OB Case Presentation Mishell Kris Sorongon

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

General Data M. M. G. 37 y/o Married G2P1 (1001) Filipino Fairview Quezon City SSS Specialist

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

Family History (+) Diabetes Mellitus - mother (+) Hypertension – Grandmother (+) Asthma – aunt (-) Heart disease (-) Cancer

Personal and Social History Non-smoker Non-drinker of alcoholic beverages Works in SSS

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

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

Gyne History (-) OCP use (+) Papsmear (March, 2009) normal results (+) sexually active (-) vaginal bleeding (-) vaginal discharge

Reason for Admission Epigastric pain

LMP: January 17, 2010 EDC by LMP: October 24, 2010 G2P1 (1001) 30 1/7 weeks AOG

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

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

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

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

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

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

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: ++

Admitting Diagnosis 37 year old G2P1 (1001) Pregnancy uterine 30 1/7 weeks AOG chronic hypertensive vascular disease with superimposed preeclampsia, mild

Problem List Epigastric pain Bipedal edema BP: 140/100 mmHg Hypertension Pregnancy at 30 1/7 weeks AOG

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: ++

Laboratory Work-ups CBC 13.2/38.5/4.12/10 700/N81L14E1M4/160 000 MCV 94 MCH 32 MCHC 34

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

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

Risk Factors Young age and nulliparity multiple pregnancy BMI > 35 African American ethnicity Maternal age > 35 years old History of chronic hypertension Family history

Definition systolic BP (SBP) ≥ 140mmHg and/or diastolic BP (DBP) ≥ 90mmHg confirmed by readings over several hours apart

Categories of Hypertensive Diseases Gestational Hypertension Preeclampsia Eclampsia Preeclampsia superimposed on Chronic Hypertension Chronic Hypertension

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)

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

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

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)

Chronic Hypertension detection prior to 20 weeks AOG and persistence beyond 12 weeks postpartum

Preeclampsia

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

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

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

Pathophysiology

Normotensive gravidas Decreased pressor responsiveness to several vasoactive peptides and amines, esp Angiotensin II Preeclampsia Hyperresponsiveness to angiotensin II and endothelin

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

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

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

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

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

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 1000 - Fetal-growth restriction and perinatal mortality Risks for eclampsia, cerebrovascular hemorrhage, and maternal death.

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

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

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

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 15-20 m IV until there’s satisfactory response (DBP 90-100 mmHg) Side-effects: palpitations, tachycardia, headaches, flushing

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

Prophylaxis Aspirin, 60-80 mg OD suppression of thromboxane synthesis by platelets and promoting prostacyclin production Antioxidants significantly reduces endothelical cell activation

Thank you!

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

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. 200-500mg tab Q6 Lowers BP by reducing sympathetic outflow from brainstem Suited for long-term use

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