Presentation on theme: "Hypertension in Pregnancy"— Presentation transcript:
1Hypertension in Pregnancy Ramon M. Gonzalez, MDProfessorUST Medicine and Surgery
2A 26y/o G weeks known hypertensive for 6 years was admitted because of severe hypertension VS- BP-200/100mmHg, PR- 76/min, RR-20/min, T-36.5C. She was taking calcium channel blockers for her HPN which she was taking regularly.
3Hypertensive Disorders Complicating Pregnancy Gestational HypertensionSystolic BP≥ 140 or diastolic ≥ 90 mmHg for the first time after 20 weeks gestationNo proteinuriaBP returns to normal before 12 weeks postpartumFinal diagnosis made only postpartumMay have other signs or symptoms of preeclampsia
4Hypertensive Disorders Complicating Pregnancy PreeclampsiaMinimum criteriaBP ≥ 140/90 mmHg after 20 weeks gestationProteinuria ≥ 300mg/24 hours or ≥ 1+ dipstickSevere preeclampsiaBP ≥ 160/110 mmHgProteiunuria 2.0gms/24 hrs or ≥ 2+ dipstickSerum creatinine > 1.2mg/dlPlatelets < 100,00/ulElevated LDH, ALT or AST
5Hypertensive Disorders Complicating Pregnancy EclampsiaSeizures that cannot be attributed to other causes in women with preeclampsiaChronic HypertensionBP ≥ 140/90 mmHg before pregnancy or diagnosed before 20 weeks gestationHypertension first diagnosed after 20 weeks gestation and persistent after 12 weeks postpartum
6Hypertensive Disorders Complicating Pregnancy Superimposed PreeclampsiaNew onset proteinuria ≥ 300mg/24 hrs in hypertensive women but no proteinuria before 20 weeks gestation
8Maternal Assessment Duration of hypertension Current therapy Degree of BP controlOther medical complications
9Maternal Assessment Serum creatinine Quantification of urine proteins ECGEchocardiographyBlood chemistry
10What are the effects of chronic hypertension on pregnancy? What is the management of chronic hypertension during pregnancy?Can we prevent superimposition of preeclampsia ?What is the management of chronic hypertension with superimposed preeclampsia?
11What are the effects of chronic hypertension on pregnancy?
19What is the management of chronic hypertension during pregnancy?
20Management Blood pressure control Fetal antepartum surveillance Prevention of preeclampsiaDetection of preeclampsia
21Blood Pressure Control Ca Channel BlockersAdrenergic Blocking AgentsVasodilatorsDiureticsACE Inhibitors/ARBcontraindicated
22El Guindy, A.A. and Nabhan, A.F. (2008) Journal of Perinatal Medicine A randomized trial of tight vs. less tight control of mild essential and gestational hypertension in pregnancyEl Guindy, A.A. and Nabhan, A.F. (2008)Journal of Perinatal MedicineWomen in the tight control groupWere less likely to develop severe hypertension (RR 0.32, 95% CI 0.14 to 0.74)Delivered babies with older gestational ages (36.6 ±2.2 weeks vs 35.8 ± 2.2 weeks: P<0.05)Fewer preterm deliveries (RR 0.52, 95%CI 0.28 to 0.99)No significant differences between groups regarding stillbirth or IUGR
25PreeclampsiaPregnancy specific syndrome that can affect virtually every organ system.Disorder of unknown etiology affecting 5-10% of all pregnancies.In developed countries 16% of maternal deaths were due to hypertensive disorder.POGS (2006) % maternal deaths were due to hypertensive disorder.
26Pathogenesis Vasospam Increased resistance → hypertension Endothelial cell damage → leakage of blood constituents, including platelets and fibrinogenDecreased blood flow → ischemia of tissues → necrosis, hemorrhage and other end organ disturbances
27Pathogenesis Endothelial cell activation Increased pressor responses Increased sensitivity to angiotensin IIProstaglandinProstacyclin: thromboxane A2 ratio decreasesNitric oxideDecreased nitric oxide synthase expressionEndothelinsPotent vasoconstrictor which is increased in preeclampsia
28Cardiovascular System ↑ Cardiac afterloadhypertension↑Cardiac preloadDiminished hypervolemia↑ intravenous crystalloidsExtravasation of intravascular fluid into the extracellular spacePulmonary edema
29Blood Volume and Coagulation HemoconcentrationHallmark of preeclampsiaVasospasm and endothelial leakageThrombocytopeniaHemolysisEndothelial disruptionHELLP syndrome
34Prevention of Superimposed Preeclampsia Systematic Review by Duley et al59 trials with 37,560 women given Aspirin17% reduction in the risk of preeclampsia (RR 0.83, ), especially in high risk patients8% reduction in the relative risk of preterm birth (RR 0.92, )14% reduction in fetal and neonatal deaths (RR 0.86, )10% reduction in SGA babies (0.90, )
35Detection of Preeclampsia BP monitoring24 hour urine proteins
36What is the management of chronic hypertension with superimposed preeclampsia?
37ManagementTermination of pregnancy with the least possible trauma to mother and babyBirth of an infant who subsequently thrivesComplete restoration of health to the mother
38Severe PreeclampsiaClinical course is progressive deterioration in both maternal and fetal conditionAssociated with high rates of maternal and perinatal morbidity and mortality
39Management of Severe Preeclampsia AggressiveHigh neonatal mortality and morbidity due to prematurityProlonged NICU stayLong term disabilityExpectant- Fetal death- Asphyxial damage inutero- Increased maternalmorbidity
47Expectant Management Prolongs pregnancy Higher gestational age Higher birth weightLower incidence of admission to NICULower incidence of neonatal complicationNo difference in the incidence of CS, abruptio placenta, HELLP syndrome and postpartum stay
48Guidelines for Expectant Management Hospitalization in a tertiary hospital- Good facilities to monitor the mother and fetus- NICU facilities- Trained personnelsMgSO4AntihypertensivesCorticosteroids
54Maternal Indications for Delivery in Women With Severe Preeclampsia Persistent severe headache or visual changes; eclampsiaPulmonary edemaUncontrolled severe HPNEpigastric pain/RUQ pain with AST or ALT >2 times the upper limit of normalSibai et al AmJOG 2007
55Maternal Indications for Delivery in Women With Severe Preeclampsia Oliguria (<500ml/24hr)HELLP syndromePlatelet counts <100,000/mm3Deterioration of renal function(serum creatinine >/=1.5 mg/dl)Suspected abruptio placenta, progressive labor, and/or rupture of membranesSibai et al AmJOG 2007
56Fetal Indications For Delivery In Women With Severe Preeclampsia Repetitive late or severe variable decelerationBiophysical profile </=4 on 2 occasions at 6 hours apartIUGR (Estimated fetal weight <5th percentile)Umbilical artery Doppler with reverse end diastolic flowSevere oligohydramniosSibai et al AmJOG 2007
57Mode of Delivery Vaginal delivery - Inducible cervix - No fetal distressCesarean section