P R E G N A N C Y  I N D U C E D  H Y P E R T E N S I O N
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P R E G N A N C Y I N D U C E D H Y P E R T E N S I O N

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P R E G N A N C Y  I N D U C E D  H Y P E R T E N S I O N P R E G N A N C Y I N D U C E D H Y P E R T E N S I O N Presentation Transcript

  • PREGNANCY INDUCED HYPERTENSION PIH
  • Gestational Hypertension or pregnancy-induced hypertension
    • Defined as the
      • Development of new arterial hypertension in a pregnant woman after 20 weeks gestation
  • INCIDENCE
    • 5 percent to 8 percent of all pregnancies.
    • Young women
    • First pregnancy
    • Twin pregnancies
    • Previous pre-eclmaptic pregnancy
    • Diabetese Mallitus
    • Chronic hypertension
  • Types
    • PIH
    • Pre-eclampsia (Toxemia of pregnancy)
      • Mild
      • Severe
    • Eclampsia
    • HELLP syndrome
  • PIH
    • MILD
    • BP 140/90
    • SEVERE
    • BP 160/110 or more
  • Characteristics of Pre-Eclampsia
    • Hypertension
    • Protienuria
    • Edema
  • PRIMARY CHARACTERISTICS
    • High blood pressure
    • 140/90 mm Hg
    • or a significant increase in one or both pressures
    • Proteinuria (300 mg or >/24 hours urine)
            • Or Urinolysis +++ or ++++
    • Edema or recent rapid weight gain
  • ECLAMPSIA
    • Severe form of PIH
    • Women with eclampsia have seizures
    • Occurance one in 1,600 pregnancies
    • Develops near the end of pregnancy, in most cases.
  • HELLP syndrome
    • Complication of severe pre-eclampsia or eclampsia.
    • group of physical changes:
    • Breakdown of RBCs,
    • Changes in the liver
    • Low platelets
  • HELLP
    • H: Haemolysis
    • EL: Elevated Liver Enzymes
    • LP: Low Platelets
  • HELLP Diagnosis
    • Hemolysis
    • Blood smear
    • Bilirubin 1.2 mg/dl or more
    • Elevated liver enzymes
    • SGOT (asperate aminotransferase) > 70 U/L
    • Lactate dehydrogenase > 600 U/L
    • Low Platelets
    • <100,000 per mm 3
  • cause of PIH
    • unknown
    • ???
  • Pathophysiology
    • Immunologic response
    • Endothelial Dysfunction
    • Abnormal Prostaglandin Metabolism
    • Platelet Dysfunction
    • Calcium
    • Coagulation factors
    • Fatty metabolism
    • Markers of angiogenesis
  • 1-Immunologic response
      • Abnormal
      • fetal-maternal antigen-antibody response
      • Spermatozoa cause formation antibody or prostaglandins which cause VC
      • Normally at 20 weeks, Maternal spiral arteries are invaded by trophoblast causing release of PGI and NO,
      • this mechanism lacks in pre eclampsia
      • >>>> high resistance low flow uteroplacental circulation
  • 2 Endothelial cell dysfunction
    • in response to unknown factors
    • Resulting in imbalance in the production of :PGI 2 and EDRF(NO) >> Vasodialator
    • &
    • :TXA 2 derived from platelets & endothelaium >> Vasoconstrictor
    • ET-1: chorionic plate arteries constrictor, elevated in pre-eclampsia
    • &
    • pre term rupture of membrane
  • 3 Platelet factor
    • Normally aggregating platelet release (serotonin) 5HT + 5HT receptors >> release of NO &
    • Prostacyclin >> Angiotensin II >> improve uteroplacental blood flow
    • Loss of 5-HT receptor prevents stimulation of angiotensin II release in pre eclampsia
  • 4 CALCIUM
    • Instead of normal slow rise of intracellular Calcium concentration
    • In Pre eclampsia Ca ++ increases rapidly
    • also enhanced by angiotensin II
    • (Sensitive indicator of subsequent development)
  • 4 Other Factors
    • Coagulation factors
    • disturbance between plasma ratio of von Willebrand factor and factor VIII
    • Fatty metabolism
    • increased free fatty uptake by liver
    • hypertriglyceridemia
    • Markers of angiogenesis
    • FLT-I, VEGF (vascular endothelial growth factor)
  • RISK FACTORS for PIH
    • pre-existing hypertension
    • kidney disease
    • Diabetes Mallitus
    • PIH with a previous pregnancy
    • Mother's age
    • younger than 20 or older than 40
    • multiple fetuses (twins, triplets)
    • Vascular Diseases
  • Why is pregnancy-induced hypertension a concern?
    • With high blood pressure there is an increase in the resistance of blood vessels.
    • This may hinder blood flow in many different organ systems in the expectant mother including the liver, kidneys, brain, uterus, and placenta.
    • Baby required to be delivered early, before 37 weeks gestation.
  • Complications More Morbidity/Mortality Septic shock Meconium aspiration CVA, Seizures Small for age Rupture of Liver Intracranial Hemorrhage ARF Oligohydromnios PPH IUG retardation Placental Abruption Respiratory Distress CCF with pulmonary edema Pre-maturity DIC Fetal Maternal
  • Symptoms of PIH Coagulopathy Thrombocytopnia Platelet dysfunction Microangiopathic hemolysis Hematological Protienuruia, Sodium retention Decreased GFR Renal Failure Renal Impaired function, Elevated enzymes Hematoma, Rupture Hepatic Decreased intravascular volume Increased arteriolar resistance Hypertension, Heart failure Cardiovascular Upper airway edema Pulmonary edema Pulmonary Headach, Visual distubances Hyperexcitability, Seizers Intracranail hemorrhages, Cerebral edema Neurological
  • How is pregnancy-induced hypertension diagnosed
    • Increase in blood pressure levels
    • but other symptoms help
    • Tests for pregnancy-induced hypertension may include the following:
    • blood pressure measurement
    • urine testing
    • assessment of edema
    • frequent weight measurements
    • eye examination (retinal changes )
    • Liver and Renal function tests
    • Blood clotting tests
  • goal of treatment
    • To prevent the:
    • Condition from becoming bad to worse
    • Complications.
  • Treatment for pregnancy-induced
    • Specific treatment will be determined by the physician based on:
    • pregnancy, overall health, and medical history
    • extent of the disease
    • Tolerance for specific medications, procedures, or therapies
    • expectations for the course of the disease
    • Patient’s opinion or preference
  • Obstetric Management
    • Bedrest (either at home or in the hospital)
    • Hospitalization (specialized personnel and equipment)
    • Magnesium sulfate (or other antihypertensives for PIH)
    • Fetal monitoring may include:
      • fetal movement counting - fetal kicks and movements
      • change in the number/frequency : means fetus under stress.
      • nonstress testing - measures the fetal heart rate in response to the fetus' movements.
      • biophysical profile - combines nonstress test with ultrasound
      • Doppler flow studies
    • Continued laboratory testing of urine and blood (for changes that may signal worsening of PIH)
    • Corticosteroids (help mature the lungs of the fetus)
    • Delivery of the baby (if treatments do not control PIH or if the fetus or mother is in danger)
    • What antihypertensive medication is used in PIH ?
  • ANTIHYPERTENSIVES caution No Myocardial depressants No Adversely effect fetal and neonatal blood pressure control , skull defects, oligohydromnios , toxicity Not in late pregnancy Caution Alpha Blockers Calcium Channel Blocker ACE inhibitors /Angiotensin II receptor antagonist Beta Blocker Diuretic
  • 250 – 500 mg 2-3 times/day Centrally acting Alph 2 receptor agonist Methyldopa (Aldomet) Vasodilator no myocardial depression 10-20mg BD Nifedipine (ADALET) 0.5-1.5 µgm/kgmin Cyanide toxocity if treatment exceeds 3 days Sodium Nitropruside Isorbid dinitrate, Glyceryl trinitrate, isorbid mono nitrate Nitrates
        • Vasodilator
        • Causes tachycardia fluid retention
        • Oral 25 mg BD
        • IV 10mg in 10 ml saline in 20 minutes
    Hydralazine (Apresoline)
        • Arteriolar dilator
        • I/V Max 200 mg
        • 2mg/min until satisfactory response
        • Oral 200 mg BID upto 1200mg
    • Labetalol
    • Alpha methyldopa 500 mg PO bid (up to 2 grams bid)
    • Labetolol 200 mg PO bid (up to 1200 mg bid)
    • Felodipine 5 mg PO daily (up to 20 mg daily)
    • Hydrochlorothiazide
      • Not usually initiated in pregnancy due to volume depletion
      • May be continued if on pre-pregnancy - consult with local expert opinion
    • Nifedipine XL 30 mg PO bid (up to 120 mg daily)
    • Hydralazine 10 mg PO tid (up to 25 mg tid
  • GOAL of Antihypertensives
    • Blood Pressure < 150/100
    • (much higher than non-pregnant goal)
    • Anti-hypertensives are not indicated for mild to moderate chronic Hypertension in pregnancy
    • BP <150/100 does not reduce risk to fetus or prevent Preeclampsia
      • Antihypertensives benefit mother only
      • do not reduce pregnancy complications
  • Pre-Operative Evaluation
  • Investigations ?
    • Blood complete picture
    • Platelet count
    • Coagulation assay, PT, APTT, Fibrinogen, D - dimer
    • Serum Urea/creatinine Electrolytes Uric Acid
    • LFTs
    • Urinolysis, Microscopy, 24 Hours specimen for protien and creatinine clearence
    • Type and screen Blood
  • Monitors
    • NIBP
    • SaO 2
    • Hourly deep tendon reflex
    • Muscle strength
    • Serial Magnesium Sulphate levels
    • Foleys Catheter for urine volume
    • Urine concentration
    • Fetal heart Rate
    • IBP
    • CVP Persistent oligouria, difficulty in fluid management therapy in ante/post partum period, Pulmonary edema
    • PA
    • Severe eclampsia Left ventricular systolic function is markedly reduced
    • CVP 92% versus PA 8%
  • What condition mandate immediate Delivery
  • Immediate Delivery
    • Severe Hypertension
    • Progressive thrombocytopenia
    • Liver dysfunction
    • Progressive Renal dysfunction
    • Persistent headache
    • Evidence of fetal jeopardy
    • Premonitory signs of ECLAMPSIA
  • What drug therapy is the treatment of choice for Seizure prophylaxis
    • Diazepam
    • Phenytoin
    • Magnesium Sulphate
  • How to use Magnesium Sulphate
    • 4 - 6 Grams in 20 minutes
    • followed by 1-2 gram per hour
    • Monitor
    • Urine output
    • Respiratory rate
    • Patellar reflexes
    • Serum levels 4 hourly
  • Serum levels of Magnesium Sulphate Asystole 20 mEq/L Respiratory Arrest 15 mEq/L Loss of deep tendon reflexes Prolonged P-Q interval Widening QRS complexes 10 mEq/L Therapeutic range 5 mEq/L
  • Role of Magnesium Sulphate
    • CNS depressant & Anticonvulsant
    • CVS Mild Anti-hypertensive effect
    • Neuromuscular Junction
    • Inhibits Ach release
    • decrease membrane excitability
    • augment Non and depolarizing muscle relaxant
    • Uterus
        • Mild relaxant effect on vascular & uterine smooth muscle
        • Improve uterine blood flow
  • What are fetal effects of MgSO 4
    • MgSO 4 crosses the placenta
        • Neonatal depression
            • Respiratory
            • Hyporeflexia
            • Decreased beat to beat variability in heart rate
  • Treatment of Eclampsia
    • Stop convulsion (Thiopentone 50-100 mg)
    • ABC
    • Apply monitors (Pulse Oximeter, NIBP, ECG)
    • I/V line
    • Check BP repeatedly
    • Administer MgSO 4
    • Treat hypertension
    • Deliver baby
  • Intraoperative Management
  • What type? Analgesia/Anesthesia for patient with pre-eclampsia in labour
    • EPIDURAL
      • Superior pain relief
      • Attenuate the hypertensive response to pain
      • Reduce circulating level of catecholamines/hormones
      • Improve intervillous blood flow
      • Stable Cardiac output
      • Increased Risk for C-section
  • Any Role of Prehydration
    • Prehydration with crystalloid
    • compensate for decreased prelaod and after laod >>> ANP >> VD >>renal elimination of excess ECF
    • AVOID if there is recent excessive weight gain (overhydration)
    • Monitor for pulmonary oedema
  • Role of Bleeding time or Platelet count for EPIDURAL
    • BT not useful
      • Skin bleeding time is not predictor for pre-eclamptic epidural vein bleeding
    • Platelet count reliable
            • 50- 80,000
  • Commonly used Local Anaesthetics
    • Bupivacain
        • 4 times potent then lignocain
        • Onset 5 times longer then lignocain
        • Fast in, slow out
    • Ropivacain
        • Single levorotatory isomer rather then racemic solution
        • Less cardiotoxic
    • Levobupivacain
        • Single levorotatory isomer
        • Less cardiotoxic
    • Lignocain
        • More Motor block
        • More hypotension
        • instant onset
            • Note: with adrenaline should not be used in severe pre-eclampsia
  • What type of anaesthesia for C Section
    • Spinal
    • General
  • Spinal Anaesthesia
    • Best even in severe pre-eclampsia
    • GA
    • Severe hypertensive response to intubation
    • Risk of difficult intubation due to airway edema
    • Epidural
    • Less reliable anaesthesia than spinal
    • Risk of trauma to epidural vein
    • Risk of hypotension 6 times less in pre eclamptic pregnant woman
    • .75% hyperbaric Bupivacain 11-12 mg with or without 15-20 µg Fentanyl or morphine 100-200 µg
  • General Anesthesia
    • Aspiration prophylaxis
    • Thiopentone sodium induction
    • Suxamethonium with cricoid pressure
    • Attenute intubation response by deep anaesthesia & lignocain
    • Smaller ETT 6-6.5 mm (airway edema)
    • Nondepolarizing agent after recovery from suxamethonium Remember MgSO 4
    • 2/3 rd MAC for adequate depth of anaesthesia
    • MgSO 4 intra and Post op period
    • IBP line for continuous blood pressure monitoring
    • Anti HTN drugs
  • The End
  • Pathology of pregnancy, childbirth and the perpurium Maternal death Other Fetal intervention - Fetal surgery Complications related to the fetus Puerperal fever - Peripartum cardiomyopathy - Postpartum thyroiditis - Galactorrhea - Postpartum depression Maternal complications in the weeks after childbirth Premature birth - Postmature birth - Cephalopelvic disproportion - Dystocia ( Shoulder dystocia ) - Fetal distress - Vasa praevia - Uterine rupture - hemorrhage - Placenta accreta - Umbilical cord prolapse - Amniotic fluid embolism Complications of labour and delivery Polyhydramnios - Oligohydramnios - Chorioamnionitis - Premature rupture of membranes - Amniotic band syndrome - Placenta praevia - Braxton Hicks contractions - Antepartum haemorrhage – abruption Maternal care related to the F etus and amniotic cavity & possible delivery problems Hyperemesis gravidarum - Gestational pemphigoid - Intrahepatic cholestasis of pregnancy Other, predominantly related to pregnancy Pregnancy-induced hypertension - Pre- eclampsia - Eclampsia - Gestational diabetes Oedema , proteinuria and hypertensive disorders Ectopic pregnancy - Hydatidiform mole - Miscarriage Pregnancy ē abortive outcome