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PIH(Pregnancy-induced-hypertension)

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Title: PIH(Pregnancy-induced-hypertension)


1
PIH(Pregnancy-induced-hypertension)
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  • ??. ?????? ????????
  • 17 ???????? 2546
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2
?????????
  • Common and form one of the deadly triad
    (hemorrhage,infection)
  • most common medical risk factor (Ventura and
    colleagues,2000, National Center for Health
    Statistics)
  • 18 of maternal deaths in USA(1987-1990) were
    from complication of PIH

3
Terminology
  • Any new-onset pregnancy-related hypertension
  • include hypertension without proteinuria
  • potential precursor to preeclampsia or eclampsia
  • most hypertensive nulliparous women had only
    transient uncomplicated hypertension that
    subsided promptly after delivery

4
Diagnosis
  • Gestational hypertension ( PIH
    or transient hypertension )
  • Preeclampsia
  • Eclampsia
  • Preeclampsia superimposed on chronic hypertension
  • Chronic hypertension

5
Gestational hypertension (PIH or transient
hypertension)
  • BP gt/ 140/90 mmHg for first time during
    pregnancy
  • No proteinuria
  • BP return to normal lt 12 weeks postpartum
  • Final diagnosis made only postpartum
  • May have other signs of preeclampsia, for
    example, epigastric discomfort or
    thrombocytopenia

6
Transient hypertension
  • preeclampsia does not develop and BP has turned
    to normal by 12 weeks postpartum

7
Preeclampsia
  • Minimal criteria
  • 1.BP gt/ 140/90 mmHg after 20 weeks gestation
  • 2.Proteinuria gt/ 300 mg/24 hours or gt/ 1
    dipstick

8
  • Increased certainty of preeclampsia
  • BP gt/ 160/110mmHg
  • Proteinuria 2.0 g/24 hours or gt/ 2 dipstick
  • Serum creatinine gt 1.2 mg/dL unless known to be
    previously elevated
  • Platelets lt 100,000/mm3
  • Microangiopathic hemolysis (increased LDH)
  • Elevated ALT or AST
  • Persistent headache or other cerebral or visual
    disturbance
  • Persistent epigastric pain

9
Severity of preeclampsia
  • Severe
  • gt/ 110 mmHg
  • gt/ 2
  • present
  • present
  • present
  • present
  • present(eclampsia)
  • Mild
  • DBP lt 100 mmHg
  • proteinuria trace to 1
  • headache absent
  • visual disturbance absent
  • upper abdominal pain absent
  • oliguria absent
  • convulsion absent

10
Severity of preeclampsia(2)
  • Severe
  • elevated
  • present
  • marked
  • obvious
  • present
  • Mild
  • Serum creatinine normal
  • thrombocytopenia absent
  • liver enzyme elevation minimal
  • fetal growth restriction absent
  • pulmonary edema absent

11
Eclampsia
  • Preeclampsia that is complicated by generalized
    tonic-clonic convulsions
  • fatal coma without convulsions
  • All pregnant women with convulsions should be
    considered to have eclampsia
  • Most common in the last trimester
  • increasingly more frequent as term approaches

12
Eclampsia (2)
  • Seizures may appear before, during or after labor
  • Seizures that develop more than 48 hours
    postpartum may be encountered up to 10 days
    postpartum
  • the convulsive movements
    ---gt facial twitchings
    ---gt
    generalized muscular contraction
    ---gt jaws open and close violently
    ---gt all muscles alternately
    contract and relax ---gt lies motionless

13
Complication of eclampsia
  • respiratory arrest, coma, hypoxemia ---gt lactic
    acidosis
  • fever from CNS hemorrhage
  • fetal bradycardia (usually recovers 3 - 5 min, if
    gt 10 min ---gtplacental abruption must be
    considered

14
Complication (2)
  • pulmonary edema aspiration pneumonitis, cardiac
    failure
  • blindness retinal detachment, occipital lobe
    ischemia, infarction, edema (prognosis is good
    and usually complete return to normal lt 1 wk)
  • psychosis usually lasts for lt 2 wk

15
Superimposed Preeclampsia ( on chronic
hypertension )
  • New-onset proteinuria gt/ 300 mg/24 hours in
    hypertensive women but no proteinuria before 20
    weeks gestation
  • A sudden increase in proteinuria or blood
    pressure or platelet count lt 100,000/mm3 in women
    with hypertension and proteinuria before 20
    weeks gestation

16
Chronic hypertension
  • BP gt/ 140/90 mmHg before pregnancy or diagnosed
    before 20 weeks gestation or
  • Hypertension first diagnosed after 20 weeks
    gestation and persistent after 12 weeks
    postpartum

17
Underlying chronic hypertension
  • Essential familial hypertension
  • arterial abnormalities
  • renovascular hypertension
  • coarctation of aorta
  • endocrine disorders
  • diabetes
  • cushing syndrome
  • primary aldosteronism
  • pheochromocytoma
  • thyrotoxicosis

18
  • Glomerulonephritis (acute and chronic)
  • renoprival hypertension
  • chronic glomerulonephritis
  • chronic renal insufficiency
  • diabetic nephropathy
  • polycystic kidney disease
  • acute renal failure
  • obesity
  • connective-tissue diseases
  • lupus erythematosus
  • scleroderma
  • periarteritis nodosa

19
Risk factor
  • Multiple pregnancy
  • Familial history of PIH
  • DM
  • Antiphospholipid syndrome
  • History of chronic hypertension
  • Maternal age gt 35 year
  • Obesity
  • African-American ethnicity(Conde - Agudelao and
    Beligan,2000Sibai and colleagues,1997Walker,2000
    )

20
  • Smoking during pregnancy has been associated with
    a reduced risk of hypertension during pregnancy(
    Zhang and colleagues, 1999)
  • Placenta previa has also been claimed to reduce
    risk of hypertensive disorders due to
    pregnancy(Ananth and colleagues, 1997 )

21
Pathogenesis
  • Risk factors

Vasospasm platelet aggregation microangiopathy
regional bl. flow
PGI2 TXA2, vasoconstrictor
22
Pathology
  • Cardiovascular changes
  • Hypovolemia
  • - from vasospasm and
    increased vascular permeability
  • ---gt hemoconcentration
  • ---gt edema
  • Coagulation
  • - thrombocytopenia
  • - microthrombi ---gt DIC
  • - decreased antithrombin III ---gt prolong PT
  • -microangiopathy ---gt fragmentation hemolysis

23
Pathology (2)
  • Fluid and electrolyte changes
  • HCO3 is lowered following an eclamptic
    convulsion
  • Kidney
  • Decreased GFR
  • ---gt oliguria
  • ---gt renal failure
  • ---gt uric acid, creatinine is elevated
  • Glomerulopathy
  • ---gt proteinuria
  • Increased tubular reabsorption
  • ---gt increased serum calcium

24
Pathology(3)
  • Liver elevated liver enzyme in severe case
  • subcapsular hematoma
  • Brain infarction, hemorrhage, cerebral edema
    ---gt headache, visual disturbance, convulsion
  • EEG ---gtnonspecific change
  • Placenta decreased blood flow
  • ---gt IUGR, fetal distress
  • Lung pulmonary edema

25
HELLP Syndrome
  • Hemolysis
  • Elevated liver enzymes
  • Low Platelet

26
Prediction
  • Angiotensin sensitivity test angiotensin II
    infusion
  • roll over test
  • uric acid
  • Ca metabolism
  • fibronectin
  • urinary kallikrein excretion
  • coagulation activator
  • marker of oxidative stress
  • immunological factors
  • placental peptides
  • doppler velocimetry of the uterine arteries

27
Prevention
  • Early prenatal detection
  • 1 -28 wk., ANC every 4 wk.
  • 28 - 36 wk., ANC every 2 wk.
  • gt 36 wk., ANC every 1 wk.
  • Dietary manipulation
  • salt restriction, high calcium, fish oil
  • Low dose aspirin
  • suppression of thromboxane synthesis
  • Antioxidant control lipid peroxidation --/--gt
    endothelial cell dysfunction

28
Management
  • Objective
  • termination of pregnancy with the least possible
    trauma to mother and fetus
  • birth of an infant who subsequently thrives
  • complete restoration of health to the mother

29
Hospital management
  • Detailed examination
  • BW. OD
  • Urine protein on admittance
    and at least every 2 days thereafter
  • BP every 4 hours, except between midnight and
    morning
  • Plasma creatinine, Hct., platelet count, liver
    enzymes
  • Frequent evaluation of fetal size and amniotic
    fluid volume either clinlcally or with sonography

30
Hospital management(2)
  • Reduce physical activity is beneficial (absolute
    bed rest is not necessary, sedatives and
    transquilizers are not prescribed)
  • protein and calories should be included in the
    diet
  • sodium and fluid intake should not be limited or
    forced
  • further management depends upon
  • 1. Severity of preeclampsia
  • 2. Duration of gestation
  • 3. Condition of the cervix

31
Specific treatment
  • Prevent convulsion
  • control BP
  • termination of pregnancy

32
Prevent convulsion
  • MgSO4 therapy is superior to phenytoin in
    preventing eclamptic seizures
  • Hallak and associates (1999) ---gt maternal
    seizures were associated with fetal brain injury
    due to maternal hypoxia during the convulsion

33
MgSO4 dosage schedule
  • Continuous intravenous infusion
  • 1. MgSO4 4 - 6 g. 100 mL of IV fluid IV drip in
    15 - 20 min.
  • 2. Begin 2 g/h in 100 mL of IV maintenance
    infusion
  • 3. Serum Mg level at 4 - 6 h, keep levels between
    4 -7 mEq/L
  • 4. MgSO4 is discontinued 24 h after delivery

34
  • Intermittent intramuscular injections
  • 1. 20MgSO4 4 g IV push (rate lt 1 g/min)
  • 2. 50 MgSO4 10 g IM at buttock
  • (??????5 g1.0 mL of 2lidocaine )
  • If convulsions persist after 15 min,
  • --- 20 MgSO4 2-4 g IV push (rate lt 1 g/min)
  • 3. 50 MgSO4 5 g IM alternate buttock q 4 hr.
  • but only after assuring that
  • a. the patellar reflex is present
  • b. respirations are not depressed
  • c. urine output gt/ 100 ml /4 hr.
  • 4. MgSO4 is discontinued 24 h after delivery

35
Antihypertensive drug therapy
  • Sibai and associates (1987) ---gtgrowth-restricted
    infants were twice as frequent in patient given
    labetalol compared with those treated by
    hospitalization alone
  • Von Dadelszen and associates (2000) ---gttreatment
    - induced decreases in maternal BP may adversely
    affect fetal growth

36
Antihypertensive drug therapy (2)
  • Easterling and colleagues (1999) ---gt women at
    risk for preeclampsia ( high cardiac output
    measured by doppler technique at 24 wk) were
    randomized to prophylactic atenolol or placebo,
    the incidence of preeclampsia in control group
    atenolol group 18 4
  • the use of ACEI during second and third
    trimesters should be avoided
  • diuretics should not be used

37
Hydralazine
  • SBP gt/ 160 mmHg and/or DBP gt 105 mmHg (National
    High Blood Pressure Education Program, 2000 )
  • 5 mg IV as the initial dose
  • 5 - 10 mg IV q 15 - 20 min. until a
    satisfactory response is achieved
  • Satisfactory response DBP 90 - 100 mmHg

38
Labetalol
  • Lower BP more rapidly, and associates tachycardia
    was minimal, but hydralazine lowered MAP to save
    levels more effectively
  • The Working Group(2000) recommends 20 mg IV
    bolus.
  • If not effective within 10 min, this is followed
    by 40 mg, then 80 mg every 10 min but not to
    exceed a 220 mg total dose

39
Termination of pregnancy
  • Severe preeclampsia
  • Near term

40
Post-partum
  • Physiologic diuresis 12 -72 h postpartum
  • proteinuria and edema disappear lt 1 wk
  • BP returns to normal within a few days to 2 weeks
  • Gestational hypertension must resolve within 12
    weeks

41
Counseling for future pregnancies
  • Women who had preeclampsia are more prone to
    hypertensive complications in future pregnancies
  • The earlier diagnosis, the greater recurrence
  • Multiparous are at increased risk compared with
    nulliparas

42
Counseling (2)
  • Women with early-onset severe PIH may be at risk
    for underlying thrombophilias (factor V Leiden,
    protein S and C deficiency, antiphospholipid
    antibodies)
  • Preeclampsia does not cause chronic hypertension

43
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