1. OB Case Presentation
Mishell Kris Sorongon

2. Objectives To diagnose hypertension in pregnancy
To differentiate the classification of hypertension in pregnancy
To discuss the pathophysiology of hypertension in pregnancy
To apply appropriate management for the case

3. General Data M. M. G. 37 y/o Married G2P1 (1001) Filipino
Fairview Quezon City
SSS Specialist

4. Past Medical History (-) Diabetes Mellitus
(+) Hypertension (2008) – was started on Atenolol 20 mg once a day but stopped when she became pregnant. UBP 120/80 mmHg HBP 140/100 mmHg
(+) Bronchial asthma – last attack on July 2010 was given Prednisone 5 mg twice a day for 5 days
(-) Thyroid disorders
(-) known allergies to food and drugs

5. Family History (+) Diabetes Mellitus - mother
(+) Hypertension – Grandmother
(+) Asthma – aunt
(-) Heart disease
(-) Cancer

6. Personal and Social History
Non-smoker
Non-drinker of alcoholic beverages
Works in SSS

7. Menstrual History Menarche at 14 years of age
Regular monthly intervals
Duration of 5 days
3-4 pads per day
Dysmenorrhea on D1
LMP: January 17, 2010
PMP: December 2009

8. Obstetric History G2P1 (1001)
G1 (1999) 39 weeks AOG delivered 6.6 lbs male via LTCS due to breech in SLMC. No lengthened hospital stay
G2 Present pregnancy

9. Gyne History (-) OCP use (+) Papsmear (March, 2009) normal results
(+) sexually active
(-) vaginal bleeding
(-) vaginal discharge

10. Reason for Admission
Epigastric pain

11. LMP: January 17, 2010
EDC by LMP: October 24, 2010
G2P1 (1001) 30 1/7 weeks AOG

12. First Trimester
Second Trimester
Third Trimester
First prenatal check-up at 8 weeks AOG
Started taking multivitamins, iron, and calcium once a day
No maternal illness
URTI - given Cefalexin 500 mg three times a day for 7 days
Episode of vaginal spotting - given Duvadillan once a day for 20 days then as needed
OGCT showed normal results
UTI – Amoxicillin three times a day for 7 days.
Proteinuria +2
Repeat urinalysis not done

13. History of Present Illness
Epigastric pain, severe, burning in character, no radiation. No changes in bowel habits.
Sought consult with attending physician
Blood pressure :160/100 mmHg.
(-) watery or bloody vaginal discharge (+) good fetal movement
(+) bipedal edema
(-) headache or blurring of vision.
Patient claimed that urinalysis done last week showed proteinuria 2+
Few hours prior to admission

14. Review of Systems General: no weigbt loss, anorexia, fever
Skin: no skin changes
Eyes: no blurring of vision, redness, itchiness, discharge, pain
Nose: No discharge, epistaxis, anosmia
Mouth & Throat: No bleeding, circumoral cyanosis, hoarseness, soreness, difficulty of swallowing
Pulmonary: no difficulty of breathing, cough, hemoptysis, chest wall abnormalities
Heart: No palpitations, chest pain, chest heaviness
Abdomen: (+) epigastric pain, no constipation, diarrhea, hematochezia, melena, hearburn, belching
Genitourinary: no hematuria, frequency, urgency, flank pain
Vascular: no excessive bleeding, easy bruisability
Neurologic: no headache, seizure episode, one-sided weakness or numbness

15. Physical Examination
Conscious, coherent, not in cardiorespiratory distress, VAS 9/10
BP 140/100 mmHg
Cardiac rate 76 bpm
Respiratory rate 16 cpm
Temp: 37.2 C
Weight 66 kg
Height 155 cm
BMI: 27.5

16. Physical Examination
Moist skin, no active dermatosis, (+) linea nigra , (+) striae gravidarum
No facial involuntary movement, edema, masses
Pink palpebral conjunctivae, anicteric sclerae, patent external auditory canal, non-congested turbinates, no nasal discharge, supple neck, no lymphadenopathies, no palpable anterior neck mass
Symmetrical chest expansions, clear breath sounds in all lung fields, no retractions
Adynamic precordium, normal rate, regular rhythm, S1>S2 apex, S2>S1 base, PMI at 5th LICS, no murmurs

17. Globular abdomen
Fundic Height: 29 cm EFW 2635 gm
L1 breech
L2 maternal right
L3 not engaged
FHT 140s, RLQ
Pelvic exam: normal looking external genitalia
Internal exam: admits 2 fingers with ease, Cervix closed, uterus enlarged to age of gestation
SE: not done

18. Rectovaginal exam: not done
(+) Grade 2 bipedal edema, pulses full and equal
Conscious, coherent, oriented to 3 spheres
No sensorimotor deficits
Deep tendon reflexes of upper and lower extremities: ++

19. Admitting Diagnosis
37 year old G2P1 (1001) Pregnancy uterine 30 1/7 weeks AOG
chronic hypertensive vascular disease with superimposed preeclampsia, mild

20. Problem List Epigastric pain Bipedal edema BP: 140/100 mmHg
Hypertension
Pregnancy at 30 1/7 weeks AOG

21. Salient Features Subjective Objective
37 year old G2P1 (1001) 30 1/7 w AOG
Previous LTCS due to breech (1999)
Hypertensive since 2008 maintained on Atenolol OD but stopped since January
Epigastric pain, burning, nonradiating, severe
Elevated BP: 160/100 mmHg
No blurring of vision, headache, seizure episode
Bipedal edema
Conscious, coherent, not in cardio respiratory distress
BP: 140/100 mmHg HR: 76 bpm
Deep tendon reflexes intact
Globular abdomen, FHT 140s at RLQ
Cervix closed
Bipedal edema grade 2
No sensorimotor deficits
Deep tendon reflexes: ++

22. Laboratory Work-ups
CBC 13.2/38.5/4.12/10 700/N81L14E1M4/ MCV 94 MCH 32 MCHC 34

23. Urinalysis
Light yellow, hazy, glucose 100 mg/dl (2+), negative bilirubin, ketone 15 mg/dl (1+), specific gravity 1.015, pH 6.5 protein 100 mg/dl (2+), urobilinogen 0.2, nitrites negative, blood trace – intact, leukocytes moderate (2+)
RBC 3 WBC 29 Epithelial cells 11 casts 2 bacteria 15

24. Hypertension in Pregnancy
the most common medical problem encountered in pregnancy
WHO (2006) – 16% of maternal deaths in developed countries
remains an important cause of morbidity and mortality

25. Risk Factors Young age and nulliparity multiple pregnancy BMI > 35
African American ethnicity
Maternal age > 35 years old
History of chronic hypertension
Family history

26. Definition systolic BP (SBP) ≥ 140mmHg and/or
diastolic BP (DBP) ≥ 90mmHg
confirmed by readings over several hours apart

27. Categories of Hypertensive Diseases
Gestational Hypertension
Preeclampsia
Eclampsia
Preeclampsia superimposed on Chronic Hypertension
Chronic Hypertension

28. Gestational Hypertension
Describes any form of new-onset pregnancy-related hypertension – Transient Hypertension
BP ≥ 140/90 mm Hg for first time during pregnancy
No proteinuria
BP returns to normal < 12 weeks postpartum
Final diagnosis is made only postpartum
May have other signs or symptoms of preeclampsia (e.g. Epigastric discomfort, thrombocytopenia)

29. Preeclampsia gestational HPN with proteinuria Minimum Criteria:
BP ≥ 140/90 mm Hg after 20 weeks gestation
Proteinuria ≥ 300 mg/24 hours or ≥ 1+ dipstick
* edema is abandoned as a marker because it occurs in normal pregnant woman

30. Eclampsia
Preeclampsia complicated by generalized tonic clonic convulsions – cannot be attributed to other causes
One of the most dangerous conditions in pregnancy
Most common in the last trimester and becomes increasingly more frequent as term approaches
Prognosis is always serious

31. Superimposed Preeclampsia on Chronic Hypertension
New onset proteinuria > 300 mg/24 hours in hypertensive women but no proteinuria before 20 weeks’ gestation
Sudden increase in proteinuria/ Blood Pressure/ platelet count <100,000/mm3 before 20 wks AOG (on a chronic hypertensive patient)

32. Chronic Hypertension
detection prior to 20 weeks AOG and persistence beyond 12 weeks postpartum

33. Preeclampsia

34. Increased Certainty BP ≥ 160/110 mm Hg Proteinuria
Serum creatinine > 1.2mg/dl unless known to be previously elevated
Platelets < 100,000/mm3
increased LDH (Microangiopathic hemolysis)
Elevated ALT or AST
Persistent headache or other cerebral or visual disturbance
Persistent epigastric pain

35. Indications on Severity of Preeclampsia
Abnormality
Mild
Severe
Diastolic BP
<100 mmHg
> 110 mmHg
Proteinuria
Traces to +1
Persistent > +2
Headache
Absent
Present
Visual disturbance
RUQ pain
Oliguria
Convulsion
Serum Creatinine
Normal
Elevated
Thrombocytopenia <100, 000
Liver enzyme elevation
Minimal
Marked
Fetal growth restriction
Obvious
Pulmonary Edema

36. Abnormal Placentation in Preeclampsia
Pseudovasculogenesis
Cytotrophoblasts fail to adopt an invasive endothelial phenotype
Invasion of the spiral arteries is shallow – remains small caliber, resistance vessels
Placental Ischemia

37. Pathophysiology

38. Normotensive gravidas
Decreased pressor responsiveness to several vasoactive peptides and amines, esp Angiotensin II
Preeclampsia
Hyperresponsiveness to angiotensin II and endothelin

39. Basic Management Guidelines
Termination of pregnancy with least possible trauma to the mother and the fetus
Birth of an infant who subsequently thrives
Complete restoration of the health to the
mother

40. Preeclampsia Management
Goal of Management: early identification of worsening preeclampsia and development of a management scheme that includes a plan for timely delivery
Hospitalization
Evaluate:
maternal weight and maternal status
BP monitoring q4
creatinine, hematocrit, platelet count, Liver transaminases
Urinalysis every 2 days
Fetal BPS, doppler velocimetry

41. Termination of Pregnancy
Headache, visual disturbances, epigastric pain or oliguria are indicative that convulsions may be imminent
Delivery is usually advisable for severe preeclampsia that does not improve after hospitalization
Labor should be induced by intravenous oxytocin
Cesarian delivery is indicated for cases of failed induction

42. Some Indications for Delivery in Early-Onset Severe Preeclampsia
Maternal
Persistent severe headache or visual changes; eclampsia
Shortness of breath; chest tightness with rales and/or SaO2 < 94 percent breathing room air; pulmonary edema
Uncontrolled severe hypertension despite treatment
Oliguria < 500 mL/24 hr or serum creatinine 1.5 mg/dL
Persistent platelet counts < 100,000/L
Suspected abruption, progressive labor, and/or ruptured membranes

43. Fetal
Severe growth restriction—< 5th percentile for EGA
Persistent severe oligohydramnios—AFI < 5 cm
Biophysical profile 4 done 6 hr apart
Reversed end-diastolic umbilical artery flow
Fetal death

44. Effects of Expectant Management for Severe preeclampsia
Maternal: placental abruption (20%), HELLP syndrome, pulmonary edema (4%), renal failure, and eclampsia
Perinatal mortality rates averaged from 39 to 133 per Fetal-growth restriction and perinatal mortality
Risks for eclampsia, cerebrovascular hemorrhage, and maternal death.

45. Intrapartum Management
Magnesium SO4 - used to arrest and prevent convulsions w/o producing generalized CNS depression
Loading dose: 4 gms IV, 10 gms IM
Maintenance dose: 5 gms q 4 hrs
Therapeutic level: 4-7 mEq/L
Loss of patellar reflex: 8-10mEq/L
Respiratory depression: 10mEq/L
Respiratory arrest: 12 mEq/L
Treatment MgSO4 toxicity:
calcium gluconate, 1 gm IV, Oxygenation

46. MOA: Anti-convulsant Acts by:
1. Neuronal calcium-channel blockade through N methyl- d-aspartate receptors
2. Reversal of cerebral arterial vasoconstriction distal to the middle cerebral arteries
3. Release of endothelial prostacyclin and inhibition of platelet clumping

47. Intermittent intramural injections
Every 4 hours thereafter, give 5 g of a 50% solution of magnesium sulfate injected deeply in the upper outer quadrant of alternate buttocks, but only after ensuring that
a. the patellar reflex is present
b. respirations are not depressed
c. urine output the previous 4 hours exceeded 100ml
Magnesium sulfate is discontinued 24 hours after delivery

48. Anti-hypertensive Therapy
Hydralazine - Causes direct relaxation of arteriolar
vascular smooth muscle
Drug of choice for rapid control of acute hypertension
5 mg initial dose, 5-10 mg q m IV until there’s satisfactory response (DBP mmHg)
Side-effects: palpitations, tachycardia, headaches, flushing

49. a1- and nonselective -blocker.
Labetalol
a1- and nonselective -blocker.
fewer side effects (maternal hypotension and bradycardia)
Initial: 10 mg IV q10 – 20 mg, then 40 mg, 40 mg, 80 mg
maximum dose of 220 mg per treatment cycle
Nifedipine - 10 mg PO q30 min.
third line drug that acts by limiting calcium channel causing relaxation of smooth muscle

50. Prophylaxis Aspirin, 60-80 mg OD
suppression of thromboxane synthesis by platelets and promoting prostacyclin production
Antioxidants
significantly reduces endothelical cell activation

51. Thank you!

52. Fetal Monitoring in Gestational Hypertension and Preeclampsia
(hypertension only without proteinuria, with normal laboratory results, and without symptoms)
Estimation of fetal growth and amniotic fluid status should be performed at diagnosis. If results are normal, repeat testing only if there is significant change in maternal condition
Nonstress test (NST) should be performed at diagnosis. If NST is nonreactive, perform biophysical profile (BPP). If BPP value is eight or if NST is reactive, repeat testing only if there is significant change in maternal condition

53. Anti-hypertensive Therapy
1. Methyldopa - First line anti-hypertensive agent
MOA: stimulation of central alpha-adrenergic receptors by a false transmitter that results in a decreased sympathetic outflow to the organ systems.
mg tab Q6
Lowers BP by reducing sympathetic outflow from brainstem
Suited for long-term use

54. Patient admitted to HRPU
D5LR 1 liter to run for 8 hours
Demerol 50 mg IV now
Hydralazine 4 mg IV stat
Magnesium sulfate 5 mg IM buttocks