Hypertension Lecture for Cci 2013

7/27/2019 Hypertension Lecture for Cci 2013

1/74

Hypertensive Disorders in Pregnancy

Hypertensive Disorders in

Pregnancy

Joseph U. Olivar MD, FPOGS, FPSMFM

Department of OB-GYN

Seamens Hospital

FEU-NRMF Medical Center


2/74


Case

28 y/o, G1, 32 weeks came in for first prenatal

check-up. BP of 130/90 mmHg. Repeat BP the

next day 140/80 mmHg.Is the woman hypertensive?

YES OR NO?


3/74


Gestational Hypertension

Preeclampsia

Eclampsia

Chronic Hypertension

Superimposed Preeclampsia on Chronic

hypertension

Classification of Hypertensive Disorders complicating pregnancy

(Working Group of the NHBPEP 2000):


4/74


BP 140/90mmHg for the first during

pregnancy after 20 weeks

No proteinuria

BP returns to normal


5/74


Seizures that cannot be attributed to other

causes in a woman with preeclampsia

Eclampsia


6/74


BP 140/90 mm Hg before pregnancy or

diagnosed before 20 weeks' gestation not

attributable to gestational trophoblasticdisease;

or hypertension first diagnosed after 20 weeks'gestation and persistent after 12 weeks'

postpartum

CHRONIC HYPERTENSION


7/74Hypertensive Disorders in Pregnancy

New-onset proteinuria 300 mg/24 hours in

hypertensive women but no proteinuria before 20

weeks' gestation

A sudden increase in proteinuria or blood pressure or

platelet count < 100,000/mm3 in women with

hypertension and proteinuria before 20 weeks'

gestation

SUPERIMPOSED PREECLAMPSIA

(ON CHRONIC HYPERTENSION)



Case

38 y/o, G5, 12 weeks came in for first prenatal

check-up. BP of 180/110mmHg.

Urine protein +4

Diagnosis?


10/74



11/74


Classification of Preeclampsia


12/74


Classification of Preeclampsia

Mi ld non-severe lesssevere

Severe= preeclampsia + 1 of aseries of complications


13/74


Criteria for the Diagnosis of Severe Preeclampsia

Symptoms of central nervoussystem dysfunction

Blurred vision, scotomata,

altered mental status, severeheadache

Symptoms of liver capsuledistention or rupture

Persistent right upper quadrant

and/ orepigastricpain

Symptoms

Norwitz. Expectant management of severe preeclampsia remote from term. Am J Obstet Gynecol 2008 .


14/74



Blood pressure criteria 160/110

Eclampsia

Pulmonaryedema or cyanosis

Cerebrovascularaccident Cortical blindness

IUGR (EFW < 5thpercentile for age or< 10thpercentile with evidence of

fetalcompromise

Signs



15/74



> 5 G per 24 hours or >/= 3+ on 2 random urinesamples that are collected at least 4 hours apartProteinuria

Urine output < 500 mL per 24 hours and/ or serumcreatinine > 1.2 mg/ dL

Oliguria and/or renal failure

Evidence ofhemolysis (abnormal peripheral smear,total bilirubin >1.2 mg/ dL, LDH >600 U/L)

Elevated liver enzymes (ALT >70 U/L)

Low platelets (


16/74



Liver enzymes 2x normalHepatocellular

injury

< 100,000 platelet / mm3Thrombocytopenia

Prolonged PT Low platelet count

Low fibrinogen

Coagulopathy

Laboratory findings



17/74


Pathophysiology of hypertension in pregnancy

absent trophoblastic invasion of the uterine artery

vasospasm hepatic

ischemia

hepatic

infarction

hematoma

liver

rupture

endothelial damage

edema platelet

consumption

hemolysis


18/74


Pathophysiology

brain

liver

kidneys

Hematology CBC

- platelet count

Abruptio placenta

Pulmonary edema


19/74


WHAT IS THE DEFINITIVETREATMENT?


20/74


Delivery is the only

cure for preeclampsia

Cunningham, Leveno. Pregnancy Hypertension.

In: Williams Obstetrics, 23rd ed. 2010.


21/74


Main Objectives in the Management of Severe

Preeclampsia

Safety of the mother

Deliver a healthy infant

Forestall convulsion

Prevent intracranial hemorrhage

Avoid serious damage to vital organs


22/74


When is the woman with severe preeclampsia

delivered?

Pregnancies 34 weeks of gestation

complicated by severe preeclampsia isbest managed by delivery after

maternal stabilization

Grade A

RCOG. The Management of Severe Preeclampsia. 2006

At 34 weeks

age of

gestation

short and long term neonatal

outcomes are excellent

fetal survival is already similar

to that of term gestation

pulmonary lung maturity is

achieved

Level I


23/74


SURVIVAL BY GESTATIONAL AGE


24/74


Acute Morbidity by Gestational Age


25/74


Chronic Morbidity by Gestational Age


26/74


Severe Preeclampsia Remote from Term

Although delivery is always appropriate

for the mother, it may not be optimal forthe premature fetus ( 34 weeks )

Sarsam DS. Expectant versus Aggressive Management in Severe

Preeclampsia Remote from Term. Singapore Med J. 2008.


27/74


RDS

IVHNEC

SepsisDeath

Complications of Prematurity


28/74


20 y/o G1 at 30 weeks with a BP of 150/90 mmHg

was brought to the OPD because of bilateral pedal

edema. Urinalysis done outside revealed a +4

protein and platelet count of 95,000. What is the bestmanagement for this case?

A. Admit, give MgS04, steroids, monitor BP

B. Admit, give MgS04,steroids then deliver

C. Admit, stabilize and deliver by CS

D. Admit for induction of labor then give

MgS04 postpartum

CASE


29/74


Sibai BM. Expectant Management of PreeclampsiaAJOG June 2007

An Algorithm in The Managementof Severe Preeclampsia

( < 34 weeks )


30/74


Admit to labor and delivery suite

Maternal-fetal evaluation for 24 hours

Magnesium sul fatefor 24 hours

Ant ihypertensivesif systolic blood pressure >160mmHg, diastolic blood pressure > 110 mmHg, or mean

arterial pressure >125 mmHg


31/74


Magnesium sulfate in severe preeclampsia

Loading Dose: 4 grams IV5 grams IM / buttocks

Maitenance Dose: 1-2 grams / hour


32/74


Case

20 y/o primi 36 weeks came in with a BP of

160/110 mmHg. 5mg hydralazine was given and

repeat BP after 15 minutes revealed 170/100

mmHg. What meds at the ER will you give?


33/74


Case


140/90 mmHg. She came from the lab with UA

result CHON (+1);

Ultrasound: SLIUP compatible with 28 weeks,

900 grams. Doppler of the UMA revealed

absent end flow.

Diagnosis?

What meds will you give?


34/74


Case


140/90 mmHg. She went to the laboratory to

have her CBC done. After 6 hours she came

back with a BP of 150/90 mmHg.

Platelet count = 90,000.

Diagnosis?

What meds will you give?


35/74





36/74



Maintenance

Dose:

1-2 grams / hour


37/74


Questions:

Is magnesium sulphate an antihypertensive?

What are the 3 parameters to monitor when

giving the maintenance dose of MgS04?

What is the antidote for magnesium sulphate

toxicity?

Level of Magnesium resulting to toxicity

therapeutic dose 4-7 meq/L

loss of patellar

reflex

8-10 meq/L

respiratory

depression

12 meq/L

respiratory and

Cardiac Arrest

> 12 meq/L

Ad it t l b d d li it


38/74




Magnesium sul fatefor 24 hours

Ant ihypertensivesif systolic blood pressure >160mmHg, diastolic blood pressure > 110 mmHg, or mean



39/74


When is antihypertensive therapy indicated?

Antihypertensive treatment should be started

in women with BP 160/110 mmHg. In a

woman with other markers of potentiallysevere disease, treatment can be considered

at lower degrees of BP

Grade C

Report of the National High Blood Pressure Education Program Working Group

on High Blood Pressure in Pregnancy. Am J Obstet Gynecol 2000


40/74


Anti-hypertensive meds during pregnancy

Blood Pressure 160/110 mmHg

Purpose: To prevent intracerebralhemorrhage


41/74



DRUG DOSE/ROUTE COMMENTS

LABETALOL 10-20 mg IV, then

20 -80 mg every 30

min; max of 300 mg

Not available locally

HYDRALAZINE 5 mg IV or IM then

5 mg every 15 min;

max of 20 mg

Long experience of

safety and efficacy;

drug of choice

NIFEDIPINE 10-30 mg PO then

10mg every 45 min;

max 50mg

Can be safely used

with MgS04

Update on the Use of Antihypertensive Drugs in Pregnancy. AHA, 2008


42/74




IV NICARDIPINE D5W 90 mL + Nicardipine

10 mg in soluset

Concentration =

0.1 mg/ mL

Start drip at 10 ugtts/min

(equivalent to 1 mg/hr)

Titrate every hour

(increments of 1 mg/hr).Maximum dose 10 mg/hr

Note: The IV infusion site

must be changed every 12

hours

Can be safely

used with

MgS04



43/74




METHYDOPA (B) Max of 3 grams per

day

Drug of choice

NIFEDIPINE 10 mg PO every 6hours; max of 120

mg / day

Slow or long actingpreparations may be

used; SL preparation

no longer

recommendedHYPRALAZINE 50 mg every 8

hours; max 300mg

per day

Long experience

with few adverse

effects



44/74


What blood pressure is the aim of anti-

hypertensive therapy?

The aim of anti-hypertensive therapy is to

keep the systolic BP between 140-155 anddiastolic BP between 90-100 mmHg.

Grade C

Report of the National High Blood Pressure Education Program Working Group

on High Blood Pressure in Pregnancy. Am J Obstet Gynecol 2000


45/74


Reminders:

Diuretics are relatively contraindicated and

reserved only for pulmonary edema

Hyperosmotic agents (albumin) have the

potential to promote edema formation in

the lungs and brain



46/74


y


Magnesium sulfate for 24 hours

Antihypertensives if systolic blood pressure >160 mmHg,

diastolic blood pressure > 110 mmHg, or mean arterial

pressure >125 mmHg

Any of the following present?

EclampsiaPulmonary edema

Acu te renal failure

Dissem inated intravascu lar coagu lat ion

Suspected abruptio placenta

Non-reassuring fetal status

Labor or rupture of membranes >34 weeks gestation



47/74


y





pressure >125 mmHg

Magnesium sulfateand delivery


EclampsiaPulmonary edema

Acute renal failure

Disseminated intravascular coagulation



Labor or rupture of membranes >34 weeks

YES



48/74


y





pressure >125 mmHg

HELLP syndromePersistent symptoms

Magnesium sulfate

and delivery


Eclampsia

Pulmonary edema

Acute renal failure

Disseminated intravascular coagulationSuspected abruptio placenta



YES

NO


49/74


HELLP Syndrome

H hemolysis LDH > 600 U/Ltotal Bili > 1.2

mg/dL

abnormal PBS

EL elevated liverenzymes

SGPT > 70 U/L

LP low platelets


50/74






pressure >125 mmHg

HELLP syndrome

Persistent symptomsSteroids

Magnesium sulfateand delivery


Eclampsia

Pulmonary edema

Acute renal failureDisseminated intravascular coagulation




YES

NO

YES

ANTENATAL CORTICOSTEROIDS


51/74


ANTENATAL CORTICOSTEROIDS

12 mg IM q 24 hours x 2 dosesBetamethasone

6 mg IM q 12 hours x 4 dosesDexamethasone

REDUCES

RDS

IVH

NEC

Perinatal death

Long term neurological problem


Maternal fetal evaluation for 24 hours


52/74




Antihypertensives if systolic blood pressure >160 mmHg, diastolic blood pressure > 110 mmHg, or mean


HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelets)

Persistent symptoms Steroids

Magnesium sulfate and delivery


Eclampsia

Pulmonary edema


Suspected abruptio placentaNon-reassuring fetal status


YES

YES

NO

< 24 weeks 2432 weeks 33 34 weeks

Steroids

Delivery 24 hours

after completion of

steroids

MgSO4 for 24 hou rs

Antihypertensivesif needed

SteroidsDaily evaluationof maternal-

fetal condition

Delivery if with indications

Delivery at 33-34 weeks

NO


53/74


Magnesium sulfate during expectant

management


Maintenance

Dose:

1-2 grams / hour

given for 24 hours

once a delivery decision is made and

continued for 24 hours postpartum




54/74










Eclampsia

Pulmonary edema




YES

YES

NO


Steroids

Delivery after 48 hours

MgSO4 for 24 hou rs

Ant ihyper tensivesi f needed

SteroidsDaily evaluationof m aternal-fetal cond it ion

Del ivery i f wi th indicat ions





55/74


Maternal fetal evaluation for 24 hours








Eclampsia

Pulmonary edema




YES

YES

NO


Steroids


MgSO4 for 24 hours


SteroidsDaily evaluationof maternal-fetal

condi t ion

Delivery i f with ind icat ions



56/74


Maternal Evaluation

weigh patient daily

BP monitoring q 4 hours except between 12mn

and 6am

Labs:

CBC with platelet count Urinalysis

Creatinine 24 hour urine albumin

SGPT, SGOT LDH, PBS, Total bilirubin


57/74


Fetal Evaluation

Baseline CTG

Women in labor should havecontinuous EFM

Biometry q 2 weeks, BPS 2x / week,doppler weekly and daily NST

Grade B

Grade B

Grade A




58/74









Eclampsia

Pulmonary edema




YES

YES

NO


Steroids

Delivery after 48 hoursMgSO4 for 24 hours


Steroids

Daily evaluationof maternal-fetal co ndit io n

Delivery i f with indicat ion s


Indications for Delivery (24 32 weeks)


59/74


Indications for Delivery (24-32 weeks)

Variable Indication

Maternal Persistent severe headache or visual changes; eclampsia

Pulmonary edema

Epigastric/RUQ pain with AST or ALT > 2 times the upper limits of normal

Uncontrolled severe hypertension, despite maximum doses of

antihypertensive agents

Oliguria (


60/74


Indications for Delivery

Variable Indication

Fetal Severe FGR (EFW < 5th percentile for gestational age)

Persistent severe oligohydramnios (AFI


61/74


What is the mode of delivery?

The mode of delivery should be determined

after considering the presentation of the fetus

and the fetal condition, together with thelikelihood of success of induction of labor

after assessment of the cervix

Grade C

RCOG. The Management of severe preeclampsia. Evidence Based Clinical

Guideline No. 10, 2006

How is postpartum hypertension


62/74


How is postpartum hypertension

managed?

Anti-hypertensives for BP 150/100 mmHg

Anti-hypertensive agents

Diuretics

Avoid NSAIDs

Grade C

Grade C

Grade C

Grade A



M i lf t f 24 h


63/74









Eclampsia

Pulmonary edema

Acute renal failure




YES

YES

NO


Steroids


MgSO4 for 24 hours


SteroidsDaily evaluationof

maternal-fetal condition



Terminate

pregnancy

Severe Preeclampsia < 24 weeks


64/74


Severe Preeclampsia < 24 weeks

High maternal morbidity

High perinatal morbidity and

mortality

Pregnancy termination is

recommended

Bombrys AE. Expectant Management of Severe Preeclampsia at less than

27 week gestation. Am J Obstet Gynecol, 2008.





65/74









Eclampsia

Pulmonary edema

Acute renal failure




YES

YES

NO


Steroids


MgSO4 for 24 hours


SteroidsDaily evaluationof

maternal-fetal condition



Terminate

pregnancy

CASE


66/74


20 y/o G1 at 30 weeks with a BP of 150/90 mmHg

was brought to the OPD because of bilateral pedaledema. Urinalysis done outside revealed a +4

protein and platelet count of 95,000. What is the bestmanagement for this case?

A. Admit, give MgS04, steroids, monitor BP

B. Admit, give MgS04,steroids then deliver

C. Admit, stabilize and deliver by CS

D. Admit for induction of labor then give

MgS04 postpartum

CASE

Regarding management how does


67/74


Regarding management, how does

severe preeclampsia differ from mild

preeclampsia and gestationalhypertension?

A. Giving of MgS04

B. AOG of delivery

C. Giving of antihypertensive

GH and Mild

Preeclampsia

Severe

Preeclampsia

MgS04

AOG at

delivery

37 weeks 34 weeks

Anti-HPN 160/110 mmHg 160/110 mmHg

CASE


68/74


G1, 37 weeks, BP = 160/110 mmHg. Urine dipstick (-) protein.

How will you manage the patient?

A. Give MgS04, antihypertensive and do

antenatal fetal surveillance

B. Give antihpn and proceed with induction of

labor

C. Give antihpn and send home once stableD. Give MgS04, antihypertensive and proceed

with induction of labor

CASE

CASE


69/74


35 y/o G5P4 (4004), 28 weeks AOG, was brought

to the ER due to tonic clonic convulsion.

BP = 180/110 mmHg. Stat urine protein is +3. What is thebest management?

A. Give MgS04, steroids and antihpnB. Give MgS04, steroids and deliver by

induction of labor

C. Give MgS04, stabilize and deliver by CSD. Give MgS04, steroid, antihpn and do

conservative management

CASE

21 y/o G1 38 weeks diagnosed with severe


70/74


21 y/o G1, 38 weeks, diagnosed with severe

preeclampsia underwent induction of labor under

continuous EFM. CTG suddenly revealed this

IE: cephalic, fully dilated, station +5 trace. IEdone: fully dilated, cephalic, station +3. Management?

A. Proceed with CS

B. Await deliveryC. Do forceps

D. Resuscitate


71/74


16 y/o G1, no PNCU, 1st consult at the OPD.

AOG by LMP: 34 weeks. BP = 140/90 mmHg.

FH: 24 cm, FHT: 140s. What is the best courseof management?

A. Request for biometry and doppler studiesB. Monitor bp, give methyldopa as home meds

C. Give MgS04 and antihpn

D. Admit for induction of labor


72/74


25 y/o G2, with severe preeclampsia is undergoing

induction of labor. IE: 4cm. Baseline CTG revealed

What statement/s is/are WRONG?

A. Intermittent auscultation every 15

minutes is acceptable

B. Continuous CTG is done

C. Hook to O2 and put to left lateral

decubitus position

D. All of the above


73/74



74/74

The End

Documents

Hypertension Lecture for Cci 2013