Hypertensive disorders of pregnancy

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interesting case 24/11/2011

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Hypertensive disorders of pregnancy

  1. 1. Interesting case 11/24/2011 Warawut suttison , GP
  2. 2. • A pregnant woman , 19 yrs• History taking from patient and her husband• CC : seizure 30 min PTA
  3. 3. • OB-GYN Hx : – G1P0 GA 35 wks by U/S – ANC x 8 at private clinic : normal• PH : – No underlying disease – No drug allergy• FH : – No history of seizure
  4. 4. • PE : – General appearance : confusion – Vital sign : BP 140/100 mmHg , RR 22 /min , BT 38.1 c , PR 120 /min – HEENT : pink conjunctiva , anicteric sclera – Heart and lungs : equal breath sound , normal S1S2 , no murmur – Abdomen : HF - , position : ROA , FHS : 160 , uterine contraction : can’t evaluate , EFW : 2500 gram – PV : not done
  5. 5. Provisional diagnosis
  6. 6. Hypertensive Disorders of Pregnancy
  7. 7. I. Introduction• Hypertensive disorders complicate 5 to 10 percent of all pregnancies, and together they form one member of the deadly triad• In developed countries, 16 percent of maternal deaths were due to hypertensive disorders Ref : William obstetric 23rd edition,2009
  8. 8. II. Diagnosis• Hypertension is diagnosed empirically when appropriately taken blood pressure exceeds 140 mm Hg systolic or 90 mm Hg diastolic• women who have a rise in pressure of 30 mm Hg systolic or 15 mm Hg diastolic should be seen more frequently Ref : William obstetric 23rd edition,2009
  9. 9. III. Classification and Definitions Ref : William obstetric 23rd edition,2009
  10. 10. Ref : William obstetric 23rd edition,2009
  11. 11. III. Classification and Definitions• Gestational Hypertension• Preeclampsia and eclampsia syndrome• superimposed Preeclampsia on chronic hypertension• Chronic hypertension Ref : William obstetric 23rd edition,2009
  12. 12. II. Classification and Definitions• 1. Gestational Hypertension: – Systolic BP 140 or diastolic BP 90 mm Hg for first time during pregnancy – No proteinuria – BP returns to normal before 12 weeks postpartum – Final diagnosis made only postpartum – May have other signs or symptoms of preeclampsia, for example, epigastric discomfort or thrombocytopenia Ref : William obstetric 23rd edition,2009
  13. 13. • 2. Preeclampsia and eclampsia syndrome• Preeclampsia: Minimum criteria: – BP 140/90 mm Hg after 20 weeks gestation – Proteinuria 300 mg/24 hours or 1+ dipstick Ref : William obstetric 23rd edition,2009
  14. 14. Increased certainty of preeclampsia :– BP 160/110 mm Hg– Proteinuria 2.0 g/24 hours or 2+ dipstick– Serum creatinine >1.2 mg/dL unless known to be previously elevated– Platelets < 100,000/L– Microangiopathic hemolysis—increased LDH– Elevated serum transaminase levels—ALT or AST– Persistent headache or other cerebral or visual disturbance– Persistent epigastric pain Ref : William obstetric 23rd edition,2009
  15. 15. • Eclampsia: – Seizures that cannot be attributed to other causes in a woman with preeclampsia Ref : William obstetric 23rd edition,2009
  16. 16. Ref : William obstetric 23rd edition,2009
  17. 17. • 3. Superimposed Preeclampsia On Chronic Hypertension: – New-onset proteinuria 300 mg/24 hours in hypertensive women but no proteinuria before 20 weeks gestation – A sudden increase in proteinuria or blood pressure or platelet count < 100,000/L in women with hypertension and proteinuria before 20 weeks gestation Ref : William obstetric 23rd edition,2009
  18. 18. • 4. Chronic Hypertension: – BP 140/90 mm Hg before pregnancy or diagnosed before 20 weeks gestation not attributable to gestational trophoblastic disease or – Hypertension first diagnosed after 20 weeks gestation and persistent after 12 weeks postpartum Ref : William obstetric 23rd edition,2009
  19. 19. Investigation
  20. 20. • UA (15/11) – Color : yellow – Appearance : clear – glu ,ketone – alb : neg – RBC : 2-3 – WBC : 5-10 – Epi : 5-10
  21. 21. • CBC Hb 12.4 Hct 38.2 WBC 23000 Plt 430000 PMN 66 Lymph 26 MCV 78• Coagulogram PT 9(11.2) PTT 28.1(29.2) INR 0.83
  22. 22. • Blood chemistry BUN 5 , Cr 0.9 Electrolyte : Na 136 K 2.8 HCO3 22.3 Cl 104 LFT : pro 7.9 alb 3.8 glob 4.1 DB 0.06 TB 0.47 SGOT 19 SGPT 10 ALP 136
  23. 23. Diagnosis
  24. 24. • Management – Non-severe preeclampsia – severe preeclampsia – eclampsia
  25. 25. Non severe preeclampsia• Admit• Bed rest• Monitoring for symptoms of pre-eclampsia ; daily kick counts• Body weight once a day• Blood pressure check every 6 hours , no antihypertensive drug not shown to improve perinatal outcome• Laboratory testing: baseline 24-hour urine protein collection at least 3 days• Non-stress test/biophysical profile• Termination term clinical worsing (severe PIH) Ref : Johns Hopkins Manual of Gynecology and Obstetrics, The, 3rd Edition
  26. 26. Severe preeclampsia• Principle 1. Seizure prophylaxis 2. Antihypertensive therapy 3. Delivery Ref : William obstetric 23rd edition,2009
  27. 27. Severe preeclampsia• 1. Seizure prophylaxis Ref : William obstetric 23rd edition,2009
  28. 28. Severe preeclampsia• Seizure prophylaxis• LD : Give 4 g of magnesium sulfate diluted in 100 mL of IV fluid administered over 15–20 min• MD :Begin 2 g/hr in 100 mL of IV maintenance infusion.• Monitor for magnesium toxicity: The patellar reflex is present, Respirations are not depressed, and Urine output the previous 4 hr exceeded 100 mL• Magnesium sulfate is discontinued 24 hr after delivery Ref : William obstetric 23rd edition,2009
  29. 29. Severe preeclampsia• Antihypertensive therapy• The three most commonly employed in North America and Europe are hydralazine, labetalol, and nifedipine• 1. nifedipine Dosage : – (soft capsule) 10 mg sublingual – (film-coat tablet) 10 mg oral Ref : William obstetric 23rd edition,2009
  30. 30. Severe preeclampsia• 2. hydralazine Dosage : 5 mg IV Ref : William obstetric 23rd edition,2009
  31. 31. Severe preeclampsia• Delivery – 1. induction – 2.route of delivery Ref : William obstetric 23rd edition,2009
  32. 32. Ecclampsia• Management – Control of convulsions – Intermittent administration of an antihypertensive medication – Avoidance of diuretics unless there is obvious pulmonary edema – Delivery of the fetus to achieve a "cure." Ref : William obstetric 23rd edition,2009
  33. 33. Thank you

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