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7-Hypertensive Disorders of Pregnancy.pptx
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- 2. • Affecting 5%to 10% of all pregnancies • 16% of maternal mortality in developed countries • Hypertensive disorders in pregnancy 30% chronic hypertension 70% gestational hypertension
- 3. Definitions • Hypertension isdefined as a systolic blood pressure (SBP) of 140 mm Hg or greater or a diastolic blood pressure (DBP) of 90 mm Hg or greater. • Abnormal proteinuria in pregnancy is defined as the excretion of 300 mg or more of protein in 24 hours. • Pathologic edema is seen in nondependent regions such as the face, hands, or lungs.
- 4. Classifications • Gestational hypertension •Preeclampsia or Eclampsia • Chronic hypertension • Preeclampsia superimposed on chronic hypertension
- 5. Gestational Hypertension • SBPto at least 160 mm Hg and/or DBP to at least 110 mm Hg for at least 6 hours without proteinuria • Ranges between 6% and 17% in healthy nulliparous women and between 2% and 4% in multiparous women. • 46% of women diagnosed with preterm gestational hypertension will develop proteinuria and progress to preeclampsia.
- 6. Preeclampsia and Eclampsia •Rate • Symptoms: headaches, visual changes, and epigastric or right upper quadrant pain plus nausea or vomiting. • subdivided into mild and severe • A particularly severe form of preeclampsia is the HELLP syndrome.
- 7. Criteria for theDiagnosis of Mild Preeclampsia SBP >140 mm Hg and/or DBP >90 mm Hg on two occasions at least 6 hours apart, typically occurring after 20 weeks gestation (no more than 1 week apart) Proteinuria of 300 mg in a 24-hour urine collection or >1+ on two random sample urine dipsticks at least 6 hours apart (no more than 1 week apart)
- 8. Criteria for theDiagnosis of Severe Preeclampsia SBP >160 mm Hg and/or DBP >110 mm Hg on two occasions at least 6 hours apart Proteinuria of 5 g or higher in a 24-hour urine specimen or 3+ or greater on two random urine samples collected at least 4 hours apart Oliguria <500 cc in 24 hours Thrombocytopenia platelet count <100,000/mm3 Elevated liver function test results with persistent epigastric or right upper quadrant pain Pulmonary edema Persistent, severe cerebral or visual disturbances
- 9. Chronic Hypertension • Hypertensionthat complicates pregnancy is considered chronic: • if a patient is diagnosed with hypertension before pregnancy • if hypertension is present prior to 20 weeks gestation • if it persists longer than 12 weeks after delivery.
- 10. Chronic Hypertension withSuperimposed Preeclampsia • an exacerbation of hypertension with new onset of proteinuria or symptoms of headache or epigastric pain or laboratory abnormalities such as elevated liver enzymes • increase in blood pressure to the severe range (SBP of 160 mm Hg or more; DBP of 110 mm Hg or more) in a woman whose hypertension has been well controlled
- 11. Preeclampsia • Preeclampsia isa multisystem disorder of unknown cause that is unique to human pregnancy. • Nulliparity • Advanced maternal age (>35 years) • ART • Obesity
- 12. Etiology No definitive etiology Maybe: • Placental origin • Immunologic origin • Genetic predisposition
- 13. Pathophysiology • Cardiovascular: Increasedvascular reactivity:vasodilatory (prostacyclin, nitric oxide) and vasoconstrictive (thromboxane A2, endothelin) substances. Hemoconcentration • Hematologic: Thrombocytopenia(higher levels of thromboxane A2) Hematocrit
- 14. • Renal decreasedglomerular filtration rate (GFR) oliguria profound renal insufficiency • Hepatic mildly elevated liver enzyme levels subcapsular liver hematomas hepatic rupture HELLP syndrome pathologic liver lesions: periportal hemorrhages, hepatocellular necrosis, ischemic lesions, intracellular fatty changes, and fibrin deposition.
- 15. • Central NervousSystem Eclamptic convulsions coagulopathy, fibrin deposition, and vasospasm Edema headaches and visual disturbances such as scotomata; blurred vision; and rarely, temporary blindness
- 16. Fetus and Placenta •acute atherosis of decidual arterie poor placental perfusion resulting in oligohydramnios intrauterine growth restriction placental abruption fetal distress fetal demise.
- 17. Prediction and Prevention •Doppler ultrasonography • Assessed protein or low-salt diets, diuretics, bed rest, zinc, magnesium, fish oil, or vitamin C and E supplementation and heparin to prevent preeclampsia in women. • 1.5 g per day of calcium
- 18. Management of MildPreeclampsia • laboratory evaluation • Ultrasonography • The only definitive cure for preeclampsia is delivery • In patients diagnosed with mild preeclampsia at term (>37 weeks) • For the patient who is preterm (<37 weeks) • Home management • MgSO4 administration • Antihypertensive medications • Postpartum
- 19. Management of SeverePreeclampsia severe preeclampsia should be admitted and observed initially • fetal well-being • monitoring of maternal blood pressures • symptomatology • laboratory evaluation • delivery is considered in all women with severe preeclampsia at >34 weeks
- 20. • steroids • Ultrasonographyfor fetal growth should be performed every 2 to 3 weeks • blood pressure range • Drugs typically used are hydralazine and labetalol. • close blood pressure control, continuous fetal monitoring, and intravenous MgSO4, urinary catheter • MgSO4 infusion • postpartum care
- 21. HELLP Syndrome • Theterm HELLP syndrome is used to describe preeclampsia in association with hemolysis, elevated liver enzyme levels, and low platelet count. • Immediate delivery should be performed in patients >34 weeks gestation. • Control of severe hypertension, if present; initiation of MgSO4 infusion; correction of coagulopathy, if present; and maternal stabilization • Glucocorticoids • Vaginal delivery • C.S • Postpartum management
- 22. Eclampsia • antepartum (50%) •intrapartum (25%) • postpartum (25%) Prevention of eclampsia is one of the goals in treating preeclamptic patients with MgSO4.
- 23. Management of theEclamptic Patient 1-Avoid injury A-Padded bedside rails B-Physical restraints 2-Maintain oxygenation to mother and fetus A-Oxygen at 8-10 L per minute by face mask B-Monitor oxygenation and metabolic status with transcutaneous pulse oximetry or arterial blood gas measurements 3-Minimize aspiration A-Lateral decubitus position B-Suctioning of vomitus and oral secretions C-Obtain chest x-ray after cessation of convulsion to rule out aspiration 4-Initiate MgSO4 to prevent recurrent seizures 5-Control severe hypertension 6-Initiate the delivery process
- 24. Magnesium Sulfate • Loadingdosage: 6 g i.v. over 20-30 min (6 g of 50% solution diluted in 150 cc D5W) • Maintenance dosage: 2-3 g i.v. per h (40 g in 1 L D5LR at 50 cc/h) • Additional 2 g over 5-10 min (1-2 times) can be given with persistent convulsions • If convulsions persist (2% of cases), give 250 mg sodium amobarbital i.v. over 5 min • In status eclampticus: intubation and muscular paralysis • Intramuscular dosage: 10 g i.m. (20 mL of 50% MgSO4, one half of the dose in each buttock)
- 25. Chronic Hypertension • Chronichypertension is defined as elevated blood pressure occurring prior to pregnancy or elevated blood pressure measurements prior to 20 weeks gestation • Maternal age • Race • Hypertension can be either primary or secondary • Superimposed preeclampsia in women with chronic hypertension
- 26. Management • Antihypertensive Agents Methyldopa Beta-Blockers Calcium Channel Blockers Hydralazine Diuretics Thiazide Furosemide Angiotensin-Converting Enzyme Inhibitors • Contraception