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  • 1. Chronic hypertension in Pregnancy Williams Obstetrics 23rd Edition Chapter 34, 45 Cardiology in review 2010;18:178-189 주산기 전임의 채용화
  • 2. (Khan and colleagues, 2006)
  • 3. Hypertension disorders in pregnancy  Gestational hypertension  Preeclamsia  Eclamsia  Superimposed preeclamsia (on chronic hypertension)  Chronic hypertension
  • 4. Preeclampsia Chronicsuperimposed on HypertensionChronic Hypertension New-onset proteinuria≥ 300mg/24hours BP ≥140/90 mmHg before pregnancy or in hypertensive women but no proteinuria diagnosed before 20weeks’ gestation (not before 20 weeks’ gestation attributable to gestational trophoblastic disease) A sudden increase in proteinuria Hypertension first diagnosed after blood pressure 20weeks’ gestation and persistent after platelet count <100,000/mm3 12weeks’ postpartum in women with hypertension and proteinuria before 20weeks’ gestation
  • 5. Classification and Management of BP forAdultsClassification Systolic Diastolic Lifestyle Without With mm Hg mm Hg Modification Compelling Compelling Indication IndicationsbNormal <120 And<80 Encourage Treatment not Chronic renal indicated disease or diabetesPrehypertension 120-139 or80-90 YesStage 1 140-159 or90-99 Yes Thiazide-type Chronic renal diuretics for disease or diabetesHypertension most. May Other drugs as consider ACE needed: diuretics, inhibitor, ARB, ACE inhibitors, blocker, CCB, or ARB, -blocker, combination CCBStage 2 >=160 or>=100 Yes Two-drug combination forHypertension mostc: usually thiazide-type diuretic and ACEI, or ARB, or -blocker, or CCBc
  • 6. Chronic hypertension  One of the most common medical complications encountered during pregnancy  Systemic vascular resistance index, pulse wave velocity higher during whole pregnancy  -- include hypertensive or ischemic cardiac disease, renal insufficiency, or a prior cerebrovascular event obesity DM Heredity ethnic and gender difference (African- and Latino-Americans)
  • 7. ‘ Sibai and colleagues, 1990a
  • 8. Preconceptional and Early Pregnancy Evaluation  Counseling prior to pregnancy (degree of blood-pressure control, and current therapy)  Home BP>=130/85 HTN  General health, daily activities, diet,  Cerebrovascular accident , myocardial infarction, cardiac or renal dysfunction  Ophthalmological evaluation and echocardiography Renal function (serum creatinine , quantification of proteinuria)  Multiple medication and poorly controlled increased risk for adverse pregnancy outcomes Cunningham, 1990; Lindheimer, 2007; Ramin, 2006, and all their associates
  • 9.  Severity of renal insufficiency is proportional to the risk of hypertensive complications during pregnancy Pregnancy 의 relative CIx Strong CIx Persistent diastolic BP>=110 Prior cerebrovascular hemorrhage or thrombosis Multiple hypertensive drug MI S-Cr>2mg/dL Cardiac failure Cunningham, 1990; Lindheimer, 2007; Ramin, 2006, and all their associates
  • 10. Effects of Chronic Hypertension on Pregnancy  Maternal Morbidity/Mortality  Superimposed Preeclampsia  Placental abruption  Low birth weight, IUGR  Preterm delivery, Perinatal mortality
  • 11. Management in chronic hypertension Lifestyle modification to manage hypertension Modification Recommendation Systolic Blood Pressure Reduction(Range) Weight redection Maintain normal body weight: BMI 18.5–24.9 kg/m2 5–20 mm Hg/10 kg weight loss DASH eating Diet rich in fruits, vegetables, and low-fat dairy 8–14 mm Hg plan products with a reduced content of saturated and total fat Dietary sodium Reduce dietary sodium intake to no more than 100 2–8 mm Hg reduction mmol per day: 2.4 g sodium or 6 g sodium chloride Physical activity Engage in regular aerobic physical activity such as 4–9 mm Hg brisk walking, at least 30 min per day, most days of the week Alcohol Limit consumption to no more than 2 drinks—1-oz 2–4 mm Hg consumption or 30-mL ethanol, e.g., 24-oz beer, 10-oz wine, or 3- moderation oz 80-proof whiskey—per day in most men and to no more than 1 drink per day in women and lighter weight persons
  • 12. Antihypertensive drug-Diuretics  Thiazide and loop-acting diuretics such as furosemide are commonly used in nonpregnant hypertensives  Sodium and water diuresis with volume depletion  Plasma volume during pregnancy in 20 chronically hypertensive women. Plasma volume expanded only about 20 percent in the half who continued diuretic therapy throughout pregnancy compared with 50 percent in the other half who discontinued treatment early in pregnancy Sibai and colleagues (1984)  Diuretics are usually not given as first-line therapy during pregnancy, particularly after 20 weeks
  • 13. Medical Choices in Chronic hypertension ofPregnancy Drug/Class* Doses Adverse Events in Eviden Comments Pregnancy ce Methyldopa (B) 500 mg–3 g in Peripheral edema, Large Large post 2 divided doses anxiety, night marketing mares, drowsiness, dry evidence on mouth,hypotension, safety maternal hepatitis, no major fetal adverse events Labetalol (C) 200 mg–1200 Persistent fetal Large mg/d in bradycardia, 2–3 divided hypotension, neonatal doses hypoglycemia Hydrochlorothi 12.5 mg–25 Fetal malformations, Large azide (C) mg/d electrolyte abnormalities, volume depletion Belindam. Cardiology in review 2010
  • 14. Drug/Class* Doses Adverse Events in Evidenc Comments Pregnancy eNifedipine (C) 30 mg–120 Hypotension and inhibition Small Immediate(CCB) mg/d of particularly if used in release combination with nifedipine magnesium sulfate not recommendedHydralazine (C) 50 mg–300 Hypotension, neonatal Moderate mg/d in 2– thrombocytopenia 4divided dosesAngiotensin Contraindica Oligohydraminos, IUGR, Largeconverting ted in renal failure, low birthenzyme inhibitor pregnancy weight, cardiovascular(ACEI) (D) anomalies, polydactyly, hypospadias,ands pontaneous abortions, fetal hypocalvaria, renal failure, oligohydraminos, pulmonary hypoplasia, craniofacial, limb Belindam. Cardiology in review 2010
  • 15. Drug Treatment during Pregnancy  Continuation of prepregnancy antihypertensive treatment when women become pregnant is debated  약물로 인한 BP reductionbeneficial to the mother in the long term  decrease uteroplacental perfusion feus 악화 가능 ?  BP감소시 생기는 FGR은 Tx때문인지 worse HTN의 fetal effect 인지 혼란  임신중의 mild to moderate HTN Tx(?)
  • 16. Randomized Trials of Antihypertensive Drug Therapyin Pregnancies Complicated by Mild ChronicHypertensionStudy No Mean Mean DBP Treatment Principal Gestation at Entry Findings at Entry (mm Hg) (weeks)Redman 208 21–22 88–90 Methyldopa ± Fewer(1976) hydralazine vs no midpregnancy drug losses in treated womenArias 58 15-16 90-99 Methyldopa, Compromisedand diuretics, or infants born toZamora hydralazine vs no mothers in whom(1979) drug severe hypertension developed despite treatment Haddad B, Sibai BM: Chronic hypertension in
  • 17. Randomized Trials of Antihypertensive Drug Therapyin Pregnancies Complicated by Mild ChronicHypertensionButters et al. 29 16 86 Atenolol vs Poor fetal(1990) placebo growth in treated womenSibai et al. 263 <11 91-92 Methyldopa No(1990a) vs labetalol differences vs no drug in outcomesGruppo di 283 24 95-96 Slow-release NoStudio nifedipine vs differencesIpertensione no drug in outcomesinGravidanza(1998) Haddad B, Sibai BM: Chronic hypertension in pregnancy, Ann Med 31(4):246, 1999
  • 18. Antihypertensive Therapy Selection  No evidence of major adverse fetal or maternal events.  Methyldopa : no fetal anomaly in the first trimester vascular stiffness improved Khalil and colleagues (2009)  Atenolol : FGR Birth weight Butters and colleagues (1990)  β -blocker : ominous intrapartum FHRs in 20 % Montan and Ingemarsson (1989)  Nifedipine for pregnant women with chronic hypertension : Experiences and newer safety concerns are not sufficient to permit recommendations
  • 19. Drug Treatment during Pregnancy antihypertensive treatment healthy pregnant women with With end-organ dysfunction, 150 to 160 mm Hg systolic or (left ventricular hypertrophy 100 to 110 mm Hg diastolic renal insufficiency) pressures greater August and Lindheimer, 1999; Working Group Report, 2000 limited data to treat mild chronic hypertension in pregnancy The Working Group on High Blood Pressure in Pregnancy 2000 Early Tx for HTN -> pregnancy 동안 subsequent hospitalization 감소
  • 20. Pregnancy-Aggravated Hypertension orSuperimposed Preeclampsia  Pregnancy outcome prognosis는 임신전 ds severity연관  25%에서 superimposed preeclampsia in chronic HTN Caritis and co-workers (1998)  Some chronic HTN  worsening during pregnancy with no other findings of superimposed preeclampsia M/C end of the second trimester Antihypertensive Tx 시작 or dose 증량
  • 21. Early Diagnosis of Preeclapsia Detailed examination such as headache, visual disturbances, epigastric pain, and rapid weight gain Weight determined daily Analysis for proteinuria at least every 2 days thereafter Blood pressure readings for every 4 hours Measurements of plasma or serum creatinine and liver transaminase levels, and hemogram , platelet quantification. Evaluation of fetal size and well-being and amnionic fluid volume either clinically or using sonography. 21
  • 22. Management  Supportive care (mild preeclampsia)  Reduced physical activity throughout much of the day  Absolute bed rest is not necessary  Sedatives and tranquilizers are not prescribed  Ample, but not excessive, protein and calories should be included in the diet  Sodium and fluid intakes should not be limited or forced
  • 23. Management  Severe preeclampsia  Indicative sign of convulsion  Headache  Visual disturbances  Epigastric pain  Oliguria  Management  Anticonvulsant (MgSO4)  Antihypertensive therapy (Hydralazine)  Followed delivery(vaginal delivery)
  • 24. Management  Termination of pregnancy  Delivery is the cure for preeclampsia  Indication : moderate to severe preeclampsia without improvement in hospital treatment  The prime objectives  To forestall convulsion  To prevent intracranial hemorrhage  To prevent serious damage to vital organs  To delivery a healthy infant  Induced by intravenous oxytocin  Subarachnoid or epidural block -> Induce severe hypotension
  • 25. Indications for Delivery with Early-Onset Severe PreeclampsiaMaternal FetalPersistent severe headache or visual Severe growth restriction—< 5thchanges; eclampsia percentile for EGAShortness of breath; chest tightness with Persistent severe oligohydramnios—AFIrales and/or SaO2 < 94 percent breathing < 5 cmroom air; pulmonary edemaUncontrolled severe hypertension despite Biophysical profile 4 done 6 hr aparttreatmentOliguria < 500 mL/24 hr or serum Reversed end-diastolic umbilical arterycreatinine 1.5 mg/dL flowPersistent platelet counts < 100,000/L Fetal deathSuspected abruption, progressive labor,and/or ruptured membranes
  • 26. Postpartum observation  In severe chronic hypertension and in severe preeclampsia– eclampsia.postpartum adverse outcome 치료가 비슷  Cerebral or pulmonary edema, heart failure, renal dysfunction, or cerebral hemorrhage is especially high within the first 48 hours after delivery  Delivery후 maternal peripheral resistance증가left ventricular workload 증가 상당한 interstitial fluid 양이 excretion위해 이동Pulmonary edema 가능  즉각적 severe HTN Tx+ diuretics(furosemide)
  • 27. Cardiovascular diseaseWilliams Obstetrics 23rd Edition Chapter 44 주산기 전임의 채용화
  • 28. Introduction  Heart disease is the leading cause of death in women who are 25 to 44 years old (Kung and colleagues, 2008).  Cardiac disorders of varying severity complicate approximately 1 percent of pregnancies and contribute significantly to maternal morbidity and mortality rates
  • 29. Physiological change in pregnancy Hemodynamic Changes in 10 Normal Pregnant Women at Term Compared with Their 12-Week Postpartum Values Parameter Change(Percent) Cardiac output +43 Heart rate +17 Left ventricular stroke work index +17 Vascular resistance Systemic -21 Pulmonay -34 Mean arterial pressure +4 Colloid osmotic pressure -14 Data from Clark and colleagues (1989).
  • 30. Clinical indication of Heart Diseaseduring pregnancy Symptoms Clinical Findings Progressive dyspnea or orthopnea Clinical Findings Nocturnal cough Cyanosis Hemoptysis Clubbing of fingers Syncope Persistent neck vein distension Chest pain Systolic murmur grade 3/6 or greater Diastolic murmur Cardiomegaly Persistent split second sound Criteria for pulmonary hypertension
  • 31. Diagnostic Studies  Electrocardiography  Echocardiography  Chest radiography
  • 32. Clinical classification of the New York HeartAssociation (NYHA) Class I. Uncompromised—no limitation of physical activity Class II Slight limitation of physical activity Class III Marked limitation of physical activity Class IV Severely compromised—inability to perform any physical activity without discomfort
  • 33. Predictors of cardiac complications Prior heart failure, transient ischemic attack, arrhythmia, or stroke. Baseline NYHA class III or IV or cyanosis Left-sided obstruction ( mitral valve area < 2 cm2, aortic valve area <1.5 cm2, peak left ventricular outflow tract gradient >30 mm Hg ) EF<40%
  • 34. Management of NYHA Class I and II Disease  Pneumococcal and influenza vaccines.  Cigarette smoking - prohibited  Vaginal delivery  Induction - safe  During labor - in a semirecumbent position with lateral tilt.  Vital signs - frequently between contractions.  PR>100 bpm , RR>24 -impending ventricular failure.  Evidence of cardiac decompensation - intensive medical management
  • 35. Management of Class III and IV Disease  Epidural analgesia  Vaginal delivery  Labor induction- safe (Oron and associates, 2004).
  • 36. Surgically Corrected Heart DiseaseValve Replacement before Pregnancy The maternal mortality rate is 3 to 4 percent with mechanical valves, and fetal loss is common.  Management American College of Chest Physicians Guidelines for Anticoagulation of Pregnant Women with Mechanical Prosthetic Valves Adjusted-dose LMWH twice daily throughout pregnancy. The doses should be adjusted to achieve the manufacturers peak anti-Xa level 4 hours after subcutaneous injection Adjusted-dose UFH administered every 12 hours throughout pregnancy. The doses should be adjusted to keep the midinterval aPTT at least twice control or attain an anti- Xa heparin level of 0.35 to 0.70 U/mL. LMWH or UFH as above until 13 weeks gestation with warfarin substitution until close to delivery when LMWH or UFH is resumed. Very high risk of thromboembolism : Warfarin is suggested throughout pregnancy with replacement by UFH or LMWH (as above) close to delivery. In addition, low-dose aspirin—75 to 100 mg daily—should be orally administered Bates and colleagues (2008)
  • 37. Valvular Heart Disease Type Pregnancy Management Mitral Heart failure •Limited physical activity stenosis from fluid •Pulmonay congestion Sx->Na+restriction, overload, diuretics tachycardia •β -blocker drug •new-onset atrial fibrillation –verapamil, electrocardioversion •chronic fibrillation-digoxin, β -blocker, CCB •Labor and delivery - stressful •Epidural analgesia •Vaginal delivery(Elective induction ) •heparinization with severe stenosis even if there is a sinus rhythm.
  • 38. Valvular Heart Disease Type Pregnancy Management Aortic Moderate stenosis •Asymtomatic -close observation stenosis tolerated; severe is •Symtomatic - strict limitation of life-threatening with activity decreased preload, •Prompt treatment of infections •Valve replacement or valvotomy using e.g., obstetrical cardiopulmonary bypass hemorrhage or •Narcotic epidural analgesia regional analgesia •Forceps or vacuum delivery
  • 39. Congenital Heart DiseaseEisenmenger Syndrome  Secondary pulmonary hypertension that develops from any cardiac lesion  M/C underlying defects : ASD, VSD, PDA  The prognosis for pregnancy - the severity of pulmonary hypertension  Maternal and perinatal mortality rates to approximate 50 percent
  • 40. Pulmonary Hypertension and Pregnancy  진단기준 : a mean pulmonary pressure >25 mm Hg. (non pregnant)  Diagnosis : echocardiography , right-sided catheterization  Maternal mortality 상승(65-30%)  Severe disease –CIx to pregnancy  Treatment of symptomatic -limitation of activity and avoidance of the supine position in late pregnancy. Diuretics, supplemental oxygen, and vasodilator drugs  Greatest risk : diminished venous return and right ventricular filling maternal deaths  Epidural analgesia induction
  • 41. Peripartum Cardiomyopathy  Diagnostic criteria (Pearson and associates, 2000): 임신 마지막달 또는 분맊후 5개월 이내에 cardiac failure Absence of an identifiable cause for the cardiac failure Absence of recognizable heart disease prior to the last month of pregnancy Left ventricular systolic dysfunction • HF 연관 질환 : hypertensive heart ds, MS, obesity, viral myocarditis • Chronic HTN with superimposed preeclampsiaHF during pregnancy의 common cause • Peripartum HF 의 obstetrical complication Preeclampsia, acute anemia, infection • Specific human pregnancy-related cardiomyopathies are yet undiscovered
  • 42. Idiopathic Cardiomyopathy in Pregnancy  Cardiomyopathy -the hallmark finding  Signs and symptoms of congestive heart failure.  (dyspnea , orthopnea, cough, palpitations, and chest pain)  Echocardiographic findings ( ejection fraction <45 percent or a fractional shortening < 30 percent, an end-diastolic dimension > 2.7 cm/m2) Tx : HF Tx Diuretics, hydralazine, another vasodilator ACEI-Cix Digoxin Prophylactic heparin->thromboembolism
  • 43. (Data from Felker and colleagues, 2000.)
  • 44. Hypertrophic Cardiomyopathy  Concentric left ventricular hypertrophy may be familial, and there also is a sporadic form not related to hypertension  Autosomal dominant(inheritance)  Congestive heart failure is common  Strenuous exercise –CIx (in pregnancy)  Abrupt positional changes are avoided  β -adrenergic or calcium-channel blocking drugs (Sx시, angina)  Spinal , Epidural analgesia-CIx  분맊시 infective endocarditis prophylaxis  Delivery mode –Ix 따라
  • 45. Infective Endocarditis  This infection involves cardiac endothelium and produces vegetations that usually deposit on a valve  Associated with intravenous drug abuse  Subacute bacterial endocarditis - native valve infections  Viridans-group streptococci or Enterococcus species  Among intravenous drug abusers, S. aureus is the predominant organism  Dx :murmur ultimately is heard in 80 to 85 percent of cases Anorexia, fatigue, and other constitutional symptoms "flulike."
  • 46. Infective Endocarditis  Management • Most viridans streptococci : penicillin G + gentamicin for 2 weeks. • Allergic to penicillin :intravenous ceftriaxone or vancomycin for 4 weeks • Staphylococci, enterococci : 4-6wks Tx • Prosthetic valve infection : 6-8wks Tx
  • 47. Thank you for your attension