1. SALWA NEYAZI Assisstent Prof. & Consultant OBG Pediatric & Adolescent Gynecology

2. INCIDENCE  5-8% of pregnancies  1/3 will have proteinuria  A leading cause of direct maternal mortality -(It is the leading cause of DMM in CANADA with PE) -Increased mortality risk in older gravidas  Majority nulliparous  Other risk factors: -peexisting HPT -renal disease -CVD -DM -1 st preg with new partner -multiple preg -obesity -black race -collagen vascukar disease -thrombophilias -extremes of reproductive age

3. MEASUREMENT OF BP  Use accurate mercury sphigmomanometer  Sitting position  Appropriate size cuff  Korotkoff sounds I & V (disappearance)

4. DEFINITIONS  HPT Diastolic BP ≥ 90 based on the average of 2 measurements taken on the same arm > 5 min apart after 10 min of rest  Severe HPT - Diastolic ≥ 110 on single measurement -Systolic ≥ 160  Incremental rise 30/15 is not criterion for Dx

5. PREOTEINURIA  Proteinuria indicate glomerular dysfunction  Definition: -urine protein ≥ 300 mg on 24 hrs collection -24 hrs urine sho uld be considered if proteinuria ≥ 2+ on dipstick -urine protein/creatinine ratio under study OEDEMA & WT GAIN ARE NOT PART OF THE CURRENT DEFINITION

6. C LASSIFICATIONS OF HYPERTENSIVE DISORDERS IN PREGNANCY  Preexisting HPT (prepregnancy or≤20wks gestation) -With comorbid conditions -With preeclampsia  Gestational HPT ≥ 20 wks gestation -With comorbid conditions -Preeclampsia

7. PREECLAMPSIA  Preexisting HPT with -Resistent HPT and/or -New or worsening proteinuria and/or -one or more adverse conditions  Gestational HPT with -New proteinuria and/or -one or more adverse conditions

8. MATERNAL ADVERSE CONDITIONS VASCULAR /PULMONARY -Diastolic BP ≥110 -Pulmonary edema -Chest pain -Shortness of breath RENAL -Proteinuria > 3 gm/24 hrs -Oliguria <500 ml/24 hrs -Serum albumin < 18 g/L -elevated serum creatinin Hepatic -elevated liver enzymes -RUQ pain/ epigastric pain -severe nausea & vomiting Hematologic -decreased platelets <100,000/100X10⁹/L -DIC HELLP syndrome -Hemolysis -elevated liver enzymes -low platelets CNS- -seizures -frontal headache - visual disturbances FETAL -IUGR -oligohydramnious -abnormal dopller -IUFD

9. INITIAL EVALUATION  Identify risk markers  Clinical evaluation of the mother  Evaluation of the fetus  Lab investigations  Subsequent management

10. RISK MARKERS  Maternal age >40  Previous PET  Antiphospholipid antibodies  Preexisting medical conditions  BMI>35  Family Hx of PET  Booking systolic BP≥130 or diastolic BP≥80  Interpregnancy interval >10 years  Multiple gestation

11. EVALUATION OF THE MOTHER  BP -Assess severity (severe>160/110) -High BP related to CVA not seizures  CNS -Presence & severity of headache -Visual disturbance: blurring or scotoma -Tremors, irritability, hyperreflexia, somnolence -Nausea & vomitting

12. EVALUATION OF THE MOTHER  Hematologic -Bleeding -Petechiae  Hepatic -RUQ pain/ epigastric pain -Nausea & vomitting

13. EVALUATION OF THE MOTHER (lab)  CBC----Hb, PLT  PT, APTT, INR, fibrinogen  Bilirubin  ALT, AST, LDH, ALBUMIN  Glucose. amonia to R/O acute fatty liver  Proteiuria (dipstick, 24 hr collection)  Urea, creatinin, uric acid

14. EVALUATION OF THE FETUS  Fetal movement  NST  U/S -growth (IUGR) -BPP -Doppler -AFV/ oligohydramnious

15. MANGEMENT GOALS  Prevention of adverse maternal outcomes (organ damage, seizures, CVA,death)  Prevention of adverse fetal complications (abruption, IUFD, IUGR)  Symptomatic support  Delivery is the definitive treatment  Deliver when: 1-G HPT is associated with adverse conditions, regardless of gestational age 2- At or near term

16. SUPPORTIVE MANAGEMENT  Stress reduction -quiet environment -clear explanation of Rx plan -consistent confident team approach  Pain relief  Antiemetics  Minimize liver palpation

17. ANTIHYPERTENSIVE THERAPY  Minimize the risk of CV A/ death  It is unclear whether antihypertensive therapy for mild-moderate HPT (diastolic 90-105) is beneficial  Gain time for further assessment -Facilitate vaginal delivery if possible -Prolong gestation if premature & appropriate

18. ANTIHYPERTENSIVE AGENTS--ACUTE 1-CALCIUM CHANNEL BLOCKERS NEFIDIPINE -PO / direct relaxation of the vascular smooth muscle * Immediate release ---(Adalat) -5-10 mg swallowed / repeat in 30 min if no response -may cause sudden drop in BP & fetal distress -reports of MI & CVA in the general population—should be avoided in patients at risk * Intermediate acting ----(Adalat PA) - 10 mg PO repeat dose at 30-45 min if no response -Onset of action in 90 min

19. ANTIHYPERTENSIVE AGENTS--ACUTE 2-B –BLOCKERS Labetalol -10-20 mg IV over 2 min q 10-30 min up to 300 mg -onset of action in 5-10 min -Max action 30 min -IV infusion 1-2 mg /min --------increase by 1mg q 15 min Max 4mg/min

20. ANTIHYPERTENSIVE AGENTS--ACUTE  3-ARTERIOLAR DILATORS Hydralazine -Should not be the first choice agent -A metanalysis showed that it is associated with -more adverse outcomes including: abruption, fetal distress, low APGAR, CS & oliguria - it is less effective in BP control -onset of action in 5-10 min/ Max action 30 min -5-10 mg IV q 20 min -Infusion 0.5-10 mg/hr

21. ANTIHYPERTENSIVE AGENTS - MAINTENANCE  GOAL -Without co morbid condition BP 130-155/80-105 -With comorbid condition BP 130-139/80-89 1-Centrally acting agents/ α METHYL-DOPA - Long Hx of safe use in pregnancy -drug of choice for essential HPT -500-1000 mg bd-qid Max 3000 mg/d 2-Β blockers/ LABETOLOL 100-600 bd-qid Max 1200/d 3-Calcium channel blockers/ NEFIDIPINE -intermediate release 20-40 mg/d Max 80 -extended release 20-60 ng/d Max 120 mg

22. FLUID MANAGEMENT  Monitor urine output /hourly intake output  Total IV intake should not exceed 80-125 ml/hr  In case of oliguria <15 ml/hr -follow serum creatinine -watch for magnesium toxicity -consider a small fluid bolus -consultation if persistent  Judicious fluid adminstration  Beware of pulmonary edema

23. SEIZURES PROPHYLAXIS  Difficult to predict who will seize  Not directly related to the degree of HPT or the level of proteinuria  Mg SO4 is the agent of choice for seizures prophylaxis in PET or for Rx of Eclampsia -Dosage-4 gm IV followed by 1-2 g/hr -Do not use Diazepam or Phenytoin unless Mg SO4 is contraindicated

24. MgSO4-OVERDOSE  Close observation for toxicity -Weakness, respiratory paralysis, somnolence, heart block -High risk- renal failure, oliguria ANTIDOTE  Stop MgSO4 infusion  10% Calcium gluconate 10 ml IV over 3 min

25. MANAGEMENT OF ECLAMPSIA  Call for help  Maternal lateral position  Protect the airway  MgSO4  Post-seizure: oxygen, vital signs, fetal survillance  Assess for evidence of abruption

26. TRANSPORT  Consider if resources limited & maternal/ fetal condition permits -maternal BP & symptoms stable -fetal status reassuring  D/W receiving centre & Pt/ family  Antihypertensive agent if indicated  MgSo4 if indicated

27. WHEN TO DELIVER ?  Gestational HPT at or near term  Gestational HPT with adverse conditions irrespective of gestational age -Mild IUGR alone is not an indication for delivery -Role for prolonging pregnancy with significant prematurity in a facility with sufficient resources

28. DELIVERY THE CURE  Timely delivery minimizes morbidity & mortality  Stabilize mother before delivery  Delay delivery to gain fetal maturity and allow for transfer only when fetal & maternal condition allows  Gestational HPT is a progressive disease  Expectant management is potentially harmful in presence of severe disease or suspected fetal compromise

29. PERI & POST PARTUM MANAGEMENT  Gestational HPT may present or worsen after delivery  Eclampsia 50 % before labor 25% in labor 25% early postpartum rarely 2 days or more after delivery  Mg SO4 should be continued for the first 24 hrs postpartum in high risk Pt  Avoid abrupt drop in BP---aim for 80-100 diastolic  Avoid fluid overload  Epidural analgesia is favored in the absence of low platelets or coagulopathy  Multidisciplinary approach  Patient must be monitored postpartum  Can be discharged if BP remains< 160/100 for at least 24 hrs

30. PREVENTION  ASA -low dose -small role in the prevention of early onset (<34 wks) gestational HPT with proteinuria - delay the onset of proteinuria - Reduce the risk of severer HPT (HELLP, IUGR, antiphospholipid syndrome )  Calcium supplement (1-2 gm Ca carbonate/day) -decrease the risk of HPT in preg in women who are considered high risk for gestational HPT & in communities with low Ca intake  Antioxidants (Vit C, E) are not beneficial & may be harmful (increased risk of prematurity)

31. CONCLUSION  Gestational HPT with proteinuria & adverse condition is an OB Emergency  Multidisciplinary approach for management  Prompt recognition & stabilization of the mother & fetus are important  The cure is delivery  Timing of delivery is based on -Severity -Fetal maturity & wellbeing -Maternal status

32. CONCLUSION  Antihypertensive Rx is used to prevent CVA not seizures  No evidence that antihypertensive Rx for mild –moderate HPT improves perinatal outcome  Magnesium Sulfate is the drug of choice for prevention & treatment of Eclampsia