1. Teresa G. Berg, M.D. Maternal-Fetal Medicine University Medical Associates M3 Lecture Materials

2.  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

3.  Sustained BP elevation of 140/90 or greater  Proper cuff size  Measurement taken while seated  Arm at the level of the heart  Use 5 th Korotkoff sound

4.  Chronic Hypertension  Gestational Hypertension  Preeclampsia  Eclampsia  HEELP Syndrome

5.  Chronic Hypertension ◦ Diagnosed before the 20 th week or present before the pregnancy ◦ Mild hypertension  > 140-180 mmHg systolic  > 90-100 mmHg diastolic  Gestational Hypertension  Preeclampsia  Eclampsia  HEELP Syndrome

6.  Chronic 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  Preeclampsia  Eclampsia  HEELP Syndrome

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8.  Chronic Hypertension  Gestational 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  Eclampsia  HEELP Syndrome

9. Criteria for Preeclampsia Criteria for Severe Preclampsia  Previously normotensive woman  > 140 mmHg systolic  > 90 mmHg diastolic  Proteinuria > 300 mg in 24 hour collection  Nondependent 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, scotomata)  Pulmonary edema or cyanosis  Epigastric or RUQ pain  Evidence of hepatic dysfunction  Thrombocytopenia  Intrauterine growth restriciton (IUGR)

10.  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

11. FACTORRISK RATIO Nulliparity3:1 Age > 403:1 African American1.5:1 Chronic hypertension10:1 Renal disease20:1 Antiphospholipid syndrome10:1

12.  Chronic Hypertension  Gestational Hypertension  Preeclampsia  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 Syndrome

13.  Chronic Hypertension  Gestational Hypertension  Preeclampsia  Eclampsia  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

14.  Hypertension affects 12 to 22% of pregnant patients  Hypertensive disease is directly responsible for approximately 20% of maternal mortality in the United State

15.  Vasospasm  Uterine vessels  Hemostasis  Prostanoid balance  Endothelium-derived factors  Lipid peroxide, free radicals and antioxidants

16.  Vasospasm ◦ Predominant finding in gestational hypertension and preeclampsia  Uterine vessels  Hemostasis  Prostanoid balance  Endothelium-derived factors  Lipid peroxide, free radicals and antioxidants

17.  Vasospasm  Uterine vessels ◦ Inadequate maternal vascular response to trophoblastic mediated vascular changes ◦ Endothelial damage  Hemostasis  Prostanoid balance  Endothelium-derived factors  Lipid peroxide, free radicals and antioxidants

18.  Vasospasm  Uterine vessels  Hemostasis ◦ Increase platelet activation resulting in consumption ◦ Increased endothelial fibronectin levels ◦ Decreased antithrombin III and α 2 -antiplasmin levels ◦ Allows for microthrombi development with resultant increase in endothelial damage  Prostanoid balance  Endothelium-derived factors  Lipid peroxide, free radicals and antioxidants

19.  Vasospasm  Uterine vessels  Hemostasis  Prostanoid balance ◦ Prostacyclin (PGI 2 ):Thromboxane (TXA 2 ) balance shifted to favor TXA2 ◦ TXA2 promotes:  Vasoconstriction  Platelet aggregation  Endothelium-derived factors  Lipid peroxide, free radicals and antioxidants

20.  Vasospasm  Uterine vessels  Hemostasis  Prostanoid 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 antioxidants

21.  Vasospasm  Uterine vessels  Hemostasis  Prostanoid balance  Endothelium-derived factors  Lipid peroxide, free radicals and antioxidants ◦ Increased in preeclampsia ◦ Have been implicated in vascular injury

22.  Cardiovascular effects  Hematologic effects  Neurologic effects  Pulmonary effects  Renal effects  Fetal effects

23.  Cardiovascular effects ◦ Hypertension ◦ Increased cardiac output ◦ Increased systemic vascular resistance  Hematologic effects  Neurologic effects  Pulmonary effects  Renal effects  Fetal effects

24.  Cardiovascular effects  Hematologic effects ◦ Volume contraction/Hypovolemia ◦ Elevated hematocrit ◦ Thrombocytopeniz ◦ Microangiopathic hemolytic anemia ◦ Third spacing of fluid ◦ Low oncotic pressure  Neurologic effects  Pulmonary effects  Renal effects  Fetal effects

25.  Cardiovascular effects  Hematologic effects  Neurologic effects ◦ Hyperreflexia ◦ Headache ◦ Cerebral edema ◦ Seizures  Pulmonary effects  Renal effects  Fetal effects

26.  Cardiovascular effects  Hematologic effects  Neurologic effects  Pulmonary effects ◦ Capillary leak ◦ Reduced colloid osmotic pressure ◦ Pulmonary edema  Renal effects  Fetal effects

27.  Cardiovascular effects  Hematologic effects  Neurologic effects  Pulmonary effects  Renal effects ◦ Decreased glomerular filtration rate ◦ Glomerular endotheliosis ◦ Proteinuria ◦ Oliguria ◦ Acute tubular necrosis  Fetal effects

28.  Decreased glomerular filtration rate  Glomerular endotheliosis  Proteinuria  Oliguria  Acute tubular necrosis

29.  Cardiovascular effects  Hematologic effects  Neurologic effects  Pulmonary effects  Renal effects  Fetal effects ◦ Placental abruption ◦ Fetal growth restriction ◦ Oligohydramnios ◦ Fetal distress ◦ Increased perinatal morbidity and mortality

30.  The ultimate cure is delivery  Assess gestational age  Assess cervix  Fetal well-being  Laboratory assessment  Rule out severe disease!!

31.  Delivery is always a reasonable option if term  If cervix is unfavorable and maternal disease is mild, expectant management with close observation is possible

32.  Rule out severe disease  Conservative management  Serial labs  Twice weekly visits  Antenatal fetal surveillance  Outpatient versus inpatient

33.  Worsening BP  Nonreassuring fetal condition  Development of severe PIH  Fetal lung maturity  Favorable cervix

34.  No contraindication to prostaglandin agents  If < 32 weeks, consider cesarean  When favorable, oxytocin

35.  Fetal monitoring  IV access  IV hydration  The reason to treat is maternal, not fetal  May require ICU

36.  Diastolic BP > 105-110  Systolic BP > 200  Avoid rapid reduction in BP  Do not attempt to normalize BP  Goal is DBP < 105 not < 90  May precipitate fetal distress

37.  Crises are associated with hypovolemia  Clinical assessment of hydration is inaccurate  Unprotected vascular beds are at risk, eg, uterine

38.  250-500 cc of fluid, IV  Avoid multiple doses in rapid succession  Allow time for drug to work  Maintain LLD position  Avoid over treatment

39.  Hydralazine  Labetalol  Nifedipine  Nitroprusside  Diazoxide  Clonidine

40.  Dose: 5-10 mg every 20 minutes  Onset: 10-20 minutes  Duration: 3-8 hours  Side effects: headache, flushing, tachycardia, lupus like symptoms  Mechanism: peripheral vasodilator

41.  Dose: 20mg, then 40, then 80 every 20 minutes, for a total of 220mg  Onset: 1-2 minutes  Duration: 6-16 hours  Side effects: hypotension  Mechanism: Alpha and Beta block

42.  Dose: 10 mg po, not sublingual  Onset: 5-10 minutes  Duration: 4-8 hours  Side effects: chest pain, headache, tachycardia  Mechanism: CA channel block

43.  Dose: 1 mg po  Onset: 10-20 minutes  Duration: 4-6 hours  Side effects: unpredictable, avoid rapid withdrawal  Mechanism: Alpha agonist, works centrally

44.  Dose: 0.2 – 0.8 mg/min IV  Onset: 1-2 minutes  Duration: 3-5 minutes  Side effects: cyanide accumulation, hypotension  Mechanism: direct vasodilator

45.  Magnesium sulfate  4-6 g bolus  1-2 g/hour  Monitor urine output and DTR’s  With renal dysfunction, may require a lower dose

46.  Is not a hypotensive agent  Works as a centrally acting anticonvulsant  Also blocks neuromuscular conduction  Serum levels: 6-8 mg/dL

47.  Respiratory rate < 12  DTR’s not detectable  Altered sensorium  Urine output < 25-30 cc/hour  Antidote: 10 ml of 10% solution of calcium gluconate 1 v over 3 minutes

48.  Few people die of seizures  Protect patient  Avoid insertion of airways and padded tongue blades  IV access  MGSO4 4-6 bolus, if not effective, give another 2 g

50.  Have not been shown to be as efficacious as magnesium sulfate and may result in sedation that makes evaluation of the patient more difficult ◦ Diazepam 5-10 mg IV ◦ Sodium Amytal 100 mg IV ◦ Pentobarbital 125 mg IV ◦ Dilantin 500-1000 mg IV infusion

51.  Assess maternal labs  Fetal well-being  Effect delivery  Transport when indicated  No need for immediate cesarean delivery

52.  Pulmonary edema  Oliguria  Persistent hypertension  DIC

53.  Fluid overload  Reduced colloid osmotic pressure  Occurs more commonly following delivery as colloid oncotic pressure drops further and fluid is mobilized

54.  Avoid over-hydration  Restrict fluids  Lasix 10-20 mg IV  Usually no need for albumin or Hetastarch (Hespan)

55.  25-30 cc per hour is acceptable  If less, small fluid boluses of 250-500 cc as needed  Lasix is not necessary  Postpartum diuresis is common  Persistent oliguria almost never requires a PA cath

56.  BP may remain elevated for several days  Diastolic BP less than 100 do not require treatment  By definition, preeclampsia resolves by 6 weeks

57.  Rarely occurs without abruption  Low platelets is not DIC  Requires replacement blood products and delivery

58.  Continuous lumbar epidural is preferred if platelets normal  Need adequate pre-hydration of 1000 cc  Level should always be advanced slowly to avoid low BP  Avoid spinal with severe disease

59.  He-hemolysis  EL-elevated liver enzymes  LP-low platelets

60.  Is a variant of severe preeclampsia  Platelets < 100,000  LFT’s - 2 x normal  May occur against a background of what appears to be mild disease

61.  Controversial  Steroids  Requires tertiary care  Must have stable labs and reassuring fetal status  May use antihypertensives

62.  Low dose ASA ineffective in patients at low risk  Calcium supplementation is ineffective (2.0 g of calcium gluconate per day)  No compelling evidence that either are harmful  Recent study done with antioxidant (1,000mg VitC and 400mg VitE). ◦ Small study that needs to be confirmed.

63.  Criteria for diagnosis  Laboratory and fetal assessment  Magnesium sulfate seizure prophylaxis  Timing and place of delivery