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Hypertension in Pregnancy

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Obstetrics / Gynecology Rotation 2001/02 Hypertension in Pregnancy Speaker: Khalid A. Yarouf. www.4MedStudents.com Outline Physiologic adaptations in normal pregnancy. – PowerPoint PPT presentation

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Title: Hypertension in Pregnancy


1
Hypertension in Pregnancy
Faculty of Medicine Health Sciences
(FMHS) Obstetrics / Gynecology Rotation 2001/02
  • Speaker
  • Khalid A. Yarouf

. www.4MedStudents.com
2
Outline
  • Physiologic adaptations in normal pregnancy.
  • Hypertension in Pregnancy
  • Definition.
  • Prevalence.
  • Classification.
  • Risk factors.
  • Pathogenesis.
  • Complications.
  • Diagnosis Evaluation.
  • Management.
  • Self-assessment.

3
Physiologic adaptations in normal pregnancy
  • Blood changes
  • ? Plasma volume by 40.
  • Platelets count can ? below 200 X 109/L due to
    normal maternal blood-volume expansion.
  • ? Coagulation factors (Fibrinogen, Factor VII).
  • Cardiovascular changes
  • Marked generalized vasodilation (? peripheral
    resistance)
  • ? a/w arterial resistance to constrictor actions
    of Angiotensin II.
  • ? CO Stroke volume.
  • MAP ? by 10 mm Hg.

4
Cont
  • Renal changes
  • Vasodilation ? ? Renal blood flow ? ? GFR (by
    50).
  • ? in Creatinine clearance with a concomitant ? in
    S-Creatinine urea.
  • ? Uric acid clearance Ca excretion.
  • ? Glucosuria aminoaciduria.
  • Respiratory changes.
  • Endocrine changes
  • e.g. parathyroid, adrenal, weight, GI changes.

5
Hypertension in Pregnancy
  • Definition
  • Sustained ? BP _at_ bed rest on 2 occasions at
    least 6 hours apart.
  • Prevalence 10 of all pregnancies.
  • Classification
  • Pre-eclampsia.
  • Chronic hypertension (HTN).
  • Transient HTN Gestational HTN.

6
A. Pre-eclampsia
  • Characteristic triad
  • Sustained HTN Proteinuria Edema (not
    essential for Dx).
  • Onset gt 20 weeks gestation.
  • 50 of all HTN in pregnancies.
  • Resolves after delivery.

7
1. Mild pre-eclampsia
  • Commonest entity ? has NO symptoms.
  • Characteristics
  • HTN BP 140 / 90 mm Hg OR
  • ? sBP by 30 mm Hg above non-pregnant.
  • ? dBP by 15 mm Hg above non-pregnant.
  • Proteinuria (1-2 dipstick OR gt 300 mg / 24
    hr).
  • Edema
  • (non-dependent, hands / face, a/w excessive wt
    gain)

8
2. Severe pre-eclampsia
  • Less common.
  • Can be diagnosed on basis of
  • Severe HTN (BP 160 / 110 mm Hg). OR
  • Severe proteinuria (3-4 dipstick OR gt 5 g / 24
    hr) alone without symptoms. OR
  • Only mild HTN proteinuria if signs and symptoms
    are present

9
Cont
  • Resp Plum. Edema, cyanosis.
  • Cardiac Congestive Cardiac Failure (CCF).
  • Renal Proteinuria, ? Serum creatinine,
    oliguria.
  • Hepatic ? LFTs, RUQ / epigastric pain.
  • Neurologic visual disturbance (i.e. scotomas,
    loss of peripheral vision), headache,
    convulsions.
  • GI severe nausea / vomiting.
  • Hematologic
  • thrombocytopenia, microangiopathic
    hemolysis.

10
Cont
  • HELLP syndrome
  • Type of severe pre-eclampsia.
  • Hemolysis Elevated Liver enzymes Low
    Platelets.

11
3. Eclampsia
  • Latin convulsions
  • Unexplained tonic-clonic seizures Mild /
    severe pre-eclampsia.
  • Most often occurs intra-partum (50), but can
    also occur ante-partum post-partum.

12
B. Chronic HTN
  • Pt may have any disease causing HTN
  • e.g. essential HTN, A/c chronic GN, chronic
    pyelonephritis, SLE.
  • Uncomplicated
  • Definition
  • Pre-existing HTN. OR
  • HTN diagnosed 20 weeks. OR
  • HTN persisting 6 weeks post-partum.
  • NOT induced by pregnancy.

13
Cont
  • 2. Complicated by superimposed pre-eclampsia
  • Isolated HTN without proteinuria.
  • Characterized by worsening of HTN
    proteinuria severe PIH symptoms late in
    pregnancy.

14
C. Transient HTN
  • Late HTN Gestational HTN.
  • Non-sustained (transient) ? BP without
    proteinuria / symptoms in last half of pregnancy.
  • Has no impact on pregnancy outcome.

15
Risk Factors of Pre-eclampsia
  • Maternal Factors
  • 1. Demographic criteria
  • Primagravida ? commonest risk factor.
  • Age extremes (lt20 years, gt 34 years).
  • Medical complications
  • DM Chronic HTN Pre-existing renal disease
    SLE.
  • Past Hx or FHx of pregnancy-induced HTN.
  • Fetal factors
  • Hydatidiform mole, gt 1 fetus, fetal hydrops, IUGR.

16
Pathogenesis of Pre-eclampsia
  • Pre-eclampsia / eclampsia is justly called a
    disease of theories. Despite extensive
    research, no definite cause has been identified.
    As the term toxemia indicates, the search for a
    toxin has been long, arduous, and fruitless.
  • Because of the prompt resolution of disease
    following delivery, most attention has been
    focused on placenta its membranes and on fetus.
  • Uteroplacental ischemia is postulated to be the
    center to the development of disease, which
    results in production of toxin that enters
    circulation and causes widespread endothelial
    dysfunction.

17
Complications
  • Maternal
  • Cerebral hemorrhage (50 of deaths).
  • LVF / Pulm. edema.
  • Liver / renal dysfunction.
  • Seizures.
  • DIC.
  • Abruptio placenta ante-partum painful vaginal
    bleeding.
  • Fetal due to placental insufficiency
  • Fetal loss.
  • IUGR.
  • Prematurity.

18
Diagnosis Evaluation
  • HTN is the most diagnostic sign. Because
    therere no specific diagnostic investigations,
    the initial Dx of pre-eclampsia remains clinical.
  • Hx
  • Previous HTN or proteinuria or both?
  • Previous hypertensive pregnancies?
  • P/E
  • Vitals ? ? BP.
  • In normal pregnancy, therere substantial CV
    changes with a 50 ? in CO blood volume, which
    is accompanied by a ? in BP due to peripheral
    vasodilation. The changes in pre-eclampsia tend
    to be the reverse.
  • Edema.
  • Funduscopic exam ? record baseline findings.

19
Cont (Dx)
  • For the purposes of clinical Dx further
    evaluation, pts may be divided into 2 working
    groups
  • Chronic HTN
  • Multiparous.
  • Those with previous Hx of HTN.
  • Those who developed HTN prior to 20wks gestation.
  • Pre-eclampsia.
  • 1st pregnancy develop syndrome after 20wks.

20
Table 1. Initial lab evaluation of pt
with pre-eclampsia / eclampsia
21
Notes
  • Serum uric acid correlates with poorer outcome
    for the mother baby.
  • Renal function is generally maintained in
    pre-eclampsia until late stage. If creatinine
    levels are high early in disease process,
    underlying renal disease should be suspected.
  • In pre-eclampsia, Plt count ? due to increased
    consumption intravascular destruction. Also, ?
    Plts is part of HELLP synd.
  • Maternal Hb can be ? due to hypovolemia, and its
    a/w IUGR.
  • Liver involvement
  • Inflammatory infiltrates obstructed blood flow
    in sinusoids ? local welling ? subcapsular
    hemorrhage ? upper epigastric pain.
  • ? ALT AST leak across cell membranes (can also
    be a/w HELLP synd).
  • Additional lab test for chronic HTN may include
    ANA (for SLE) and ECG.

22
Management
  • Outpatient observation
  • Use only for transient HTN / uncomplicated
    chronic HTN.
  • Specific guidelines
  • Encourage left lateral rest
  • ? to enhance placental perfusion.
  • Serially monitor mother
  • ? watching for progression to pre-eclampsia /
    superimposed pre- eclampsia.
  • ? Check for BP, U-protein, headache, epigastric
    pain, scotomata.
  • Serially monitor fetus
  • Non-stress test (NST), Amniotic Fluid Index
    (AFI), Biophysical profile (BPP).

23
Cont (Mx)
  • Inpatient observation
  • Use only for mild pre-eclampsia (lt 36 weeks
    gestation).
  • Specific guidelines
  • Encourage left lateral rest
  • ? to enhance placental perfusion.
  • Monitor mother fetus
  • ? watching for progression to severe
    pre-eclampsia or eclampsia.
  • Administer maternal steroids
  • 2 doses of betamethasone IM 24 hours apart.

24
Cont (Mx)
  • Prompt delivery
  • Use mild pre-eclampsia ( 36 weeks gestation),
    severe pre-eclampsia, eclampsia, chronic HTN with
    superimposed PIH, HELLP syndrome, or any evidence
    of maternal or fetal jeopardy.
  • Specific guidelines
  • Lower BP
  • ? keep diastolic value between 90-100 mm Hg.
  • Use IV Hydralazine / IV Labetalol.
  • Prevent convulsions. Use IV MgSO4.
  • Initiate delivery Attempt induction of labor
    vaginal delivery for 8-12 hours if mother fetus
    are stable. Otherwise, perform C-section.

25
Self-assessment
  • A 24-year-old gravida 1, para 0, at 37 weeks
    gestation was noted to have a 6-lb weight gain
    and an increase in blood pressure from 100/60 to
    130/80 in the past week. She also has 1
    proteinuria. The examination was repeated 6
    hours later and the same results were obtained.
    The best diagnosis is
  • Normal pregnancy.
  • Pre-eclampsia.
  • Eclampsia.
  • Chronic hypertension.
  • Essential hypertension.

26
Cont (test)
  • The most common warning sign of pre-eclampsia is
  • Proteinuria.
  • Headache.
  • Edema.
  • Increased BP.
  • Epigastric pain.

27
Cont (test)
  • The ultimate treatment for pre-eclampsia is
  • Magnesium sulfate.
  • Delivery.
  • An antihypertensive drug.
  • Renal dialysis.
  • Bed rest.
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