Hypertensive disorders of pregnancy


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Hypertensive disorders of pregnancy

  1. 1. Ri 簡睦旼 2012/5/3
  2. 2. Classification  Pregnancy-induced hypertension (Gestational hypertension)5-10%  Preeclampsia3.9%  Eclampsia  Preeclampsia superimposed on chronic hypertension  Chronic hypertension William’s Obstertrics, 23ed
  3. 3. Gestationa Pre- Eclampsia l HTN Eclampsia Superimposed Preeclampsia SBP≥140 Proteinuria Generalized or seizures DBP ≥ 90 Severe Preeclampsia ≥ 0.3 g/ 24hr> GA 20th wk before , during >30 mg/dL< PP 12th wk or after labor (1+ on dipstick) HELLP syndrome
  4. 4. Preeclampsia 2~7% of healthy nulliparous; 0.8~5% of multiparous women The third leading cause of maternal mortality (17%) A major cause of neonatal morbidity and mortality (intrauterine growth restriction, abruptio placentae and the need for preterm delivery) Preeclampsia Deadly Triad Hemorrhage Infection
  5. 5. Severe preeclampsia BP 160/110 mm Hg Proteinuria 2.0 g/24 hours or 2+ dipstick Increase severity /certainty  Serum creatinine >1.2 mg/dL unless known to be previously elevated  Platelets < 100,000/L  Microangiopathic hemolysis—increased LDH  Elevated serum transaminase levels—ALT or AST  Persistent headache or other cerebral or visual disturbance  Persistent epigastric pain
  6. 6. Superimposed Chronic Preeclampsia HTN SBP≥140 or Proteinuria DBP ≥ 90< GA 20th wk > 20th GA wk> PP 12th wk HTN + PTuria b4 20wk ↑proteinuria or ↑BP or PLT < 100,000/L
  7. 7. Risk factors  Nulliparity  Age >35 years (superimposed) or teenager  Obesity  Multifetal gestation  Medical illness: Chronic hypertension, lupus erythematosus, IDDM, APS, PT C/S deficiency, renal disease  Genetic: Hx / FH of previous preeclampsia or eclampsia  Hydatidiform moles  Smoking, placenta previa
  8. 8. ↓NO, PGE2, PGI2, PlGF, VEGF ↑TXA2, Endothelin Stage 1 PoorPlacentation Vasoconstriction Endothelial Stage 2 Cytokines integrity ↓ Placental oxidative Antiangiogenic stress Endothelial peptides damage sFlt-1,sEng
  9. 9. Endothelial integrity ↓Vasoconstriction Endothelial damage MAHA HELLP
  10. 10. Principle of management Difinitive treatment is delivery BP control Seizure prophylaxis
  11. 11. Evaluation of a new-onset HTN Clinical findings:  headache, visual disturbance, epigastric pain, rapid weight gain… Measure BW QD Analysis for proteinuria on admission and QOD BP measurement Q4H CRE, AST/ALT, CBC (for PLT). UA? LDH? Coagulation profile? Sonography: fetal size, amnionic fluid William’s Obstertrics, 23ed
  12. 12. Management of HTN disorder Dietary Lifestyle Place of care Antihypertensive therapy Corticosteroids Mode of delivery
  13. 13. Management of HTN disorder Dietary  Salt restriction is not recommended  Insufficient evidence to make recommendation Lifestyle  Avoid vigorous exercise  Bed rest? Place of care  Severe hypertension or preeclampsia (BP>160/110)should be hospitalized Laura Magee et al, 2008, JOGC
  14. 14. Management of HTN disorder Antihypertensive therapy  For severe hypertension (BP>160/110)  BP goal: <160/110  Initial antihypertensive: labetalol, nifedipine hydralazine.  MgSO 4 is not recommended as antihypertensive (only transient decrease in 30 mins)  Continuous FHR monitoring is advised until BP is stable. Laura Magee et al, 2008, JOGC
  15. 15. Management of HTN disorder Antihypertensive therapy  Non-severe hypertension (BP:140-159/90-109 mmHg)  BP goal: w/o cormorbid - 130-155/80-105 w/ cormorbid – 130-139/80-89  Drug of choice: methyldopa, labetalol, other beta- blockers, CCB (nifedipine). (I-A)  ACEi and ARBs should not beused. (II-2E)  Atenolol and prazosin are not recommended. Laura Magee et al, 2008, JOGC
  16. 16. Management of HTN disorder Mode of delivery  Induction of labour  Vaginal delivery, unless C/S is indicated  Oxytocin at 3rd stage of labor, esp. thrombocytopenia or coagulopathy  Ergometrine should not be given Laura Magee et al, 2008, JOGC
  17. 17. Management of HTN disorder Corticosteroids  To accelerate fetal pulmonary maturity  Pre-eclampsia & GA < 34 wks  Gestational HTN & GA < 34 wks, about to deliver within next 7 days Laura Magee et al, 2008, JOGC
  18. 18. Management of Pre-eclampsia Delivery is the only cure Timing of delivery MgSO4 Plasma volume expansion Laura Magee et al, 2008, JOGC
  19. 19. Management of Pre-eclampsia Timing of delivery  GA < 34 wks: expectant management  GA: 34-36 wks, non-severe pre-eclampsia: debated  GA > 37 wks: immediate delivery Laura Magee et al, 2008, JOGC
  20. 20. William’s Obstertrics, 23ed
  21. 21. Management of Pre-eclampsia MgSO4  First-line Tx for eclampsia  Prophylaxis against eclampsia in severe- preeclampsia  Phenytoin and BZD should not be used for eclampsia prophylaxis, unless MgSO4 is contraindicated or ineffective Plasma volume expansion  Not recommended Laura Magee et al, 2008, JOGC
  22. 22. Management for HELLPsyndrome PLT count > 50x109 /L  Prophylactic transfusion of platelets is not recommended  Consider ordering blood when PLT drop rapidly PLT count < 20 x 109 /L.  Platelet transfusion prior to vaginal delivery or C/S) Corticosteriods may be considered for PLT count < 50x109 /L Plasma exchange or plasmapheresis? Laura Magee et al, 2008, JOGC
  23. 23. Postpartum treatment BP follow-up  Peak postpartum, D3, D6 Antihypertensive therapy may be restart, BP goal <160/110 mmHg  Acceptable in breastfeeding: Nifedipine, labetalol, methyldopa, captopril, enalapril NSAID should be avoid if hypertension is difficult to control, or oliguria, CRE ↑, PLT↓ Thromboporphylaxis may be considered Laura Magee et al, 2008, JOGC