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Hypertensive Disorders of Pregnancy
Family Medicine Specialist ProgramCME
Case
A 32 year-old G2P1 woman presents for her routine ante-natal visit at 32 weeks’ gestation. Her BP is 140/90. Throughout her pregnancy to date her BP has ranged from 115/75 to 130/85. Her weight is 105 kg.
What steps do you perform as part of your initial investigation?
Case - continued
Repeated blood pressures over the next three hours range from 140/90 to 155/95.
What is your management plan?
Objectives• Describe the classification of hypertension in
pregnancy.• Discuss the appropriate monitoring and
management of hypertension in pregnancy and pre-eclampsia.
• Discuss how to determine the appropriate medication according to the condition of the woman.
• Describe a Quality Improvement project with regards to patients presenting with hypertension in pregnancy.
Classification of Hypertension
1. Pre-existing hypertension– With co-morbid conditions– With Pre-eclampsia• Resistant hypertension• New or worsening proeinuria• > 1 adverse conditions(s)
2. Gestational hypertension– With co-morbid conditions– With Pre-eclampsia• New or worsening proteinuria• > 1 adverse conditions(s)
Determining Blood Pressure
• Sitting position with arm at heart level• Appropriate size BP cuff• Accurate mercury sphygmomanometer• Repeat measurements in > 4 hour intervals
unless very high
Definitions
Hypertension• Diastolic BP of >90 mm Hg on 2 measurements > 5 minutes apart after a period of 10 minutes rest•Diastolic BP of > 110 mm Hg on a single measurement
Hypertension - Definition
• Pre-existing hypertension– Hypertension < 20 weeks gestation
• Gestational hypertension– Onset of hypertension > 20 weeks gestation
(includes preeclampsia)
Preeclampsia- Definition
• Hypertensive disorder of pregnancy– With pre-existing hypertension this means:• resistant hypertension• New/worsening proteinuria• One or more adverse conditions
– With gestational hypertension• New-onset proteinuria• One or more adverse conditions
Severe Preeclampsia - Definition
• Onset before 34 weeks gestation• Associated with heavy proteinuria – 3 – 5 gms per day
• With onset of one or more adverse conditions
Definition
• Proteinuria– Indicates glomerular dysfunction– Urine protein > +2 on dipstick– Urine protein > 200 mg/L on 24 hour collection or
urine protein/creatinine ratio > 0.03 on spot check– 24 hour urine analysis should be considered if
urine protein > +1 on dipstick
• Edema is NOT part of the definition
Preeclampsia Adverse Conditions (1)
• Vascular/Pulmonary– BP • sBP > 160 mm Hg• dBP > 110 mm Hg
– Pulmonary edema– Chest pain– Shortness of breath (dyspnea)
Preeclampsia Adverse Conditions (2)
• Renal– Oligouria– Elevated serum creatinine– Serum albumin <20 g/L
• Hepatic– Abdominal/epigastric/right upper quadrant pain– Severe nausea or vomiting– Elevated liver enzymes – AST, ALT, LDH
Preeclampsia Adverse Conditions (3)
• Central Nervous System– New or unusual headache– Seizures (eclampsia)– Visual disturbances
• HELLP Syndrome– Hemolysis– Elevated liver enzymes (AST, ALT, LDH)– Low platelet count
Preeclampsia Adverse Conditions (4)
• Hematological– Decreased platelets <100,000– Disseminated intravascular coagulopathy (DIC)
Hypertension & Fetal consequences
• Intrauterine growth restriction (IUGR)• Oligohydramnios• Placental abruption• Prematurity• Fetal compromise• Intrauterine fetal death
Incidence• 10% of all pregnancies complicated by
hypertension– one third of these will have proteinuria
• majority of preeclampsia in nulliparous patients– 2 to 5 %– Increased mortality risk in older gravidas– Increased risk in pregnancy with new partner
• multiparas have increased risk with preexisting hypertension, renal disease, diabetes mellitus
• preeclampsia is a leading case of direct maternal mortality
Preeclampsia Morbidity & Mortality
• Maternal– Stroke (sBP > 160 mm
Hg)– Pulmonary edema– Jaundice– Seizure (eclampsia)– Placental abruption– Acute renal failure
• Fetal– Oligohydramnios– Intrauterine growth
restriction (SGA)– Metabolic acidosis
• 5 minute APGARS <3• Requiring respiratory
ventilation at birth
– Fetal death
Assessment of woman - Clinical
• Blood Pressure– assess severity– ensure consistency in measuring– relationship of high BP to DIC not seizure
• Cardiorespiratory– chest pain– dyspnea– distended neck veins
Assessment of woman – Clinical (cont’d)
• Central Nervous System– presence and severity of headache– vision disturbances – blurring, scotomata– tremulousness, irritability, somnolence– hyperreflexia
• Hematologic– bleeding, petechiae
• Hepatic– RUQ and epigastric pain– nausea and vomiting
• Renal– urine output and colour
Assessment of woman - Laboratory• Hematologic– hemoglobin, platelets (HELLP), blood film– PTT, INR, fibrinogen, FDP– LDH (HELLP), uric acid, bilirubin
• Hepatic– ALT, AST (HELLP)– glucose and ammonia to rule out AFLP
• Renal– proteinuria– creatinine, urea, uric acid
Assessment of Fetus
• Fetal movement• Fetal heart rate assessment, by auscultation
or EFM• Fetal growth assessment by fundal height
measurement or ultrasound• Where resources exist:– Biophysical profile (BPP)– Amniotic fluid volume (AFV)
Maternal Stress Reduction
• Component of maternal BP is adrenergic• Maternal discomfort must be minimized• Several components
– well planned management protocol (team approach)
– clear explanation of plan to woman/family– quiet, dimly lit, isolated room– minimization of negative stimuli
Management of symptoms
• Nausea and vomiting– antiemetic of choice
• Maternal pain (headache, RUQ or epigastric pain)– morphine 2 – 4 mg IV– antacid– minimize palpation
Anti-hypertensive therapy - Goals
• minimize risk of maternal cerebro-vascular accident
• prevent placental abruption• gain time for further assessment and
treatment– stabilize for transfer to higher level facility, if
needed– facilitate vaginal delivery when possible– prolong gestation where appropriate/feasible
Anti-hypertensive agents
• Labetalol (Trandate®, Normodyne®)• Hydralazine (Apresoline®)• Nifedipine (Adalat-PA®)• Clonidine
Anti-hypertensive agents
Hydralzine• direct arteriolar vasodilator• rapid onset of action useful for hypertensive
crisis• can be used orally or via IV• should not be first choice due to high rate of
maternal/fetal adverse effects
Anti-hypertensive agents
Hydralzine (cont’d)Dosage:– 5 mg IV test dose, followed by 5 – 10 mg IV q 20
min.– infusion 0.5 – 10 mg/hourCaution: unpredictable hypotension with
resulting fetal compromiseSide Effects: flushing, headache, and maternal
tachycardia
Anti-hypertensive agents
Labetalol• Combined α and β-blocker with Intrinsic
Sympathetic Activity• Rapid onset of action useful for hypertensive
crisis• Can be used orally or via IV
Anti-hypertensive agents
LabetalolDosage: maximum 300 mg IV dose
– bolus 10 – 20 mg IV q 10 min. up to 300 mg– infusion 1 – 2 mg/min., increasing by 1 mg/ q 15
min. to a maximum of 4 mg/min. IB titrated to BP
Caution: asthmaSide Effects: fetal bradycardiaBenefits: dependable, familiar
Anti-hypertensive agents
Nifedipine• Calcium channel blocker• Direct relaxation of vascular smooth muscle• Oral agent• Not sub-lingual administration
Anti-hypertensive agents
NifedipineDosage:
– Adalat PA 10 mg bid may increase to 40 mg bid– Adalat XL starting dose 30 mg/day
Caution: magnesium toxicity (?) with use of Adalat and MgSO4 in combination
Side Effects: flushing, headache, palpitations, tocolysis
Anti-hypertensive agents
Clonidine• Potent α-2-adrenoceptor central stimulant• Used to treat mild and moderate
hypertensionDosage:
– 150 µg infused in normal saline– Per os: 0.1 mg to 0.2 mg twice a day
Side Effects: sedation, dry mouth
Seizures
• Blood pressure not a reliable predictor of who will have seizures
• No benefit to prophylaxis in absence of proteinuria
• High ‘number needed to treat’ to prevent seizure
• agents not innocuous nor completely effective• MgSO₄ is agent of choice when seizure
prophylaxis is felt to be indicated
Seizures – Possible complications
• Fetal bradycardia (more than 50%)• Placenta abruptio (10% to 20%)• Aspiration pneumonia (5% to 10%)• Cerebral hemorrhage, especially in the older
woman• Temporary loss of sigh with progressive recovery
within one week (10%)• Coma due to the cerebral edema (5%)• Psychosis that can last 2 weeks (less than 5%)
Seizures - Management
Magnesium sulfate (MgSO₄)– agent of choice for prophylaxis and termination of seizures– will control seizures within 1 to 2 hours– most woman will regain consciousness and orientation– Superior to phenytoin for prophylaxis– superior to phenytoin or diazepam in preventing
recurrence– decreased maternal morbidity and mortality with use for
cessation of seizure activity– no difference in perinatal mortality– should be on ‘essential drug list’ in every country
Seizures - Management
Magnesium sulfateLoading Dose:
– 4 g IV (20 ml of 20% solution) slowly over 20 min.– followed by 1 – 4 g / hour IV
OR– 5 g IM (10 ml of 50% solution) with 1 ml of 20%
lidocaine in same syringe twice, each side– followed by 5 g IM q 4 h
Seizures - Management
Magnesium sulfateSide Effects: weakness, paralysis, cardiac
toxicityMonitor: reflexes, respiration, level of
consciousnessCAUTION: Confirm the concentration of this
medication when calculating the dosage
Seizures - Management
Magnesium sulfateOverdose:• observe closely for possible side effects including
weakness, respiratory paralysis, somnolence• especially high risk in those with oliguria or those
receiving calcium channel blockersANTIDOTE• stop magnesium sulfate infusion• give calcium gluconate 1g IV (10 ml of 10%
solution) over 10 minutes
Seizures – Management protocols
Every labour and delivery unit should establish and post protocols for the use of magnesium sulfate.
Parameters should include:• Preparation of medication• Assessments required prior to administration• Administration protocol• Assessment for side effects• Management of toxicity• Documentation
Seizures – Differential diagnosis
When magnesium sulfate therapy fails to control seizures, consider other possible causes:• chronic epilepsy• encephalitis• meningitis• cerebral tumor• cerebral vascular malformation (aneurysm)• secondary cerebral abscesses due to parasitic or
fungal infections• severe malaria
Transport
• Consider transport only if local resources limited and maternal/fetal condition permits
• Stable maternal BP• Reassuring fetal status• Administer appropriate anti-hypertensive agents• Give MgSO₄, if appropriate• Consult with referral centre and woman/family• Woman should be transported on her left side,
accompanied by skilled birth attendant
Delivery – “The Cure”• Timely delivery minimizes maternal and neonatal
morbidity and mortality• Optimize maternal status before interventions to
deliver• Delay delivery to gain fetal maturity and to allow
transfer only when maternal and fetal condition permit
• Gestational hypertension is a progressive disease, expectant management is potentially harmful in presence of severe disease or suspected fetal compromise
When to deliver
≥37 weeks with gestational hypertension≥34 weeks with severe gestational hypertension<34 weeks with any of:
– poorly controlled diastolic BP– laboratory evidence of worsening end-organ
involvement– suspected fetal compromise– uncontrolled seizures– symptoms unresponsive to appropriate therapy
Management - Overview
• stress reduction (helps in 50% of cases)• clinical and laboratory assessment of mother and fetus• treat blood pressure if diastolic BP ≥ 110 mmHg• treat nausea and vomiting, and other symptoms
including pain effectively• consider seizure prophylaxis• consider timing and mode of delivery (induction)• consider transfer to referral center, if applicable• closely monitor the woman in the early post-partum
Case:
A 32 year old G2P1 woman presents for her routine prenatal visit at 32 weeks’ gestation. Her blood pressure is 140/90. In the past, throughout her pregnancy it has been 115/75 to 130/85. Her weight is 105 kg.
What steps do you perform as part of your initial investigation?
Case:
• Repeat measurement in ≥ 4 hour intervals unless very high
• Assess for proteinuria (urine dip stick)• Question woman about any signs and
symptoms of gestational diabetes• Order initial blood work: (liver function test,
uric acid, platelets)
Case (cont’d)
Repeat blood pressures over the next three hours range from 140/90 to 155/95
Urine dip stick: 3+What is your management plan?
Case:
• Delivery is the cure• Monitor blood pressure and control with
medications if necessary• Monitor fetal well being
Key Messages
• Health care providers must be able to promptly recognize the various presentations of hypertension in pregnancy.
• Health care providers must be able to identify appropriate monitoring and management of gestational hypertension, including having a plan for referral and transfer to a higher-level health care facility when needed.
Key Messages (cont’d)
• Health care providers must be able to take emergency measures to stop seizure activity, and to stabilize the woman.
• Magnesium sulfate is a cost effective and life-saving drug. Health care providers must advocate with national health authorities to ensure a continuous and an uninterrupted supply of this medication as part of their safe motherhood programs.