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Hypertension in Pregnancy. OBJECTIVES List criteria for the diagnosis of preeclampsia List criteria for the diagnosis of severe preeclampsia/HELLP syndrome.

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Presentation on theme: "Hypertension in Pregnancy. OBJECTIVES List criteria for the diagnosis of preeclampsia List criteria for the diagnosis of severe preeclampsia/HELLP syndrome."— Presentation transcript:

1 Hypertension in Pregnancy

2 OBJECTIVES List criteria for the diagnosis of preeclampsia List criteria for the diagnosis of severe preeclampsia/HELLP syndrome Discuss current management considerations

3 Hypertension Sustained BP elevation of 140/90 or greater Proper cuff size Measurement taken while seated Use 5 th Korotkoff sound

4 Forms of HTN in Pregnancy Gestational Hypertension Formerly called Pregnancy-Induced Hypertension No proteinuria

5 Forms of HTN in Pregnancy Gestational Hypertension Preeclampsia Hypertension with proteinuria May have other evidence of end-organ disease Edema Visual changes Headache Epigastric pain Laboratory changes

6 Older Criteria for Gestational HTN 30/15 increase in BP over baseline levels No longer appropriate 73% of patients will exceed 30 mm systolic and 57% will exceed 20 mm diastolic

7 Patient Categories 25%

8 Forms of HTN in Pregnancy Gestational Hypertension Preeclampsia Chronic Hypertension As a group these occur in 12 to 22% of pregnant patients and are directly responsible for approximately 18% of maternal mortality nationally.

9 Chronic Hypertension Pre-existing hypertension Hypertension before 20 weeks in the absence of gestation If hypertension persists beyond 6 weeks postpartum

10 Preeclampsia Hypertension after 20 weeks of gestation Proteinuria- 300mg Edema

11 Preeclampsia Hypertension after 20 weeks of gestation Proteinuria- 300mg Edema BP > 160 systolic or >110 diastolic 5grams of protein in 24 hour urine Oliguria Cerebral of visual distrubances Pulmonary edema or cyanosis Epigastric or RUQ pain Impaired liver function Thrombocytopenia IUGR

12 Risk Factors FACTORRISK RATIO Nulliparity3:1 Age > 403:1 African American1.5:1 Chronic hypertension10:1 Renal disease20:1 Antiphospholipid syndrome 10:1

13 Risk Factors FACTORRISK RATIO Family history of PIH5:1 Diabetes mellitus2:1 Twin gestation4:1

14 Prevention 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.

15 Cardiovascular Effects Hypertension Increased cardiac output Increased systemic vascular resistance Hypovolemia

16 Neurologic Effects Seizures-eclampsia Headache Cerebral edema Hyper-reflexia

17 Pulmonary Effects Capillary leak Reduced colloid osmotic pressure Pulmonary edema

18 Hematologic Effects Volume contraction Elevated hematocrit Low platelets Anemia due to hemolysis

19 Renal Effects Decreased glomerular filtration rate Increased BUN/creatinine Proteinuria Oliguria Acute tubular necrosis

20 Fetal Effects Increased perinatal morbidity Placental abruption Fetal growth restriction Oligohydramnios Fetal distress

21 Severe Preeclampsia BP > 160-180 systolic or 110 diastolic Proteinuria > 5 g per day Pulmonary edema Oliguria Elevated liver enzymes Low platelets Growth restriction Decreased AFV Headache Epigastric pain

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

23 Gestational HTN at Term Delivery is always a reasonable option if term If cervix is unfavorable and maternal disease is mild, expectant management with close observation is possible

24 Mild Gestational HTN not at Term Rule out severe disease Conservative management Serial labs Twice weekly visits Antenatal fetal surveillance Outpatient versus inpatient

25 Indications for Delivery Worsening BP Nonreassuring fetal condition Development of severe PIH Fetal lung maturity Favorable cervix

26 Unfavorable Cervix No contraindication to prostaglandin agents If < 32 weeks, consider cesarean When favorable, oxytocin

27 Hypertensive Emergencies Fetal monitoring IV access IV hydration The reason to treat is maternal, not fetal May require ICU

28 Criteria for Treatment 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

29 Characteristics of Severe HTN Crises are associated with hypovolemia Clinical assessment of hydration is inaccurate Unprotected vascular beds are at risk, eg, uterine

30 Key Steps Using Vasodilators 250-500 cc of fluid, IV Avoid multiple doses in rapid succession Allow time for drug to work Avoid over treatment

31 Acute Medical Therapy Hydralazine Labetalol Nifedipine Nitroprusside Diazoxide Clonidine

32 Hydralazine 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

33 Labetalol 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

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

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

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

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

38 Magnesium Sulfate Is not a hypotensive agent Works as a centrally acting anticonvulsant Also blocks neuromuscular conduction Serum levels: 6-8 mg/dL

39 Toxicity 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

40 Treatment of Eclampsia 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


42 Alternate Anticonvulsants Diazepam 5-10 mg IV Sodium Amytal 100 mg IV Pentobarbital 125 mg IV Dilantin 500-1000 mg IV infusion

43 After the Seizure Assess maternal labs Fetal well-being Effect delivery Transport when indicated No need for immediate cesarean delivery

44 Other Complications Pulmonary edema Oliguria Persistent hypertension DIC

45 Pulmonary Edema Fluid overload Reduced colloid osmotic pressure Occurs more commonly following delivery as colloid oncotic pressure drops further and fluid is mobilized

46 Treatment of Pulmonary Edema Avoid over-hydration Restrict fluids Lasix 10-20 mg IV Usually no need for albumin or Hetastarch (Hespan)

47 Oliguria 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

48 Persistent Hypertension BP may remain elevated for several days Diastolic BP less than 100 do not require treatment By definition, preeclampsia resolves by 6 weeks

49 Disseminated Intravascular Coagulopathy Rarely occurs without abruption Low platelets is not DIC Requires replacement blood products and delivery

50 Anesthesia Issues 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

51 HELLP Syndrome He-hemolysis EL-elevated liver enzymes LP-low platelets

52 HELLP Syndrome 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

53 Conservative Management Controversial Steroids Requires tertiary care Must have stable labs and reassuring fetal status May use antihypertensives

54 SUMMARY Criteria for diagnosis Laboratory and fetal assessment Magnesium sulfate seizure prophylaxis Timing and place of delivery

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