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Pre-Eclampsia and Hypertensive Disease in Pregnancy


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Pre-Eclampsia and Hypertensive Disease in Pregnancy

  1. 1. Pre-eclampsia and HypertensivePre-eclampsia and Hypertensive DiseaseDisease Tariq Shafi 10th September 2009
  2. 2. Plan of PresentationPlan of Presentation 1. Normal blood pressure changes in pregnancy 2. Differential diagnosis 3. Pre-existing hypertension 4. Pregnancy-induced hypertension 5. Pre-eclampsia 6. Stepwise management of pre-eclampsia
  3. 3. 1. Normal Blood Pressure Changes In Pregnancy  Measured in semi- recumbent position at 45o. Diastolic pressure recorded when sound disappears  Trimester 1-2: blood volume increases, but increased SVR due to progesterone causes drop in BP  Trimester 2-3: Cardiac output increases and RAAS activated, restoring BP Bloodpressure changesinpregnancy 0 20 40 60 80 100 120 140 0 15 40 Gestation(weeks) Bloodpressure(mmHg) SystolicBlood Pressure Diastolic Blood Pressure
  4. 4. 2. Differential Diagnosis2. Differential Diagnosis Blood pressure problems in pregnancy can be divided into three groups: 1. Chronic hypertension 2. Pregnancy-induced hypertension 3. Pre-eclampsia
  5. 5. 3. Chronic Hypertension3. Chronic Hypertension  Includes: 1. Known hypertensives 2. Patients whose hypertension is diagnosed prior to 20 weeks’ gestation  Increased risk of pre-eclampsia, intrauterine fetal growth restriction, placental abruption and stillbirth  Investigate to identify secondary hypertension, look for coexistent disease and identify pre-eclampsia  Use Methyldopa or Labetalol
  6. 6. 4. Pregnancy-Induced Hypertension  Persistently raised blood pressure after week 20 in previously normotensive woman  Not associated with proteinuria  Typically resolves within 6 weeks of delivery  Clinical sequelae and management: as Chronic Hypertension
  7. 7. 5. Pre-eclampsia  A multisystem disorder specific to pregnancy and the puerperium  Associated with hypertension and proteinuria in the second half of pregnancy  May be associated with sudden-onset oedema  Is a disease of the placenta  Affects 6% of all pregnancies
  8. 8. Pathology  Blood vessel endothelial cell damage, in association with an exaggerated maternal inflammatory response leads to vasospasm, increased capillary permeability and clotting dysfunction  These can affect all the maternal organs to varying degrees Pathology Manifestation Vasospasm Hypertension Increased permeability Proteinuria Reduced placental perfusion IUGR Reduced cerebral perfusion Eclampsia
  9. 9. Course and degrees of pre-eclampsia  The disease is progressive, but is variable and unpredictable  Hypertension usually precedes proteinuria Classification Description Mild Proteinuria and hypertension <170/110mmHg Moderate Proteinuria and hypertension ≥170/110mmHg Severe Proteinuria and hypertension < 32 weeks or with maternal complications e.g. HELLP, eclamptic fits
  10. 10. Pathophysiology  Stage 1 (Poor placentation)  Incomplete trophoblastic invasion of spiral arterioles results in reduced uteroplacental blood flow  Stage 2 (Inflammation)  The ischaemic placenta induces widespread endothelial cell damage and maternal systemic inflammatory response
  11. 11. Diagnostic Criteria  Made after 20 weeks’ gestation  New-onset hypertension (sustained BP ≥ 140/90 in a previously normotensive woman)  New-onset significant proteinuria (>0.3g/24h or ≥1+ on an MSU in the absence of a UTI)  Sudden-onset oedema (of face, hands and legs) may also be present
  12. 12. Clinical Features Headache Visual disturbances Vomiting Drowsiness Epigastric pain/tenderness Oedema Hypertension Proteinuria
  13. 13. Complications Eclampsia CVA DIC HELLP Pulmonary oedema Liver complications IUGR Placental abruption Increased mortality/morbidity Renal Failure Pre-eclampsia: a placental disease
  14. 14. Investigations To confirm the diagnosis  Dipstick urinalysis  If positive, exclude UTI by MSU  Assess protein:creatinine ratio (≥30g/nmol). If significant, do 24h urine (≥0.3g/24h) To monitor maternal complications  Serum urate (elevated)  Platelets (reduced)  LFTs (ALT/AST) (elevated)  Serum urea and creatinine (elevated) To monitor fetal complications  Ultrasound  Umbilical artery Doppler
  15. 15. 6. Stepwise Management of Pre-eclampsia  Treatment traditionally focused on treating eclampsia  However, pre-eclampsia is a mixture of diseases and presentations  The mainstay of management of pre-eclampsia is appropriate antenatal care, with a low threshold for referral for intervention
  16. 16. Risk Assessment early in Pregnancy Before 20 weeks, offer women specialist input if one of:  Previous pre-eclampsia  Multiple pregnancy  Pre-existing hypertension or booking DBP ≥ 90mmHg  Pre-existing renal disease or booking proteinuria  Pre-existing diabetes  Presence of antiphospholipid antibodies Or any two of:  First pregnancy or ≥ 10 years since last baby  Age ≥ 40 years  BMI ≥ 35  Family history of pre-eclampsia (mother or sister)
  17. 17. After 20 weeks gestation At 20 weeks, women should be assessed for the signs and symptoms of pre-eclampsia Referred to Maternity Assessment Suite if:  New hypertension  New proteinuria  Symptoms of headache or visual disturbance, or both  Epigastric pain or vomiting, or both  Reduced fetal movements, small for gestational age infant
  18. 18. After 20 weeks gestation – MAS assessment  If proteinuria only, repeat pre-eclampsia assessment in community within 1 week  Admit if any features in box below  Otherwise refer for hospital step-up assessment, to confirm the presence of significant hypertension, distinguish pre-eclampsia from the differentials and determine follow-up Diastolic ≥110 and ≥1+ protein on dipstick Systolic ≥170 and ≥1+ protein on dipstick Diastolic ≥90 and new proteinuria ≥1+ on dipstick with symptoms
  19. 19. Hospital Step-Up Assessment  Assessment includes blood pressure readings, urinalysis for protein, monitoring of symptoms and foetal movements, fundal height and foetal monitoring for gestation  If SBP < 140 and DBP <90 and protein:creatinine ratio ≥ 30mg/mmol and symptoms/bloods abnormal, admit  If SBP 140-169 and DBP 90-109 and protein:creatinine ratio ≥ 30mg/mmol or symptoms or bloods abnormal, admit
  20. 20. Inpatient Management  Assess blood pressure, urinalysis  Assess signs (oedema, auscultate heart and lung fields, epigastric tenderness, fundi for papilloedema, tendon reflexes and clonus)  Assess fetal size, presentation and well-being. Do CTG, U/S for biometry, umbilical artery Doppler, liquor volume, biophysical score  Do PET bloods, Group and Save or Cross-match  Monitor observations including fluid balance and urine output
  21. 21. Management of blood pressure  Mandatory when systolic blood pressure ≥ 170mmHg and diastolic blood pressure ≥ 110mmHg  The use of antihypertensives to treat mild to moderate hypertension reduces the risk of severe hypertension  Early treatment reduces neonatal complications e.g. respiratory distress syndrome  Oral methyldopa or labetalol used for mild to moderate hypertension  Sustained, markedly elevated blood pressure treated by IV labetalol
  22. 22. Management of complications Eclampsia  Magnesium sulphate (IV or IM)  Used as prevention if sustained SBP >160, DBP >110; proteinuria > 1g/24h or ≥ 3+ on dipstick; liver and/or renal impairment; coagulopathy  IM route easier to administer  IV route provides better blood levels
  23. 23. HELLP Syndrome  Activation of coagulation cascade destroys red blood cells, consumes platelets and causes periportal necrosis in liver  Causes headache, blurred vision, malaise, upper abdominal pain, paraesthesia  May cause liver rupture and seizure or coma
  24. 24. Timing of Delivery  Pre-eclampsia is progressive and cured only by delivery  Complications likely within 2 weeks of proteinuria Setting Action Mild hypertension, no fetal compromise Monitor. Induce at term Moderate or severe pre- eclampsia After 34 weeks: delivery. Before 34 weeks: Steroids, treat hypertension and monitor. Delivery if mother/fetus deteriorates Severe pre-eclampsia with complications Delivery
  25. 25. Conduct of Delivery  The ultimate cure for pre-eclampsia, but does not have an immediate effect  Epidural analgesia helps reduce the blood pressure  Antihypertensives can be used during labour  Oxytocin used in third stage Before 34 weeks Caesarean section After 34 weeks Vaginal delivery Induce with prostaglandins
  26. 26. Post-natal care of the pre-eclamptic patient  It often takes at least 24h post delivery for severe disease to improve and it may worsen during this time Parameter Measurement Blood investigations LFTs, platelets, renal function Fluid balance Urine output Blood pressure Monitor. Continued admission advisable until 5 days postpartum. Treat with beta blocker if raised
  27. 27. Summary  Blood pressure falls in early pregnancy, restored during the third trimester  Chronic hypertension and pregnancy-induced hypertension associated with risks to mother and fetus.  Pre-eclampsia is a placental disease and affects multiple systems in the body. It resolves after pregnancy  Main concern is eclampsia, HELLP, CVA, placental abruption and pulmonary oedema in the mother; IUGR and stillbirth in the fetus  Blood pressure treated by antihypertensives  Eclampsia treated by magnesium sulphate  Moderate or severe pre-eclampsia requires delivery; if gestation less than 34 weeks, delay if possible. If complications or fetal distress, deliver regardless  Continue monitoring postpartum for blood investigations, fluid balance and blood pressure
  28. 28. References 1. Impey L, Child C. Obstetrics and Gynaecology. 3rd Ed. Oxford: Wiley-Blackwell; 2008. Chapter 20 2. Parisaei M, Shailendra A, Dutta R, Broadbent JAM. Obstetrics and Gynaecology (Crash Course Series). 2nd Ed. Edinburgh: Elsevier; 2008. Chapter 35 3. Walker JJ. Stepwise Management. In: Lyall F, Belfort M, editors. Pre-eclampsia – Etiology and Clinical Practice. 2nd Ed. Cambridge: Cambridge University Press; 2008. Chapter 24 4. Nottingham University Hospitals NHS Trust Guidelines