Presented by Dr A/Shakor MBChB GEZIRA UNIVERSITY -SUDAN Head of Anatomy Department Somali...

Presented by Dr A/ShakorMBChB GEZIRA UNIVERSITY -SUDAN

Head of Anatomy Department Head of Anatomy Department Somali International UniversitySomali International University

OBJECTIVES Be able to define hypertension in relationship to

pregnancy. Be able to classify hypertensive diseases in

pregnant women. Be able to list criteria for the diagnosis of

preeclampsia. Be able to list criteria for the diagnosis of severe

preeclampsia/HELLP syndrome. Be able to discuss current management

considerations. Understand and discuss the effects of

hypertension on the mother and fetus.

HypertensionSustained BP elevation of 140/90 or

greater.Proper cuff size.Measurement taken while seated.Arm at the level of the heart.Use Korotkoff sound.

Hypertensive Disease Associated with Pregnancy

Chronic Hypertension.Gestational Hypertension.Preeclampsia.Eclampsia.HELLP Syndrome.

Hypertensive Disease Associated with Pregnancy

Chronic Hypertension◦ Diagnosed before the 20th week or present

before the pregnancy◦ Mild hypertension

> 140-180 mmHg systolic > 90-100 mmHg diastolic

Gestational HypertensionGestational Hypertension PreeclampsiaPreeclampsia EclampsiaEclampsia HEELP SyndromeHEELP Syndrome

Hypertensive Disease Associated with Pregnancy

Chronic HypertensionChronic Hypertension

Gestational Hypertension◦ Criteria

Develops after 20 weeks of gestation Proteinuria is absent Blood pressures return to normal postpartum

◦ Morbidity is directly related to the degree of hypertension

PreeclampsiaPreeclampsia EclampsiaEclampsia HEELP SyndromeHEELP Syndrome

Hypertensive Disease Associated with Pregnancy

Chronic HypertensionChronic Hypertension Gestational HypertensionGestational Hypertension

Preeclampsia◦ Criteria

Develops after 20 weeks Blood pressure elevated on two occasions at least 6

hours apart Associated with proteinuria and edema

May occur less than 20 weeks with gestational trophoblastic neoplasia

EclampsiaEclampsia HEELP SyndromeHEELP Syndrome

Preeclampsia vs. Severe Preeclampsia

Criteria for Preeclampsia

Criteria for Severe Preclampsia

Previously normotensive woman

> 140 mmHg systolic> 90 mmHg diastolicProteinuria > 300 mg in

24 hour collectionNondependent edema

BP > 160 systolic or >110 diastolic

> 5 gr of protein in 24 hour urine or > 3+ on 2 dipstick urines greater than 4 hours apart

Oliguria < 500 mL in 24 hours Cerebral or visual distrubances

(headache) Pulmonary edema or cyanosis Epigastric or RUQ pain Evidence of hepatic

dysfunction Thrombocytopenia Intrauterine growth restriciton

(IUGR)

Risk Factors for Preeclampsia

Nulliparity Multifetal gestations Maternal age over 35 Preeclampsia in a

previous pregnancy Chronic hypertension Pregestational diabetes

Vascular and connective tissue disorders

Nephropathy Antiphospholipid

syndrome Obesity African-American race

Risk FactorsFACTOR RISK RATIO

Nulliparity 3:1

Age > 40 3:1

African American 1.5:1

Chronic hypertension 10:1

Renal disease 20:1

Antiphospholipid syndrome 10:1

Hypertensive Disease Associated with Pregnancy

Chronic HypertensionChronic Hypertension Gestational HypertensionGestational Hypertension PreeclampsiaPreeclampsia

Eclampsia◦ Diagnosis of preeclampsia◦ Presence of convulsions not explained by a

neurologic disorder Grand mal seizure activity

◦ Occurs in 0.5 to 4% or patients with preeclampsia

HEELP SyndromeHEELP Syndrome

Hypertensive Disease Associated with Pregnancy

Chronic HypertensionChronic Hypertension Gestational HypertensionGestational Hypertension PreeclampsiaPreeclampsia EclampsiaEclampsia

HELLP Syndrome◦ A distinct clinical entity with:

Hemolysis, Elevated Liver enzymes, Low Platelets◦ Occurs in 4 to 12 % of patients with severe

preeclampsia Microangiopathic hemolysis Thrombocytopenia Hepatocellular dysfunction

Morbidity and Mortality from Hypertensive Disease

Hypertension affects 12 to 22% of pregnant patients

Hypertensive disease is directly responsible for approximately 20% of maternal mortality in the United State

PathophysiologyVasospasm.Uterine vessels.Hemostasis.Prostanoid balance.Endothelium-derived factors.Lipid peroxide, free radicals and antioxidants.

PathophysiologyVasospasm

◦ Predominant finding in gestational hypertension and preeclampsia

Uterine vesselsUterine vessels HemostasisHemostasis Prostanoid balanceProstanoid balance Endothelium-derived factorsEndothelium-derived factors Lipid peroxide, free radicals and antioxidantsLipid peroxide, free radicals and antioxidants

Pathophysiology Vasospasm

Uterine vessels:◦ Inadequate maternal vascular response to

trophoblastic mediated vascular changes◦ Endothelial damage

HemostasisHemostasis Prostanoid balanceProstanoid balance Endothelium-derived factorsEndothelium-derived factors Lipid peroxide, free radicals and antioxidantsLipid peroxide, free radicals and antioxidants

Pathophysiology VasospasmVasospasm Uterine vesselsUterine vessels

Hemostasis◦ Increase platelet activation resulting in

consumption◦ Increased endothelial fibronectin levels◦ Decreased antithrombin III and α2-antiplasmin

levels◦ Allows for microthrombi development with

resultant increase in endothelial damage Prostanoid balanceProstanoid balance Endothelium-derived factorsEndothelium-derived factors Lipid peroxide, free radicals and antioxidantsLipid peroxide, free radicals and antioxidants

Pathophysiology VasospasmVasospasm Uterine vesselsUterine vessels HemostasisHemostasis

Prostanoid balance◦ TXA2 promotes:

Vasoconstriction Platelet aggregation

Endothelium-derived factorsEndothelium-derived factors Lipid peroxide, free radicals and antioxidantsLipid peroxide, free radicals and antioxidants

Pathophysiology VasospasmVasospasm Uterine vesselsUterine vessels HemostasisHemostasis Prostanoid balanceProstanoid balance

Endothelium-derived factors◦ Nitric oxide is decreased in patients with

preeclampsia As this is a vasodilator, this may result in

vasoconstriction Lipid peroxide, free radicals and antioxidantsLipid peroxide, free radicals and antioxidants

Pathophysiology VasospasmVasospasm Uterine vesselsUterine vessels HemostasisHemostasis Prostanoid balanceProstanoid balance Endothelium-derived factorsEndothelium-derived factors

Lipid peroxide, free radicals and antioxidants◦ Increased in preeclampsia◦ Have been implicated in vascular injury

Pathophysiologic Changes

1. Cardiovascular effects.2. Hematologic effects.3. Neurologic effects.4. Pulmonary effects.5. Renal effects.6. Fetal effects.

Pathophysiologic ChangesCardiovascular effects

◦ Hypertension◦ Increased cardiac output◦ Increased systemic vascular resistance

Hematologic effects Neurologic effects Pulmonary effects Renal effects Fetal effects

Pathophysiologic Changes Cardiovascular effectsCardiovascular effects

Hematologic effects◦ Hypovolemia.◦ Elevated hematocrit◦ Thrombocytopenia◦ hemolytic anemia.◦ Low oncotic pressure

Neurologic effectsNeurologic effects Pulmonary effectsPulmonary effects Renal effectsRenal effects Fetal effectsFetal effects

Pathophysiologic Changes Cardiovascular effectsCardiovascular effects Hematologic effectsHematologic effects

Neurologic effects:◦ Hyperreflexia◦ Headache◦ Cerebral edema◦ Seizures

Pulmonary effectsPulmonary effects Renal effectsRenal effects Fetal effectsFetal effects

Pathophysiologic Changes Cardiovascular effectsCardiovascular effects Hematologic effectsHematologic effects Neurologic effectsNeurologic effects

Pulmonary effects◦ Pulmonary edema

Renal effectsRenal effects Fetal effectsFetal effects

Pathophysiologic Changes Cardiovascular effectsCardiovascular effects Hematologic effectsHematologic effects Neurologic effectsNeurologic effects Pulmonary effectsPulmonary effects

Renal effects◦ Decreased glomerular filtration rate◦ Proteinuria◦ Oliguria◦ Acute tubular necrosis

Fetal effectsFetal effects

Pathophysiologic Changes Cardiovascular effectsCardiovascular effects Hematologic effectsHematologic effects Neurologic effectsNeurologic effects Pulmonary effectsPulmonary effects Renal effectsRenal effects

Fetal effects:◦ Placental abruption◦ Fetal growth restriction◦ Oligohydramnios.◦ Fetal distress◦ Increased perinatal morbidity and mortality

Management:A. The ultimate cure is delivery.B. Assess gestational age.C. Assess cervix.D. Fetal well-being.E. Laboratory assessment.F. Rule out severe disease!!

Gestational HTN at TermGestational HTN at TermDelivery is always a reasonable option if

term.If cervix is unfavorable and maternal

disease is mild, expectant management with close observation is possible.

Mild Gestational HTN not at Term:A. Rule out severe diseaseB. Conservative managementC. Serial labsD. Twice weekly visitsE. Antenatal fetal surveillanceF. Outpatient versus inpatient

Indications for DeliveryWorsening BP.Non-reassuring fetal condition.Development of severe PIH.Fetal lung maturity.Favorable cervix.

Hypertensive EmergenciesFetal monitoring.IV access.IV hydration.The reason to treat is maternal, not fetal.May require ICU.

Criteria for TreatmentDiastolic BP > 105-110Systolic BP > 200Avoid rapid reduction in BPDo not attempt to normalize BPGoal is DBP < 105 not < 90May precipitate fetal distress

Key Steps Using Vasodilators250-500 cc of fluid, IVAvoid multiple doses in rapid successionAllow time for drug to workMaintain LLD positionAvoid over treatment

Acute Medical TherapyHydralazineLabetalolNifedipineNitroprussideDiazoxideClonidine

HydralazineDose: 5-10 mg every 20 minutesOnset: 10-20 minutesDuration: 3-8 hoursSide effects: headache, tachycardia.Mechanism: peripheral vasodilator

LabetalolDose: 20mg, then 40, then 80 every 20

minutes, for a total of 220mg Onset: 1-2 minutesDuration: 6-16 hoursSide effects: hypotensionMechanism: Alpha and Beta block

NifedipineDose: 10 mg , not sublingualOnset: 5-10 minutesDuration: 4-8 hoursSide effects: chest pain, headache,

tachycardiaMechanism: CA channel block

ClonidineDose: 1 mg poOnset: 10-20 minutesDuration: 4-6 hoursSide effects: unpredictable, avoid rapid

withdrawalMechanism: Alpha agonist, works

centrally

NitroprussideDose: 0.2 – 0.8 mg/min IVOnset: 1-2 minutesDuration: 3-5 minutesSide effects: cyanide accumulation,

hypotensionMechanism: direct vasodilator

Seizure ProphylaxisMagnesium sulfate4-6 g bolus1-2 g/hourMonitor urine output.With renal dysfunction, may require a lower

dose

Magnesium Sulfate.Is not a hypotensive agentWorks as a centrally acting anticonvulsantAlso blocks neuromuscular conduction

Treatment of EclampsiaFew people die of seizuresProtect patientAvoid insertion of airways and padded tongue

bladesIV accessMGSO4

Alternate AnticonvulsantsHave not been shown to be as efficacious as

magnesium sulfate and may result in sedation that makes evaluation of the patient more difficultDiazepam 5-10 mg IVSodium Amytal 100 mg IVPentobarbital 125 mg IVDilantin 500-1000 mg IV infusion

After the SeizureAssess maternal labsFetal well-beingEffect deliveryTransport when indicatedNo need for immediate cesarean delivery

Other ComplicationsPulmonary edemaOliguriaPersistent hypertensionDIC

Pulmonary Edema Fluid overload Reduced colloid osmotic pressure Occurs more commonly following delivery

as colloid oncotic pressure drops further and fluid is mobilized

Treatment of Pulmonary EdemaAvoid over-hydrationRestrict fluidsLasix 10-20 mg IVUsually no need for albumin.

Oliguria25-30 cc per hour is acceptableIf less, small fluid boluses of 250-500 cc as

neededLasix is not necessaryPostpartum diuresis is common

Persistent HypertensionBP may remain elevated for several daysDiastolic BP less than 100 do not require

treatmentBy definition, preeclampsia resolves by 6

weeks

Disseminated Intravascular CoagulopathyRarely occurs without abruptionLow platelets is not DICRequires replacement blood products and

delivery

Anesthesia IssuesContinuous lumbar epidural is preferred if

platelets normalNeed adequate pre-hydration of 1000 ccLevel should always be advanced slowly to

avoid low BPAvoid spinal with severe disease

HELLP SyndromeHe-hemolysisEL-elevated liver enzymesLP-low platelets

HELLP SyndromeIs a variant of severe preeclampsiaPlatelets < 100,000LFT’s - 2 x normalMay occur against a background of what

appears to be mild disease

SUMMARYCriteria for diagnosisLaboratory and fetal assessment

Magnesium sulfate seizure prophylaxis

Timing and place of delivery

Any comment any question?????