Hypertension in Pregnancy

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Hypertension in Pregnancy

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Hypertension in Pregnancy

  1. 1. http://crisbertcualteros.page.tl HYPERTENSION IN PREGNANCY
  2. 2. DEFINITION OF TERMS <ul><li>HYPERTENSION </li></ul><ul><li>bp of 140/90 mm Hg or more on two separate occasions with the patient supine or in sitting position (after resting for 5 mins) using Korotkoff V to measure the diastolic reading </li></ul>
  3. 3. Normal Pregnancy Blood Pressure
  4. 4. DEFINITION OF TERMS <ul><li>PROTEINURIA </li></ul><ul><li>urinary protein spillage of 300 mg/24 hrs or more or 100 mg/dl concentration or more in 2 random specimens taken 6 hrs apart or +1 on dip stick method </li></ul>
  5. 5. HYPERTENSIVE DISORDERS COMPLICATING PREGNANCY <ul><li>GESTATIONAL HYPERTENSION </li></ul><ul><li>PREECLAMPSIA </li></ul><ul><li>ECLAMPSIA </li></ul><ul><li>CHRONIC HYPERTENSION </li></ul><ul><li>PREECLAMPSIA SUPERIMPOSED ON CHRONIC HYPERTENSION </li></ul>
  6. 6. GESTATIONAL HYPERTENSION <ul><li>BP > 140/90 mm Hg for the 1 st time during pregnancy </li></ul><ul><li>No proteinuria </li></ul><ul><li>BP returns to normal < 12 wks postpartum </li></ul><ul><li>Final diagnosis made only postpartum </li></ul>
  7. 7. PREECLAMPSIA <ul><li>Minimum Criteria: </li></ul><ul><li>BP > 140/90 mm Hg after 20 wks gestation </li></ul><ul><li>Proteinuria > 300 mg/24 hrs or > 1+ dipstick </li></ul>
  8. 8. <ul><li>In which of the ff clinical situations is preeclampsia the most likely consideration: </li></ul><ul><li>+++ bipedal edema, ++ urinary proteins </li></ul><ul><li>BP - 150/100, + urinary proteins </li></ul><ul><li>BP - 160/110, ++ bipedal edema </li></ul><ul><li>+++ urinary proteins, serum creatinine - 3 mg/dl </li></ul>
  9. 9. ECLAMPSIA <ul><li>Seizures that cannot be attributed to other causes in a woman with preeclampsia </li></ul><ul><li>Epilepsy, Encephalitis, Meningitis, Cerebral tumor, Ruptured Cerebral Aneurysm </li></ul><ul><li>Grand mal type </li></ul><ul><li>May be encountered up to 10 days postpartum </li></ul>
  10. 10. CHRONIC HYPERTENSION <ul><li>BP > 140/90 mm Hg before pregnancy or diagnosed before 20 wks gestation </li></ul><ul><li>Hpn 1 st diagnosed after 20 weeks gestation and persistent after 12 weeks postpartum </li></ul>
  11. 11. CHRONIC HYPERTENSION <ul><li>Diagnosis is suggested by: </li></ul><ul><li>Hpn antecedent to pregnancy </li></ul><ul><li>Hpn detected before 20 weeks (unless there is gestational trophoblastic disease) </li></ul><ul><li>Persistent Hpn long after delivery </li></ul><ul><li>(> 12 wks postpartum) </li></ul>
  12. 12. SUPERIMPOSED PREECLAMPSIA (on Chronic Hypertension) <ul><li>New-onset proteinuria > 300 mg/24 hrs in hypertensive women but no proteinuria before 20 wks gestation </li></ul><ul><li>A sudden increase in proteinuria or blood pressure or platelet count < 100,000/ cu mm in women with hpn and proteinuria before 20 wks gestation </li></ul>
  13. 13. PREECLAMPSIA: Indications of Severity <ul><li>ABNORMALITY MILD SEVERE </li></ul><ul><li>Diastolic bp < 100 110 or > </li></ul><ul><li>Proteinuria trace- +1 persistent+2 or > </li></ul><ul><li>Headache absent present </li></ul><ul><li>Visual Dist. absent present </li></ul><ul><li>Upper abd’l pain absent present </li></ul><ul><li>Oliguria absent present </li></ul><ul><li>Convulsions absent present (ecl) </li></ul><ul><li>Serum Creatinine normal elevated </li></ul>
  14. 14. PREECLAMPSIA: Indications of Severity <ul><li>ABNORMALITY MILD SEVERE </li></ul><ul><li>Thrombocytopenia absent present </li></ul><ul><li>Hyperbilirubinemia absent present </li></ul><ul><li>Liver enzyme </li></ul><ul><li>elevation minimal marked </li></ul><ul><li>Fetal growth </li></ul><ul><li>restriction absent obvious </li></ul><ul><li>Pulm. Edema absent present </li></ul>
  15. 15. <ul><li>A 39 yr old G1P0, 32 wks gestation was admitted for severe headache. BP was noted to be 170/110. UA: +++ proteins. </li></ul><ul><li>Prenatal check-up started at 10 wks gestation. Usual BP 100-110/60-70. </li></ul><ul><li>Admitting impression is: </li></ul><ul><li>Gestational Hypertension </li></ul><ul><li>Mild Preeclampsia </li></ul><ul><li>Severe Preeclampsia </li></ul><ul><li>Chronic Hypertension with Severe Preeclampsia </li></ul>
  16. 16. <ul><li>Which of the ff women is most likely a chronic hypertensive: </li></ul><ul><ul><li>A. G4P3 with BP of 150/100 at 16 weeks gestation </li></ul></ul><ul><ul><li>B. G1P0 with BP 160/110 at 32 weeks gestation </li></ul></ul><ul><ul><li>C. G2P1 with BP of 140/100 1 day post partum </li></ul></ul><ul><ul><li>D. G2P1 with BP of 160/110 and history of preeclampsia in the first pregnancy </li></ul></ul>
  17. 17. <ul><li>Preeclampsia is more common in: </li></ul><ul><li>Women 25-30 years old than in women > 40 years old </li></ul><ul><li>Whites than in blacks </li></ul><ul><li>Singletons than in multifetal pregnancies </li></ul><ul><li>Nulliparous than in multiparous women </li></ul>
  18. 18. INCIDENCE <ul><li>More likely to develop in: </li></ul><ul><li>Woman exposed to chorionic villi for the first time </li></ul><ul><li>Woman exposed to a superabundance of chorionic villi </li></ul><ul><li>Woman with preexisting vascular disease </li></ul><ul><li>Woman genetically predisposed to hpn developing during pregnancy </li></ul>
  19. 19. PREECLAMPSIA INCIDENCE <ul><li>RISK FACTORS: </li></ul><ul><li>Nulliparity </li></ul><ul><li>Race/Ethnicity </li></ul><ul><li>Multifetal pregnancy </li></ul><ul><li>Hx of chronic hpn </li></ul><ul><li>Maternal age > 35 yrs </li></ul><ul><li>Obesity </li></ul>
  20. 20. <ul><li>Preeclampsia is more common in: </li></ul><ul><li>Women 25-30 years old than in women > 40 years old </li></ul><ul><li>Whites than in blacks </li></ul><ul><li>Single than in multifetal pregnancies </li></ul><ul><li>Nulliparous than in multiparous women </li></ul>
  21. 21. TROPHOBLASTIC INVASION Before invasion After invasion
  22. 23. HELLP SYNDROME <ul><li>H EMOLYSIS </li></ul><ul><li>E LEVATED L IVER ENZYMES </li></ul><ul><li>L OW P LATELETS </li></ul><ul><li>20% of women with severe preeclampsia </li></ul><ul><li>3 – 27% recurrence in subsequent pregnancies </li></ul>
  23. 24. PREDICTION <ul><li>ANGIOTENSIN II INFUSION </li></ul><ul><ul><li><8 ng/kg/min PPV – 20-40% </li></ul></ul><ul><li>MEAN ARTERIAL PRESSURE </li></ul><ul><li>MAP = DBP + (SBP-DBP) </li></ul><ul><ul><li>2 nd tri MAP > 90 mm Hg </li></ul></ul><ul><ul><li>3 rd tri MAP > 105 mm Hg PPV – 20-40% </li></ul></ul><ul><li>ROLL-OVER TEST </li></ul><ul><li>28-32 wks gestation </li></ul><ul><ul><li>inc. of 20 mm Hg diastolic bp or > PPV – 33% </li></ul></ul><ul><li>URINARY CALCIUM LEVEL </li></ul><ul><ul><li>hypocalciuria PPV – 32% Sensitivity – 88% </li></ul></ul>
  24. 25. PREDICTION <ul><li>URINARY KALLIKREIN EXCRETION </li></ul><ul><ul><li>decreased PPV – 91% Sensitivity – 83% </li></ul></ul><ul><li>FIBRONECTIN </li></ul><ul><ul><li>increased PPV – 12% Sensitivity – 69% </li></ul></ul><ul><li>DOPPLER VELOCIMETRY OF UTERINE ARTERY </li></ul><ul><li>18-22 wks gestation ; repeat at 24 wks </li></ul><ul><ul><li>increased uterine artery resistance </li></ul></ul><ul><li>PPV – 28% Sensitivity – 78% </li></ul>
  25. 26. PREECLAMPSIA PREVENTION <ul><li>DIETARY MANIPULATION </li></ul><ul><li>salt restriction – ineffective </li></ul><ul><li>Calcium supplementation </li></ul><ul><li>reduce risk of preeclampsia; further studies re ideal dose </li></ul><ul><li>COCHRANE 07 </li></ul><ul><li>Fish oil – ineffective </li></ul><ul><li>LOW-DOSE ASPIRIN </li></ul><ul><li>80 mg </li></ul><ul><li>moderate benefits (17% reduction in risk) for prevention of </li></ul><ul><li>preeclampsia; further studies needed (who, when, how much) COCHRANE 07 </li></ul>
  26. 27. PREECLAMPSIA PREVENTION <ul><li>ANTIOXIDANTS </li></ul><ul><li>Vitamin C </li></ul><ul><li>Vitamin E </li></ul><ul><li>studies are of poor quality; there seems to be a reduction in incidence of preeclampsia but with increased risk for preterm birth </li></ul><ul><li>COCHRANE 07 </li></ul>
  27. 28. PREECLAMPSIA MANAGEMENT <ul><li>Early Prenatal Detection </li></ul><ul><li>Prenatal check-up </li></ul><ul><li>Hospital Management </li></ul><ul><li>Hx and PE </li></ul><ul><li>Weight daily </li></ul><ul><li>Urinalysis every 2 days </li></ul><ul><li>BP every 4 hrs </li></ul>
  28. 29. PREECLAMPSIA MANAGEMENT <ul><li>Lab: Serum creatinine </li></ul><ul><li>Hematocrit </li></ul><ul><li>Platelet count </li></ul><ul><li>Serum liver enzymes </li></ul><ul><li>Fetal size and amnionic fluid evaluation </li></ul><ul><li>Reduced physical activity </li></ul><ul><li>Na and fluid intake not restricted nor </li></ul><ul><li>forced </li></ul>
  29. 30. PREECLAMPSIA MANAGEMENT <ul><li>Further management depends upon: </li></ul><ul><li>Severity of preeclampsia </li></ul><ul><li>Age of gestation </li></ul><ul><li>Condition of the cervix </li></ul><ul><li>DELIVERY – the only cure </li></ul>
  30. 31. TERMINATION OF PREGNANCY <ul><li>Near term </li></ul><ul><li>Severe Preeclampsia </li></ul><ul><li>Labor induction with oxytocin (if not otherwise contraindicated) </li></ul><ul><li>Vaginal delivery </li></ul><ul><li>Cesarean delivery </li></ul>
  31. 32. PREECLAMPSIA DRUG THERAPY <ul><li>MAGNESIUM SULFATE </li></ul><ul><li>to control convulsions </li></ul><ul><li>ANTIHYPERTENSIVE THERAPY </li></ul><ul><li>GLUCOCORTICOIDS </li></ul><ul><li>to enhance fetal maturation in </li></ul><ul><li>pregnancies between 24-34 wks </li></ul><ul><li>decreased incidence of RDS </li></ul><ul><li>does not worsen maternal HPN </li></ul><ul><li>significant but transient improvement in </li></ul><ul><li>platelet count </li></ul>
  32. 33. <ul><li>Which of the ff parameters should be met before giving the subsequent doses of Magnesium sulfate: </li></ul><ul><li>liver enzymes should be normal </li></ul><ul><li>serum magnesium levels should not be more than 2 MEq/L </li></ul><ul><li>patellar reflexes should be present </li></ul><ul><li>BP should be 160/110 or more </li></ul>
  33. 34. MAGNESIUM SULFATE <ul><li>Effective anticonvulsant </li></ul><ul><li>No CNS depression </li></ul><ul><li>Not given to treat hypertension </li></ul><ul><li>Indications: Severe Preeclampsia </li></ul><ul><li>Eclampsia </li></ul><ul><li>Mild Preeclampsia in labor - ? </li></ul><ul><li>Given during labor and for 24 hours postpartum </li></ul>
  34. 35. MAGNESIUM SULFATE Dosage Schedule <ul><li>CONTINUOUS IV INFUSION </li></ul><ul><li>Loading Dose – 4-6 gms MgSO4 in 100 ml of IV fluid over 15 – 20 mins </li></ul><ul><li>Maintenance Infusion – 2 g/hr in 100 ml IV fluid </li></ul><ul><li>Discontinue 24 h after delivery. </li></ul>
  35. 36. MAGNESIUM SULFATE Dosage Schedule <ul><li>INTERMITTENT IM INJECTIONS </li></ul><ul><li>Loading Dose – 4g 20% sol MgSO4 IV at rate not > 1g/min </li></ul><ul><li>5 g 50% MgSO4 deep IM to each buttock (+ 1 ml 2% LIDOCAINE) </li></ul><ul><li>If convulsions persist after 15 mins 2 g 20% IV at rate not > 1g/min </li></ul>
  36. 37. MAGNESIUM SULFATE Dosage Schedule <ul><li>Maintenance – 5 g 50% deep IM every 4 hrs provided that: </li></ul><ul><li> - urine output >100ml/4 hrs </li></ul><ul><li>- patellar reflex is present </li></ul><ul><li>- respirations are not depressed </li></ul><ul><li>Discontinue 24 hrs after delivery </li></ul>
  37. 38. MAGNESIUM SULFATE Toxicity <ul><li>Plasma Mg Level </li></ul><ul><li>Normal <2 mEq/L </li></ul><ul><li>Therapeutic Level 4-7 mEq/L </li></ul><ul><li>Absent Patellar Reflex 10 mEq/L </li></ul><ul><li>Respiratory Paralysis 12 mEq/L </li></ul><ul><li>Antidote: Ca gluconate – 1g IV </li></ul>
  38. 39. <ul><li>Which of the ff parameters should be met before giving the subsequent doses of Magnesium sulfate: </li></ul><ul><li>liver enzymes should be normal </li></ul><ul><li>serum magnesium levels should not be more than 2 MEq/L </li></ul><ul><li>patellar reflexes should be present </li></ul><ul><li>BP should be 160/110 or more </li></ul>
  39. 40. ANTIHYPERTENSIVES <ul><li>HYDRALAZINE </li></ul><ul><li>Indication: persistent systolic bp 160 mm Hg or > and /or diastolic bp greater than 105 mm Hg </li></ul><ul><li>Dose: </li></ul><ul><li>5-10 mg at 15-20 min intervals </li></ul><ul><li>until diastolic bp is 90-100 mm Hg </li></ul>
  40. 41. ANTIHYPERTENSIVES <ul><li>ACE-INHIBITORS </li></ul><ul><li>Contraindicated in pregnancy </li></ul><ul><li>Complications </li></ul><ul><li>Oligohydramnios </li></ul><ul><li>Fetal growth restriction </li></ul><ul><li>Bony malformations </li></ul><ul><li>Limb contractures </li></ul><ul><li>Persistent PDA </li></ul><ul><li>Pulmonary hypoplasia </li></ul><ul><li>Respiratory Distress Syndrome </li></ul><ul><li>Prolonged neonatal hypotension </li></ul><ul><li>Neonatal Death </li></ul>
  41. 42. <ul><li>Which of the ff antihypertensives is contraindicated in pregnancy: </li></ul><ul><li>Methyldopa </li></ul><ul><li>Hydralazine </li></ul><ul><li>Ace-inhibitors </li></ul><ul><li>Beta-blockers </li></ul>
  42. 43. DIURETICS <ul><li>Not used to lower bp </li></ul><ul><li>Produce intravascular volume depletion </li></ul><ul><li>Worsen maternal hemoconcentration </li></ul><ul><li>Use is limited to presence of pulmonary edema (FUROSEMIDE) </li></ul><ul><li>May be used in persistent severe postpartum hypertension </li></ul>
  43. 44. FLUID THERAPY <ul><li>LACTATED RINGER SOLUTION </li></ul><ul><li>60-125 ml/hr </li></ul><ul><li>Infusion of large fluid volumes increase the risk of pulmonary and cerebral edema </li></ul>
  44. 45. OPERATIVE DELIVERY
  45. 46. <ul><li>FORCEPS DELIVERY </li></ul><ul><li>TYPES </li></ul><ul><li>Outlet Forceps </li></ul><ul><ul><li>Scalp is visible at introitus without separating the labia </li></ul></ul><ul><ul><li>Fetal skull has reached pelvic floor </li></ul></ul><ul><ul><li>Sagittal suture is in A-P diameter or right or left OA or OP position </li></ul></ul><ul><ul><li>Fetal head is at or on perineum </li></ul></ul><ul><ul><li>Rotation does not exceed 45 </li></ul></ul><ul><ul><li>degrees </li></ul></ul>
  46. 47. <ul><li>FORCEPS DELIVERY </li></ul><ul><li>TYPES </li></ul><ul><li>Low Forceps </li></ul><ul><ul><li>Leading point of fetal skull is at St +2 cm or > and not on pelvic floor </li></ul></ul><ul><ul><ul><li>Rotation is 45 degrees or less to occiput anterior or posterior </li></ul></ul></ul><ul><ul><ul><li>Rotation is greater than </li></ul></ul></ul><ul><ul><ul><li>45 degrees </li></ul></ul></ul><ul><li>Mid Forceps </li></ul><ul><ul><li>Station above +2 cm but head is engaged </li></ul></ul><ul><li>(High Forceps) </li></ul>
  47. 48. <ul><li>Forceps extraction was contemplated at full dilatation with the vertex at the pelvic floor (station +3/3), direct occiput anterior. The type of procedure is: </li></ul><ul><li>A. outlet forceps extraction </li></ul><ul><li>B. low forceps extraction </li></ul><ul><li>C. midforceps extraction </li></ul><ul><li>D. high forceps extraction </li></ul>
  48. 49. <ul><li>FORCEPS APPLICATION </li></ul><ul><li>PREREQUISITES </li></ul><ul><li>Head must be engaged </li></ul><ul><li>Fetus must present as vertex or face with chin anterior </li></ul><ul><li>Position of head must be precisely known </li></ul><ul><li>Cervix must be completely dilated </li></ul><ul><li>Membranes must be ruptured </li></ul><ul><li>There should be no suspected cephalo-pelvic disproportion </li></ul>
  49. 50. <ul><li>In which of the ff conditions can forceps be safely applied: </li></ul><ul><li>A. Cervix 9 cm Station +3 ruptured membranes direct occiput anterior </li></ul><ul><li>B. Cervix 10 cm Station +2 ruptured membranes left occiput anterior </li></ul><ul><li>C. Cervix 10 cm Station +3 intact membranes direct occiput posterior </li></ul><ul><li>D. Cervix 10 cm Station +1 ruptured membranes direct mentoposterior </li></ul>
  50. 51. CESAREAN SECTION DEFINITION <ul><li>Birth of a fetus through incisions in the abdominal wall (laparotomy) and the uterine wall (hysterotomy) </li></ul>
  51. 52. CESAREAN SECTION MOST COMMON INDICATIONS <ul><li>Repeat cesarean </li></ul><ul><li>Dystocia or failure to progress in labor </li></ul><ul><li>Breech presentation </li></ul><ul><li>Fetal distress </li></ul>
  52. 53. ABDOMINAL INCISION cosmetic advantage less likely to dehisce Pfannenstiel TRANSVERSE when more room needed easier to extend upward less time consuming infraumbilical; midline VERTICAL
  53. 54. UTERINE INCISION <ul><li>CLASSICAL INCISION </li></ul><ul><ul><li>More likely to rupture in the next pregnancy </li></ul></ul><ul><li>LOW VERTICAL (KRONIG) INCISION </li></ul><ul><ul><li>May tear through cervix </li></ul></ul><ul><li>LOW TRANSVERSE (KERR) INCISION </li></ul><ul><ul><li>Less blood loss </li></ul></ul><ul><ul><li>Easiest to repair </li></ul></ul><ul><ul><li>Located at a site least likely to rupture in next pregnancy </li></ul></ul><ul><ul><li>Does not promote adherence of bowel or omentum to incisional line </li></ul></ul>
  54. 55. CLASSICAL CESAREAN SECTION INDICATIONS <ul><li>Lower uterine segment not accessible </li></ul><ul><ul><li>Bladder adhesions </li></ul></ul><ul><ul><li>Lower uterine segment myoma </li></ul></ul><ul><ul><li>Invasive carcinoma of cervix </li></ul></ul><ul><li>Transverse lie of a large fetus, w/ ruptured membranes & impacted shoulder </li></ul><ul><li>Anteriorly implanted placenta previa </li></ul><ul><li>Lower uterine segment not thinned out </li></ul><ul><ul><li>very small fetuses in breech presentation </li></ul></ul>
  55. 56. KRONIG KERR
  56. 57. VAGINAL BIRTH AFTER CESAREAN SECTION <ul><li>CRAIGIN’S DICTUM: </li></ul><ul><li>“ Once a cesarean, </li></ul><ul><li>always a cesarean” </li></ul>
  57. 58. VAGINAL BIRTH AFTER CESAREAN SECTION <ul><li>RECOMMENDATIONS FOR SELECTION OF CANDIDATES FOR VBAC </li></ul><ul><li>No more than 1 prior low transverse cesarean delivery </li></ul><ul><li>Clinically adequate pelvis </li></ul><ul><li>No other uterine scars or previous rupture </li></ul><ul><li>Availability of competent physician </li></ul><ul><li>Availability of anesthesia and personnel for emergency cesarean delivery </li></ul>
  58. 59. UTERINE RUPTURE INCIDENCE FF TRIAL OF LABOR <ul><li>Type of prior uterine incision </li></ul><ul><ul><li>Classical CS – 12% (7% before labor) </li></ul></ul><ul><ul><li>T-incisions </li></ul></ul><ul><li>Number of prior cesareans </li></ul><ul><ul><li>One prior CS – 0.6-0.8% </li></ul></ul><ul><ul><li>Two prior CS – 1.8-3.7% </li></ul></ul><ul><li>Use of Oxytocin </li></ul><ul><ul><li>2.3% (oxytocin-induced labors) vs 1% </li></ul></ul><ul><ul><li>Oxytocin – may be used w/ caution </li></ul></ul>
  59. 60. <ul><li>In a patient you are monitoring for a trial of labor after a previous cesarean section, you see sudden severe fetal heart rate decelerations on the cardiotocograph. Which of the ff should you initially consider: </li></ul><ul><li>A. cord compression </li></ul><ul><li>B. abruptio placenta </li></ul><ul><li>C. uterine hyperstimulation </li></ul><ul><li>D. ruptured uterus </li></ul>
  60. 61. <ul><li>You see a 30 yr old G2P1, 9 weeks AOG, at the out-patient clinic for her first prenatal check-up. She had a classical cesarean section on her first delivery and she wants a trial of labor for this pregnancy. TVS reveals an 9-week live intrauterine pregnancy. Plan for delivery is: </li></ul><ul><li>A. induce labor at term </li></ul><ul><li>B. allow a trial of labor if fetus is of adequate size and in vertex presentation at term </li></ul><ul><li>C. repeat cesarean section at the first sign of labor </li></ul><ul><li>D. repeat cesarean section at term before onset of labor </li></ul>
  61. 62. <ul><li>Please visit: </li></ul><ul><li>http://crisbertcualteros.page.tl </li></ul>
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