Downloaded 111 times
Uploaded byAyub Medical College
Hypertensive disorders in pregnancy By Dr Anum Fatima
Hypertensive disorders are common and serious conditions seen in obstetrics. They include gestational hypertension, preeclampsia, eclampsia, and chronic hypertension with or without superimposed preeclampsia. Preeclampsia is defined as new hypertension and proteinuria after 20 weeks of gestation. It is caused by reduced placental perfusion leading to release of anti-angiogenic factors from the placenta that cause maternal endothelial dysfunction. Complications include organ damage, seizures, and death. Treatment involves blood pressure control, delivery once the fetus is mature, and magnesium sulfate to prevent seizures in severe preeclampsia and eclampsia.
More Related Content
Similar to Hypertensive disorders in pregnancy By Dr Anum Fatima
Hypertensive disorders in pregnancy By Dr Anum Fatima
- 1. Hypertensive disorders in pregnancy ANUMFATIMA 08-226 Batch E
- 2. Hypertensive disorders arethe most common and yet serious conditions seen in obstetrics
- 3.
- 4. Blood Pressure ≥140/90mmHg on two or more occasions - in a previously normotensive patient - after 20 weeks gestation - without proteinuria - returning to normal 12 weeks after delivery Almost half of these develop preeclampsia syndrome GESTATIONAL HYPERTENSION
- 5. GESTATIONAL HYPERTENSION GESTATION ≥20 WEEKS SUSTAINED HYPERTENSION ( ≥ 140/90) No proteinuria
- 6. DEFINITION SYMPTOMS EXAMINATION GESTATIONAL HYPERTENSION Sustained B.P Noproteinuria NONE Unremarkable
- 7. Preeclampsia ◦ It isdefined as hypertension of at least 140/90mm Hg recorded on two separate occasions at least 4 hours apart and in the presence of at least 300mg protein in a 24 hour collection of urine, arising after the 20th week of gestation in a previously normotensive woman and resolving completely by the 6th postpartum week.
- 8. ( RISK FACTORS forPREECLAMPSIA DEMOGRAPHIC OBSTETRICS MEDICAL NULLIPARA (Age extremes <20yrs , >35yrs ) 1. Multiple gestation 2. Molar pregnancy 3. Non-immune hydrops 1. Diabetes mellitus 2. Chronic HTN 3. Renal disease 4. SLE
- 9. MILD PREECLAMPSIA GESTATION ≥20 WEEKS SUSTAINED HYPERTENSION (≥ 140/90) Proteinuria (≥300mg /24 hr)
- 10. NONE SYMPTOMS EXAMINATION PATHO - PYSIOLOGY MILD PREECLAMPSIA NONE NONE DiffuseVasospasm Capillary injury
- 11. MILD PREECLAMPSIA LABORATORY FINDINGS MANAGEMENT PROTEINPROTEINURIA URIA Proteinuria (1-2+) Hemoconcentration <36 wks Conservative >36 wks MgSO4 and Delivery
- 12. GESTATIONAL HYPERTENSION GESTATION ≥20 WEEKS SUSTAINED HYPERTENSION (≥ 140/90) NO PROTEINURIA MILD PREECLAMPSIA SUSTAINED HYPERTENSION ( ≥ 140/90) Proteinuria ( ≥ 300mg /24 hr) GESTATION ≥ 20 WEEKS
- 13. BLOOD PRESSURE PROTEINURIA SYMPTOMS CRITERIA: SEVERE PREECLEMPSIA ≥160/110 ≥ 5grams 1. Headache 2. Epigastric pain 3. Visual changes
- 14. CRITERIA: SEVERE PREECLEMPSIA LABORATORY FINDINGS SIGNS DIC Elevated Liver enzymes 1.Pulmonary edema 2. Oliguria 3. cyanosis
- 15. new onset ofseizures or unexplained coma during pregnancy in patients with pre-existing preeclampsia and without pre-existing neurological disorder. ECLAMPSIA
- 16. rebra ECLAMPSIA SYMPTOMS PATHO - PYSIOLOGY RISK FACTORSSame as Preeclampsia Cerebral vasospasm , ischemia and edema Generalized tonic- clonic SEIZURES
- 17. ECLAMPSIA LABORATORY FINDINGS MANAGEMENT Proteinuria Hemoconcentration DIC Elevated Liver enzymes 1. Stopconvulsions with MgSO4 2. Prompt delivery at any gestational age 3. Lower diastolic B.P 90- 100mm/Hg
- 18. MANAGEMENT IV MgSO4 –To prevent convulsions ( continue 24 hrs post-partum ) LOWER B.P ( hydralazine or labetalol) INDUCE LABOR (IV oxytocin and amniotomy )
- 19. Blood pressure ≥140/90 before 20 weeks of gestation OR persistence of hypertension beyond 12 weeks after delivery. CHRONIC HYPERTENSION
- 20. CHRONIC HYPERTENSION GESTATION <20 WEEKS OR Prepragnancy SUSTAINED HYPERTENSION (≥140/90) +/- PROTEINURIA
- 21. CHRONIC HTN PREGNANCY PROGNOSIS GOOD PROGNOSIS POOR PROGNOSIS WORST PROGNOSIS B.P140/90 to 179/109 No end organ damage KIDNEYS: Renal disease EYES : Retinopathy HEART : Left Ventricular Hypertrophy (B.P >180/90) Uncontrolled HTN Chronic HTN +Superimposed PIH
- 22. D MANAGEMENT OF CHRONICHYPERTENSION If antihypertensive meds needed - Methyl dopa is drug of choice (or labetalol) Serial ultrasounds (increase risk of IUGR >30 weeks ) Induce labor at term DC antihypertensive meds (if B.P <100 mm Hg diastolic) Serial B.P and urine protein (watch for superimposed preeclampsia)
- 23. SUPERIMPOSED PREECLAMPSIA (on ChronicHypertension) New-onset proteinuria > 300 mg/24 hrs in hypertensive women but no proteinuria before 20 wks gestation A sudden increase in proteinuria or blood pressure or platelet count < 100,000/ cu mm in women with hypertension and proteinuria before 20 wks gestation. 23
- 24. CHRONIC HTN SUPERIMPOSEDPIH CHRONIC HYPERTENSION Worsening BLOOD PRESSURE Worsening proteinuria
- 25. MANAGEMENT of ChronicHTN and superimposed PIH IV MgSO4 – To prevent convulsions ( continue 24 hrs post-partum ) LOWER B.P - Diastolic 90-100 mm Hg( hydralazine or labetalol) INDUCE LABOR (IV oxytocin and amniotomy )
- 26. HELLP Syndrome HTNpatients with hemolysis (H), elevated liver enzymes (EL), low platelet count (LP) 4-12% of pt. with severe preeclampsia and eclampsia develop HELLP syndrome
- 27. PATHOPHYSIOLOGY Complex disease Appears to be triggered by the placenta ◦ Can occur in molar pregnancies where fetus absent ◦ Can also occur in abdominal pregnancy (pregnancy not in uterus)
- 28. TWO – STAGEMODEL FOR PREECLAMPSIA Stage 1: reduced placental perfusion Abnormal implantation Stage 2 : maternal syndrome -hypertension -proteinuria -endothelial dysfunction
- 29.
- 30. Impair/ inadequate trophoblastinvasion to the spiral arteries Spiral arteries retain their charecteristic (narrow, tortuous, high resistance) Reduce blood supply to placenta Result in placental hypoperfusion As a compensation High BP in maternal
- 31. Stage 1: reduced placental perfusion Abnormal implantation Stage 2: maternal syndrome -hypertension -proteinuria -endothelial dysfunction WHAT CAUSES MATERNAL SYNDROME ????? WHAT GETS INTO MATERNAL CIRCULATION ???
- 32. ANTI-ANGIOGENIC FACTORS ANGIOGENIC FACTORS Vascular endothelial growth (VEGF) includingplacental growth factor Transforming growth factor- beta (TGF-B) Look after maternal endothelium Soluble endoglin (sEng) Soluble FMS-like tyrosine kinase-1 (sFlt-1) Released from diseased placenta
- 33.
- 34. Coagulation disturbance Activated endothelialcells promote coagulation and increase vasopressor sensitivity Widespread coagulation occur (DIC) Fibrin deposition in kidney & placenta HPT & placental insufficiency
- 35. Cardiovascular • Generalized vasospasm •Increased peripheral resistance • Reduced central venous/ pulmonary pressure Hematological • Platelet activation and depletion • Coagulopathy • Decreased plasma volume • Increased blood viscosity • Proteinuria • Decreased glomerular filtration rate • Decreased urate excretion Renal Hepatic • Periportal necrosis • Subscapular hematoma • Cerebral oedema • Cerebral haemorrhages Central Nervous System Organ Specific Changes associated with Pre-eclampsia
- 36.
- 37. RISK FACTORS Maternal related History of Preeclampsia in previous pregnancy Advanced maternal age Family history of Preeclampsia History of placental abruption, IUGR, fetal death Obesity, BMI>35 doubles the risk Hypertension Diabetes Thrombotic vascular diseases
- 38. Multiple gestation Molar pregnancy Smoking
- 39. Large placenta Prolonged pregnancy Placental hydrops Chromosomal abnormality Fetal/placental factors
- 40. Hemoglobin andhematocrit platelet count : decreased, if < 1 lakh coagulation profile LFTs : indicated in all patients RFTs : raised (S.urea creatinine is decreased in Norm pregnancy) Urine Routine : proteinuria OBSTETRIC MANAGEMENT 1. Maternal evaluation
- 41. 2. Fetal evaluation: Daily fetal movement count Ultrasound Doppler ultrasound for fetal blood flow
- 42. 3. Treatment ofHypertension: Antihypertensive drugs used in pregnancy are -methyldopa -hydralazine -labetalol
- 43. 4. Seizure Prophylaxis • Routinelyused in severe PE • Magnesium sulphate: most commonly used • Initiated with onset of labor till 24h postpsrtum • For caesarean, started 2hrs before the section till 12hrs postpartum
- 44. it can begiven either IV or IM. IV has good prognosis. Loading dose for IV is 4g. i.e. 8 ml diluted in 12ml normal saline. This 20 ml is given in 20 minutes. Maintenance dose is 20 g i.e. 40ml diluted in 60ml normal saline and given at rate of 1g/hr. Recommended regime for MgSO4
- 45. IM is alsoused. Loading dose is as IV. Maintenance dose is 5g every 4 hrs in alternate buttocks for 24hrs. Mgso4 acts on NM junction and inhibit entry of Ca++ ions thus inhibiting excitability of neurons.
- 46. Side effects ofMgSO4 Maternal : flushing perspiration headache, muscle weakness pulmonary oedema Neonatal: lethargy hypotonia respiratory depression
- 47. Management of MgSO4Toxicity Calcium gluconate is antagonist for MgSO4. it is usually given as 10 ml of 10% Calcium gluconate in 10 minutes
- 48. The only definitive treatment Preeclampticpatients divided into 3 categories A- Preeclampsia features fully subside B- partial control, but BP maintains a steady high level C- persistently increasing BP to severe level or addition of other features 5. Delivery
- 49. Management: A: can waittill spontaneous onset of labor don’t exceed Expected Date of Delivery B: >37wk terminate without delay <37wk, expectant management at least till 34wks C: terminate irrespective of POG start seizure prophylaxis and steroids if<34wks
- 50. Delivery in Eclampsia Unlesscontraindicated: Eclamptic women should undergo normal vaginal delivery Indications for caesarean section - Fetal distress Placental abruption Unfavourable cervix Failed induction of labour Recurrent seizures
- 51. Investigations 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
- 52. Complications 1. Maternal: a. Convulsionsand coma (eclampsia). b. Cerebral haemorrhage. c. Renal failure. d. Heart failure. e. Liver failure. f. Disseminated intravascular coagulation. g. Abruptio placentae. h. Residual chronic hypertension in about 1/3 of cases. i. Recurrent pre-eclampsia in next pregnancies. www.freelivedoctor.com
- 53. Complications 2.Foetal: a. Intrauterine growthretardation (IUGR). b. Intrauterine foetal death. c. Prematurity and its complications. www.freelivedoctor.com
- 54. PREVENTION • Regular Antenatalcheckup: rapid gain in weight rising blood pressure edema proteinuria/deranged liver or renal profile • Low dose Aspirin in High risk group: ↑PGs and↓TXA2 • Calcium supplementation: no effects unless women are calcium deficient • Antioxidants- Vitamin C and E • Nutritional supplementation: zinc, magnesium, fish oil, low salt diet
- 55. Differential Diagnosis meningitis encephalitis space occupying lesion electrolyte disturbance vasculitis amniotic fluid embolism medications organ failure stroke
- 56.