pregnancy related hypertensive disorders

Zahid ullahRoll no 08-216BATCH “L”

Introduction

1. Hypertensive disorders of pregnancy are leading causes of maternal mortality.

2. Worldwide: 50,000 women die each year.

Definitions

Hypertension in pregnancy:

Bl/P of 140/90 or more is abnormal.

If there is a rise of 30 mmHg or more in the systolic blood pressure or 15 mmHg or more in the diastolic blood pressure In 2 occasions 6 hours apart.

Mean arterial BP> 105 mmHg .

Systolic + 2 Diastolic Mean arterial BP = -----------------------------

3

Classifications

National High Blood Pressure Education Program Classification ( NHEP) 2000 Gestational hypertension. Preeclampsia (mild, severe). Eclampsia. Superimposed preeclampsia upon chronic hypertension.

Chronic hypertension with pregnancy.

Definitions Gestational hypertension:

Hypertension for first time after 20 w, without Proteinuria. BP returns to normal before 12 weeks postpartum.

Chronic hypertension with

pregnancy: Hypertension antedates pregnancy and

detected before 20 w, & lasts more than 12 weeks postpartum.

Definitions Preeclampsia:

The development of hypertension and Proteinuria after 20 w

May occur earlier in vesicular mole or twins.

Eclampsia (in Greek= Flash of light): The occurrence of convulsions (without

any neurological disease) in a woman with pre-eclampsia.

Definitions

Superimposed pre-eclampsia: ¤ It is the new development of

Proteinuria after 20 weeks gestation in a patient with chronic hypertension

Definitions Proteinuria:

≥ 300mg/24 hours urine.

Heavy Proteinuria : = ≥ 2gm/24 hours

Preeclampsia

Epidemiology

Risk factors: Chronic hypertension. Chronic nephritis. Past history . Family history. Obesity. Multiple pregnancy.

Epidemiology ( risks)

Diabetes mellitus. Nulliparity. Teenage Pregnancy. Smoking. Stress

Multisystem Features Of Preeclampsia

Hypertension Proteinuria

Eclampsia HELLP syndrome

Intra-uterine growth restriction

Multi-organ disease

Cerebral vessels

Fetus

Liver

Systemic blood vessels Kidneys

A): Signs: :

it is a disease of signs :2 cardinal signs + or - Edema:

Hypertension: usually precedes Proteinuria,

Proteinuria: detected by Boiling test. Quantitative assay.

+ or - Edema

The lower extremities. Abdominal wall, vulva or may be

generalized anasarca.

usually after hypertension.

Peripheral edema is not a useful diagnostic criterion

1) it is common in normal pregnancy.

2) PE can occur without edema (dry type).

so its presence does not ensure a poor prognosis and its absence not ensure a favorable outcome.

B) Symptoms (non specific):

Headache. Blurring of vision. Nausea and vomiting. Epigastric pain (distension of the

liver capsule) Oliguria or anuria

Severity Of Pre-eclampsia

The severity of pre-eclampsia is assessed by:

The frequency and intensity of the signs and symptoms.

The more the severity of PET, the more likely is the need to terminate pregnancy.

4) Diagnosis Of Eclampsia:

Eclamptic fit stages ( 4 stages): Premonitory stage (1/2 minute): Eye rolled up. Twitches of the face and hands.

Tonic stage (1/2 minute): Generalized tonic spasm with episthotonus.

Cyanosis. Tongue may be bitten between the clenched teeth.


Clonic stage (1-2 minutes): Convulsions . Tongue may be bitten. face is congested and cyanosed. conjunctival congestion. blood stained froth from the mouth, Stertorous breathing, temperature may rise. involuntary passage of urine or stool. Gradually convulsions stop.


Coma: Variable duration due to respiratory

and metabolic acidosis. Deep coma may occurs (cerebral

hemorrhage). Labor usually starts shortly after the

fit.

Classifications of Eclampsia

Ante partum (65%) with the best prognosis.

Intrapartum (20%). Postpartum (15%) with the worst prognosis as it indicates extensive pathology and multisystem damage..

Classifications of Eclampsia 1)Mild

2) Severe (Eden's criteria): Coma > 6 hours. Temperature > 39 (pneumonia or pontine hge)

Systolic Bp > 200 (risk of cerebral hge) Pulse > 120/min ( acute heart failure). Anuria or Oliguria( renal failure). Respiratory rate > 40/min( pneumonia) More than 10 fits (status eclampticus).

Investigations

A. Laboratory: Urine: 24 hour urine, Proteinuria. Kidney functions: serum creatinine, urea,

creatinine clearance and uric acid. Liver functions: bilirubin, Enzymes Blood: CBC, HCt , Hemolysis and Platelet

count (Thrombocytopenia). Coagulation Profile: Bleeding and

clotting time

Investigations

B. InstrumentalFundus Examination .

C. Imaging techniques :CT scan for the brain. Ultrasonograghy .

E. Doppler .

VI. Differential Diagnosis:

A. Hypertension With Pregnancy.

B. Proteinuria With Pregnancy.

C. Edema With Pregnancy:


D. Convulsions With Pregnancy: Eclampsia. Epilepsy. Hysteria. Meningitis and Encephalitis. Tetanus. Tetany. Strychnine poisoning. Brain tumors. Uremic convulsions


E. Coma With Pregnancy: Hypoglycemic . Hyperglycemic coma Uremic coma. Hepatic coma. Alcoholic coma. Cerebral coma.


F. HELLP Syndrome:

Acute fatty liver in pregnancy.

Hepatitis. Thrombocytopenia purpura. Hemolytic Uremic syndrome.

Treatment PREVENTION. Antepartum ttt.

Proper antenatal care Expectant treatment. Control hypertension. Treatment of eclampsia . Prevention and control of convulsions. Termination of pregnancy .

Intrapartum care. Postpartum care.

PreventionPrevention

Low dose aspirin: 75 mg/day.

Decrease TxA2 (from Platelets).Not affect endothelial prostacyclin (PGI2 )

Calcium supplementation: Ca++ supplementation may increase the production of prostacyclin (PGI2 ) from endothelial cells.

TTT of preeclampsia

Expectant Treatment . Control of Hypertension. Prevention of convulsions . Termination of pregnancy .

1) Expectant Treatment

Rest: Complete Physical and mental rest.

Diet: Increase protein and carbohydrate with low Na diet !!!!!.

Sedation AND TRANQULIZER: Phenobarbitone & DIAZEPAAM.

Observation ( MATERNAL & FETAL).

1) Expectant Treatment (Observation) Maternal:

Blood pressure. Pulse and Respiratory rate. Urine output. Proteinuria. Any new symptoms. Investigations (creatinine, creatinine

clearance, blood picture, coagulation profile,….)

Fetal: fetal well-being

2) Control of Hypertension:

A)Parentral drugs: 1) Hydralazine:

It is a peripheral VD. The best Antihypertensive drug used

during Pre-eclampsia and Eclampsia. Dose: 5-10mg IV or IM as initial dose. Repeated every 20-30 minutes until

blood pressure is controlled.

2)Control of Hypertension: 2) Labetalol (Trandate): α and non selective β- adrenergic blocker

resulting in VD. Dose: 10-20mg IV . The dose can be doubled every 10 minutes

if proper response is not achieved. 3) Diaz oxide (Hyperstat):

Used in severe dangerous resistant hypertension as a last resort.

Dose: 50-150mg IV bolus dose. Repeated every 1-2 minutes until BP

decreases.

2)Control of Hypertension: A )Oral drugs:1) α-methyl DOPA (aldomet):

It is the most commonly used. It is α-adrenergic agonist causing

depletion of catecholamine stores. Dose: 500mg 3-4 times/day orally.

2)Control of Hypertension: 3) β- adrenergic blockers:

Atenolol (tenormin) 50-100mg 4 times daily. Labetalol (Trandate) 10-20mg 3 times daily.

4) Prazocin (minipres): It is postsynaptic α-adrenergic receptor

blocker resulting in VD and reflex tachycardia.

It is a weak Antihypertensive drug so used in combination with other drugs.

5) Calcium Channel Blocker: Nifedipine (adalat or Epilat) .

TTT of Preeclampsia

3)Prevention of convulsions .

4)Termination of pregnancy

Treatment of Eclampsia

1) General and first aid measures( A &B &C &D …………cont )

Ensure patent airway with tracheal and bronchial suction.

Put the patients in Trendlenburg position (to avoid aspiration of secretions) .

Insert a catheter. Nasogastric tube may be inserted .

Nothing by mouth and fluid chart. Full laboratory investigation.


2) Observation: Pulse, temperature,

BP and RR. Level of consciousness.

Duration of coma. Fetal heart sounds. Urine output and

albuminuria .

Number of convulsions

4) Control of Convulsions:

A) Magnesium Sulfate (MgSO4): It is the drug of choice. Mechanism:

CNS depression. Mild VD. Mild diuresis. Inhibits platelet aggregation. Increase PGI2 synthesis.

Magnesium Sulfate (MgSO4):

It can be given IV (20%) or IM (50%) or SC (15%):

The therapeutic level is 4-7mEq/L. The total dose of MgSO4 should not exceed

24 gms in 24 hours . The dose of MgSO4 is monitored by:

Preserved patellar reflex. Respiratory rate >16/min. Urine output >100ml/4hours. Serum Mg++ level.

Is stopped 24 hours after delivery.N.B Antidote is ca gluconate

Magnesium Sulfate (MgSO4):

IV regimen: initially 4-6 gm (20%) in 100ml

solution . Given over 15-20 minutes.

Then, 2 gm/hour by IV drip. IM regimen:

10 gms of 50% solution are given deeply IM (5 gms in each buttock).

Maintain with 5 gm/6 hours of 50% solution.

Side effects of MgSO4 (small safety margin)

At a level of 8-10mEq/L patellar reflex is lost and starts myometrial inhibition.

10-15mEq/L respiratory depression. >15mEq/L cardiac depression. Curare like action. Synergistic effect with Ca++ channel

blockers. Uterine inertia. Neonatal hypermagnesemia. Decreased beat to beat variability in FHS.Antidote : 10ml of 10 percent calcium

gluconate


B ) Phyntoin (Epanutin): In severe pre-

eclampsia In imminent

eclampsia . The dose is 15mg/kg.


C) Diazepam (Valium): This regimen is mainly for eclamptic

patients. Initially 20-40mg IV slowly over 5

minutes. then 10-20mg/6hours. then the dose is adjusted at

10mg/hour to maintain drowsiness.


7)Termination of Pregnancy Indications:

Eclampsia. Retinal hemorrhage: Deteriorated cardiac, renal or liver functions. Severe PET not controlled after 24 hours. Mild PET reaching 38 weeks and not

controlled. Expectant treatment reaching maturity. Deterioration of the fetal conditions. Other obstetric indications as CPD,

malpresentations, APH,…

7)Termination of Pregnancy

Methods: As a rule vaginal delivery is safer and

better than CS. Artificial rupture of membranes .

CS.


8) Management during labor: With the onset of labor give IV

hypotensives and sedation. The patient must be at rest with

oxygen source and other equipments for treating fits.

Maternal observation. Continuous electronic fetal monitoring.

Treatment of Eclampsia9) Postpartum management Improvement is monitored by:

Increased urine output. Decreased edema. Disappearance of Proteinuria within 1 week Decreased hemotocrite value to normal

level. BP normalize within 2 weeks

No ergometrine postpartum. MgSO4 stopped 24 hours postpartum.

Prognosis: BP usually normalize after placental

delivery . Hypertension may persist. Postpartum eclampsia carries the worst

prognosis. Maternal mortality is about 2% in

severe preeclampsia and 10% in eclampsia.

Perinatal mortality rate is about 5% in mild cases, 25% in severe cases and 30% in eclampsia.

pregnancy related hypertensive disorders

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