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HYPERTENSIVE DISORDERS IN PREGANCY. OBJECTIVES. At the end of this session you should be able to: Outline diagnostic features of pre-eclampsia Classify pre-eclampsia according to severity Outline risk factors for pre-eclampsia Outline maternal and fetal complications of pre-eclampsia. - PowerPoint PPT Presentation
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HYPERTENSIVE
DISORDERS IN PREGANCY
OBJECTIVES
At the end of this session you should be able to:
1. Outline diagnostic features of pre-eclampsia
2. Classify pre-eclampsia according to severity
3. Outline risk factors for pre-eclampsia
4. Outline maternal and fetal complications of pre-
eclampsia.
5. Describe the management of pre-eclampsia and
eclampsia.
I. INTRODUCTION
Synonyms:
Toxemia of pregnancy, pre-eclampsia, EPH gestosis, pregnancy induced hypertension.
Pre-eclampsia commonly manifests after the 20th week of pregnancy.
Prevalence of pre-eclampsia: varies from one place to another Severe pre-eclampsia and eclampsia
Are serious and potentially fatal Third commonest cause of maternal mortality
Occurs prior to, during or after delivery
II. DIAGNOSIS OF PRE-ECLAMPSIA
When SBP > 140 mm Hg, DBP > 90 mm Hg
in a woman known to be normotensive prior
to pregnancy.
The diagnosis requires 2 such abnormal BP
measurements recorded at least 6 hours apart.
III. RISK FACTORS
Young maternal age Nulliparity: 85% of pre-eclampsia occur in
primigravida. Increased placental tissue for gestational age:
Hydatiform moles, twin pregnancies Family history of pre -eclampsia Diabetes mellitus Renal diseases, Chromosomal abnormality in the fetus (eg, trisomy).
RISK FACTORS cont
Worrisome signs for pre-eclapmsia development
Rapid increase of weight during the latter ½ of
pregnancy
An upward trend in diastolic BP even while still
within normal range
IV. CLASSIFICATION OF PRE
ECLAMPSIA:
ACCORDING TO SEVERITY
1. Mild pre-eclampsia2. Moderate pre-eclampsia3. Severe pre-eclampsia
1. Mild to Moderate Pre eclampsia Diagnostic Features
Systolic BP is 140 -160 mmHg Diastolic BP is 90 – 100 mmHg Proteinuria up to ++
2. Severe pre-eclampsia
Also called – Imminent eclampsiaSymptoms Severe & persistent occipital or frontal headaches Visual disturbance: blurred vision, photophobia Epigastric and/or right upper-quadrant pain Signs Diastolic BP > 11ommHg, systolic BP > 160mmHg Proteinuria +++ or more Altered mental status Hyper-reflexia Oliguria
HELLP SYNDROME
Is a severe form of pre-eclampsia
Affects approx 10% of women with severe preeclampsia and 30-50% of women with eclampsia.
Characterized by:
Hemolysis,
Elevated liver enzymes
Low platelet count.
Increased mortality rate and DIC
V. PATHOPHYSIOLOGY
There are several theories and etiologic mechanisms.
Vasospasm theory: Most favored theory
Vasospasms → vasoconstriction → resistance →
arterial BP
Eclampsia:
Cerebral arterial vasospasm → cerebral edema or
infarction and/or cerebral hemorrhage
VI. COMPLICATIONS OF SEVERE PRE-ECLAMPSIA AND ECLAMPSIA
Maternal complications
CVS Haemoconcentration (cause: vasoconstriction and vascular
permeability) Hamatological changes – HELLP → DIC
Kidneys Decr RBF→ ↓GFR → RTN and RCN→ acute RF Proteinuria – due to permeability to large protein,⇈ Oliguria – both renal perfusion and GFR decrease.
COMPLICATIONS OF SEVERE PRE ECLAMPSIA AND ECLAMPSIA cont
Brain Cerebral edema Infarction, cerebral hemorrhage Blindness: Due to -?retinal artery vasospasms and
retinal detachment Fever 39ºC: a grave sign, may be a consequence of
intracranial hemorrhage. Coma – may be a result of CVA
COMPLICATIONS OF SEVERE PRE ECLAMPSIA AND ECLAMPSIA cont
RS : Pulmonary oedema and cyanosis
Utero-placental perfusion Vasospasms → decr perfusion → distress and
death Histological changes in the placental bed: acute
artherosis – lipid rich cells of the uteroplacental arteries
Fetal complications IUFD, IUGR
MAJOR CAUSES OF MATERNAL DEATH
Cerebrovascular accident (CVA)
Pulmonary oedema
Cardiac failure,
Renal failure
VII. WORK UP - INVESTIGATIONS
Urine analysis Proteinuria
A 24-hour urine collection Quantity of urine and protein
Uric acid level: GFR and creatinine clearance decrease →in ↑uric acid
levels. LFT – Transaminases USS – fetal wellbeing, if the GA is < 20/40 R/O
moles.
VIII. MANAGEMENT OF PRE ECLAMPSIA
1. MILD - MOD PRE ECLAMPSIA
A: Dispensary & Health centre
Antihypertensives
Aldomet 250 mg 8 hourly for 7 days,
Bed rest at home
REFER within one week to Hospital for further
management
MANAGEMENT OF PRE ECLAMPSIA
1. MILD - MOD PRE ECLAMPSIA cont
B. Hospital
Antihypertensives: Aldomet,
Bed rest at home,
Sequential work ups,
Fetal movements monitoring,
Schedule antenatal clinic every 2 weeks up to 32 wks and
weekly thereafter
MANAGEMENT OF PRE ECLAMPSIA
1. MILD - MOD PRE ECLAMPSIA cont
B. Hospital Strongly advice the woman to deliver in a hospital Plan delivery at 38/40 Advice the mother to come to the health facility in case of
severe headache, blurred vision, nausea or upper abdominal pain.
Manage as severe pre-eclampsia: If not responding to treatment i.e. if the systolic BP is > 160 mmHg, or the diastolic BP is > 100mmHg or there is proteinuria +++
MANAGEMENT OF SEVERE PRE ECLAMPSIA AND ECLAMPSIA
Note: Severe pre-eclampsia is managed like eclampsia
Management protocol for eclampsia Keep airway clear Control convulsions Control BP Control fluid balance Antibiotics Investigations Deliver the mother
MANAGEMENT CONT
BP CONTROL
Keep SBP between 140 -160 mm Hg and DBP between 90 -
110 mm Hg
?Why these levels: Avoid potential reduction in either
uteroplacental blood flow or cerebral perfusion pressure.
Drugs:
Anti HPTs: Hydralazine, nifedipine, or labetalol
Diuretics are not used except in the presence of pulmonary
edema
MANAGEMENT: CONTROL CONVULSIONS
I. An overview on MgSO4. Mechanism:
Cerebral vasodilator → reducing cerebral vasospasm → ↓ischemia (brain).
Superior to other anti-convulsants used to control and prevent fits; Important part of mgt of eclampsia Recurrence rate after MgSO4 = 10 -15%
Improves maternal and fetal outcome
CONTROL CONVULSIONS - REGIMEN
1. INTRAMUSCULAR REGIMEN
i. Loading dose
Give MgSO4 4 g (i.e. 20mls of 20% solution) +
200mls NS or sterile water I.V over 5 minutes
Follow promptly with 10g (i.e. 20ml of 50%
solution), 5g in each buttock as deep I.M with
1ml of 2% lignocaine in the same syringe
MANAGEMENT CONT
CONTROL CONVULSIONS - REGIMEN
1. INTRAMUSCULAR REGIMEN cont
ii. Maintenance dose
MgSO4 5 g (i.e. 10ml of 50% solution) + 1 ml
lignocaine 2% 4 hourly in alternate buttocks.
NOTE:
IM inj. are painful and are complicated by local
abscess formation in 0.5% of cases.
The intravenous (IV) route is therefore preferred
MANAGEMENT CONT
CONTROL CONVULSIONS - REGIMEN
2. INTRAVENOUS REGIMEN
i. Loading dose
MgSO4 4 g (i.e. 20mls of 20% solution) + 200mls
NS I.V over 5 minutes
ii. Maintenance dose
MgSO4 4 g (i.e. 20ml of 20% solution) IN 500ml NS
4 hourly for 24 hrs after the last fits
MANAGEMENT CONT
CONTROL CONVULSIONS - REGIMEN
Recurrent fits (any regimen):
Therapeutic dose may not have been reached
Give 2g (i.e. 10ml of 20% solution) i.v. over 5
minutes
Treatment duration:
Continue for 24 hours after delivery or last
convulsion, whichever occurs first
MANAGEMENT CONT
Magnesium toxicity
Causes loss of deep tendon reflexes, followed by respiratory depression and ultimately respiratoryarrest.Thus, before repeating MgSO4, ensure that; RR ≥ 16/min Patellar reflexes are present Urinary output is at least 30ml per hour over 4 hours Otherwise withhold or delay MgSO4 Keep antidote ready In case of respiratory arrest: Assist ventilation and administer
calcium gluconate
MANAGEMENT CONT
DELIVER THE MOTHER
Delivery should be within 6-8 hours of onset of fits
Vaginal delivery is the safest mode of delivery Assessment
R/O contraindications to SVD Bishop score
If the cervix is favourable - induce labour Otherwise prepare for C/S
MANAGEMENT CONT
Management of labour
1st stage
Relieve pain: pethidine 25 mg iv every 2-4 hours
Augmentation of labour
Monitor FHR,
2nd stage: Assist with vacuum extraction
3rd stage: Active management
Oxytocin 10 IU i.m after delivery of anterior shoulder
Cord traction
Squeezing clots after delivery of the placenta
MANAGEMENT CONT
Management of labour
If there is delay perform C/S
Post delivery: Continue observation for at least 48 hrs post
delivery Record and monitor BP and urine output for at
least 48 hours after delivery, Keep the pt in hospital until BP stabilizes, Continue with aldomet PO until BP back to
normal