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Pregnancy Induced Hypertension

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Title: Pregnancy Induced Hypertension


1
Pregnancy Induced Hypertension
  • Prof. Duan Tao,M.D.
  • Shanghai 1st Maternity and Infant Hospital

2
Pregnancy Induced Hypertension
  • Definition
  • Toxemia
  • Gestosis
  • Preeclampsia-Eclampsia
  • Pregnancy Induced Hypertension
  • EPH Syndrome

3
Theories about causes
  • Still Unknown
  • Utero-placental ischemia
  • Neuro-endocrinologyPGI2/TXA2
  • Immunology-hereditary
  • Chronic DIC

4
Theory
  • Primipaternity
  • Robillard PY. Eur J Obstet Gynecol Reprod Biol,
    1999.
  • Dekker 392 multiparous PIH women , 22-25 have
    new partners, 3.4 in control group.

5
My Theory
  • Trigger off theory
  • The open Shield in Chicago
  • Lying In Hospital

6
Diagnosis
  • Hypertension of pregnancy
  • BP ? 140 / 90 mmHg ALONE
  • or WITH mild oedema (after 20wks of gestation)

7
Diagnosis
  • American Way
  • Preeclampsia
  • I) Mild preeclampsia
  • BP ? 140/90mmHg, but lt160/110mmHg,
  • Edema mild
  • Proteinuria Trace / 1

8
Diagnosis
  • II) Severe preeclampsia
  • BP ? 160/110 mmHg
  • Edema marked
  • Proteinuria 2 or more

9
Diagnosis
  • With headache,visual disturbances, abdominal
    pain, oliguria, thrombocytopenia, bilirubin,
    liver enzymes, creatinine, foetal growth
    retardation, pulmonary oedema
  • Eclampsia
  • Severe preeclamsia with CONVULSION

10
Diagnosis
  • Chinese way
  • Mild preeclampsia
  • BP ? 140/90mmHg, but lt150/100mmHg,
  • or with an elevation of 30/15 mmHg
  • Edema and/or
  • Proteinuria Trace

11
Diagnosis
Moderate preeclampsia BP ? 150/100mmHg, but
lt160/110mmHg, Edema and/or Proteinuria 1
12
Diagnosis
Severe preeclampsia BP ? 160/110mmHg Edema
and/or Proteinuria 24
13
Pathophysiology
  • Vasospasm haemorrage necrosis end organ
    changes
  • Reduced placental perfusion? IUGR foetal
    death
  • Increased cardiac output
  • Increased extra cellular fluid volume

14
Pathophysiology
  • Haemoconcentration
  • Hypercoagulability-DIC - reduced clotting factors
    - bleeding
  • Reduced GFR oligouria - anuria
  • No electrolytic imbalance

15
Pathophisiology
  • Serious Complications
  • Hellp syndrome
  • Abruptio placentae
  • Pulmonary oedema
  • Acute renal failure

16
Pathophysiology
  • Serious Complications
  • Cerebral haemorrhage
  • Visual disturbances blindness
  • Hepatic rupture
  • Electrolytic imbalance
  • Postpartum collapse

17
Differential Diagnosis
  • Chronic hypertension essential / renal / others
  • Mostly obese, elderly, parous likely to be on
    antihypertensive drugs
  • Usually preexists / appears early (lt20wks)
    persists postpartum
  • End organ damage maybe present

18
Differential Diagnosis
  • Diagnostic confusion
  • 10 of 24(42) women initially thought to have had
    eclampsia were later found to have had other
    cerebro-vascular pathology-hypertensive
    encephalopathy, cerebral hemorrhage, or cerebral
    infarction. Suspected eclampsia, unresponsive to
    Mgso4 therapy warrants a prompt neuroimaging
    study.
  • Am J Obstet Gynecol. 19971761139-1148

19
OBJECTIVES OF MANAGEMENT
  • Cure / prevent progression -
  • Close monitoring
  • Reduce blood pressure -tatrget- 140/90mmHg
  • Promote foetal maturity
  • Prolong pregnancy (34 - 36 weeks)
  • To achieve foetal maturity ? termination
  • Delivery- best day, best way best place
  • Prevent / manage complications

20
MATERNAL MONITORING
  • Look for appearance of ominous features
  • Daily- record b.P 4 times, monitor urine output
    test for proteinuria quali. / Quant
  • Alt.Day- body weight
  • Every 4th day- uric acid, platelet count, liver
    function
  • Weekly- creatinine

21
FOETAL MONITORING
  • Daily - clinical foetal monitoring - fhs, fundal
    ht. Abdominal girth, amniotic fluid, foetal
    movement count, C.T.G
  • Ultrasound - on admission then 3 weekly for
    foetal biophysical parameters, placenta and
    amniotic fluid volume
  • Dopller ultrasonography for placental blood flow
    velocity every 4th day
  • L/s ratio for maturity

22
Anticonvulsion
  • The history of MgSO4
  • Magnesium sulfate in the treatment of eclamptic
    convulsion
  • 1)It was first used to control tetanic
    convulsions in early 1900s. The modern obstetric
    use of Mgso4 was first popularized by Pritchard
    IM 10 g load, then 5g/4hrs (1955)

23
Anticonvulsion
  • 2)Zuspan recommended continuous intravenous
    infusion 4g load, then 1g/hr (1966)
  • ( This regimen was used in the United States
    before 1980s,and is currently used in Europe and
    South Africa, it was found to produce levels less
    than 4.8mg/dl in the majority of women treated).

24
Anticonvulsion
  • 3)Sibai modified IV infusion 6g load, then 2g/hr
    (1981)
  • 4)Pritchard recommended that the appropriate
    serum levels of Mgso4 for treatment of eclamptic
    convulsions were 3.5-7 Meq /L(or
    4.2-8.4mg/dl)(1979)

25
Anticonvulsion
  • 5)Magnesium level mg/dl 1.2x magnesium level
    Meq/L
  • 6)If the patients were treated according to the
    recommended regimen, 10 of the eclamptic
    seizures will recur

26
Anticonvulsion
  • The usage of MgSO4
  • 1)15-22.5g/d 1.5-2g/hr
  • 2)I.M.Vs I.V.
  • 3)I.V./day,I.M./night
  • 25 MgSO420ml2Lidocaine 2ml
  • 4)The effect of MgSO4BP/ Proteinuria /Edema
  • Attentionspatellar reflex /respiratory/ urine
    output

27
Anticonvulsion
  • Phenytoin (Europe way)
  • If contraindications of MgSO4 exist, use
    Phenytoin. Loading dose 15 mg/kg at 40 mg/min
    with continous monitorization of the cardiac
    function and BP every 5 minutes. The therapeutic
    range is 10-20 µg/ml.

28
Sedatives
  • Diazepam10mg IV
  • Pethedine100mg
  • Chloropramazine50mg

29
Antihypertensives
  • Apresolinea blocker/25mg5GS 500ml
  • CaptoprilACE II blocker,banned because of fetal
    damage.
  • NifedipineCalcium channel blocker , quick/short
    lasting, 10mg q6h.

30
Antihypertensives
  • Labetalolaandß blocker,
  • 50-100mg5GS 500ml
  • Nitroprusside sodiumVery potent, but with toxic
    effect.
  • 50mg5GS 500ml
  • Rigitinea-blocker,first choice for PIH patients
    with cardiac disease.
  • 10-40mg5GS 500ml

31
Caveats for antihypertensive therapy
  • 1)There is great individual variability in
    response to these drugs, and they do not lower
    blood pressure predictably, precisely, or
    smoothly.
  • 2)Lowering blood pressure too rapidly or
    excessively may produce fetal distress,
    particularly in the setting of IUGR or an
    abnormal fetal heart rate tracing.

32
Caveats for antihypertensive therapy
  • 3)Epidural anesthesia will lower the blood
    pressure approximately 15, frequently abrogating
    the need for antihypertensive medication.
  • 4)The gravida with chronic renal insufficiency
    has hypertension that is more difficult to
    control, in part due to volume expansion.

33
Caveats for antihypertensive therapy
  • 5) Severe hypertension without proteinuria should
    prompt a urine screen for cocaine.
  • 6)With prolonged unconsciousness, papilledema,
    lateralizing signs, seizures on magnesium
    sulfate, or seizures more than 48 hours after
    delivery, a CT scan should be performed to rule
    out intracranial hemorrhage.

34
Volume Expansion
  • Choice between crystalloid and colloid.
  • Diuresis
  • Furosemide10-20mg/iv
  • Mannitol20 250ml,within 15-20

35
Management of Eclampsia
  • Mafia Look
  • protocol for managing eclampsia
  • 1)Convulsions are controlled or prevented with a
    loading dose of 6 g Mgso4 in 100ml 5dextrose in
    Ringers lactated solution, given over 15
    minutes, followed by a maintenance dose of 2g/hr,
    the dose is adjusted according to patellar
    reflexes and urine output in the previous 4-hour
    period.

36
Management of Eclampsia
  • 2)Diuretics, plasma volume expanders, and
    invasive hemodynamic monitoring are not used.
  • 3)Induction and/or delivery is initiated within 4
    hours after maternal stabilization.

37
Management of Eclampsia
  • 4)Mgso4 is continued for 24 hrs after delivery
    or, if postpartum, 24 hrs after the last
    convulsion. In some cases, the infusion may be
    continued for longer.
  • Witlin and Sibai. Hypertensive diseases in
    pregnancy. In Medicine of the fetus and mother,
    2nd ed. Reece EA, Hobbins J (eds). Philadelphia,
    PA. Lippincott-Raven, 1998, 997-1020.

38
Hint
  • DAMMCALD
  • D Diazepam A Apresoline
  • M MgSO4 M Mannitol
  • C Chlorpremazine A Antibiotics
  • L Lasix D Digitalis

39
DELIVERY
TREATMENT
BEST DAY - WHEN ?
1 ) at 36 weeks - in all controlled cases 2 )
after 32 weeks - for foetal salvage Decreased
foetal movement Severe IUGR with
oligohydramnios Late deceleration with poor
variability Reversed umbilical diastolic blood
flow
40
DELIVERY
TREATMENT
BEST DAY - WHEN ?
3) any time - if progressive in spite of
treatment, when - Bp gt160 /100 mmHg Urine
output lt 400 ml / 24 hours Platelet count lt
50,000 / cmm Serum creatinine increases
progressively Ldh gt1000 iu / l
41
DELIVERY
TREATMENT
BEST WAY - HOW ?
1 ) Induction with oxytocin -after 36 weeks If
foetal condition is good Cervix is favourable /
cerviprime Application of forceps / ventouse
42
DELIVERY
TREATMENT
BEST WAY - HOW ?
2 ) By C-S If termination before 36 weeks In
cases of maternal / fotal jeopardy Anaesthesia -
general / epidural / spinal better left to
anaesthetist
43
DELIVERY
TREATMENT
Best place - where ? High-risk pregnancy unit /
tertiary hospital / well equipped hospital
44
POSTPARTUM
TREATMENT
1 ) PPH - be prepared to face it Uterine atony /
DIC - FDP/bleeding disorder Oxytocics / uterine
massage / packing / uterine artery ligation /
internal iliac artery ligation / hysterectomy
2 ) neonatal care - Presence of
paediatrician is a must Incubator is helpful
45
POSTPARTUM
TREATMENT
3 ) Drugs - Judicious use of
antihypertensives, iv fluids, diuretics,
diazepam in the first 48 hours
4) Follow up for 6 weeks
46
TORCH Syndrome
  • Why TORCH?
  • T Toxoplasma
  • O Others(Treponema pallidum,syphilis)
  • R Rubella Virus
  • C Cytomegalo Virus
  • H Herpes Simplex Virus

47
TORCH Syndrome
  • Characteristics
  • Mother---Minimal/Flu-like
  • Fetus---Fatal/malformatiom
  • Risk Population
  • Way of fetal Infection
  • 1.Intrauterine infection
  • 2.Birth canal infection
  • 3.Postpartum infection

48
TORCH Syndrome
  • Effect on the mother minimal
  • Effect on the fetus
  • 1. Toxoplasma
  • Abortion,fetal death,cranial
    malformation,neural dysfunction.
  • 2. Others(Treponema pallidum, syphilis)
  • Abortion,fetal death,congenital
  • syphilis

49
TORCH Syndrome
  • 3. Rubella Virus
  • Congenital rubella syndrome(CRS),
  • CRS triade cardiovascular malformation,
    congenital cataract, deaf.
  • 4. Cytomegalo Virus
  • Abortion,fetal death,neural and cardiovascular
    malformation.

50
TORCH Syndrome
  • 5. Herpes Simplex Virus
  • IUGR,cranial malformation,neonatal infection
  • Diagnosis
  • 1.History and Symptoms
  • 2.Lab Test antibodies/PCR

51
TORCH Syndrome
  • Management
  • 1.Therapeutic abortion
  • 2.Drugs
  • The existing problems

52
HELLP SYNDROME
  • What is HELLP?
  • H hemolysis
  • EL elevated liver enzyme
  • LP low platelet count
  • Severe complication of PIH

53
HELLP SYNDROME
  • Effect on the mother
  • Effect on the fetus
  • Clinical manifestation
  • Diagnosis and differential diagnosis
  • Management

54
Antiphospholipid Syndrome
  • Characteristics
  • 1. anticardiolipin antibody ()
  • lupus coagulant ()
  • 2.Symptoms like thrombosis, recurrent
    spontaneous abortion, thrombocytopenia

55
Antiphospholipid Syndrome
  • Clinical manifestation
  • Diagnosis
  • Management
  • 1.aspirin
  • 2.heparin
  • 3.steroids

56
Thank U !
  • Prof. Duan Tao, M.D.
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