Pregnancy Induced Hypertension - PowerPoint PPT Presentation

Loading...

PPT – Pregnancy Induced Hypertension PowerPoint presentation | free to view - id: 3d1e22-ZjFlN



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Pregnancy Induced Hypertension

Description:

Pregnancy Induced Hypertension Jun Ma Dept. of Obstetrics & Gynecology The First Hospital of Xi an Jiaotong Univ Introduction Incidence: China: 9.4%, worldwide: 7 ... – PowerPoint PPT presentation

Number of Views:1047
Avg rating:3.0/5.0
Slides: 50
Provided by: obgynfirs
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Pregnancy Induced Hypertension


1
Pregnancy Induced Hypertension
  • Jun Ma
  • Dept. of Obstetrics Gynecology
  • The First Hospital of Xian Jiaotong Univ

2
Introduction
  • Incidence China 9.4, worldwide 7-12
  • The most common and yet serious conditions seen
    in obstetrics
  • cause substantial morbidity and mortality in the
    mother and fetus
  • Death due to cerebral hemorrhage, aspiration
    pneumonia, hypoxic encephalophathy,
    thromboembolism, hepatic rupture, renal failure

3
Hypertension in pregnancy
  • Definition
  • Diastolic BP 90 mmHg
  • Systolic BP 140 mmHg
  • Or as an increase in the diastolic BP of 15
    mmHg or in the systolic blood pressure of 30
    mmHg, as compared to previous pressure
  • The increased blood pressures be present on at
    least two separate occasions, gt 6h apart

4
Classification
5
Classification of Hypertensive Disorders in
Pregnancy (ACOG)
  • Pregnancy-induced hypertension
  • Preeclampsia
  • Mild
  • Severe
  • Eclampsia
  • Chronic hypertension preceding pregnancy
  • Chronic hypertension with superimposed PIH
  • Superimposed preeclampsia
  • Superimposed eclampsia
  • Gestational hypertension

6
Classification (1)
  • Pregnancy-induced hypertension
  • Hypertension associated with proteinuria and
    edema, occurring primarily in nulliparas after
    the 20th week or near term.
  • Preeclampsia
  • ?mild ?
  • BP 140/90mmHg
  • Onset after 20 weeks gestation
  • Proteinuria (gt300mg/24-hr urine collection) or
  • Epigastric discomfort
  • Thrombocytopenia

7
Classification (2)
  • ?severe?
  • BP 160/110 mmHg
  • Marked proteinuria (gt1-2 g/24-hr urine collection
    or 2 or more), oliguria
  • Cerabral or visual disturbances such as headache
    and scotomata
  • Pulmonary edema or cyanosis
  • Epigastric or right upper quadrant pain (probably
    caused by subcapsular hepatic hemorrhage)
  • Evidence of hepatic dysfunction, or
    thrombocytopenia

8
Classification (3)
  • Eclampsia
  • Meets the criteria of preeclampsia
  • Presence of convulsions, not attributable to
    other neurological disease,
  • Occurrence 0.5 -4 , with 25 occurring in the
    1st 72 hs postpartum

9
Classification (4)
  • Chronic hypertension proceeding pregnancy
    (essential or secondary to renal disease,
    endocrine disease, or other causes)
  • BP 140/90 mmHg
  • Presents before 20 wk gestation
  • Persists beyond 12 wk postpartum

10
Classification (5)
  • Chronic hypertension with superimposed
    preeclampsia or eclamptia
  • Coexistence of preeclampsia or eclampsia with
    preexisting chronic hypertension
  • Cause greatest risk
  • When diagnosis is obscure, it is always wise to
    assume that the findings represent preeclampsia
    and treat accordingly.

11
Classification (6)
  • Gestational hypertension not mentioned in the
    ACOG
  • Finding of hypertension in late pregnancy in the
    absence of other findings suggestive or
    preeclampsia
  • Transient hypertension of pregnancy
  • May develop into chronic hypertension if elevated
    BP persists beyond 12 weeks postpartum

12
High risk factors
  • Nulliparous
  • lt18ys or gt40 ys, multiple pregnancy
  • Has previous gestational hypertensive disorders
  • Chronic nephritis
  • Diabetic
  • Malnutrition
  • Low social status
  • Hydatidiform mole

13
Etiology UNCLEAR
  • Immune mechanism (rejection phenomenon,
    insufficient blocking Ab)
  • Injury of vascular endothelium----disruption of
    the equilibrium between vasoconstriction and
    vasodilatation, imbalance between PGI and TXA
  • Compromised placenta profusion
  • Genetic factor
  • Dietary factors nutrition deficiency
  • Insulin resistance
  • Increase CNS irritability

14
Pathophysiology
15
Central nervous system
  • Raised BP disrupt autoregulation
  • Increased permeability due to vasospasm---thrombos
    is of arterioles, microinfarcts, and petechial
    hemorrhage
  • Cerebral edema increased intracranial pressure
  • CT scan (1/3-1/2 positive) focal hypodensity
  • Cerebral angiography diffuse arterial
    vasoconstriction
  • EEG nonspecific abnormality (75 in eclamptic
    patient)

16
Eyes
  • Serous retinal detachment
  • Cortical blindness

17
Pulmonary system
  • Pulmonary edema
  • Cardiogenic or noncardiogenic
  • Excessive fluid retention, decreased hepatic
    synthesis of albumin, decreased plasma colloid
    oncotic pressure,
  • Often occurs postpartum
  • Aspiration of gastric contents the most dreaded
    complications of eclamptic seizures

18
Kidneys
  • Characteristic lesion of preeclampsia
    glomeruloendotheliosis
  • Swelling of the glomerular capillary endothelium
  • Decreased GFR
  • Fibrin split products deposit on basement
    membrane
  • Proteinuria
  • Increase of plasma uric acid, creatinine,

19
Liver
  • The spectrum of liver disease in preeclampsia is
    broad
  • Subclinical involvement
  • Rupture of the liver or hepatic infarction
  • HELLP syndrome hemolysis, elevated liver enzymes
    and low platelets

20
Cardiovascular system
  • Generalized vasoconstriction, low-output,
    high-resistance state
  • Untreated preeclamptic women are significantly
    volume-depleted
  • Capillary leak
  • Cardiac ischemia, hemorrhage, infarction, heart
    failure
  • Increased sensitivity to vasoconstrictor effects
    of angiotensin

21
Blood (1)
  • Volume reduced plasma volume
  • Normal physiologic volume expansion does not
    occur
  • Generalized vasoconstriction and capillary leak
  • Hematocrit

22
Blood (2) coagulation
  • Isolated thrombocytopenia lt150,000/ml
  • Microangiopathic hemolytic anemia
  • DIC (5)
  • HELLP syndrome in severe preeclampsia
  • schistocytes on the peripheral blood smear
  • lactic dehydrogenase gt 600 u/L
  • total bilirubin gt 1.2 mg/dl
  • aspartate aminotransferase gt70 U/L
  • platelet count lt100,000/mm3
  • Misdiagnosis hepatitis, gallbladder disease, ITP

23
Endocrine system
  • Vascular sensitivity to catecholamines and other
    endogenous vasopressors such as antidiuretic
    hormone and angiotensin II is increased in
    preeclampsia
  • Disequilibrium of prostacyclin/ thromboxane A2

24
Placenta perfusion
  • 500 mm vs 200 mm
  • Acute atherosis of spiral arteries fibrinoid
    necrosis of the arterial wall, the presence of
    lipid and lipophages and a mononuclear cell
    infiltrate around the damaged vessel----vessel
    obliteration---- placental infarction
  • Fetus is subjected to poor intervillous blood
    flow
  • IUGR or stillbirth

25
Clinical findings (1)
  • Symptoms and signs
  • Hypertension
  • Diastolic pressure 90 mmHg or
  • Systolic pressure 140 mmHg or
  • Increase of 30/15 mmHg
  • Proteinuria
  • gt300 mg/24-hr urine collection or
  • or more on dipstick of a random urine

26
Clinical findings (2)
  • Edema
  • Weight gain 1-2 lb/wk or 5 lb/wk is considered
    worrisome
  • Degree of edema
  • Preeclampsia may occur in women with no edema
  • Most recent reports omit it from the definition

27
Clinical findings (3)
  • Differing clinical picture in preeclampsia-eclamps
    ia crises patient may present with
  • Eclamptic seizures
  • Liver dysfunction and IUGR
  • Pulmonary edema
  • Abruptio placenta
  • Renal failure
  • Ascites and anasarca

28
Clinical findings (4)
  • Laboratory findings (1)
  • Blood test elevated Hb or Hct, in severe cases,
    anemia secondary to hemolysis, thrombocytopenia,
    FDP increase, decreased coagulation factors
  • Urine analysis proteinuria and hyaline cast,
    specific gravity gt 1.020
  • Liver function ALT and AST increase, alkaline
    phosphatase increase, LDH increase, serum albumin
  • Renal function uric acid 6 mg/dl, serum
    creatinine may be elevated

29
Clinical findings (5)
  • Laboratory findings (2)
  • Retinal check
  • Other tests ECG, placenta function, fetal
    maturity, cerebral angiography, etc

30
Differential diagnosis
  • Pregnancy complicated with chronic nephritis
  • Eclampsia should be distinguished from epilepsy,
    encephalitis, brain tumor, anomalies and rupture
    of cerebral vessel, hypoglycemia shock, diabetic
    hyperosmatic coma

31
Complications
  • Preterm delivery
  • Fetal risks acute and chronic uteroplacental
    insufficiency
  • Intrapartum fetal distress or stillbirth
  • IUGR
  • Oligohydramnios

32
Predictive evaluation (1)
  • Mean arterial pressure, MAP (sys. Bp 2 x Dia.
    Bp) /3
  • MAPgt 85 mmHg suggestive of eclampsia
  • MAP gt 140 mmHg high likelihood of seizure and
    maternal mortality and morbidity

33
Predictive evaluation (2)
  • Roll over test ROT
  • Preeclamptic patients are more sensitive to
    angiotensin II
  • Difference between Bp obtained at left recumbent
    position and supine position (at a 5 min
    interval)
  • Positive gt 20 mmHg
  • Urine calcium/ creatinine lt 0.04

34
Prevention
  • Calcium supplementation not effective in low
    risk women bur show effect in high risk group
  • Aspirin (antithrombotic) uncertain
  • Good prenatal care and regular visits
  • Baseline test for high-risk women
  • Eclampsia cannot always be prevented, it may
    occur suddenly and without warning.

35
Treatment
  • Mild preeclampsia bed rest delivery
  • Hospitalization or home regimen
  • Bed rest (position and why) and daily weighing
  • Daily urine dipstick measurements of proteinuria
  • Blood pressure monitoring
  • Fetal heart rate testing
  • Periodic 24-h urine collection
  • Ultrasound
  • Liver function, renal function, coagulation

36
A. Mild preeclampsia bed rest delivery
  • Observe for danger signals severe headache,
    epigastric pain, visual disturbances
  • Sedatives debatable

37
B. Severe preeclampsia
  • Prevention of convulsion magnesium sulfate or
    diazepam and phenytoin
  • Control of maternal blood pressure
    antihypertensive therapy
  • Initiation of delivery the definitive mode of
    therapy if severe preeclampsia develops at or gt
    36 wk or if there is evidence of fetal lung
    maturity or fetal jeopardy.

38
Magnesium sulfate
  • Decreases the amount of acetylcholine released at
    the neuromuscular junction
  • Blocks calcium entry into neurons
  • Vasodilates the smaller-diameter intracranial
    vessels

39
Magnesium sulfate
  • Prevent convulsion
  • Virtually ineffective on blood pressure
  • i.v. or i.m.
  • 5g loading dose 5-10 min, i.v.
  • 1-2g/hr constant infusion
  • Total dose 20-30 g/d

40
  • Toxicity
  • Diminished or loss of patellar reflex
  • Diminished respiration
  • Muscle paralysis
  • Blurred speech
  • Cardiac arrest

41
  • How to prevent toxicity?
  • Frequent evaluation of patellar reflex and
    respirations
  • Maintenance of urine output at gt25 ml/hr or 600
    ml/d
  • Reversal of toxicity
  • Slow i.v . 10 calcium gloconate
  • Oxygen supplementation
  • Cardiorespiratory support

42
Antihypertensive therapy reduce the Dia.
pressure to 90-110 mmHg
  • Indication
  • Bpgt 160/110 mmHg
  • Dia. Bp gt 110 mmHg
  • MAP gt 140 mmHg
  • Chronic hypertension with previous
    antihypertensive drugs usage

43
Antihypertensive therapy
  • Medications
  • Hydrolazine initial choice
  • Labetolol
  • Nifedipine
  • Nimoldipine
  • Methyldoe
  • Sodium nitroprusside

44
Mechanism of action
Effects
Medication
Direct peripheral vasodilation
CO, RBF maternal flushing, headache, tachycardia
hydralazine
CO, RBF maternal flushing, headache, neonatal
depressed respirations
a, b- adrenergic blocker
labetalol
CO, RBF maternal orthostatic hypotension Headache,
no neonatal effects
Calcium channel blocker
nifedipine
Direct peripheral arteriolar vasodilation
CO, RBF maternal flushing, headache, tachycardia
methyldopa
Metabolite (cyanide) toxic to fetus
sodium nitroprusside
Direct peripheral vasodilation
45
  • Plasma expander
  • Diuretics

46
Delivery
  • Indication of termination of pregnancy
  • Preeclampsia close to term
  • lt34 wk with decreased placental function
  • 2 hs after control of seizure

47
Delivery
  • Induction of labor
  • First stage close monitor, rest and sedation
  • Second stage shorten as much as possible
  • Third stage postpartum hemorrhage
  • Cesarean section
  • Induction of labor unsuccessful
  • Induction of labor not possible
  • Maternal or fetal status is worsening

48
Eclampsia
  • No aura preceding seizure
  • Multiple tonic-clonic seizures
  • Unconsciousness
  • Hyperventilation after seizure
  • Tongue biting, broken bones, head trauma and
    aspiration, pulmonary edema and retinal detachment

49
Management
  • Control of seizure
  • Control of hypertension
  • Delivery
  • Proper nursing care
About PowerShow.com