Successfully reported this slideshow.

Gestational hypertension

71

Share

Loading in …3
×
1 of 50
1 of 50

More Related Content

Related Books

Free with a 14 day trial from Scribd

See all

Gestational hypertension

  1. 1. HYPERTENSION Gestational Hypertension Mohammad Ilyas, M.D. Assistant Clinical Professor University of Florida / Health Sciences Center Jacksonville, Florida USA
  2. 2. Outline 1. Definition, Regulation and Pathophysiology 2. Measurement of Blood Pressure, Staging of Hypertension and Ambulatory Blood Pressure Monitoring 3. Evaluation of Primary Versus Secondary 4. Sequel of Hypertension and Hypertension Emergencies 5. Management of Hypertension (Non-Pharmacology versus Drug Therapy) 6. The Relation Between Hypertension: Obesity, Drugs, Stress and Sleep Disorders. 7. Hypertension in Renal diseases and Pregnancies 8. Pediatric, Neonatal and Genetic Hypertension
  3. 3. Hypertension in Pregnancy • Most common medical problem encountered during pregnancy • 8% of pregnancies • Third leading cause of maternal mortality, after thromboembolism and non-obstetric injuries • Maternal DBP > 110 is associated with ↑ risk of placental abruption and fetal growth restriction • Superimposed preeclampsia cause most of the morbidity
  4. 4. Hypertension in Pregnancy • 4 categories 1. Chronic Hypertension 2. Pregnancy Induced hypertension 3. Preeclampsia-eclampsia 4. Preeclampsia superimposed on chronic HTN
  5. 5. DEFINITION Chronic hypertension, if blood pressure elevation >140/90 before 20 weeks and persists ≥12 weeks postpartum Gestational hypertension of pregnancy, if blood pressure returns to normal by 12 weeks postpartum
  6. 6. Chronic Hypertension  Treatment of mild to moderate chronic hypertension neither benefits the fetus nor prevents preeclampsia.  Excessively lowering blood pressure may result in decreased placental perfusion and adverse perinatal outcomes.  When BP is 150 to 180/100 to 110 mm Hg, pharmacologic treatment is needed to prevent maternal end-organ damage.
  7. 7. Treatment of Chronic Hypertension  Methyldopa , labetalol, and nifedipine most common oral agents.  AVOID: ACEI and ARBs, atenolol, thiazide diuretics  Women in active labor with uncontrolled severe chronic hypertension require treatment with intravenous labetalol or hydralazine.
  8. 8. Pregnancy Induced Hypertension (Gestational) • Usually mild and later in pregnancy • BP ≥140/90 mmHg (severe when ≥160/≥110 mmHg) • Previously normotensive • ≥20 weeks of gestation • No renal or other systemic involvement • No proteinuria or new signs of end-organ dysfunction • Resolves 12 weeks postpartum • May become preeclampsia
  9. 9. Gestational Hypertension to Preeclampsia  The pathophysiology of gestational hypertension is unknown.  Different diseases with a similar phenotype (hypertension)  Primiparity is a strong risk factor for preeclampsia, but not for GH  The recurrence risk for gestational hypertension is ~40% (for PE 5%)  Total blood and plasma volumes are significantly lower in women with preeclampsia (mean 2660 mL/m2 and 1790 mL/m2, respectively) than in women with gestational hypertension (3139 mL/m2 and 2132 mL/m2, respectively)
  10. 10. GH versus PE Features Gestational HTN Preeclampsia Hypertension + ++ Primiparity + 10% Recurrence 25-45 % 5% Total Plasma Volume 2132 mL/m2 (mean) 1790 mL/m2 (mean) Proteinuria Negative Positive Gestational age Usually late (>20weeks) Usually early (<20 weeks) Complications Rarely Increase risk Post partum Resolve < 12 weeks Resolve < 6 weeks
  11. 11. RISK OF PROGRESSION TO PREECLAMPSIA  Preeclampsia develops in 15 to 25 % of women with initial GH,  Early onset of GH are more likely to progress to preeclampsia (33 versus 37 weeks)  40 to 50 % of women with GH presenting at ≤30 weeks developed preeclampsia as compared with about 10 % of those who developed gestational hypertension at ≥36 weeks  Women who go on to develop preeclampsia have higher total vascular resistance at presentation than women with uncomplicated GH
  12. 12. PERINATAL OUTCOME  Pregnancy outcomes of patients with non-severe gestational hypertension are generally favorable.  The mean birth weight and rates of fetal growth restriction, preterm birth, abruption, and perinatal death are similar to those in the general obstetrical population.  Severe gestational hypertension appear to be at increased risk of maternal and perinatal morbidity  These pregnancies have significantly higher rates of preterm delivery, small for gestational age infants, and abruptio placentae
  13. 13. MANAGEMENT  Non-severe gestational hypertension, monitoring blood pressure once or twice weekly and weekly assessment of proteinuria, platelet count, and liver enzymes  Patient education and counseling  Fetal assessment, monitor fetal movement daily  No antihypertensive therapy — unless hypertension is severe (≥160 mmHg systolic or ≥110 mmHg diastolic)  No antenatal glucocorticoids  Timing of delivery at 370/7ths to 386/7ths weeks  Intrapartum management  administer magnesium sulfate for seizure prophylaxis
  14. 14. Preeclampsia • New onset HTN • After 20 weeks of gestation, or • Early post-partum, previously normotensive • Resolves within 48 hrs postpartum • With the following (Renal or other systemic) • Proteinuria > 300 mg/24hr • Oliguria or Serum-plasma creatinine ratio > 0.09 mmol/L • Headaches with hyperreflexia, eclampsia, clonus or visual disturbances • ↑ LFTs, glutathione-S-Transferase alpha 1-1, alanine aminotransferase or right abdominal pain • Thrombocytopenia, ↑ LDH, hemolysis, DIC • 10% in primigravid • 20-25% with history of chronic HTN
  15. 15. Diagnostic Criteria for Preeclampsia 1. SBP of 140 mm Hg or more or a DBP of 90 mm Hg or more on two occasions at least six hours apart after 20 weeks of gestation AND 2. Proteinuria – 300 mg in a 24-hour urine specimen or 1+ or greater on urine dipstick testing of two random urine samples collected at least four hours apart.  A random urine protein/creatinine ratio < 0.21 indicates that significant proteinuria is unlikely with a NPV of 83%.  Generalized edema (affecting the face and hands) is often present in patients with preeclampsia but is not a diagnostic criterion.
  16. 16. Mild vs. Severe Preeclampsia Mild Severe Systolic arterial pressure 140 mm Hg – 160 mm Hg ≥160 mm Hg Diastolic arterial pressure 90 mm Hg – 110 mm Hg ≥110 mm Hg Urinary protein <5 g/24 hr Dipstick +or 2 + ≥5 g/24 hr Dipstick 3+or 4+ Urine output >500 mL/24 hr ≤500 mL/24 hr Headache No Yes Visual disturbances No Yes Epigastric pain No Yes
  17. 17. Maternal Risk Factors • First pregnancy • Age younger than 18 or older than 35 • Prior h/o preeclampsia • Black race • Medical risk factors for preeclampsia - chronic HTN, renal disease, diabetes, anti-phospholipid syndrome • Twins • Family history
  18. 18. Etiology Exact mechanism not known • Immunologic • Genetic • Placental ischemia • Endothelial cell dysfunction • Vasospasm • Hyper-responsive response to vasoactive hormones (e.g. angiotensin II & epinephrine)
  19. 19. Risk Factors FACTOR RISK RATIO Renal disease 20:1 Chronic hypertension 10:1 Antiphospholipid syndrome 10:1 Family history of PIH 5:1 Twin gestation 4:1 Nulliparity 3:1 Age > 40 3:1 Diabetes mellitus 2:1 African American 1.5:1
  20. 20. Symptoms of preeclampsia • Visual disturbances • Headache • Epigastric pain • Rapidly increasing or nondependent edema - may be a signal of developing preeclampsia • Rapid weight gain - result of edema due to capillary leak as well as renal Na and fluid retention
  21. 21. Pathophysiology
  22. 22. Organ involvement • Airway edema • Cardiac • Renal • Hepatic • Uterine
  23. 23. Upper airway edema • Upper airway edema • Laryngeal edema • Airway obstruction • Potential for airway compromise or difficulty in intubation
  24. 24. Cardiac/Pulmonary • Increased CO & SVR • CVP normal or slightly increased • Plasma volume reduced • Pulmonary edema • Decrease oncotic/colloid pressure • Capillary/endothelial damage  leak • Vasoconstriction •  increase PWP and CVP • Occurs 3 % of preeclamptic patients
  25. 25. Hepatic • Usually mild • Severe PIH or preeclampsia complicated by HELLP  periportal hemorrhages ischemic lesion generalized swelling hepatic swelling  epigastric pain
  26. 26. Renal • Adversely affected  proteinuria • GFR and CrCl  decrease • BUN increase, may correlate w/ severity • RBF compromised • ARF w/ oliguria – PIH, esp. w/ abruption, DIC, HELLP *Oliguria + renal failure may occur in the absence of hypovolemia. Be careful w/ hydration  pulmonary edema*
  27. 27. Uterine • Activity increased • Hyperactive/hypersensitive to oxytocin • Preterm labor – frequent • Uterine/placental blood flow – decreased by 50-70% • Abruption – incidence increased
  28. 28. Morbidity / Mortality Maternal complications: • Leading cause of maternal death in PIH is intracranial hemorrhage • Seizures • Pulmonary edema • ARF • Proteinuria • Hepatic swelling with or without liver dysfunction • DIC (usually associated with placental abruption and is uncommon as a primary manifestation of preeclampsia)
  29. 29. Morbidity / Mortality Fetal complications: • Abruptio placentae • IUGR • Premature delivery • Intrauterine fetal death
  30. 30. HELLP Syndrome • Hemolysis • Elevated Liver enzymes • Low Platelets • < 36 wks • Malaise (90%), epigastric pain (90%), N/V (50%) • Self-limiting • Multi-system failure
  31. 31. Diagnosis Criteria for HELLP  HTN SPB is ≥160 mmHg or DPB is ≥110 mmHg  Proteinuria ≥0.3 grams in a 24-hour urine specimen or protein (mg/dL)/creatinine (mg/dL) ratio ≥0.3  Platelet count <100,000/microliter  Serum creatinine >1.1 mg/dL or doubling of serum creatinine in the absence of other renal disease  Liver transaminases at least twice the normal concentrations  Pulmonary edema  Cerebral or visual symptoms
  32. 32. HELLP Syndrome • Hemostasis is not problematic unless PLT < 40,000 • Rate of fall in PLT count is important • Regional anesthesia - contraindicated  fall is sudden • PLT count  normal within 72 hrs of delivery • Thrombocytopenia may persist for longer periods. • Definitive cure is delivery
  33. 33. Treatment • Management of maternal hemodynamics & prevention of eclampsia are key to a favorable outcome • MgSO4 - Rx of choice for preeclampsia. • Does not significantly reduce systemic BP at the serum concentration that are efficacious in treating preeclampsia • Goals • Control BP • Prevent seizures • Deliver the fetus
  34. 34. Controlling the HTN • Hydralazine • Labetalol • Nitroglycerin • Nifedipine • Esmolol • Na Nitroprusside – risk of cyanide toxicity in the fetus
  35. 35. Preventing Seizures • MgSO4 - Drug of choice. Narrow therapeutic index • Reduce > 50% w/o any serious maternal morbidity • 4g IV Bolus over 10 minutes, then infusion @ 1g/hr • Renal failure - rate of infusion  by serum Mg levels • Plasma Level should be between 4-6 mmol/L • Monitor clinical signs for toxicity • Toxic: 10 ml of 10% Ca Gluconate IV slowly
  36. 36. MgSO4 Toxicity • 5-10 mEq/L – Prolonged PR, widened QRS • 11-14 mEq/L – Depressed tendon reflexes • 15-24 mEq/L – SA, AV node block, respiratory paralysis • >25 mEq/L - Cardiac arrest
  37. 37. Quiz
  38. 38. Quiz 1. Which of the following is NOT true about Hypertension in Pregnancy ? A. HTN is the Most common medical problem encountered during pregnancy B. Majority of the of pregnancies complicate with HTN. C. Third leading cause of maternal mortality, after thromboembolism and non-obstetric injuries D. Maternal DBP > 110 is associated with ↑ risk of placental abruption and fetal growth restriction E. Superimposed preeclampsia cause most of the morbidity
  39. 39. Quiz 1. Which of the following is NOT true about Hypertension in Pregnancy ? A. HTN is the Most common medical problem encountered during pregnancy B. Majority of the of pregnancies complicate with HTN. C. Third leading cause of maternal mortality, after thromboembolism and non-obstetric injuries D. Maternal DBP > 110 is associated with ↑ risk of placental abruption and fetal growth restriction E. Superimposed preeclampsia cause most of the morbidity
  40. 40. Quiz 2. Which of the following is the RISK for progression to preeclampsia? A. Gestational diabetes B. Gestational hypertension C. Late onset of GH are more likely to progress to preeclampsia D. Low total vascular resistance
  41. 41. Quiz 2. Which of the following is the RISK for progression to preeclampsia? A. Gestational diabetes B. Gestational hypertension C. Late onset of GH are more likely to progress to preeclampsia D. Low total vascular resistance
  42. 42. Quiz 3. Hypertension in Pregnancy can be categorized in the following categories EXCEPT? A. Chronic Hypertension B. Malignant hypertension C. Pregnancy Induced hypertension D. Preeclampsia-eclampsia E. Preeclampsia superimposed on chronic HTN
  43. 43. Quiz 3. Hypertension in Pregnancy can be categorized in the following categories EXCEPT? A. Chronic Hypertension B. Malignant hypertension C. Pregnancy Induced hypertension D. Preeclampsia-eclampsia E. Preeclampsia superimposed on chronic HTN
  44. 44. Quiz 4. Which of the following statement about Gestational Hypertension is TRUE? A. The pathophysiology of gestational hypertension is known. B. GH and PE are same diseases with a different phenotype (hypertension) C. Primiparity is a weak risk factor for preeclampsia, but not for GH D. The recurrence risk for gestational hypertension is ~40% (for PE 5%) E. Total blood and plasma volumes are significantly higher in preeclampsia than in women with gestational hypertension
  45. 45. Quiz 4. Which of the following statement about Gestational Hypertension is TRUE? A. The pathophysiology of gestational hypertension is known. B. GH and PE are same diseases with a different phenotype (hypertension) C. Primiparity is a weak risk factor for preeclampsia, but not for GH D. The recurrence risk for gestational hypertension is ~40% (for PE 5%) E. Total blood and plasma volumes are significantly higher in preeclampsia than in women with gestational hypertension
  46. 46. Quiz 5. All of the following are required for management of GH, EXCEPT? A. Monitoring blood pressure once or twice weekly B. Weekly assessment of proteinuria, platelet count, and liver enzymes C. Patient education and counseling D. No antihypertensive therapy — unless hypertension is severe (≥160 mmHg systolic or ≥110 mmHg diastolic) E. Antenatal glucocorticoids
  47. 47. Quiz 5. All of the following are required for management of GH, EXCEPT? A. Monitoring blood pressure once or twice weekly B. Weekly assessment of proteinuria, platelet count, and liver enzymes C. Patient education and counseling D. No antihypertensive therapy — unless hypertension is severe (≥160 mmHg systolic or ≥110 mmHg diastolic) E. Antenatal glucocorticoids

×