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HYPERTENSIVE DISORDERS IN PREGANCY. OBJECTIVES At the end of this session you should be able to: 1. Outline diagnostic features of pre-eclampsia 2. Classify.

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Presentation on theme: "HYPERTENSIVE DISORDERS IN PREGANCY. OBJECTIVES At the end of this session you should be able to: 1. Outline diagnostic features of pre-eclampsia 2. Classify."— Presentation transcript:

1 HYPERTENSIVE DISORDERS IN PREGANCY

2 OBJECTIVES At the end of this session you should be able to: 1. Outline diagnostic features of pre-eclampsia 2. Classify pre-eclampsia according to severity 3. Outline risk factors for pre-eclampsia 4. Outline maternal and fetal complications of pre- eclampsia. 5. Describe the management of pre-eclampsia and eclampsia.

3 I. INTRODUCTION  Synonyms: Toxemia of pregnancy, pre-eclampsia, EPH gestosis, pregnancy induced hypertension.  Pre-eclampsia commonly manifests after the 20th week of pregnancy.  Prevalence of pre-eclampsia: varies from one place to another  Severe pre-eclampsia and eclampsia Are serious and potentially fatal Third commonest cause of maternal mortality  Occurs prior to, during or after delivery

4 II. DIAGNOSIS OF PRE-ECLAMPSIA  When SBP > 140 mm Hg, DBP > 90 mm Hg in a woman known to be normotensive prior to pregnancy.  The diagnosis requires 2 such abnormal BP measurements recorded at least 6 hours apart.

5 III. RISK FACTORS  Young maternal age  Nulliparity: 85% of pre-eclampsia occur in primigravida.  Increased placental tissue for gestational age: Hydatiform moles, twin pregnancies  Family history of pre -eclampsia  Diabetes mellitus  Renal diseases,  Chromosomal abnormality in the fetus (eg, trisomy).

6 RISK FACTORS cont Worrisome signs for pre-eclapmsia development  Rapid increase of weight during the latter ½ of pregnancy  An upward trend in diastolic BP even while still within normal range

7 IV. CLASSIFICATION OF PRE ECLAMPSIA: ACCORDING TO SEVERITY 1. Mild pre-eclampsia 2. Moderate pre-eclampsia 3. Severe pre-eclampsia 1. Mild to Moderate Pre eclampsia Diagnostic Features Systolic BP is mmHg Diastolic BP is 90 – 100 mmHg Proteinuria up to ++

8 2. Severe pre-eclampsia Also called – Imminent eclampsia Symptoms  Severe & persistent occipital or frontal headaches  Visual disturbance: blurred vision, photophobia  Epigastric and/or right upper-quadrant pain Signs  Diastolic BP > 11ommHg, systolic BP > 160mmHg  Proteinuria +++ or more  Altered mental status  Hyper-reflexia  Oliguria

9 HELLP SYNDROME Is a severe form of pre-eclampsia  Affects approx 10% of women with severe preeclampsia and 30-50% of women with eclampsia.  Characterized by: Hemolysis, Elevated liver enzymes Low platelet count.  Increased mortality rate and DIC

10 V. PATHOPHYSIOLOGY  There are several theories and etiologic mechanisms.  Vasospasm theory: Most favored theory Vasospasms → vasoconstriction → resistance → arterial BP Eclampsia: Cerebral arterial vasospasm → cerebral edema or infarction and/or cerebral hemorrhage

11 VI. COMPLICATIONS OF SEVERE PRE- ECLAMPSIA AND ECLAMPSIA Maternal complications  CVS Haemoconcentration (cause: vasoconstriction and vascular permeability) Hamatological changes – HELLP → DIC  Kidneys Decr RBF→ ↓GFR → RTN and RCN→ acute RF Proteinuria – due to ⇈ permeability to large protein, Oliguria – both renal perfusion and GFR decrease.

12 COMPLICATIONS OF SEVERE PRE ECLAMPSIA AND ECLAMPSIA cont Brain  Cerebral edema  Infarction, cerebral hemorrhage  Blindness: Due to -?retinal artery vasospasms and retinal detachment  Fever 39ºC: a grave sign, may be a consequence of intracranial hemorrhage.  Coma – may be a result of CVA

13 COMPLICATIONS OF SEVERE PRE ECLAMPSIA AND ECLAMPSIA cont RS : Pulmonary oedema and cyanosis Utero-placental perfusion Vasospasms → decr perfusion → distress and death Histological changes in the placental bed: acute artherosis – lipid rich cells of the uteroplacental arteries Fetal complications  IUFD, IUGR

14 MAJOR CAUSES OF MATERNAL DEATH  Cerebrovascular accident (CVA)  Pulmonary oedema  Cardiac failure,  Renal failure

15 VII. WORK UP - INVESTIGATIONS  Urine analysis Proteinuria  A 24-hour urine collection Quantity of urine and protein  Uric acid level: GFR and creatinine clearance decrease →in ↑uric acid levels.  LFT – Transaminases  USS – fetal wellbeing, if the GA is < 20/40 R/O moles.

16 VIII. MANAGEMENT OF PRE ECLAMPSIA 1. MILD - MOD PRE ECLAMPSIA A: Dispensary & Health centre  Antihypertensives Aldomet 250 mg 8 hourly for 7 days,  Bed rest at home  REFER within one week to Hospital for further management

17 MANAGEMENT OF PRE ECLAMPSIA 1. MILD - MOD PRE ECLAMPSIA cont B. Hospital  Antihypertensives: Aldomet,  Bed rest at home,  Sequential work ups,  Fetal movements monitoring,  Schedule antenatal clinic every 2 weeks up to 32 wks and weekly thereafter

18 MANAGEMENT OF PRE ECLAMPSIA 1. MILD - MOD PRE ECLAMPSIA cont B. Hospital  Strongly advice the woman to deliver in a hospital  Plan delivery at 38/40  Advice the mother to come to the health facility in case of severe headache, blurred vision, nausea or upper abdominal pain.  Manage as severe pre-eclampsia: If not responding to treatment i.e. if the systolic BP is > 160 mmHg, or the diastolic BP is > 100mmHg or there is proteinuria +++

19 MANAGEMENT OF SEVERE PRE ECLAMPSIA AND ECLAMPSIA Note: Severe pre-eclampsia is managed like eclampsia Management protocol for eclampsia  Keep airway clear  Control convulsions  Control BP  Control fluid balance  Antibiotics  Investigations  Deliver the mother

20 MANAGEMENT CONT BP CONTROL  Keep SBP between mm Hg and DBP between mm Hg  ?Why these levels: Avoid potential reduction in either uteroplacental blood flow or cerebral perfusion pressure. Drugs:  Anti HPTs: Hydralazine, nifedipine, or labetalol  Diuretics are not used except in the presence of pulmonary edema

21 MANAGEMENT: CONTROL CONVULSIONS I. An overview on MgSO4.  Mechanism: Cerebral vasodilator → reducing cerebral vasospasm → ↓ischemia (brain).  Superior to other anti-convulsants used to control and prevent fits; Important part of mgt of eclampsia Recurrence rate after MgSO4 = %  Improves maternal and fetal outcome

22 CONTROL CONVULSIONS - REGIMEN 1. INTRAMUSCULAR REGIMEN i. Loading dose  Give MgSO4 4 g (i.e. 20mls of 20% solution) + 200mls NS or sterile water I.V over 5 minutes  Follow promptly with 10g (i.e. 20ml of 50% solution), 5g in each buttock as deep I.M with 1ml of 2% lignocaine in the same syringe

23 MANAGEMENT CONT CONTROL CONVULSIONS - REGIMEN 1. INTRAMUSCULAR REGIMEN cont ii. Maintenance dose MgSO4 5 g (i.e. 10ml of 50% solution) + 1 ml lignocaine 2% 4 hourly in alternate buttocks. NOTE:  IM inj. are painful and are complicated by local abscess formation in 0.5% of cases.  The intravenous (IV) route is therefore preferred

24 MANAGEMENT CONT CONTROL CONVULSIONS - REGIMEN 2. INTRAVENOUS REGIMEN i. Loading dose MgSO4 4 g (i.e. 20mls of 20% solution) + 200mls NS I.V over 5 minutes ii. Maintenance dose MgSO4 4 g (i.e. 20ml of 20% solution) IN 500ml NS 4 hourly for 24 hrs after the last fits

25 MANAGEMENT CONT CONTROL CONVULSIONS - REGIMEN Recurrent fits (any regimen):  Therapeutic dose may not have been reached  Give 2g (i.e. 10ml of 20% solution) i.v. over 5 minutes Treatment duration: Continue for 24 hours after delivery or last convulsion, whichever occurs first

26 MANAGEMENT CONT Magnesium toxicity Causes loss of deep tendon reflexes, followed by respiratory depression and ultimately respiratory arrest. Thus, before repeating MgSO4, ensure that;  RR ≥ 16/min  Patellar reflexes are present  Urinary output is at least 30ml per hour over 4 hours  Otherwise withhold or delay MgSO4  Keep antidote ready  In case of respiratory arrest: Assist ventilation and administer calcium gluconate

27 MANAGEMENT CONT DELIVER THE MOTHER  Delivery should be within 6-8 hours of onset of fits  Vaginal delivery is the safest mode of delivery  Assessment R/O contraindications to SVD Bishop score  If the cervix is favourable - induce labour  Otherwise prepare for C/S

28 MANAGEMENT CONT Management of labour  1st stage Relieve pain: pethidine 25 mg iv every 2-4 hours Augmentation of labour Monitor FHR,  2nd stage: Assist with vacuum extraction  3 rd stage: Active management Oxytocin 10 IU i.m after delivery of anterior shoulder Cord traction Squeezing clots after delivery of the placenta

29 MANAGEMENT CONT Management of labour  If there is delay perform C/S  Post delivery: Continue observation for at least 48 hrs post delivery Record and monitor BP and urine output for at least 48 hours after delivery, Keep the pt in hospital until BP stabilizes, Continue with aldomet PO until BP back to normal


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