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(Eng) pregnancy induced hypertension
1) The document discusses pregnancy induced hypertension, its classification, diagnosis, and management. It defines four types of hypertensive disorders in pregnancy: gestational hypertension, preeclampsia-eclampsia (mild and severe), superimposed preeclampsia-eclampsia, and chronic (preexisting) hypertension. 2) For diagnosis of hypertension in pregnancy, blood pressure must exceed 140/90 mmHg. Diagnosis of mild or severe preeclampsia depends on blood pressure levels and presence of proteinuria. 3) Management of mild preeclampsia can involve outpatient monitoring with regular visits or inpatient monitoring with maternal and fetal monitoring and treatment if signs worsen.
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(Eng) pregnancy induced hypertension
- 1. PREGNANCY INDUCED HYPERTENSION dr. IGede Mega Putra, O&G (C) Obstetrics and Gynecology Departement Faculty of Medicine Udayana University
- 2. Introduction Hypertensive disorderscomplicate 5 to 10 percent of all pregnancies, and together they form deadly triad, along with hemorrhage and infection WHO systematically reviews maternal mortality : In developed countries, 16 % maternal deaths were due to hypertensive disorders. This percentage is greater than three other leading causes: hemorrhage—13 percent, abortion —8 percent, and sepsis—2 percent. Almost 16 percent of 3201 maternal deaths were from complications of pregnancy-related hypertension. Over half of these hypertension-related deaths were preventable.
- 3. Terminology and classification Gestational hypertension Preeclampsia-eclampsia(mild and severe PE ) Superimposed Preeclampsia-eclampsia Chronic(preexisting) hypertension. Classification of hypertensive disorders complicating pregnancy describes into four types: 1 2 3 4
- 4. Diagnosis Hypertension in Pregnancy Hypertensionis diagnosed empirically when appropriately taken blood pressure exceeds 140 mm Hg systolic or 90 mm Hg diastolic. Korotkoff phase V is used to define diastolic pressure.
- 5. Diagnosis Hypertension in Pregnancy GestationalHypertension Mild Preeclampsia Systolic BP 140 or diastolic BP 90 mm Hg for first time during pregnancy, without proteinuria and BP returns to normal before 12 weeks postpartum BP 140/90 mmHg or over, but less than 160/ll0 mm Hg, after 20 weeks gestation Proteinuria 0,3 gr / L in 24 hours or +1-2 on dipstick
- 6. Diagnosis Hypertension in Pregnancy SeverePreeclampsia • BP160/110 mmHg or over, after 20 weeks gestation • Proteinuria 5 gr in 24 hours or +3-4 on dipstick • Oligouria, urine production less than 500 cc in 24 hrs along with increasing level of creatinin serum • Subjective complain : visual disturbance, persistent headache, epigastric pain • HELLP syndrome (Hemolysis, Elevated Liver enzyme, Low Platelet count) • Cyanosis and Intrauterine fetal growth restriction Eclampsia Seizures that cannot be attributed to other causes in a woman with preeclampsia
- 7. Diagnosis Hypertension in Pregnancy SuperimposedPreeclampsia On Chronic Hypertension: • New-onset proteinuria 300 mg/24 hours in hypertensive women but no proteinuria before 20 weeks' gestation • A sudden increase in proteinuria or blood pressure or platelet count < 100,000/L in women with hypertension and proteinuria before 20 weeks' gestation Chronic Hypertension BP 140/90 mm Hg before pregnancy or diagnosed before 20 weeks' gestation not attributable to gestational trophoblastic disease or Hypertension first diagnosed before 20 weeks' gestation and persistent after 12 weeks postpartum
- 9. What is thediagnose when 32 weeks of pregnancy come to you with blood pressuere 150/100 with proteinuria +2 with complained nausea and headache? ? Break question
- 10. Pathofisiology disease of theories Abnormality vascularizationof placenta theory Placenta ischemic, free radical, and endotel dysfunction Imunology intolerance between mother and fetus theory Cardiovascular adaptation theory Genetic deficiency theory Nutrition deficiency theory Inflammation theory 1 2 3 4567
- 11. Abnormality vascularisation of placentatheory In normal pregnancy In pregnancy induced hypertension 1 Remodeling the uterine spiral arterioles 2 invaded by endovascular trophoblasts 3 Replace the vascular endothelial and muscular linings to enlarge the vessel diameter & making the lining more firm 4 Easily distention and vasodilatation 5 reduced the blood pressure, vascular resistance, and increasing blood flow in utero-plasenta 2 Incomplete trophoblastic invasion shallow invasion uterine spiral arterioles 3 muscularis lining uterine spiral arterioles become rigid, hard to distention and vasodilatation failed remmodeling 4 mean external diameter is only half vessels in normal 5 impairs placental blood flow diminished perfusion and a hypoxic environment
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- 13. Placenta ischemic, freeradical, and endotel dysfunction 1 2 3 4 Remmodeling failure in remmodeling and cause ischemia and hypoxia Free Radical produce free radical “hidroxyl” Damage Sel damage membran sel And increased in lipid peroxide Dysfunction caused endothelial dysfunction Endothelial dysfunction further cause: 1.Prostaglandin metabolism impairment tromboxane >> 2.Platelet agregation 3.Glomerular endotheliosis 4.Increased capillary permeability 5.Increased vasopressor production 6.Coagulation factor stimulation.
- 14. In normal pregnant Immuneresponse don’t reject conception product because of HLA-G. Imnonology intolerence between mother and fetus theory Women with pregnancy induced hypertension •Decreased in HLA-G make intolerance maternal to placenta. •Early in a pregnancy, extravillous trophoblast express reduced amounts of immunosuppressive human leukocyte antigen G (HLA-G) defective placental vascularization. •Beginning in the early second trimester, in preeclampsia a significantly lower proportion of helper T cells (Th1) compared with normotensive women.
- 15. Cardiovascular adaptation theory 1 2 3 4 Women withpregnancy induced hypertension Loss refracter capability againts vasoconstrictor in blood vassels blood vassels become very sensitive with vasopressor product high blood pressure
- 16. Genetic deficiency theory • Associationbetween HLA-DR4 and proteinuric hypertension. • Angiotensinogen gene variant T235 had a higher incidence preeclampsia and fetal growth restriction. • Some of the inherited thrombophilias considerations in the development of hypertensive disorders due to pregnancy predispose some women to preeclampsia. • Polymorphisms of the genes for TNF, lymphotoxin-alpha, interleukin-1B have been studied with varying results.
- 17. Clinical trial fromEcuador with double blind showed that women given calcium suplementation 14% preeclampsia compared with placebo 17%. Nutrition deficiency theory Fish Oil Fish oil consumption could reduce the risk of preeclampsia Calcium Calcium deficiency increase risk of getting preeclampsia/eclampsia
- 18. Increased capillary permeabilitymanifest by edema and proteinuria. Inflammation theory In response to ischemic changes release antiangiogenic and metabolic factors and other inflammatory mediators provoke endothelial cell dysfunction extreme activated state of leukocytes in the maternal Tumor necrosis factor- (TNF-) & interleukins (IL generate highly toxic radicals injure endothelial cells, modify their nitric oxide production, and interfere with prostaglandin balance production of the lipid- laden macrophage foam cells
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- 20. Management of mild Preeclampsia Baseon NICE Guidlines (Nasional Institute for Health and Care Exellence) Improving health and social care through evidence-based guidance Outpatient Inpatient Obstetrics/active
- 21. Outpatient Mild Preeclampsia (NICE recommendation) 1 2 3 A.Tidakmutlak harus tirah baring, dianjurkan ambulasi sesuai keinginannya. Tidak mutlak harus tirah baring, dianjurkan ambulasi sesuai keinginannya Do not recommend salt restriction during pregnancy solely to prevent gestational hypertension or pre-eclampsia. (NICE recommendation ) If conservative management of severe gestational hypertension or pre- eclampsia is planned, carry out all the following tests at diagnosis: ultrasound fetal growth and amniotic fluid volume assessment umbilical artery doppler velocimetry (NICE reccomendation )
- 22. 4 5 6 Laboratory test :complete blood count, homocystein urinalysis, renal function test, random blood sugar Advise women with more than one moderate risk factor for pre-eclampsia to take 75 mg of aspirin* daily from 12 weeks until the birth of the baby. Factors indicating moderate risk are 1.first pregnancy 2.age 40 years or older 3.pregnancy interval of more than 10 years 4.body mass index (BMI) of 35 kg/m2 or more at first visit 5.family history of pre-eclampsia 6.multiple pregnancy. (NICE reccomendation ) Office visit every 1 week Outpatient Mild Preeclampsia (NICE recommendation)
- 23. inpatient Mild Preeclampsia (NICE recommendation) A.Tidakmutlak harus tirah baring, dianjurkan ambulasi sesuai keinginannya. Indication Inpatient If the result of fetal assesment are doubtful or even poor, hospitalize for termination There are no improvement on patient condition after 2 visit If there is one or more abnormal laboratory finding If there any tendency to become severe preeclampsia ( one or two sign or symptomps of severe PE ) Maternal Monitoring Laboratory Monitoring Fetal Monitoring
- 24. inpatient Mild Preeclampsia (NICE recommendation) MaternalMonitoring Maternal Blood Pressure Monitoring maternal blood pressure Every 4 hours, unless mother is sleeping Sign Impending Eclampsia • Epigastrial Pain. • Mata berkunang-kunang • Irritable • Headache . Edema on extremity And face Clinical sign of fluid accumulation in preeclampsia shoild be monitored every day Monitoring maternal weight Body every day Acumulation of fluid should be monitored every day
- 25. inpatient Mild Preeclampsia (NICE recommendation) USGDoppler Umbilical artery doppler Uterine arteri doppler BPP Biophysical Profile Fetal Growth Fetal growth shoul be monitored with USG every 3-4 weeks Fetal Monitoring NST NST should be twice a week • Poor, deliver the baby • Doubtful, re-evaluate NST, fetal well being, one day after • Good, continue the treatment for at least 4 days If the pregnancy are preterm : discharge from hospital If the pregnancy are term : deliver the baby If there are subjective complains : treat as severe PE case
- 26. inpatient Mild Preeclampsia (NICE recommendation) UrineLaboratory Urine labratory for proteinuria should be monitored when admission and followed for next 2 days Urine Production monitor of Urine production every day Normal production 0,5- 1cc/Kg/hours Laboratory Monitoring Blood Test Hematocrite, Platelet, Liver function test, Kidney function test monitored every 2 weeks Gestosis Index Gestos index should be monitored for the prognostic value in preeclamsia case
- 27. Management of Severe Preeclampsia Baseon Clinical Medicine Emergency LANGE Medical decision making In a pregnant patient with hypertension, the presence of proteinuria is enough to make a diagnosis of preeclampsia Before confirmation of proteinuria, other diagnoses should be considered.
- 28. Management of Severe Preeclampsia Baseon Clinical Medicine Emergency LANGE Pregnant Female (Usually > 20 weeks) BP >140/90 And Proteinuria Ask about symptoms of headache, abdominal pain, visual disturbances, or edema seizures No seizures Eclampsia Preeclampsia Hemolysis (anemia), Abnormal Liver Enzimes, Thrombocytopenia HELLP Syndrome Initial treatment is focused on stabilizing the patient. Place the woman in the left lateral decubitus position to improve circulation Initial Treatment
- 29. Algorithm of Severe Preeclampsia Baseon Clinical Medicine Emergency LANGE And NICE Guidlines Severe preeclampsia • Hospitalized • Maternal and Fetal Evaluation 24 hours • MgSO4 24 hours • Anthyhipertensive if sistolik ≥ 160 mmHg dan atau Diastolik ≥ 110 atau MAP > 125 mmHg Tidak Maternal distress and (or) Non reassuring Fetal status < 24 wks 24-<34 wks 34-36+6 wks Delivery Conservatif 37 wks SuccessFailed if required, a course of corticosteroids has been completed. Termination No Yes
- 30. Management of Severe Preeclampsia Baseon Clinical Medicine Emergency LANGE ABC Apply supplemental oxygen, cardiac monitoring, and establish intravenous (IV) access. Avoid over hydration, as it may result in pulmonary edema Antihypertensive therapy is indicated in the setting of severe hypertension (systolic blood pressure >160 mmHg or diastolic blood pressure >1 1 0 mmHg) Magnesium remains the drug of choice for the treatment of severe preeclampsia and eclampsia The definitive treatment of preeclampsia and eclampsia is delivery of the fetus Antihypertensive MgSO4
- 31. Airway and Breathing Apply supplementaloxygen Cardiac Monitoring Apply Cardiac monitor Intravenous Line Establish IV access ABC Severe Preeclampsia (NICE recommendation)
- 32. Antihypertensive Severe Preeclampsia (NICE recommendation) •Dangerous hypertension can cause cerebrovascular hemorrhage, hypertensive encephalopathy and can trigger eclamptic convulsions, afterload congestive heart failure and placental abruption. • Recommended that treatment lowering systolic pressures to 160 mm Hg. • Most of these were hemorrhagic—93 percent —and all women had systolic pressures > 160 mm Hg before suffering their stroke. • The three most commonly are hydralazine, labetalol, and nifedipine. Orally administered nifedipine as first-line treatment for severe gestational hypertension.
- 33. Antihypertensive Severe Preeclampsia (NICE recommendation) Theuse of antihypertensive drugs in attempts to prolong pregnancy or modify perinatal outcomes in pregnancies.
- 34. Magnesium Sulfat Severe Preeclampsia (NICE recommendation) Inmore severe cases of preeclampsia, as well as in eclampsia, magnesium sulfate is an effective anticonvulsant that avoids producing central nervous system depression in either the mother or the infant.
- 35. Definitive therapy Severe Preeclampsia (NICErecommendation) Conservative Therapy • If gestational age less than 37 weeks, without subjective complain and fetal well being is good. • Bed rest. • IVFD Ringer lactate 60 cc/hour • Magnesium sulfate: first dose MgSO4 40% 10 gram intramuscular, continue with MgSO4 40% 5 gram every 6 hours until 24 hours. • Give antihypertension Nifedipine 3x10 mg (orally) if BP systolic < 180 mmHg and diastolic < 110 mmHg or clonidin 1 amp diluted into 10 cc and give first dose 5 cc in 5 minute, the rest 5 cc given if BP still high. • Evaluation with complete blood count, LF, RF, UL, Gestosis Index, Proteinuria @ 24 hours.
- 36. Definitive therapy Severe Preeclampsia (NICErecommendation) Active Therapy • If gestational age 37 weeks or more, fetus well beeing is not good, there are subjective complains, HELLP Syndrome, failed for conservative treatment, or after 24 hours conservative treatment BP still 160/110 or higher • Medication : Hospitalize the patient IVFD Ringer lactate 60 cc/hour Magnesium sulfate: first dose MgSO4 40% 10 gram intramuscular, continue with MgSO4 40% 5 gram every 6 hours until 24 hours after the baby has beeen delivered Give antihypertension Nifedipine 3x10 mg (orally) if BP systolic < 180 mmHg and diastolic < 110 mmHg or clonidin 1 amp diluted into 10 cc and give first dose 5 cc in 5 minute, the rest 5 cc given if BP still high.
- 37. Definitive therapy Severe Preeclampsia (NICErecommendation) Active Therapy Obstetric Treatment : • Cesarean Section done if the fetal well being assessment result is poor, patient still not in labor • with unfavorable pelvic score, or in case of induction failure • Induction (by using oxytocin) is performed if PS are favorable with normal result of NST • In severe PE cases the patient has to be in labor in 24 hours.
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