational (Pregnancy-Induced) Hypertension (PIH) Development of hypertension in pregnancy

after 20 weeks ↑Risks of progression to PET if diagnosed

<32 weeks Assess by:

◦ Clinical assessment◦ Dipstix for proteinuria (should be negative)◦ Check fetal wellbeing

Essential Hypertension Pre-existing raised blood pressure May be on treatment or just under

observation May be known prior to pregnancy or

detected at booking as raised BP

Risks to Mum Risks to Baby Worsening of BP Superimposed pre-

eclampsia Medical over-

intervention

Teratogenesis from certain drugs (eg ACEI)

IUGR Pre-eclampsia Hypoglycaemia if

on labetolol and breastfeeding

Pre-pregnancy If planned, review medications

◦ Take off teratogenic meds e.g. ACEI or similar◦ Take off diuretics (reduce plasma vol and fetal

perfusion) Optimise diet/ weight loss (if raised BMI) Stop smoking Start folic acid

Early pregnancy

Review meds at booking Take off any teratogenic meds Start folic acid Early booking at hospital for risk review Dating scan +/- NT (combined) scan Plan for pregnancy

◦ Including issues re: obesity, screening for GDM◦ Low dose aspirin from 12 weeks

Pregnancy Regular BP checks May need to come

off meds if BP ↓↓ May need to start or

restart meds later in pregnancy as BP rises

Growth scans (screen for IUGR)

Joint care between MW and hospital

Later Pregnancy If BP well controlled and fetal growth

normal, aim to labour spontaneously or induce as postdates

If BP raised, try control first with medications

If superimposed PET or fetal growth issues, consider delivering early

NO ERGOMETRINE at delivery-syntocinon only

Post delivery Watch BP for at least 24-48 hours May need oral antihypertensives Communicate closely with GP to ensure that

BP monitoring is taken over and ongoing care is handed over to GP

Summary

• Know definitions PIH, PET, essential HT• Differentiate between each• What questions to ask• What tests to do• Prevention of PET• Treatment of PET• Treatment of PIH• Treatment of essential HT in pregnancy

What is the definition of mild hypertension in pregnancy?

BP 140/90

What three symptoms do you specifically ask about in pre-eclampsia?

Headaches, visual disturbances, epigastric pain

Which of these is not a moderate risk factor for pre-eclampsia?◦ Twins◦ Diabetes◦ Maternal age >40

Quick Quiz (1)

TRUE or FALSE: Calcium has been shown to prevent PET in UK populations

FALSE Name a drug used to treat severe hypertension in

pregnancy/PET Labetolol, Hydralazine, Nifedipine What is the anticonvulsant of choice in PET? Magnesium sulphate

Which of these is not altered in HELLP syndrome?◦ Platelets◦ ALT◦ Alkaline phosphatase

Quick Quiz (2)

TRUE or FALSE? IUGR is present in >50% women with PET <28 weeks

TRUE TRUE OR FALSE? Lisinopril is teratogenic TRUE TRUE OR FALSE? Moderate PIH is an indication for

delivery <37 weeks FALSE TRUE OR FALSE? Women with severe PET and early

gestation should be transferred out to a tertiary unit ASAP

FALSE

Quick Quiz (3)

Magnesium overdose is not associated with which of the following?◦ Vomiting◦ Cardiac arrest◦ Muscle weakness

Which drug is the antidote to magnesium overdose?

Calcium gluconate Which blood tests should you do in pre-

eclampsia?

Quick Quiz (4)

neil vanes, obstetric and gynaecology uhcw. pre-eclampsia eclampsia pregnancy-induced (gestational)...

Documents

appendix h

revised version of new

hellp syndrome8student

new partnerfamily history

iugrhypoxiaprematurity

abnormal u e6student

severe pet rates eclampsia

risk of pethistory