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OB Case Presentation Mishell Kris Sorongon
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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
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General Data M. M. G. 37 y/o Married G2P1 (1001) Filipino
Fairview Quezon City SSS Specialist
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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
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Family History (+) Diabetes Mellitus - mother
(+) Hypertension – Grandmother (+) Asthma – aunt (-) Heart disease (-) Cancer
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Personal and Social History
Non-smoker Non-drinker of alcoholic beverages Works in SSS
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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
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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
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Gyne History (-) OCP use (+) Papsmear (March, 2009) normal results
(+) sexually active (-) vaginal bleeding (-) vaginal discharge
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Reason for Admission Epigastric pain
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LMP: January 17, 2010 EDC by LMP: October 24, 2010 G2P1 (1001) 30 1/7 weeks AOG
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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
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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
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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
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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
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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
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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
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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: ++
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Admitting Diagnosis 37 year old G2P1 (1001) Pregnancy uterine 30 1/7 weeks AOG chronic hypertensive vascular disease with superimposed preeclampsia, mild
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Problem List Epigastric pain Bipedal edema BP: 140/100 mmHg
Hypertension Pregnancy at 30 1/7 weeks AOG
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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: ++
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Laboratory Work-ups CBC 13.2/38.5/4.12/10 700/N81L14E1M4/ MCV 94 MCH 32 MCHC 34
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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
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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
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Risk Factors Young age and nulliparity multiple pregnancy BMI > 35
African American ethnicity Maternal age > 35 years old History of chronic hypertension Family history
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Definition systolic BP (SBP) ≥ 140mmHg and/or
diastolic BP (DBP) ≥ 90mmHg confirmed by readings over several hours apart
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Categories of Hypertensive Diseases
Gestational Hypertension Preeclampsia Eclampsia Preeclampsia superimposed on Chronic Hypertension Chronic Hypertension
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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)
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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
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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
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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)
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Chronic Hypertension detection prior to 20 weeks AOG and persistence beyond 12 weeks postpartum
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Preeclampsia
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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
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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
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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
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Pathophysiology
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Normotensive gravidas
Decreased pressor responsiveness to several vasoactive peptides and amines, esp Angiotensin II Preeclampsia Hyperresponsiveness to angiotensin II and endothelin
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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Prophylaxis Aspirin, 60-80 mg OD
suppression of thromboxane synthesis by platelets and promoting prostacyclin production Antioxidants significantly reduces endothelical cell activation
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Thank you!
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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
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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
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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
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