High Risk Pregnancy

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Hypertensive Disorders in Pregnancy.

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High Risk Pregnancy

  1. 1. Hypertension in PregnancyHypertension in Pregnancy ClassificationClassification  Chronic hypertension  Gestational hypertension (only during pregnancy)  Preeclampsia Superimposed upon chronic hypertension or Renal Disease  Preeclampsia - eclampsia  Transient hypertension (only after pregnancy)
  2. 2. Chronic HypertensionChronic Hypertension Defined as hypertension diagnosed  Before pregnancy  Before the 20th week of gestation  During pregnancy and not resolved postpartum
  3. 3. Gestational HypertensionGestational Hypertension Gestational Hypertension: – Systolic >140 – Diastolic>90 – No Proteinurea – 25% Develop Pre-eclampsia
  4. 4. Gestational HypertensionGestational Hypertension Diagnosis of gestational hypertension:  Detected for first time after midpregnancy  No proteinuria  Only until a more specific diagnosis can be assigned postpartum If preeclampsia does not develop and  BP returns to normal by 12 weeks postpartum, diagnosis is transient hypertension.  BP remains high postpartum, diagnosis is chronic hypertension.  Proteinurea develops Preeclampsia is diagnosed (25% incidence)
  5. 5. Hypertension in PregnancyHypertension in Pregnancy Complicates 7-10% of pregnancies – 70% Preeclampsia-eclampsia – 30% Chronic hypertension Eclampsia 0.05% incidence 20% of Maternal Deaths Cause of 10% of Preterm birth Etiology unknown
  6. 6. Hypertension in PregnancyHypertension in Pregnancy Young female 3 fold increased risk Africans 2 fold increased risk Multifetal pregnancies – Twins – Triplets Hypertension Renal Disease Collagen Vascular Disease
  7. 7. ** INCIDENCE: 5-10% 0f all pregnancies . 20% recurrence This is the third most important cause of maternal mortality worldwide ** DEFINITION OF HYPEWRTENSION:  D.B.P. > 90 mmHg or  S.B.P. > 140 mmHg or  Rise in D.B.P. of at least 15 mmHg (physiological changes) or  Rise in S.B.P. of at least 30 mmHg ** PROTIENUREA: Proteinurea is defined as urinary excretion 0.3 g protein or greater in a 24-hour 30 mg/dl (+1 or greater on urine dip specimen) ** OEDEMA: 90% pregnancy. progressive abandoned +/-
  8. 8. •Enlarged placenta e.g…………. •Pre-existing hypertension, renal •Pre-existing vascular disease •P0 >>>> multip •Family history •New husband
  9. 9. Symptoms of Pre-eclampsiaSymptoms of Pre-eclampsia  Visual disturbances typical of preeclampsia are scintillations and scotomata. These disturbances are presumed to be due to cerebral vasospasm.  Headache is of new onset and may be described as frontal, throbbing, or similar to a migraine headache. However, no classic headache of preeclampsia exists.  Epigastric pain is due to hepatic swelling and inflammation, with stretch of the liver capsule. Pain may be of sudden onset, it may be constant, and it may be moderate-to-severe in intensity.
  10. 10. Symptoms of preeclampsiaSymptoms of preeclampsia  While mild lower extremity edema is common in normal pregnancy, rapidly increasing or nondependent edema may be a signal of developing preeclampsia. However, this signal theory remains controversial and recently has been removed from most criteria for the diagnosis of preeclampsia.  Rapid weight gain is a result of edema due to capillary leak as well as renal sodium and fluid retention.
  11. 11. Physical Findings inPhysical Findings in PreeclampsiaPreeclampsia Blood Pressure Proteinurea Retinal vasospasm or Retinal edema Right upper quadrant (RUQ) abdominal tenderness stems from liver swelling and capsular stretch
  12. 12. Physical findings inPhysical findings in PreeclampsiaPreeclampsia – Brisk, or hyperactive, reflexes are common during pregnancy, but clonus is a sign of neuromuscular irritability that raises concern. – Among pregnant women, 30% have some lower extremity edema as part of their normal pregnancy. However, a sudden change in dependent edema, edema in nondependent areas such as the face and hands, or rapid weight gain suggests a pathologic process and warrants further evaluation
  13. 13. •Why screening •Accuracy. Uterine artery doppler at 24 weeks, notching on both uterine arteries identifies 80% who will develop PET,,, 5% false positive
  14. 14. Methods Used to Prevent Hypertensive Disorders of Pregnancy Proper prenatal care Low-salt diet Diuretics Antihypertensive drugs Nutritional supplementation Magnesium (365 mg/d) Zinc (20 mg/d) Calcium (1500–200 mg/d) Fish oil Antithrombotic agents Low-dose aspirin (50–150 mg/d) Dipyridamole (225–300 mg/d) Subcutaneous heparin (15,000 IU/d)
  15. 15.  HELLP SYNDROME  ABRUPTIO PLACENTAE  PULMONARY OEDEMA  ACUTE RENAL FAILURE  CEREBRAL HAEMORRHAGE  VISUAL DISTURBANCES & BLINDNESS  HEPATIC RUPTURE  ELECTROLYTIC IMBALANCE  POSTPARTUM COLLAPSE SERIOUS COMPLICATIONS: -
  16. 16. CURE / PREVENT PROGRESSION - – CLOSE MONITORING REDUCE BLOOD PRESSURE -TATRGET- 140/90 PROMOTE FOETAL MATURITY PROLONG PREGNANCY (34 - 36 WEEKS) – TO ACHIEVE FOETAL MATURITY  TERMINATION DELIVERY-DELIVERY- BEST DAY, BEST WAY & BEST PLACE PREVENT / MANAGE COMPLICATIONS OBJECTIVES OF MANAGEMENT HYPERTENSION DURING PREGNANCY
  17. 17. ** Definite treatment is delivery (ending the pregnancy). But, Mother vs. Fetus
  18. 18. ** Mild pre-eclampsia: diastolic /90-95 & proteinurea trace-1+ ** Moderate pre-eclampsia ** Severe pre-eclampsia ** Does the treatment improve the condition? Then why. Adv/disadv
  19. 19. CONTROL OF ACUTE SEVERE HYPERTENSION • There is no consensus on the optimum acute treatment. • The important objective is to reduce the blood pressure to safe levels. (but not too low!). • Parenteral hydralazine is used most commonly but oral nifedipine should be considered . The combined a- and (B- blocking agent labetalol is commonly used. The potent vasodilator and calcium channel blocker nifedipine is a useful second-line treatment. Its major drawback is severe headache. Angiotensin-converting enzyme (ACE) inhibitors have deleterious fetal effects and their use is not recommended. If a woman with chronic hypertension becomes pregnant on an ACE inhibitor, change to another anti-hypertensioe agent is advised. LONGER-TERM CONTROL OF SEVERE HYPERTENSION
  20. 20. • There is still insufficient trial evidence to determine whether the benefits outweigh any disadvantages. • If it is to be used, the suggested indications are: ,-DBP >_100 mmHg -pregnancy <_34 weeks *fetal and maternal state otherwise good. • Methyldopa remains the drug of first choice. The combined a- and (B- blocking agent labetalol is commonly used. The potent vasodilator and calcium channel blocker nifedipine is a useful second-line treatment. Its major drawback is severe headache. Angiotensin-converting enzyme (ACE) inhibitors have deleterious fetal effects and their use is not recommended. If a woman with chronic hypertension becomes pregnant on an ACE inhibitor, change to another anti-hypertensioe agent is advised. LONGER-TERM CONTROL OF SEVERE HYPERTENSION
  21. 21. Timing of delivery • The most common grounds for delivery are:  progressive fetal compromise, (i.e. when the baby is safer delivered).  unacceptable risk to maternal health, e.g. uncontrollable BP, impending renal failure or heart failure, HELLP syndrome, DIC, eclampsia .
  22. 22. The mode of delivery (caesarean section versus vaginal) depends on: -The seriousness of the situation -The gestational age -The degree of fetal/maternal compromise. • Epidural analgesia is the method of choice for labour (as long as a coagulation defect has been excluded). • Appropriate facilities for the care of the newborn available

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