Hypertensive Disorder of Pregnancy


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Hypertensive Disorder of Pregnancy

  1. 1. Af r ica int er nat ional univer sit y f acult y of medicine and healt h sciences www.doctor.sd Hypertensive Disorder of Pregnancy Presented by: Dr. Elwaleed Mudather Gyae. & obs
  2. 2. Hypertensive disorders of pregnancy www.doctor.sd o Hypertensive disorders in pregnancy are a major cause of maternal and fetal mortality - In the developing countries the maternal mortality is about 70-120 per 100.000 maternities - in UK it is about 0.9 per 100.000 maternities accounting for about 16% of all maternal death - The over all perinatal mortality is around 35 per 1000 total birth but may reach 160 per 1000 total birth is severe disease
  3. 3. www.doctor.sd o Definition of hypertension:- -BP should be measured in the sitting position . - The sphygmomanometer at the level of the heart . - Using a cuff wide enough to cover 80% of arm - Hypertension is defined as:- o BP 140 over 90 mmHg or more measured in two consecutive occasions 4 hours or more apart Increase of 30 mmHg systolic or 15 mmHg DBP. From the pre pregnancy BP
  4. 4. www.doctor.sd Definition of proteinuria o 300 mg or more total protein excretion in 24hours urine collection. Classification - Based on these definitions hypertensive disorders of pregnancy can be classified in to
  5. 5. 1) GESTATIONAL HYPERTENSION www.doctor.sd Onset of Hypertension without proteinuria arising for the first time after 20 week of gestation with resolution to baseline by 12 week postpartum .
  6. 6. 2) pre-eclampsia www.doctor.sd Hypertension of at least 140 over 90 mmHg recorded on two separate occasions at least 4 hours apart & in the presence of at least 300mg of protein in 24 hours collection of urine arising de novo after the 20th week of gestation in a previously normotensive women & resolving completely by the 6th postpartum week
  7. 7. 3)Pre existing Chronic hypertension with or without renal disease:- www.doctor.sd hypertension. diagnosed before pregnancy or in the first 20th week of pregnancy. Can be ;- o 1- Essential hypertension or o 2-Secondary hypertension. o --glomerulonephritis. o --renal artery stenosis. o --diabetic nephropathy. o --Polycystic kidneys. o --SLE. o --conns syndrome --Coarctation of the aorta. -
  8. 8. 4) Chronic hypertension superimposed by pre-eclampsia www.doctor.sd proteinuria ,or other symptoms &signs of pre- eclampsia developing for the first time in pregnancy in a women with a chronic hypertension.
  9. 9. GESTATIONAL HYPERTENSION www.doctor.sd 1-more in multi than primigravida 2- frequency and severity increases with maternal age. 3- often recurs and familial 4- those women have a high incidence of hypertension later in life. .
  10. 10. www.doctor.sd pre- eclampsia - It is a multi system disease specific to pregnancy in human. - Affecting 10- 15% of PG and 5 – 7% of multigravida .
  11. 11. www.doctor.sd o Risks factors includes:- - 1-More common at the extremes of age - 2-More common in PG - 3-More common in the short and obese women - 4-Is familial and may recur - 5-More common in cases with excessive amount of chorinic tissue such as:- ---hydatidiform mole 70% of cases - ---multiple pregnancy 25% of cases - ---hydrops fetalis - ---poorly controlled diabetes
  12. 12. www.doctor.sd - 6--more common in patient with pre existing chronic renal disease and previous PE. - 7-Is not associated with increase incidence of hypertension in later life. - Clinical feature:- PE is characterized by lack of symptoms until an advanced stage reached. Patient may report. Swelling of feet and ankle, difficulty in putting on her shoes, tightness of rings and tightness and puffiness of the face. Sign includes hypertension and non dependent oedema. urine may show proteinuria
  13. 13. Aetiology of pre-eclampsia:- www.doctor.sd - Cause is unknown - Genetic factors together with an abnormal immunological reaction to the first pregnancy have been postulated this leads to defective trophoblast invasion of the spiral arteries and as a result the spiral arteries remain muscular, un dilated and respond to presser agent such as angiogenesis2. placental blood flow is therefore reduced & this results in release of factors in the maternal circulation that targeted the vascular endothelium which result in wide vascular endothelial dysfunction
  14. 14. www.doctor.sd with the development of hypertension, altered vascular reactivity, Activation of the coagulation cascade and multi system damage. - generalized maternal endothelial damage affects every system in the body with the following effects.
  15. 15. www.doctor.sd - Maternal effects - Cardio vascular and pulmonary effect:- * hypertension * Peripheral oedema due to leaking endothelium *Cardiac failure due to the high systemic vascular resistance *Pulmonary oedema may arise due to an imbalance between a reduced colloid osmotic pressure, and the pulmonary capillary wedge pressure - *Acute adult respiratory distress syndrome also can occur.
  16. 16. www.doctor.sd The kidneys:- - glomerular endothelial cells swell- block the capillaries. - Impaired renal function may result in a rise in plasma urate (an early feature), urea, and creatinine. - Proteinuria develops.
  17. 17. www.doctor.sd o The liver:_ - Hepato-celluar damage can occur due to fibrin deposits in the sinusoids. - In some cases jaundice and severe liver damage can follow. - The potentially dangerous HELLP syndrome (haemolysis, elevated liver enzyme and low platelets) must be considered in severe cases. - Subcapsular haemorrhage and even liver rupture my occur
  18. 18. www.doctor.sd o Coagulation:- - Increasingly generalized endothelial damage commonly causes slight intravascular coagulation. - Disseminated intravascular coagulation (DIC) is rare but serious Central nervous system:- - Sudden elevation of BP can causes arterial damage and loss of vascular auto regulation which may leads to cerebral oedma, haemorrhages and infacts
  19. 19. www.doctor.sd - Cerebral haemorrhage & pulmonary oedema are the commonest causes of maternal death from eclampsia. o Placenta:- - Hypertension is associated with constriction of uterine blood vessel. Pathological change in spiral arteries and fibrin deposition, infacts and other pathological change.
  20. 20. Complication of pre-eclampsia:- www.doctor.sd A- feto- placental - Abruptio placenta - IUGR - IUFD - Preterm labour B- maternal complication:-  Eclampsia  Pulmonary oedema:- --- secondary to hypertension ---Adult respiratory distress syndrome
  21. 21. www.doctor.sd - --- following prolonged hypoxia - --- fluid over load - Cardiac failure - CVA and other haemorrhages due to fibrinoid necrosis and rupture of wall of small vessels. - HELLP syndrome o Renal failure due to : ---ischaemia --- tubular necrosis --- cortical necrosis
  22. 22. www.doctor.sd o DIC. o blindness o Micro angiopathic haemolytic anaemia acute or sub acute haemolysis with the appearance of fragmented RBCs and reticuloytes in the prephral blood smear associated with thrombocytopenia haemoglobinaemia and hemoglobinuria
  23. 23. Management of pre-eclapsia:- www.doctor.sd o The aim of management is:- o To minimize the hazards both to the mother and to the fetus until such a time as the fetus stand a better chance of survival outside the uterus than inside, or until further prolongation of pregnancy creates a threats to the mother life or health
  24. 24. Antenatal manangement www.doctor.sd - Initial assessment - all patient found to have hypertension should be admitted to hospital or obstetric day unit for full initial assessment and plan of management should be formulated according to the severity of disease and the duration of pregnancy.
  25. 25. www.doctor.sd - Classification according to severity: - hypertensive disorders can be classified according to severity to 1.mild:- DBP 90 and more but less than 110 mmHg No significant proteinuria Normal fetal growth 2. sever:- - DBP 110 mmHg and more or - DBP 90 and more with significant proteinuria or fetal growth restriction.
  26. 26. www.doctor.sd - 3- imminent eclampsia:- - -DBP 90 or more with symptoms such as - Severe persisting headache usually frontal but may be occipital. - Visual disturbance (flash of light diplopia) - -upper abdominal pain, nausea, vomiting (due to oedema of gastric mucosa, subcapsular Hge and stretching of liver capsule ). - Oliguria (urine less than 30 ml per hour) - Hyperflexia or clonus -
  27. 27. www.doctor.sd - 4- eclampsia:- - -DBP 90 and more +convulsion (grand mal epileptiform convulsion). Eclampsia - In majority of cases it occur antepartum usually in the last quarter of pregnancy. - In few case it occurs intrapartum or postpartum - Haemorrhagic complication are common.
  28. 28. www.doctor.sd neurological complications may include coma focal motor deficits and cortical blindness. Differential Diagnosis:- o Cerebral malaria o CVA o Amniotic fluid embolism o Water intoxication o Meningitis Pathology of Eclampsia:- Is thought to involve cerebral vasospasm leading to ischaemia, disruption of the blood brain barrier
  29. 29. www.doctor.sd 1) Mild hypertension without IUGR or impairment of fetal well being:- - In general implies minimal or no added risk to the mother or fetus. - No immediate indication for antihypertensive or other treatment. - Out patient surveillance on weekly ANC visits with assessment of symptoms. Weight, BP, fetal size & movement. Amniotic fluid volume, Urine for protein CTG, scan for growth at 28- 34wks
  30. 30. www.doctor.sd - Rest at home but it benefits have never been clearly defined. - Sedation is not necessary. - If labour has not commenced at term induction may be advocated largely on empirical ground. 2) severe PIH:- o Admission to hospital o BP and other vital sign 6 hourly o Urine for protein daily
  31. 31. www.doctor.sd - Fetal movement (kick chart) - Clinical examination includes fundal height and amount of liquor. - Weekly renal and liver function test as well as platelets count, coagulation status and protein excretion. Elevated urate levels and falling platelets reflect worsening of the clinical condition. - Fetal size and liquor volume are assessed by ultra sound.
  32. 32. www.doctor.sd - CTG is repeated at intervals determined by clinical status and can be enforced by a biophysical profile - Doppler ultra sound :- absent or reversed flow in the umbilical artery during diastoly is associated with high perinatal mortality. - Antihypertensive:- - Is to protect the mother from the risk of cerebral haemorrhage, - left Ventricular failure, renal failure, DIC and convulsion.
  33. 33. www.doctor.sd - Is indicated when the mean arterial BP exceed the threshold for vessel injury(140mmHg) - The drugs have no effect on the progress of the disease. Therapeutic options include the following. 1. Methyldopa - central alpha stimulants - Dose up to 2gm/day
  34. 34. www.doctor.sd - Side effect include sedation ,headache, nightmares depression, dizziness, haemolytic anaemia positive coombs test. - 2- calcium channel blockers e.g. Nifedipine - 3- vasodilators e.g hydrallazine - 4- labetolol (100—200mg) - has both Beta and alfa adrenoceptor blocking action
  35. 35. www.doctor.sd - Termination of pregnancy:- - The definitive treatment of severe PIH is delivery of the fetus. - In most cases labour should be induced at completed 37wks - Elective C/S may be considered in patient less than 34wks and when there is some additional obstetric indication.
  36. 36. www.doctor.sd - Management of imminent eclampsia and Eclampsia:- - Left lateral position, secure air way, oxygen. - Control of fits with anticonvulsants : - 1- diazpam dose 10mg I.V in 4min. Followed by 40mg in 500cc of 5%Dext.water 2-4ml/hour. Safe- immediate action, but it has short action& can sedate the fetus & the patient - Magnezium sulphate: is the drug of first choice it is - - Anti convulsant ,Antihypertensive and tocolytic with prolong .action
  37. 37. www.doctor.sd - Therapeutic dose is close to toxic dose. - Dose ;-- intravenous;- loading dose 4gm in 100ml over 15 -20 min. Maintenance dose 1 - 1.5gm hourly for 24 hours from the last fit. intramuscular;- loading dose10 gm as 50% sol. 5gm in each buttock. maintenance 5gm as 50% sol. 4houly - Monitoring by reflexes, respiratory rate (>16/min) . urinary out put ( >30ml/ hour) and blood level. - Toxic effect include hypotension and respiratory failure. - Antidote is Calcium. gluconate. - 3- phenytoin - 4- thiopentone
  38. 38. www.doctor.sd o Control of hypertension:- 1- hydralazine : 5mg intravenous repeated every 20 min to a maximum cumulative dose 20 mg. 2- labetolol :- 40mh I.V escalated to 40, 80 every 10 min to cumulative dose of 300mg 3- diazoxide (300mg). - Maintenance of fluid, electrolytes and acid- base balance by monitoring CVP, urea electrolytes and blood gases - Monitoring of Hb, platelets count, transaminases and coagulation profiles
  39. 39. www.doctor.sd o Delivery of fetus:- o The definitive treatment of eclampsia is delivery o Attempts to prolong pregnancy in order to improve maturity are unlikely to be of value. o However it is in appropriate to deliver an unstable mother even if there is fetal distress. o Once seizures are controlled, severe hypertension treated and hypoxia corrected delivery can be expedited
  40. 40. www.doctor.sd o Vaginal delivery should be considered but caesarean section is likely to be required in PG remote from term with an unfavorable cervix. o After delivery high dependency cares should be continued for a minimum of 24 hours o Treatment of complication.
  41. 41. www.doctor.sd  Prophylaxis :- o Regular and efficient ANC is the best weapon in prevention early detection and reduction of the hazards of Pre-eclampsia o Reduction of sodium is of no benefit