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  2. INTRODUCTION • Hypertensive disorders are the most common medical complication of pregnancy • It complicates up to 10% of pregnancies • It is a leading cause of maternal and perinatal morbidity and mortality worldwide Rates are rising because of the older, more obese obstetric population with medical issues
  3. Principle • Generalization that is accepted as true and that can be used as a basis for reasoning or conduct • Rule • Norm
  4. Management of pre-eclampsia •Adequate and proper antenatal care is the most important in the management of pre-eclampsia. •Maternal antenatal monitoring includes identification of women at high risk, early detection by recognition of the clinical signs and symptoms, and progression of the condition to severe state. •After diagnosis, subsequent treatment depends on the results of initial maternal and fetal assessment
  5. Principles of management of preeclampsia Admission to hospital Stabilization of hypertension Request necessary investigations Close fetomaternal monitoring Prevent eclampsia Delivery as at when appropriate Post natal care including counseling on future pregnancies/risks/family planning.
  6. DEFINITIONS OF HYPERTENSION • Blood pressure (BP) should be measured thrice, with the average of the 2nd and 3rd values taken as the BP for the visit • Hypertension in pregnancy is systolic blood pressure (sBP)>140mmHg and /or diastolic blood pressure (dBP)>90mmHg. • Severe hypertension is sBP >160mmHg and/or dBP>110mmHg • White-coat effect is observed when BP is >140/90mmHg in the hospital but <135/85mmHg at home
  7. Measurement and definition of Proteinuria • In early pregnancy to detect pre-existing renal disease and at >20 weeks to screen for pre- eclampsia in at risk patients • Screening is by dip-stick testing with low sensitivity (55%) but reasonable specificity (84%) • A negative or trace result should not exclude further investigation.
  8. Measurement of Proteinuria • Quantification by 24-hr collection is often inaccurate. • Now replaced by spot urine sample • Protein to creatinine ratio of >30mg/mmol represent significant proteinuria in singleton pregnancy and >40mg/mmol in multiples
  9. Classification of hypertensive disorders of pregnancy • 1 Pre-existing hypertension(1-3%) • 2. Gestational hypertension (5-6%) • Pre-eclampsia /eclampsia (2-8%) • Others
  10. Adverse conditions and severe complications of preeclampsia • Organ system affected Adverse conditions Severe complications • ( risk of severe comp) (that warrant delivery) • CNS .Headache/visual Eclampsia • symptoms PRES • Cortical blindness • Retinal detachment • GCS <13 • Stroke,TIA,RIND • uncontrolled severe bp • over 12hrs despite 3 anti • hypertensive agents • PRES-(posterior reversible leukoenchepalopathy syndrome) • RIND(reversible neurological deficit< 48hrs) •
  11. Adverse conditions and severe complications of preeclampsia Organ system affected Adverse conditions Severe complications (increase risk of SC) (that warrant delivery) • Cardiorespiratory Chest pain/dyspnoea Oxygen saturation<90% • Oxygen saturation<97%. Need for >50%oxygen>1H • Intubation other than CS • Pulmonary oedema • Positive inotropic support • Myocardial infarction/ischaemia • Haematological Elevated WBC count Platelet count <50 x109/L • Elevated INR or aPTT Transfusion of blood prod • Low platelet count • Renal Elevated serum creatinine Acute kidney injury • Elevated serum uric acid New indication for dialys
  12. Adverse conditions and severe complications of preeclampsia Organ system affected Adverse conditions Severe complications (that increses risk of SC) ( that warrant delivery) Hepatic Nausea and vomiting Hepatic dysfunction(iNR RUQ or epigastric pain >2 in absence of warfarin Elevated serun AST,ALT Hepatic haematoma or LDH or bilirubin rupture Feto-placental Non-reassuring FHR Abruption with evidence IUGR of maternal/fetal compr Oligohydramnios Stillbirth Absence or reversed end-diastolic flow by Doppler velocimetry
  13. Diagnostic and therapeutic considerations • Pre-existing or chronic hypertension • Must be differentiated from white –coat effect (about 30% of early pregnanacies) • Associated with the following • Super-imposed preeclampsia=20% • Abruption (1-2%) • Preterm delivery (33%) • IUGR (15%) • NICU admission (50%)
  14. Diagnostic and therapeutic considerations • The white –coat effect in early pregnancy is associated with 40% chance of superimposed gestational hypertension and 8% chance of pre-eclampsia • More than 95% of women with pre-existing hypertension have essential hypertension • Need to investigate thoroughly • .(urinalysis,serum creatinine,potassium,FBS, ECG)
  15. Gestational hypertension • Appears at >20weeks • Risks depend on gestational age at presentation and progression to pre-eclampsia • About 35% at <34 weeks will develop pre- eclampsia over an average of 5 weeks • Women with prior gestational hypertension are likely to have recurrence(21%) • Women with prior pre-eclampsia may develop gestational hypertension(22%)
  16. Classification of hypertension in pregnancy. • •Mild hypertension diastolic blood pressure 90–99 mmHg, systolic blood pressure 140–149 mmHg. • • Moderate hypertension diastolic blood pressure 100–109 mmHg, systolic blood pressure 150–159 mmHg. • • Severe hypertension diastolic blood pressure 110 mmHg or greater, systolic blood pressure 160 mmHg or greater.
  17. MANAGEMENT OF GESTATIONAL HYPERTENSION Degree of hypertension Mild hypertension Moderate hypertension Severe hypertension Admit to hospital No (Yes) No (Yes) Yes,until blood pressure is 150/100 or lower Treat No With oral labetolol as first line .keep bp at systolic <150 and diastolic at 80-100 mmHg With oral labetolol as first line .keep bp at systolic <150 and diastolic at 80-100 mmHg Measure blood pressure Not less than once a week At least twice weekly At least four times a day Test for proteinuria At each visit At each visit Daily
  18. Timing of delivery • Best at 37 weeks • Labour induction decreases poor maternal outcome and it is cost saving • Expectant care at 34-36 weeks may decrease neonatal respiratory morbidity • At <34 weeks, there is insufficient evidence to make recommendation.
  19. Pre-eclampsia • Defined as gestational hypertension with proteinuria or one/more adverse conditions or severe complications listed in previous slide Factors independently associated with adverse maternal outcome - Preterm preeclampsia - - chest pain/dyspnoea - -abnormal oxygen saturation/platelet count/creatinine/AST. - DEGREE OF PROTEINUIA NOT ASSOCIATED WITH SHORT TERM ADVERSE PREGNANCY OUTCOME.
  20. PRE-ECLAMPSIA • However,the disease can develop for the first time after delivery • Or- worsen rather than improve during the post natal period. • It is advisable that all post partum patients become educated about symptoms suggestive of new or worsening preeclampsia after leaving the hospital
  21. DIAGNOSIS • ACOG says that Proteinuria ,or elevated protein in urine should not be considered the single criterion besides new-onset hypertension, in diagnosing preeclampsia • Equal weight should be given to reduced platelet count, renal insufficiency, severe headache, heart-lung compromise and , impared liver function.
  22. DIAGNOSIS • Any of these ,concurrent with new-onset hypertension at 20 weeks of pregnancy or beyond is enough to establish preeclampsia,even in the absence of proteinuria • Reviews of maternal mortality data have shown that waiting for proteinuria to present can result in delayed intervention or missed diagnosis.,as not all women with preeclampsia develop proteinuria
  23. Predicting pre-eclampsia • Demographics and family history • -maternal age >40years • -family history of preeclampsia(mum or sister) • -family history of early-onset cardiovascular disease
  24. Predicting pre-eclampsia • Past medical or obstetric history • -Previous pre-eclampsia (*) • -Antiphospholipid antibody syndrome(*) • -Pre existing medical condition (s) • -Pre existing hypertension or booking dBP>90 • -Pre existing renal disease or booking proteinuria • -Pre existing diabetes mellitus • Heritable thrombophilias • Non-smoking • Previous miscarriage at <10 weeks with same partner.
  25. Risk makers for preeclampsia • Current pregnancy (First trimester) • Multiple pregnancy(*) • Overweight/obesity • First ongoing pregnancy • New partner • Reproductive technologies • Inter-pregnancy interval>10years • Booking sBP>130mmHg or dBP>90mmHg • GTD, Abnormal PAPP-A. • Vaginal bleeding in early pregnancy
  26. Risk makers for pre-eclampsia • Second or third trimester • Gestational hypertension • Abnormal AFP, hCG, inh A or E3 • Excessive weight gain in pregnancy • Infection during pregnancy (UTI, periodontal disease) • Abnormal uterine artery Doppler • IUGR
  27. Predicting preeclampsia • No single test predicts pre-eclampsia sufficiently to be recommeded for use in clinical practice to improve outcome. • THE CONFIDENTIAL ENQUIRY INTO MATERNAL DEATH HAVE RELATED UNDERAPPRECIATION OF RISK IN PRE-ECLAMPSIA TO POTENTIALLYAVOIDABLE DEATHS.
  28. MANAGEMENT OF PET Degree of hypertension Mild hypertension Moderate hypertension Severe hypertension Admit to hospital Yes Yes Yes Treat No With oral labetolol as first line .keep bp at systolic <150 and diastolic at 80-100 mmHg With oral/IV labetolol as first line .keep bp at systolic <150 and diastolic at 80-100 mmHg Measure blood presssure At least four times a day At least four times a day More than 4 times a day depending on clincal circumstance Test for proteinuria Do not repeat quantification Do not repeat quantification Do not repeat quantification
  29. Timing of delivery • Refers to pregnancy prolongation following a period of observation and stabilisation • Only about 40% of women are eligible • Should be offered only in experienced centres where neonates can be cared for (secondary or tertiary care centre)
  30. Timing of delivery • Expectant care at<24 weeks is associated with substanticl maternal complication rates (including death) (27-71%) and perinatal mortality (80%)] • Termination of pregnancy should be discussed
  31. Timing of delivery • At 24- 33 weeks + 6 days • Associated with lower rates of maternal complications (5%) and fewer neonatal complications despite poorer fetal growth • Average pregnancy prolongation is 2 weeks • At 34-36 weeks + 6 days • Expectant management appears to decrease neonatal respiratory distress syndrome.
  32. Indications for delivery • Term gestation • Severe maternal complications • Stillbirth or non-reassuring fetal monitoring
  33. Most commonly used agents for treating BP>160/110 Agent Dosage Onset Peak Duration Comments Labetalol Start with 20mgIV 5mins 30mins 4hrs Best avoided in women repeat 20-80mg IV with asthma or heart q 30min.maximum failure of 300mg(then switch to oral tablets Nifedipine 5-10mg cap or 5-10mins 30mins -6hrs 10mg tab orally every 30 mins Hydralazine .Start with 5mgIV 5mins 30mins repeat 5-10mgIV every 30mins ORAL LABETALOL HAS BEEN RECOMMENDED AS AN INITIAL THERAPY FOR SEVERE HYPERTENSION.(NICE GUIDELINE )
  34. Doses of commonly used drugs to treat BP149-159/99-109 Agent Dosage Comments Aldomet 250-500mg po-qid ( max 2g/D) Labetalol 100-400mg po bid-tid (max 1200mg/D) Nifedipine Slow –release preparation 20-60mg po OD (maximun 120mg /day) No compelling evidence that antihypertensives are associated with neuro- developmental effects. Gestational hypertension and pre-eclamapsia can be associated with an increase in adverse paediatric neurodevelopmental effects(inattention,aggresion)
  35. Other considerations • Most cases of severe pregnancy hypertension are not associated with clear end-organ dysfunction(e g eclampsia),so BP can be lowered over hours • MgS04 may lower BP transiently 30mins after loading dose • If Nifedipine is used as antihypertensive,it may be prudent to administer MgS04 over 20mins rather than 5mins. • Antenatal corticosteroids and MgS04 for fetal
  36. USE OF CORTICOSTEROIDS • Corticosteroids for fetal lung maturation delivery is anticipated within 7 days • • give two doses of betamethasone* 12 mg intramuscularly 24 hours apart in women between 24 and 34 weeks • • consider giving two doses of betamethasone* 12 mg intramuscularly 24 hours apart in women between 35 and 36 weeks. • DON’T GIVE STEROIDS TO TREAT HELLP
  37. Fetal monitoring Mild/moderate gestational hypertension • Ultrasound scan for fetal growth and amniotic fluid volume assessment at gestational age <34 weeks. • If results are normal, there is no need for repeat • After 34 weeks, routine ultrasound is not advocated unless there is in indication • CTG can be performed if there is abnormal fetal activity
  38. Severe gestational hypertension/Preeclampsia • Perform CTG at diagnosis • Carry out ultrasound for fetal growth and amniotic fluid assessment at diagnosis • Ultrasound can be performed every two weeks and CTG weekly
  39. Care plan to be recorded • -Time and nature of future fetal monitoring • Fetal indication for delivery and if and when corticosteroid should be given • When discussion with neonatologist and anaesthetists should be take place and what decisions should be made.
  40. Magnesium sulphate • Magnesium sulphate (MgS04 (4 g intravenously (IV) halves the risk of recurrent eclampsia • Recurrent seizures should be treated with another 2-4-g IVdose • MgS04 more than halves the eclampsia occurrence in women with pre-eclampsia • Abruption risk is also decreased • 100 women with pre-eclampsia must be treated to prevent one seizure,GUIDELINES agree that only women with severe pre-eclampsia be treated.
  41. Caesarean section vs induction of labour • Choose mode of delivery for women with severe hypertension, severe pre-eclampsia or eclampsia according to the clinical circumstances and the woman's preference.
  42. MANAGEMENT OF LABOUR • Hourly BP check in mild/moderate GH • ½ hrly in severe hypertension • Do not routinely limit the duration of the second stage of labour: • Recommend operative birth in the second stage of labour for women with severe hypertension whose hypertension has not responded to initial treatment. rd
  43. Fluid management • Intravenous fluid intake should be minimized.(80mls/hr if there is no ongoing bleeding) • Use 0.9% Normal saline/Ringers Lactate Better to avoid colloids(albumin/haemacel)
  44. Management of coagulation disorders before delivery • Platelet transfusion is recommeded for counts <20x 109/L,20-49x109/L prior to CS or >50 x109/L ( with excessive bleeding, platelet dysfunction.
  45. PREVENTION OF PREECLAMPSIA • Several randomised trials reported the use of various methods to reduce the rate or severity or both of pre- eclampsia. • Include protein and salt restriction,zinc,magnesium, fish oil, vit C, E supplement. • Cochrane review showed benefit of calcium supplimentation for preeclampsia prevention in women with low dietary intake is unclear (Knight 2000) • Even though these trial had limited sample sizes, results showed a minimum to no benefit (Sibai 1998) • Observational studies suggest that heparin reduces recurrent preeclampsia in women with thrombophilia (Kupferminc 2001)
  46. Eclampsia • Preceded by severe pre-eclampsia in majority of cases( beware of atypical cases) Mortality higher in antepartum eclampsia • If treated early and adequately, mortality should be towards zero.
  47. Principles of management of Eclampsia Maintain airway, breathing & circulatiion - Control B.P Oxygen administration 8-10L/min -Request for investigations Arrest convulsion - Delivery within 6-8hrs Ventilatory support -Prevent complications Prevention of injury - Post partum care ( intensive)
  48. Causes of death • -Cardiac failure • -Pulmonary oedama • -Cerebral haemorrage/oedema • -Adult respiratory distress syndrome • -Acute renal failure • -Cardiopulmonary arrest • -Pulmonary embolisn • -Puerperal sepsis
  49. Prognosis • -Long interval between onset of fit and commencement of treatment (delay) • -Antepartum eclampsia • -Coma between fits • -Fits more than 10 • sBP>200mmHg • -Temp >102 degrees F • -Oliguria • -Jaundice
  50. RISKS IN FUTURE PREGNANCY Gestational hypertension Pre-eclampsia Severe pre- eclampsia/eclampsi a,HELLP synrome Gestational hypertension 16-47% 13-53% Pre-eclampsia 2-7% (16%). If birth was needed before 34 weeks risk is about 25%. If birth was needed before 28 weeks risk is about 55% Cardiovascular disease Increased risk of hypertension and its complications Increased risk of hypertension and its complications Increased risk of hypertension and its complications
  51. Indications for referral to critical care levels Level 3 care Severe pre-eclampsia and needing ventilation Level 2 care Eclampsia HELLP syndrome Haemorrhage Hyperkalaemia Severe oliguria Coagulation support Intravenous antihypertensive treatment Intial stabilisation of severe hypertension Evidence of cardiac failure Abnormal neurology Pre-eclampsia with mild to moderate hypertension
  52. Post-natal investigation,monitoring and treatment In women with gestational hypertension who have given birth, measure blood pressure: • daily for the first 2 days after birth • at least once between day 3 and day 5 after birth • as clinically indicated if antihypertensive treatment is changed after birth.
  53. Post-partum management • Continue use of antenatal antihypertensive treatment • Consider reducing the antihypertensive treatment if BP<130/80mmHg • Stop methy-dopa within 2 days of delivery if on the treatment • Start antihypertensive if BP>150/100mmHg postnatally • Follow up patients appropriately until 6-8 weeks post partum
  54. Post-natal investigation,monitoring and treatment • With those not on antihypertensives • Measure BP qid while woman is in hospital • At least once daily after discharge • Start antihypertensive if BP>150/100 • Check all investigations results before discharge.
  55. Patients education  •Patients should be made aware of the need to seek immediate advice from a healthcare professional if they experience symptoms of pre- eclampsia.  -severe headache  •-problems with vision, such as blurring or flashing before the eyes  •-severe pain just below the ribs  •-vomiting
  56. CONCLUSION -Identifying at Risk Patients during antenatal booking is Key to reducing the incidence and complications of the disease -Delivery should be discussed in patients presenting before 24 weeks of gestation -Eclamptic /preeclamptic patients with one end organ insult should be transferred to High Dependency Unit