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Presented by Dr A/ShakorMBChB GEZIRA UNIVERSITY -SUDAN
Head of Anatomy Department Head of Anatomy Department Somali International UniversitySomali International University
OBJECTIVES Be able to define hypertension in relationship to
pregnancy. Be able to classify hypertensive diseases in
pregnant women. Be able to list criteria for the diagnosis of
preeclampsia. Be able to list criteria for the diagnosis of severe
preeclampsia/HELLP syndrome. Be able to discuss current management
considerations. Understand and discuss the effects of
hypertension on the mother and fetus.
HypertensionSustained BP elevation of 140/90 or
greater.Proper cuff size.Measurement taken while seated.Arm at the level of the heart.Use Korotkoff sound.
Hypertensive Disease Associated with Pregnancy
Chronic Hypertension.Gestational Hypertension.Preeclampsia.Eclampsia.HELLP Syndrome.
Hypertensive Disease Associated with Pregnancy
Chronic Hypertension◦ Diagnosed before the 20th week or present
before the pregnancy◦ Mild hypertension
> 140-180 mmHg systolic > 90-100 mmHg diastolic
Gestational HypertensionGestational Hypertension PreeclampsiaPreeclampsia EclampsiaEclampsia HEELP SyndromeHEELP Syndrome
Hypertensive Disease Associated with Pregnancy
Chronic HypertensionChronic Hypertension
Gestational Hypertension◦ Criteria
Develops after 20 weeks of gestation Proteinuria is absent Blood pressures return to normal postpartum
◦ Morbidity is directly related to the degree of hypertension
PreeclampsiaPreeclampsia EclampsiaEclampsia HEELP SyndromeHEELP Syndrome
Hypertensive Disease Associated with Pregnancy
Chronic HypertensionChronic Hypertension Gestational HypertensionGestational Hypertension
Preeclampsia◦ Criteria
Develops after 20 weeks Blood pressure elevated on two occasions at least 6
hours apart Associated with proteinuria and edema
May occur less than 20 weeks with gestational trophoblastic neoplasia
EclampsiaEclampsia HEELP SyndromeHEELP Syndrome
Preeclampsia vs. Severe Preeclampsia
Criteria for Preeclampsia
Criteria for Severe Preclampsia
Previously normotensive woman
> 140 mmHg systolic> 90 mmHg diastolicProteinuria > 300 mg in
24 hour collectionNondependent edema
BP > 160 systolic or >110 diastolic
> 5 gr of protein in 24 hour urine or > 3+ on 2 dipstick urines greater than 4 hours apart
Oliguria < 500 mL in 24 hours Cerebral or visual distrubances
(headache) Pulmonary edema or cyanosis Epigastric or RUQ pain Evidence of hepatic
dysfunction Thrombocytopenia Intrauterine growth restriciton
(IUGR)
Risk Factors for Preeclampsia
Nulliparity Multifetal gestations Maternal age over 35 Preeclampsia in a
previous pregnancy Chronic hypertension Pregestational diabetes
Vascular and connective tissue disorders
Nephropathy Antiphospholipid
syndrome Obesity African-American race
Risk FactorsFACTOR RISK RATIO
Nulliparity 3:1
Age > 40 3:1
African American 1.5:1
Chronic hypertension 10:1
Renal disease 20:1
Antiphospholipid syndrome 10:1
Hypertensive Disease Associated with Pregnancy
Chronic HypertensionChronic Hypertension Gestational HypertensionGestational Hypertension PreeclampsiaPreeclampsia
Eclampsia◦ Diagnosis of preeclampsia◦ Presence of convulsions not explained by a
neurologic disorder Grand mal seizure activity
◦ Occurs in 0.5 to 4% or patients with preeclampsia
HEELP SyndromeHEELP Syndrome
Hypertensive Disease Associated with Pregnancy
Chronic HypertensionChronic Hypertension Gestational HypertensionGestational Hypertension PreeclampsiaPreeclampsia EclampsiaEclampsia
HELLP Syndrome◦ A distinct clinical entity with:
Hemolysis, Elevated Liver enzymes, Low Platelets◦ Occurs in 4 to 12 % of patients with severe
preeclampsia Microangiopathic hemolysis Thrombocytopenia Hepatocellular dysfunction
Morbidity and Mortality from Hypertensive Disease
Hypertension affects 12 to 22% of pregnant patients
Hypertensive disease is directly responsible for approximately 20% of maternal mortality in the United State
PathophysiologyVasospasm.Uterine vessels.Hemostasis.Prostanoid balance.Endothelium-derived factors.Lipid peroxide, free radicals and antioxidants.
PathophysiologyVasospasm
◦ Predominant finding in gestational hypertension and preeclampsia
Uterine vesselsUterine vessels HemostasisHemostasis Prostanoid balanceProstanoid balance Endothelium-derived factorsEndothelium-derived factors Lipid peroxide, free radicals and antioxidantsLipid peroxide, free radicals and antioxidants
Pathophysiology Vasospasm
Uterine vessels:◦ Inadequate maternal vascular response to
trophoblastic mediated vascular changes◦ Endothelial damage
HemostasisHemostasis Prostanoid balanceProstanoid balance Endothelium-derived factorsEndothelium-derived factors Lipid peroxide, free radicals and antioxidantsLipid peroxide, free radicals and antioxidants
Pathophysiology VasospasmVasospasm Uterine vesselsUterine vessels
Hemostasis◦ Increase platelet activation resulting in
consumption◦ Increased endothelial fibronectin levels◦ Decreased antithrombin III and α2-antiplasmin
levels◦ Allows for microthrombi development with
resultant increase in endothelial damage Prostanoid balanceProstanoid balance Endothelium-derived factorsEndothelium-derived factors Lipid peroxide, free radicals and antioxidantsLipid peroxide, free radicals and antioxidants
Pathophysiology VasospasmVasospasm Uterine vesselsUterine vessels HemostasisHemostasis
Prostanoid balance◦ TXA2 promotes:
Vasoconstriction Platelet aggregation
Endothelium-derived factorsEndothelium-derived factors Lipid peroxide, free radicals and antioxidantsLipid peroxide, free radicals and antioxidants
Pathophysiology VasospasmVasospasm Uterine vesselsUterine vessels HemostasisHemostasis Prostanoid balanceProstanoid balance
Endothelium-derived factors◦ Nitric oxide is decreased in patients with
preeclampsia As this is a vasodilator, this may result in
vasoconstriction Lipid peroxide, free radicals and antioxidantsLipid peroxide, free radicals and antioxidants
Pathophysiology VasospasmVasospasm Uterine vesselsUterine vessels HemostasisHemostasis Prostanoid balanceProstanoid balance Endothelium-derived factorsEndothelium-derived factors
Lipid peroxide, free radicals and antioxidants◦ Increased in preeclampsia◦ Have been implicated in vascular injury
Pathophysiologic Changes
1. Cardiovascular effects.2. Hematologic effects.3. Neurologic effects.4. Pulmonary effects.5. Renal effects.6. Fetal effects.
Pathophysiologic ChangesCardiovascular effects
◦ Hypertension◦ Increased cardiac output◦ Increased systemic vascular resistance
Hematologic effects Neurologic effects Pulmonary effects Renal effects Fetal effects
Pathophysiologic Changes Cardiovascular effectsCardiovascular effects
Hematologic effects◦ Hypovolemia.◦ Elevated hematocrit◦ Thrombocytopenia◦ hemolytic anemia.◦ Low oncotic pressure
Neurologic effectsNeurologic effects Pulmonary effectsPulmonary effects Renal effectsRenal effects Fetal effectsFetal effects
Pathophysiologic Changes Cardiovascular effectsCardiovascular effects Hematologic effectsHematologic effects
Neurologic effects:◦ Hyperreflexia◦ Headache◦ Cerebral edema◦ Seizures
Pulmonary effectsPulmonary effects Renal effectsRenal effects Fetal effectsFetal effects
Pathophysiologic Changes Cardiovascular effectsCardiovascular effects Hematologic effectsHematologic effects Neurologic effectsNeurologic effects
Pulmonary effects◦ Pulmonary edema
Renal effectsRenal effects Fetal effectsFetal effects
Pathophysiologic Changes Cardiovascular effectsCardiovascular effects Hematologic effectsHematologic effects Neurologic effectsNeurologic effects Pulmonary effectsPulmonary effects
Renal effects◦ Decreased glomerular filtration rate◦ Proteinuria◦ Oliguria◦ Acute tubular necrosis
Fetal effectsFetal effects
Pathophysiologic Changes Cardiovascular effectsCardiovascular effects Hematologic effectsHematologic effects Neurologic effectsNeurologic effects Pulmonary effectsPulmonary effects Renal effectsRenal effects
Fetal effects:◦ Placental abruption◦ Fetal growth restriction◦ Oligohydramnios.◦ Fetal distress◦ Increased perinatal morbidity and mortality
Management:A. The ultimate cure is delivery.B. Assess gestational age.C. Assess cervix.D. Fetal well-being.E. Laboratory assessment.F. Rule out severe disease!!
Gestational HTN at TermGestational HTN at TermDelivery is always a reasonable option if
term.If cervix is unfavorable and maternal
disease is mild, expectant management with close observation is possible.
Mild Gestational HTN not at Term:A. Rule out severe diseaseB. Conservative managementC. Serial labsD. Twice weekly visitsE. Antenatal fetal surveillanceF. Outpatient versus inpatient
Indications for DeliveryWorsening BP.Non-reassuring fetal condition.Development of severe PIH.Fetal lung maturity.Favorable cervix.
Hypertensive EmergenciesFetal monitoring.IV access.IV hydration.The reason to treat is maternal, not fetal.May require ICU.
Criteria for TreatmentDiastolic BP > 105-110Systolic BP > 200Avoid rapid reduction in BPDo not attempt to normalize BPGoal is DBP < 105 not < 90May precipitate fetal distress
Key Steps Using Vasodilators250-500 cc of fluid, IVAvoid multiple doses in rapid successionAllow time for drug to workMaintain LLD positionAvoid over treatment
Acute Medical TherapyHydralazineLabetalolNifedipineNitroprussideDiazoxideClonidine
HydralazineDose: 5-10 mg every 20 minutesOnset: 10-20 minutesDuration: 3-8 hoursSide effects: headache, tachycardia.Mechanism: peripheral vasodilator
LabetalolDose: 20mg, then 40, then 80 every 20
minutes, for a total of 220mg Onset: 1-2 minutesDuration: 6-16 hoursSide effects: hypotensionMechanism: Alpha and Beta block
NifedipineDose: 10 mg , not sublingualOnset: 5-10 minutesDuration: 4-8 hoursSide effects: chest pain, headache,
tachycardiaMechanism: CA channel block
ClonidineDose: 1 mg poOnset: 10-20 minutesDuration: 4-6 hoursSide effects: unpredictable, avoid rapid
withdrawalMechanism: Alpha agonist, works
centrally
NitroprussideDose: 0.2 – 0.8 mg/min IVOnset: 1-2 minutesDuration: 3-5 minutesSide effects: cyanide accumulation,
hypotensionMechanism: direct vasodilator
Seizure ProphylaxisMagnesium sulfate4-6 g bolus1-2 g/hourMonitor urine output.With renal dysfunction, may require a lower
dose
Magnesium Sulfate.Is not a hypotensive agentWorks as a centrally acting anticonvulsantAlso blocks neuromuscular conduction
Treatment of EclampsiaFew people die of seizuresProtect patientAvoid insertion of airways and padded tongue
bladesIV accessMGSO4
Alternate AnticonvulsantsHave not been shown to be as efficacious as
magnesium sulfate and may result in sedation that makes evaluation of the patient more difficultDiazepam 5-10 mg IVSodium Amytal 100 mg IVPentobarbital 125 mg IVDilantin 500-1000 mg IV infusion
After the SeizureAssess maternal labsFetal well-beingEffect deliveryTransport when indicatedNo need for immediate cesarean delivery
Other ComplicationsPulmonary edemaOliguriaPersistent hypertensionDIC
Pulmonary Edema Fluid overload Reduced colloid osmotic pressure Occurs more commonly following delivery
as colloid oncotic pressure drops further and fluid is mobilized
Treatment of Pulmonary EdemaAvoid over-hydrationRestrict fluidsLasix 10-20 mg IVUsually no need for albumin.
Oliguria25-30 cc per hour is acceptableIf less, small fluid boluses of 250-500 cc as
neededLasix is not necessaryPostpartum diuresis is common
Persistent HypertensionBP may remain elevated for several daysDiastolic BP less than 100 do not require
treatmentBy definition, preeclampsia resolves by 6
weeks
Disseminated Intravascular CoagulopathyRarely occurs without abruptionLow platelets is not DICRequires replacement blood products and
delivery
Anesthesia IssuesContinuous lumbar epidural is preferred if
platelets normalNeed adequate pre-hydration of 1000 ccLevel should always be advanced slowly to
avoid low BPAvoid spinal with severe disease
HELLP SyndromeHe-hemolysisEL-elevated liver enzymesLP-low platelets
HELLP SyndromeIs a variant of severe preeclampsiaPlatelets < 100,000LFT’s - 2 x normalMay occur against a background of what
appears to be mild disease
SUMMARYCriteria for diagnosisLaboratory and fetal assessment
Magnesium sulfate seizure prophylaxis
Timing and place of delivery
Any comment any question?????