Hypertensive Disorders of Pregnancy Blok 25

8/10/2019 Hypertensive Disorders of Pregnancy Blok 25

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HYPERTENSIVE DISORDERS OFPREGNANCY

Adrian Setiawan, M.D.

Department of Obstetrics andGynecology,Faculty of MedicineKRIDA WACANA CHRISTIAN UNIVERSITY


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General Classification

Preeclampsia or Eclampsia (hypertension andproteinuria unique to pregnancy)

Chronic hypertension Chronic hypertension with superimposed

preeclampsia

Gestational or transient hypertension(National Institutes of Health Working GroupReport on High Blood Pressure in Pregnancy,2000.

Adopted by ACOG ,2002)


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Diagnosis of Hypertension

Blood pressure readings vary depending onmaternal position and the gestational age ofthe pregnancy.

Tends to be lower in the LLD position, higherin the sitting position.

In the supine position some elevatedpressure, some have supine hypotension dueto compression of the vena cava by theuterus.


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Arterial blood pressure normally declinesduring 1st and 2nd trimester

The diagnosis of hypertension should bereserved for patients with a systolic greaterthan or equal to 140 mmHg or a diastolicgreater than or equal to 90 mmHg.

BP should be taken in the sittting or lateraldecubitus position after woman has rested atleast 10 minutes.


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PREECLAMPSIA

A syndrome unique to pregnancy, characterized bythe new onset of hypertension and proteinuria in thelatter half of gestation divided into mild and severepreeclampsia.

Classically affecting the first pregnancy, but alsooccurs in multiparas or change in husband

Two criteria for diagnosis of preeclampsia : the BP 140/90 mmHg and development of new onset

proteinuria after 20th wks AOG. Proteiunuria defined as 0.3 gram protein in a 24

hour urine collection ,

usually correlates 30 mg/dl (+1 on dipstick)


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Criteria for Severe

Preeclampsia BP 160/110 mmHg at rest on two occasions

at least 6 hr apart

Proteinuria 5 gram in a 24 h urine collectionor qualitative +3

Oliguria (< 500 ml in 24 hr)

Cerebral or visual disturbances Pulmonary edema or cyanosis


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Epigastric or right upper quadrant pain

Impaired liver function (elevated liver

enzyme) Thrombocytopenia

Fetal growth restriction

(ACOG, Practice Bulletin No.33, Washington,DC,2002)


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Eclampsia

Is the presence of tonic clonic seizures in awoman with preeclampsia that cannot beattributed to other causes.


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Chronic Hypertension

The diagnosis of chronic hypertensionrequires at least one of the following : knownhypertension before pregnancy, developmentof hypertension before 20 weeks gestation,or, in cases in which hypertension is firstnoted during pregnancy, persistence of

elevated blood pressures greater than 12weeks postpartum.


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Chronic Hypertension with

Superimposed Preeclampsia The diagnosis of gestationla hypertension is

made if hypertension without proteinuria firstappears after 20 weeks gestation or within 48 to

72 hours after delivery and resolves by 12 weekspostpartum.

The diagnosis of gestational hypertension canonly be made in retrospect, if the pregnancy has

been completed without the development ofproteinuria and if the blood pressure hasreturned to normal before the 12 weekpostpartum.


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Etiology Preeclampsia /

Eclampsia Preeclampsia is called a disease of theories,

because genetic,immunologic,vascular,hormonal, nutritional, and behavioral factorshave all been proposed as causes. No singledefinitive cause has been identified and theorigins of the disease are considered to be

multifactorial.


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Placental ischemia, or hypoxia appears to becentral to the development of the diseaseand has been attributed to failure of thecytotrophoblasts to adequately invade theuterine spiral arteries and establish the lowresistance uteroplacental circulation

characteristic of normal pregnan


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It is postulated that uteroplacental ischemiaresults in oxidative stress leading toproduction and release of toxins that enterthe circulation and cause widespreadinflammation, endothelial dysfunction andactivation of the coagulation system.

Endothelial dysfunction leads to imbalancebetween different classes of locally producedvasoconstrictors and vasodilators.


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Endothelial changes also appear to involve arelative deficiency in the production of nitricoxide, a vasodilator and inhibitor of plateletaggregation along with increased production ofendothelin-1. Endothelin 1 is an extremelypotent vasoconstrictor and activator platelets.

The net effect of these processes would bespread vasoconstriction leading to hypoxic and

ischemic damage in different vascularbeds,systemic hypertension, the HELLPsyndrome or DIC and worsening placentalischemia.


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Pathophysiology

Generalized vasospasm

GFR and renal blood flow are significantly

lower Damage of glomerular membranes ,

increasing their permeability to proteins andleading to proteinuria.

Cerebral vascular resistance is high inpatients with PE and Eclampsia


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Pathology

Lack of decidualization of the myometrialsegments of the spiral arteries

Glomerular capillary endotheliosis Ischemia, hemorrhage and necrosis in many

organs, presumably secondary to arteriolarconstriction.


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Clinical and laboratory

manifestations

Weight gain and edema

Elevation of blood pressure

Proteinuria Increase serum uric acid concentration

Thrombocytopenia

Liver function : elevated serum enzyme levels(alanine aminotransferase and aspartateaminotransferase)


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Retroplacental hemorrhage or abruptio

Visual disturbance

Laboratory : CBC, platelet count,LDH,Ureum, creatinin and uric acid, urinalysis 24hour urine for protein and creatinine, liverfunction tests.


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Evaluation and management

Delivery is the only definitive cure forpreeclampsia and eclampsia after a period ofstabilization, regardless of the gestationalage of the fetus.

Seizure prophylaxis : magnesium sulfate

Antihypertensive therapy : hydralazine,

labetalol, nifedipine, methyldopa


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MANAGEMENT OF PREECLAMPSIA

ADEQUAT AND PROPER PRENATAL CARE

IDENTIFICATION OF WOMEN AT HIGH RISK

EARLY DETECTION BY THE RECOGNATION OF CLINICAL

SIGNS AND SYMPTOMS

THE PROGRESSION OF CONDITION TO SEVERE STATE


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MATERNAL AND PERINATAL OUTCOME IN WOMEN WITH MILD

PREECLAMPSIA, > 36 WEEKS GESTATION ARE USUALLY

FAVOURABLE

MATERNAL AND PERINATAL OUTCOMES DEPEND ON :

GESTATIONAL AGE AT TIME OF DISEASE ONSET

SEVERITY OF DISEASE

QUAITY OF MANAGEMENT

PRESENCE OR ABSENCE OF PRE-EXISTING MEDICAL

DISORDERS


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MILD PREECLAMPSIA

AMBULATORY CAREBED REST : NOT NECESSARILY

REGULAR DIET, NO SALT RESTRICTION

PRENATAL VITAMINNO OTHER MEDICATION : ANTI HYPERTENSIVE,

SEDATIVE, DIURETICS

ANTENAL VISIT : EVERY WEEK


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HOSPITAL CARE

PERSISTENT HYPERTENSION MORE THAN 2 WEEKS

PERSISTENT PROTENURIA MORE THAN 2 WEEKS

ABNORMAL LABORATORY TEST

ABNORMAL FETAL GROWTH

ONE OR MORE SIGN AND SYMPTOM SEVERE PE


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OBSTETRIC MANAGEMENT

GESTATIONAL AGE < 37 WEEKS

~ SIGN AND SYMPTOM ARE NOT WORSENED

MAINTAIN UNTIL TERM

GESTATIONAL AGE > 37 WEEKS

~ WAIT UNTIL THE ONSET OF LABOR

~ CERVIX IS FAVORABLE, INDUCTION OF LABOR


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SEVERE PREECLAMPSIA

MEDICAL TREATMENT

OBSTETRIC MANAGEMENT :

CONSERVATIVE : - PREGNANCY 37 WEEKS

ACTIVE : - PREGNANCY 37 WEEKS

- FETAL INDICATION- MATERNAL INDICATION


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MEDICAL TREATMENT :

HOSPITALIZE

TOTAL BED REST

FLUID THERAPY : RINGER LACTATE, DEXTROSE 5%.

Mg SO4 IV

ANTI HYPERTENSION :

HYDRALAZINLABETALOL

NIFEDIPINE : 10 20 mg / ORALLY EVERY - 1 H,

MAX : 120 mg / 24 Hours

DIURETIC : NOT RECOMMENDED ANTI OXYDANT : N-ACETYL CYSTEIN

CORTICOSTEROID + LUNG MATURITY 34 WEEKS


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CONSERVATIVE MANAGEMENT:

GOAL : TO IMPROVE INFANT OUTCOME,

WITHOUT COMPROMISING THE MOTHER

PREGNANCY 37 WEEKS, IMPENDING ECLAMPSIA (-)

ACTIVE MANAGEMENT : TO TERMINATE THE PREGNANCY

INDICATION

FETAL : - PREGNANCY 37 WEEKS

- IUGR AND ABNORMAL

BIOPHYSICAL PROFILE


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MATERNAL : - PERSISTENT HYPERTENTION- IMPENDING ECLAMPSIA

- COMPLICATION : HELLP SYNDROME,

ABRUPTIO PLAC., OLIGURIA

ROUTE OF DELIVERY :

VAGINAL DELIVERY IS PREFERABLE THAN CS.


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ECLAMPSIA : PE + CONVULSION

BASIC MANAGEMENT :

CONTROL THE AIRWAY, BREATHING, CIRCULATION (ABC)

STABILIZE THE MOTHER

CONTROL CONVULSION

CORRECT MATERNAL HYPOXEMIA / ACIDEMIA

PREVENT COMPLICATION : HYPERTENSION CRISIS

TERMINATE PREGNANCY

MEDICAL TREATMENT :

SAME AS SEVERE PREECLAMPSIA


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COMPLICATION : P.E AND ECLAMPSIA

MOTHER

BABY

HELLP SYNDROME

LIVER RUPTURED

PULMONARY EDEMA

RENAL FAILURE

ABRUPTIO PLACENTAE

DIC

CEREBROL VASCULER ACCIDENT

MATERNAL DEATH

IUGR

PREMATURE LABOR

INTRA CRANIAL HAEMORRHAGE

CEREBRAL PALSY

PNEUMO THORAX

IUFD


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HELLP SYNDROME

FIRST DISCRIBED BY WEINSTEIN 1982:

ACRONYM OF : H : HEMOLYSIS

EL : ELEVATED LIVER ENZYM

LP : LOW PLATETLED COUNT

INCIDENCE : 2%-12% AMONG PATIENTS WITH

PREECLAMPSIA.

30% OCCURS IN POSTPARTUM


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CRITERIA DIAGNOSTIC

LABORATORY FINDING:

HEMOLYSIS

ABNORMAL PERIPHERAL SMEAR : SCHISTOCYTES ANDBURR CELLS

TOTAL BILIRUBIN LEVEL > 1,2 mg/Dl

LACTATE DEHYDROGENASE LEVEL > 600 /L

ELEVATED LIVER FUCTION

SGOT LEVEL 70 / L (LDH)

LACTATE DEHYDROGENASE LEVEL > 600 /L

LOW PLATELET COUNT

PLATELET COUNT < 100.000/m3

THE LABORATORY DIAGNOSTIC CRITERIA USED AT THE UNIVERSITY OF TENNESSEE

DIVISION OF MATERNAL FETAL MEDECINE, MEMPHIS TN. WITLIN AND SIBAI (1999)


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CLASS I : PLATELET 50.000/m3

WITH : LDH

600 U/L

SGOT 40 U/L

CLASS II : PLATELET 50.000/m3 - < 100.000/m3

WITH : LDH 600 U/L

SGOT

40 U/L

CLASS II : PLATELET 50.000/m3 - < 150.000/m3

WITH : LDH

600 U/L

SGOT 40 U/L

CLASSIFICATION BASED ON PLATELET COUNT

(MISSISIPPI):


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MANAGEMENT OF HELLP SYNDROME

MATERNAL STABILISATION IS THE MAYOR PRIORITY

BEGIN WITH A STANDART MANAGEMENT OF SEVERE

PREECLAMPSIA

HELLP SYNDROME IS NOT AN INDICATION FOR CS


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MEDICAL MANAGEMENT

SAME AS SEVERE PREECLAMPSIA

WHEN THROMBOCYTE COUNT IS < 50.000 mm3, 10 UNITS

OF THROMBOCYTE OR FRESH WHOLE BLOOD MUST BE

GIVEN

WHEN PATIENT IS COMATOUS, SHE MUST BE TAKEN TO

THE ICU

WHEN THROMBOCYTE COUNTS IS < 50.000/mm3

FIBRINOGEN LEVEL, PROTHROMBINE TIME, PARTIAL

THROMBOPLASTIN TIME, D-DIMMER MUST BE CHECKED

TO FIND DIC


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WHEN MOTHERS IS STABLE TERMINATE THE

PREGNANCY OR CONSERVATIVE MANAGEMENT.

CONSERVATIVE MANAGEMENT CAN BE DONE

WHEN :

THE BLOOD PRESSURE < 160/110 m g

THE OLIGURIA RESPONSE TO FLUID

REPLACEMENT

THERE IS NO EPIGASTRIC PAIN

THE GESTATIONAL AGE IS < 34 WEEKS


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