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  • HELLP syndrome is characterized by liver compromise during or after a pregnancy, complicated by hypertension and/or preeclampsia. The letters stand for: H emolytic anemia (when red blood cells break down) E levated  L iver transminases (sign of liver problems) L ow  P latelet count (causing problems in blood clotting). This condition usually appears in the third trimester and most commonly in first-time pregnancies, but it can begin as early as 20 weeks and recur in subsequent pregnancies. A simple explanation of the disease is that it is a very severe form of preeclampsia. About 15 percent (in one study) of women with preeclampsia go on to develop HELLP.
  • PIH-New_edited-13-09-10.ppt

    1. 1. Hypertension Arising in Pregnancy
    2. 2. <ul><li>Hypertension is one of the common complications. </li></ul><ul><li>Increased maternal and perinatal morbidity and mortality. </li></ul><ul><li>Underlying pathology </li></ul><ul><ul><li>Pre-existing or </li></ul></ul><ul><ul><li>During pregnancy </li></ul></ul><ul><ul><ul><li>Preeclampsia </li></ul></ul></ul><ul><ul><ul><li>Eclampsia </li></ul></ul></ul><ul><ul><ul><li>Gestational hypertension </li></ul></ul></ul>
    3. 3. <ul><li>Hypertension (BP ≥ 140/90 mm Hg) during pregnancy can be classified as chronic or gestational. </li></ul><ul><li>Chronic hypertension is BP that is high before pregnancy or before 20 wk gestation. It is seen about 1 to 5% of all pregnancies. </li></ul><ul><li>Gestational hypertension develops after 20 wk gestation (typically after 37 wk) and remits by 6 wk postpartum; it occurs in about 5 to 10% of pregnancies, more commonly in multifetal pregnancy. </li></ul>
    4. 4. PREECLAMPSIA <ul><li>Preeclampsia is a common problem during pregnancy, affecting up to one in seven pregnant women around the world. </li></ul><ul><li>This condition is defined by high blood pressure and excess protein in the urine after 20 weeks of pregnancy. </li></ul><ul><li>It can lead to serious, even deadly complications for mother and the unborn baby. </li></ul>
    5. 5. <ul><li>Globally, preeclampsia and other high blood pressure disorders during pregnancy are a leading cause of maternal and infant illness and death. </li></ul><ul><li>The only cure for preeclampsia is delivery of the baby. After baby is born, blood pressure usually returns to normal within a few days. </li></ul><ul><li>So delivery is the obvious solution when preeclampsia is found near the end of the pregnancy, which is typically the case. </li></ul>
    6. 6. <ul><li>Preeclampsia is a multisystem disorder which is peculiar to the pregnant state. </li></ul><ul><li>It usually manifests for the first time beyond the 20 th week and is characterised by the appearance of hypertension to the extent of 140/90 mmHg or more with proteinuria or edema or both. </li></ul><ul><li>The cause remains obscure but there is intense vasospastic condition affecting almost all the vessels specially those of the uterus and the kidneys. </li></ul>
    7. 7. <ul><li>Pathophysiological changes are more evident on the uteroplacental bed, liver and kidneys. </li></ul><ul><li>The change are mostly related to a combination of vasospastic state and Disseminated Intravascular Coagulopathy (DIC). </li></ul><ul><li>HELLP syndrome ( H emolysis; E levated L iver Enzymes; L ow P latelet Count) is observed in 10-15% of those with preeclampsia – eclampsia. </li></ul><ul><li>Incidence varies from 5-15%, more in primigravidae. </li></ul><ul><li>The onset is usually insidious. </li></ul><ul><li>It is principally a syndrome of signs, such as rapid gain in weight, edema of legs, raised BP and proteinuria. </li></ul>
    8. 8. <ul><li>Maternal hazards include eclampsia, abruptio placentae, oliguria or anuria, dimness of vision or blindness, increased operative interference, postpartum shock and puerperal sepsis. </li></ul><ul><li>Fetal risk are due to intrauterine death, dysmaturity, asphyxia or prematurity. </li></ul><ul><li>Prevention includes regular antenatal check-up to detect at the earliest the evidences of preeclampsia features so that prompt therapy can be instituted. </li></ul><ul><li>Treatment modalities, a case of severe preeclampsia should have prophylactic anticonvulsant therapy and urgent termination of pregnancy. </li></ul>
    9. 9. <ul><li>Predisposing factors : </li></ul><ul><li>Elderly and young primigravidae </li></ul><ul><li>Family history of pre-eclampsia, eclampsia or hypertension </li></ul><ul><li>Poor and under-privileged sector – more due to neglect in antenatal care rather than nutritional cause </li></ul><ul><li>Pregnancy complications such as hydatidiform mole, multiple pregnancy, polyhydramnios, Rh-incompatibility </li></ul>
    10. 10. <ul><li>Medical disorders – hypertension, nephritis, diabetes </li></ul><ul><li>Hereditary – though to be single recessive gene disorder. </li></ul><ul><li>Basic pathology is intense vasospasm affecting almost all the vessels - uterus, kidney and brain. </li></ul><ul><li>Responsible agent for vasospasm - humoral in origin. </li></ul>
    11. 11. <ul><li>Edema </li></ul><ul><li>Excessive accumulation of fluids in the extracellular tissue spaces is not clear. </li></ul><ul><li>Excessive retention of sodium in the edematous state is probably due to increase aldosterone out of activation of corticosterone by angiotensin . </li></ul>
    12. 12. <ul><li>Proteinuria : </li></ul><ul><li>Spasm of the afferent glomerular arterioles --> anoxin damage to the endothelium of the glomerular tuff --> increased capillary permeability --> increased leakage of proteins. </li></ul><ul><li>Tubular reabsorption is simultaneously depressed. </li></ul><ul><li>Albumin constitutes 50-60% and alpha globulin constitutes 10-15% of the total proteins excreted in the urine. </li></ul>
    13. 13. Clinical types <ul><li>Proteinuria is more significant than blood pressure to predict fetal outcome. </li></ul><ul><li>Mild </li></ul><ul><li>Severe </li></ul>Mild : this includes cases of sustained rise of blood pressure of more than 140/90 mmHg but less than 160 systolic or 110 diastolic without significant proteinuria.
    14. 14. <ul><li>A persistent diastolic pressure of > 110 mmHg. </li></ul><ul><li>Persistent severe epigastric pain </li></ul><ul><li>Cerebral or visual disturbances </li></ul><ul><li>Oliguria </li></ul><ul><li>Protein excretion of >5 gm/day </li></ul><ul><li>Platelet count <1,00,000/µL </li></ul><ul><li>Elevated liver enzymes </li></ul><ul><li>Retinal hemorrhages, exudates or papilledema </li></ul><ul><li>Intrauterine growth restriction of the fetus </li></ul><ul><li>Pulmonary edema. </li></ul>Severe : is diagnosed when one or more of the following manifestations exist.
    15. 15. Clinical features <ul><li>Pre-eclampsia frequently occurs in primigravidae (70%). It is more often associated with obstetrical medical complications such as multiple pregnancy, polyhydramnios, pre-existing hypertension, diabetes etc. </li></ul><ul><li>The clinical manifestations appear usually after the 20th week. </li></ul><ul><li>Onset : Usually insidious and the syndrome runs a slow course. On rare occasion, the onset becomes acute and follows a rapid course. </li></ul><ul><li>Symptoms : Pre-eclampsia is principally a syndrome of signs and when symptoms appear, it is usually late. </li></ul><ul><li>Mild symptoms : Slight swelling over the ankles which persists on rising from the bed in the morning or tightness of the ring on the finger is the early manifestation of pre-eclampsia edema. Gradually, the swelling may extend to the face, abdominal wall, vulva and even the whole body. </li></ul>
    16. 16. SIGNS AND SYMPTOMS <ul><li>The signs of preeclampsia are elevated blood pressure (hypertension) and the presence of excess protein in urine (proteinuria) after 20 weeks of pregnancy. </li></ul><ul><li>Other signs and symptoms are not always noticeable: </li></ul><ul><li>Severe headaches </li></ul><ul><li>Changes in vision, including temporary loss of vision, blurred vision or light sensitivity </li></ul><ul><li>Upper abdominal pain, usually under the ribs on the right side </li></ul><ul><li>Unexplained anxiety </li></ul>
    17. 17. <ul><li>Nausea or vomiting </li></ul><ul><li>Dizziness </li></ul><ul><li>Decreased urine output </li></ul><ul><li>Swelling (edema), particularly in the face and hands. </li></ul>
    18. 18. <ul><li>Abnormal weight gain : rapid weight gain more than 2.3 kg a month or more than 0.46 kg a week. </li></ul><ul><li>Rise in blood pressure : > 140/90 mmHg. </li></ul><ul><li>Edema : Visible edema over the ankles on rising from the bed in the morning is pathological. May spread to other parts of the body in uncared cases. Sudden and generalized edema may indicate imminent eclampsia. </li></ul><ul><li>No manifestation of chronic cardiovascular or renal pathology. </li></ul><ul><li>Abdominal examination reveals chronic placental insufficiency such as scanty weight --> visible edema and/or hypertension --> proteinuria. </li></ul>
    19. 19. Alarming symptoms - associated with acute onset of the syndrome <ul><li>Headache – either located over the occipital or frontal region. </li></ul><ul><li>Disturbed sleep </li></ul><ul><li>Decreased urinary output – less than 500 mL in 24 hours is very ominous. </li></ul><ul><li>Epigastric pain – acute pain associated with vomiting, at times coffee color, is due to hemorrhagic gastritis or due to subcapsular hemorrhage in the liver. </li></ul><ul><li>Eye symptoms – blurring or dimness of vision or at times complete blindness. Vision is usually regained within 4-6 weeks following delivery. The eye symptoms are due to spasm of retinal vessels, edema and retinal detachment. Reattachment of the retina occurs following subsidence of edema and normalization of blood pressure after delivery. </li></ul>
    20. 20. Investigations <ul><li>Urine : Proteinuria is the last feature of pre-eclampsia to appear. It may be trace or at timescopious so that urine becomes solid on boiling (10-15 gm/liter). There may be few hyaline casts, epithelial cells, or even few red cells. 24 hours urine collection for protein measurement is done. </li></ul><ul><li>Ophthalmoscopic examination : Retinal edema, constriction of the arterioles, alteration of normal ratio of vein: arteriole diameter from 3:2 to 3:1 and nicking of the veins where crossed by the arterioles. </li></ul>
    21. 21. <ul><li>Blood values : Blood changes are not specific and often inconsistent. Serum uric acid level (biochemical marker of pre-eclampsia) of more than 4.5 mg% indicates the presence of pre-eclampsia. Blood urea level remains normal or slightly raised. Serum creatinine level may be more than 1 mg/dL. There may be thrombocytopenia of varying degrees. Hepatic enzyme levels may be increased. </li></ul><ul><li>Antenatal fetal monitoring – Antenatal fetal well being assessment is done by clinical examination, daily fetal kick count, ultrasonography for fetal growth and liquor pockets, cardiotocography, umbilical artery flow velocimetry and biophysical profile. </li></ul>
    22. 22. <ul><li>Course of the disease : Pre-eclampsia is usually insidious in onset and runs a slow course. Rarely, the onset may be acute and follows rapid course of events. </li></ul><ul><li>If detected early : With prompt and effective treatment the pre-eclamptic features may subside completely. </li></ul><ul><li>If left untreated and uncared for : </li></ul><ul><ul><li>Pre-eclamptic features remain stationary at varying degrees till delivery. </li></ul></ul><ul><ul><li>Aggravation of the pre-eclamptic features with appearance of symptoms of acute fulminating pre-eclampsia as mentioned earlier. This happens mostly in cases with acute onset. </li></ul></ul><ul><ul><li>Eclampsia – It may occur following acute fulminating pre-eclampsia or bypassing it. In fact, eclampsia can occur even with a blood pressure of 140/90 mmHg </li></ul></ul><ul><ul><li>Spontaneous remission of the pre-eclampsia features – a rare and fortunate event. </li></ul></ul>
    23. 23. COMPLICATIONS OF PREECLAMPSIA <ul><li>HELLP syndrome </li></ul><ul><li>Eclampsia – within 48 hours </li></ul><ul><li>Liver necrosis </li></ul><ul><li>Brain – cerebral edema </li></ul><ul><li>Heart failure </li></ul><ul><li>Salt retention </li></ul>
    24. 24. PATHOPHYSIOLOGY <ul><li>Brain : Apart from cerebral edema, capillary thrombosis, patches of hemorrhages and necrosis may occur. Cerebral function is not impaired although there is increased irritability as evidenced in the electro-encephalogram (EEG). This explains exaggerated reflexes on examination. </li></ul><ul><li>Heart : Sub-endothelial hemorrhages may occur. Focal necrosis and hemorrhage in the myocardium may affect the conducting system leading to heart failure. </li></ul><ul><li>Lungs : There is evidence of edema or hemorrhagic bronchopneumonia. </li></ul><ul><li>Other organs : Adrenal glands show hemorrhage and necrosis. Stomach shows feature of hemorrhagic gastritis. </li></ul>
    25. 25. The warning signs and symptoms of ECLAMPSIA : <ul><li>Pain in the upper right side of abdomen </li></ul><ul><li>Severe headache </li></ul><ul><li>Vision problems, seeing flashing lights </li></ul><ul><li>Change in mental status, decreased alertness </li></ul><ul><li>Abnormal weight gain 0.46 kg per week or 2.3 kg per month. </li></ul>
    26. 26. Problems for the fetus <ul><li>Preeclampsia affects the arteries carrying blood to placenta. </li></ul><ul><li>Less oxygen and nutrients. </li></ul><ul><li>Slow growth or low birth weight. </li></ul><ul><li>Preterm birth. </li></ul><ul><li>Preeclampsia increases the risk of placental abruption — in which the placenta separates from the inner wall of the uterus before delivery. </li></ul><ul><li>Severe abruption causes heavy bleeding, resulting in shock. </li></ul>
    27. 27. GESTATIONAL HYPERTENSION <ul><li>A sustained rise of blood pressure to 140/90 mmHg or more on at least two occasions 4 or more hours apart beyond the 20 th week of pregnancy or during the first 24 hours after delivery in a previously normotensive woman is called gestational hypertension . </li></ul><ul><li>It is associated with a much higher incidence of essential hypertension in later life than pre-eclampsia. </li></ul><ul><li>Both are thus seem to be two phases of the same disorder. </li></ul>
    28. 28. <ul><li>It should fulfill 3 criteria </li></ul><ul><li>Absence of any evidences for the underlying cause of hypertension </li></ul><ul><li>Unassociated with other evidences of preeclampsia (edema or proteinuria). </li></ul><ul><li>The blood pressure should come down to normal within 10 days following delivery. </li></ul><ul><li>The hypertensive effect may be a stress response . </li></ul><ul><li>Perinatal mortality remains unaffected. </li></ul><ul><li>These patients are more likely to develop hypertension with the use of oral contraceptives or in subsequent pregnancies. </li></ul>
    29. 29. <ul><li>Gestational edema is excessive accumulation of fluid with demonstrable pitting edema over the ankles greater than 1+ after 12 hours in bed or gain in weight of 2 kg or more in a week due to influence of pregnancy. </li></ul><ul><li>Gestational proteinuria is the presence of protein of more than 0.3 gm in the 24 hours urine during or under the influence of pregnancy in the absence of hypertension, edema or renal infection. It may be orthostatic proteinuria. </li></ul>
    30. 30. Effects of pregnancy on the disease <ul><li>There may be a midpregnancy fall of blood pressure in about 50% , the BP tends to rise in the last trimester which may or may not reach its previous level. </li></ul><ul><li>In 50%, the BP tends to rise progressively as pregnancy advances. </li></ul><ul><li>In about 20%, it is superimposed by pre-eclampsia evidenced by rise of BP to the extent of 30 mm systolic and 15 mmHg diastolic associated with edema and/or proteinuria. </li></ul><ul><li>Rarely, malignant hypertension supervenes. </li></ul><ul><li>In 30%, there is permanent deterioration of the hypertension following delivery. </li></ul>
    31. 31. Effects of the disease on pregnancy <ul><li>Maternal risk : In the milder form, the maternal risk remains unaltered but in the severe form or when superimposed by pre-eclampsia, the maternal risk is much increased. </li></ul><ul><li>Fetal risk : Due to chronic placental insufficiency, the babies are likely to be growth retarded. In the milder form, with the BP less than 160/100 mmHg, the perinatal loss is about 10%. When the BP exceeds 160/100 mmHg, the perinatal loss doubles and when complicated by pre-eclampsia, it trebles. </li></ul>
    32. 32. PRINCIPLES OF TREATMENT <ul><li>To stabilise the BP to below 160/100 mmHg </li></ul><ul><li>To prevent superimposition of preeclampsia </li></ul><ul><li>To monitor the maternal and fetal well being </li></ul><ul><li>To terminate the pregnancy at the optimal time. </li></ul>
    33. 33. General Management <ul><li>In mild cases with BP less than 160/100 mmHg, adequate rest (physical and mental), low salt and a sedative (phenobarbitone) are all that are needed. </li></ul><ul><li>The check up should be more frequent 1-2 weeks interval up to 28 weeks and thereafter weekly. </li></ul><ul><li>Depends upon the severity of disease. </li></ul>Obstetric Management
    34. 34. Antihypertensive Drugs <ul><li>Routine use of antihypertensive drug is controversial. </li></ul><ul><li>It may lower the BP and thereby benefit the mother but the diminished pressure may reduce the placental perfusion which may be detrimental to the fetus. </li></ul><ul><li>Antihypertensive drugs should be used only when the pressure is raised beyond 160/100 mmHg. </li></ul><ul><li>In cases, where the drugs have been used before pregnancy, care should be taken to adjust the dose during pregnancy, specially, during the midpregnancy when the BP tends to fall. </li></ul>
    35. 35. MANAGEMENT <ul><li>Rest </li></ul><ul><li>Diet </li></ul><ul><li>Laxative </li></ul><ul><li>Diuretics </li></ul><ul><li>Antihypertensives </li></ul>• Doxazosin Mesylate • Irbesartan • Candesartan • Valsartan • Fosinopril Sodium • Lercanidine HCl • Nebivolol HCl • Quinapril • S-Atenolol • Telmisartan • Trandolapril • Imidapril
    36. 36. Thank You