bp control in pregnancy by mr mhafzam.pptx

sdsdas d dasdsad

1. Hypertension in Pregnancy Prepared by: Mohamad Hanif Adha bin Mohd Hanafiah Supervisor: Dr Asmalia binti Khalid

2. Contents Introduction Definition Classification Management

3. Introduction

4. Hypertension in pregnancy constitute one of the leading causes of maternal and perinatal mortality worldwide. Hypertension in pregnancy complicate 10% of all pregnancies. Covers a spectrum of conditions; preeclampsia, eclampsia, chronic hypertension and gestational hypertension. Is not a preventable condition but early recognition and prompt treatment can prevent the development of both maternal and fetal morbidity and mortality.

5. Definition

6. Hypertension Hypertension is defined as persistent elevation of systolic blood pressure (BP) of 140mmHg or greater and/or diastolic BP of 90mmHg or greater taken at least twice on 2 separate occasions (≥ 140/90 mmHg) Systolic (mmHg) Diastolic (mmHg)

7. Definition hypertension in pregnancy Systolic blood pressure ≥ 140 and/or Diastolic blood pressure ≥ 90 An increased systolic blood pressure of 30mmHg and diastolic blood pressure of 15mmHg above baseline BP is no longer recognized as hypertension if absolute values are below 140/90mmHg If proteinuria or hyperuricemia present --this warrrants close observation Severe hypertension: Systolic blood pressure ≥ 160 and/or Diastolic blood pressure ≥ 110

8. International Society for the Study of Hypertension in Pregnancy ISSHP 2018

9. Proteinuria Significant proteinuria is defined as: i )urine dipstick test ≥ 2+ (1g per litre ), approximately ≥ 300mg protein/day proteinuria ii) 24 hour urine collection (gold standard) Total protein ≥ 300mg/day iii) protein creatinine ratio (PCR) ≥ 30mg/ mmol (significant) If positive ≥ 230mg/ mmol ( nephrotic range) Semi quantitative by dipstick: + 0.3g/L ++ 1.0g/L +++ 3.0g/L ++++ >20g/L *significant proteinuria -reflects advanced disease and poorer prognosis -51% with persistent proteinuria without hypertension will develop PE in remainder PE

10. Classification

11. Based on ISSHP 2013 (International Society for Study of Hypertension in Pregnancy) PREVIOUSLY

12. Latest Classification ISSHP 2018 CPG Management of Hypertension, 5 th edition

13. International Society for Study of Hypertension in Pregnancy (ISSHP 2018) Hypertension known before pregnancy or present in the first 20 weeks 1. Chronic hypertension Essential Secondary 2. White coat hypertension 3. Masked hypertension Hypertension arising de novo or after 20 weeks Transient gestational hypertension Gestational hypertension Pre eclampsia- de novo or superimposed on chronic hypertension

14. CPG Management of hypertension, 5 th ed 1. Gestational hypertension 2. Chronic hypertension 3. Preeclampsia: de novo or superimposed on chronic hypertension 4. Isolated office hypertension/ white coat hypertension

15. Types Definition Criteria PE Presence of de novo hypertension after 20 weeks Significant proteinuria Renal insufficeincey : creat > 90 micromol /l or oliguria Neurological: convulsions , hypererflexia with clonus , severe headache, visual disturbance Haematological : thrombocytopenia, coagulopathhy , hemolyisis Liver disease: raised transaminase , epigastric /RUQ pain Fetal growth restriction (IUGR)/ doppler Gestational hypertension First time detected after 20 weeks Followed by normalization of BP 3 months postpartum Without PE criteria Chronic hypertension Pre existing hypertension -preconception/before 20 weeks -fails to resolve postpartum Complicated to PE PE superimposed to chronic hypertension Chronic hypertension with features of PE De novo proteinuria after 20 week gestation A sudden increase in severity of hypertension Appearance of features of preeclampsia- eclampsia A sudden increase in proteinuria in women who have pre-existing proteinuria early in gestation

16. 1. Gestational hypertension Definition: De novo/New onset of hypertension First time detected after 20 weeks gestation Followed by normalization of BP 3 months postpartum + Without preeclampsia criteria Prevalence 6-15% in nulliparous & 2-4% in multiparas It can progress into preeclampsia in 25% of cases

17. 2. Chronic hypertension Definition: Preexisting hypertension prior conception or New onset of hypertension before 20 weeks gestation Persist after 3 months postpartum 25% of chronic hypertension will develop superimposed preeclampsia Chronic hypertension can be due to: Essential/primary Secondary – eg : renal disease, vasculitis etc

18. 3. Preeclampsia (de novo) Definition: Gestational hypertension + with preeclampsia criteria Preeclampsia criteria ( must be 1 or more) Significant proteinuria Other maternal organ dysfunction: Renal involvement : creatinine > 90 µ /l or oliguria Liv er involvemen t (elevated transaminase > 40 IU/L) with or without RUQ or epigastric abdominal pain Neurological : convulsions , hyperreflexia with clonus, severe headache, visual disturbance Hematological : thrombocytopenia (platelet < 150000 µ/L), coagulopathy, hemolysis Uteropla cental dysfunction: Fetal growth restriction (IUGR)/stillbirth

19. 4. Preeclampsia superimposed to chronic HPT Definition: Chronic hypertension + preeclampsia criteria . Criteria (presence any of the following): De novo proteinuria after 20 week gestation A sudden increase in severity of hypertension Appearance of features of preeclampsia-eclampsia A sudden increase in proteinuria in women who have pre-existing proteinuria early in gestation

20. Severe preeclampsia defined by American college of obsetectricians and gynaecologists 1. Systolic BP >/= 160mmHg or Diastolic BP >/= 110mmHg on 2 occasions at least 4 hours apart while patient is resting 2. Thrombocytopenia- platelet count below 100 000/cm3 3. Abnormal liver enzymes (elevated AST/ALT), severe persistent right upper quadrant or epigastric pain unresponsive to treatment 4. Pulmonary oedema 5. New onset cerebral/visual disturbances

21. Pathophysiology of preeclampsia

22. COMPLICATIONS OF PREECLAMPSIA LUNGS -Pulmonary oedema HEPATIC -Hepatic failure -Hepatic rupture -Subcapsular haemorrhage RENAL -Renal failure -nephrotic syndrome -HELLP syndrome -DIVC -IUGR -prematurity -Intrauterine death -Placental abruptio CNS -Eclampsia -Cerebral edema -Cerebral haemorrhage

23. Prediction and prevention of Preeclampsia High risk factor s for development of preeclampsia (1 criteria) Moderate risk factors for development of preeclampsia (≥ 2 criteria) Hypertensive disease during previous pregnancy Chronic kidney disease Autoimmune disease , eg : SLE, Anti- phospholipid syndrome (APS) Type 1 or type DM, and chronic hypertension Primigravida Age > 40 years Pregnancy interval > 10 years BMI > 35kg/m2 a first visit Family history of PE Multiple pregnancy Aspirin -women with 2 or more moderate or 1 high risk factor should be started on low dose aspirin from 12 weeks up to 16 weeks of gestation until delivery in order to reduce the incidence of PE -dosage: 100-150mg/day at night Calcium -low dose calcium 500mg-1000mg daily before 20 weeks of gestation reduced the risk of PE

24. Exercise (aerobic exercise for 50min, 3x per week)- reduced gestational hypertension and PE Vitamin D -no proven role of vitamin D in reducing the risk of PE Combined vitamin C and E are not reconmmended- increase the incidence of LOW BIRTH WEIGHT Prediction and prevention of Preeclampsia

25. HELLP syndrome haemolysis (H), elevated liver enzymes (EL) and low platelets(LP) syndrome Is a variant of severe preeclampsia (10-20% of severe preeclampsia patient) Hypertension not always a clinical feature Can present with vague symptoms of nausea, vomiting, epigastric pain and right upper quadrant pain --because of these there is delay in diagnosis Management of HELLP as for preeclampsia is to evaluate, stabilise and deliver Tennessee Classification System Microangiopathic haemolytic anemia. Thrombocytopenia ≤100 x 109 /L. Hepatic dysfunction enzyme: – AST or ASOT ≥70IU/L – LDH ≥600IU/L

26. Management

27. Triage GZ? Yellow zone? Red zone?

28. Triage Malaysian triage scale new revised 2022

29. History taking Medical illness Sx of impending eclampsia -frontal headache -blurry vision -epigastric/RUQ pain -vomiting Complications of preeclampsia -shortness of breath -eclampsia -unilateral body weakness

30. Physical examination Vital signs: BP , spo2 Focus examination -lungs any crepitations -abdomen: tender epigastric/RUQ symphyseal-fundal height -CNS: hyperreflexia and clonus Bedside scan: fetal heart/ movement

31. Investigations Investigations FBC Anemia, thrombocytopenia Busecr Acute kidney injury LFT Elevated transaminase (>2x of normal upper limit) If GGT or bilirubin raised—indicate HELLP syndrome Coagulation profile INR and APTT prolong Uric acid Non specific marker of preeclampsia PE profile ( fbc / busecr / lft /coagulation profile/ ufeme ) + uric acid

32. Investigations Urinalysis -UFEME -24 hour urine protein -protein creatinine ratio ≥ 2+ protein > 300mg/dL > 0.3g Chest Xray Pulmonary oedema CT brain ICB/cerebral edema

33. Principles of management Control blood pressure –depends on classification of hypertension Seizure prophylaxis Monitoring of mother and fetal complication Strict fluid management Timely delivery *definitive management of preeclampsia is delivery

34. 1. Control of blood pressure ( nonsevere hypertension) Start treatment when BP ≥ 140/90 regardless of type of hypertension in pregnancy Aim BP: 110-140/80-85mmHg AVOID: ACEI and ARBs, atenolol, thiazide diuretics Stop methyldopa after delivery Choice of oral medication: Methydopa Labetalol Nifedipine

35. Drugs Mode of action Starting dose (mg/day) Max dose (mg/day) Half life (hours) Adverse effects Methyldopa (first line) Centrally acting (false transmitter precursor) 250 =250mg TDS 3000 =1000mg TDS 1.8 Depression Drowsiness Lupus-like syndrome Blood dyscrasias Liver dysfunction Labetalol (alternative first line) Alpha or beta blockers 100 =100mg BD 2000 4 Complete heart block Heart failure bronchochonstriction Nifedipine (second line) Calcium channel blockers 10 =10mg TDS 60 =20mg TDS 3.4 Tachycardia Hypotension Headache Flushing tachyphylaxis

36. 1. Control of blood pressure (severe hypertension/hypertensive crisis) SBP ≥ 160 or DBP ≥ 110 Avoid too rapid fall in BP, aim sBP 140-160 and dBP 90-100mmHg Choice of medications: 1. Oral nifedepine 2. Parenteral labetalol or hydralazine 3. Consider MgS04

37. Labetalol 1 ampoule IV Labetalol contains 25mg/5mls (1mls = 5mg IV Labetalol) Side effects: Maternal bradycardia Fetal bradycardia Contraindications: Bronchial asthma Congestive heart failure Heart block

38. Dose of IV Labetalol Bolus dose IV Labetalol Indications BP ≥ 160/110mmHg Preparation Dilution is not necessary Use pure form with concentration 5mg/1ml Withdraw 1 ampoule Put 25mg or 5mls labetalol in 5cc syringe Bolus dose(s) IV labetalol 10mg (2mls): over 1 minute Repeat at 5 minute intervals Maximum dose 200mg (40mls) 1 ampule IV Labetalol contains 25mg/5mls (1mls = 5mg)

39. Dose of IV Labetalol infusion 1 ampule IV Labetalol contains 25mg/5mls (1mls = 5mg) Infusion dose Infusion Labetolol Indication BP ≥ 160/110mmHg after 2 or 3 boluses of intravenous labetalol Effective dose 20mg-160mg/hr (4-32mls/hr) Preparation Dilution is not necessary ; Withdraw 8 ampoules . Put 200mg or 40mls labetalol in 50cc syringe Titration (infusion syringe pump) Starting dose is 20mg/ hr (4ml/ hr ) Increase every 30 minutes to achieve target BP Titration of dose: 20mg/ hr (4ml/ hr ) 40mg/ hr (8ml/ hr )80mg/H (16ml/ hr )160mg/ hr (32ml/ hr ) Maintain the dose if target BP is achieved

40. Hydralazine 1 ampoule IV hydralazine contains 20mg/1ml Side effects: Maternal hypotension Maternal tachycardia Headache and dizziness

41. Dose of IV Hydralazine Bolus dose IV Hydralazine Indication BP ≥ 160/110mmHg when parenteral Labetalol is contraindicated , or parenteral Labetalol fails to control BP Preparation Withdraw 1 ampoule Dilute 20mg or 1mls hydralazine + 19mls of NS = 20mg/20mls (1mg/1ml) Bolus(s) dose IV Hydralazine 5mg (5ml); over 15-20minutes Repeat every 15 -20minutes Maximum dose 20mg (20mls) 1 ampule IV hydralazine contains 20mg/1ml

42. Dose of IV Hydralazine Infusion Infusion dose IV Hydralazine Indication BP ≥ 160/110mmHg after 2 or 3 boluses of intravenous hydralazine Effective dose 1-10mg/hr Preparation Withdraw 2 ampoules. Dilute 40mg or 2mls hydralazine + 38mls of NS = 40mg/40ml (1mg/1ml) Titration (infusion syringe pump) Starting dose is 5mg/ hr (5ml/ hr ) Increase 1mg/ hr (1mg/1ml) every 20 minutes Maintain the dose if target BP is achieved 1 ampule IV hydralazine contains 20mg/1ml

43. 2. Prevention/ Control eclampsia Drug Mode of action Dosage Adverse effects i )Magnesium sulphate Cerebral depressant, reverse cerebral vasoconstriction Depending on mode of administration; intramuscular or intravenous Respiratory arrest, arrythmias ii)Diazepam GAVA receptors, chloride gates Bolus 10mg, infusion 40mg and titrate Respiratory depression, drowsiness, tolerance

44. i )Magnesium sulphate Is not anticonvulsant Is associated with almost 50% risk reduction of eclampsia Is cleared by kidney, hence the dose must be reduced if there is impairment of renal function 2. Prevention/ Control eclampsia

45. Indications of MgSO4 Eclampsia Severe preeclampsia Severe hypertension associated with any of the following: -significant proteinuria -symptoms of impending eclampsia: headache, blurry vision, epigastric pain, nausea or vomiting -complications from severe preeclampsia: HELLP syndrome, acute pulmonary oedema, placenta abruptio, intrauterine death 4. As fetal neuroprotection for woman whose delivery is indicated ≤ 32 weeks 2. Prevention/ Control eclampsia

46. Magnesium sulphate 1 vial MgSO4 contains 2.47g/5ml (1g=2ml) Can be given intravenously or intramuscularly Contraindications: Heart failure Renal failure

47. Dose of IM Magnesium sulphate Loading dose Maintenance dosed Dose Total 10g (5g each buttock) 5g every 4H in alternate buttock Preparation 10ml (5g) of MgSO4 + 1ml of local anesthesia = 11ml 10ml (5g) of MgSO4 + 1ml of local anesthesia = 11ml Administritation IM injection in each buttock at upper outer quadrant IM injection into alternate buttock every 4hourly 1 vial MgSO4 contains 2.47g/5ml (1g=2ml) #Continue for 24 hours after last convulsion or delivery

48. Dose of IV Magnesium sulphate Loading dose Maintenance dose Infusion pump Syringe pump Dose 4g 1g/ hr 1g/ hr Preparation 8ml (4g) of MgSO4 with 12ml NS =20ml 50ml (24.7g) +450ml NS = 24.7g/500ml (1g/21ml) 10ml (5g) of MgSO4 + 40ml NS = 5g/50ml (1g/10ml) Administration Give 4g MgSO4 in slow bolus for 15-20minutes 21ml/ hr (1g/ hr ) 10ml/ hr (1g/ hr ) 1 vial MgSO4 contains 2.47g/5ml (1g=2ml)

49. Intravenous MgSO4 How to dilute: 1 vial = 5mls (2.47g), we will used 2 vial to get 10mls (5g) Loading dose: 4g 4g (8mls) dilute with 12mls NS in 20cc syringe -give slow bolus for 15-20 minutes ( avoid cardiac arrest) Maintenance: 1g/ hr 5g (10mls) dilute with 40mls NS in 50cc syringe = 5g in 50mls or 1g in 10mls -run 10mls/ hr or 1g/ hr (syringe pump) 24.7g (50mls) dilute in 450mls NS = 24.7g in 1pint NS or 1g in 21mls -run 21mls/ hr or 1g/ hr (infusion pump)

50. Recurrent seizure 2g (4ml)MgSO4 + 8ml NS given 15-20 minutes and continue with maintenance dose 1g/hour for 24 hour after last seizure or delivery Hsnz O&G practice: Maintenance dose of MgSO4 : 1g/hr over 24 hr Dilution: 1 vial (2.47g) or 5mls of MgSO4 dilute in 45mls NS in 50cc syringe -run 20mls/hr (1g/hr)

51. Magnesium sulphate monitoring Present of patellar reflex -- every 15 min Respiratory rate >16/min -- every 15 min Urine output (30ml/ hr ) – every hour MgSO4 infusion should be stopped if Absent patellar reflex Respiratory depression Serum magnesium > 3.5mmol/L

52. Magnesium sulphate toxicity Clinical features Mg level ( mmo /L) Management Therapeutic range 1.7-3.5 ECG changes -prolong PR interval -widened QRS complex 5.0-10.0 stop infusion Loss of deep tendon reflexes 10.0 If respiratory normal, stop infusion until the reflexes return If respiratory depressed, stop infusion, give oxygen, maintain aiway , give antidote Respiratory paralysis 15.0 Stop infusion, give antidote Maternal collapse >25 Initiate resuscitation, CPR, give antidote Antidote: 10% calcium gluconate 10ml IV over 10 minutes

53. Diazepam The alternative is intravenous diazepam, but inferior efficacy as compared to mgso4 Use when MgSO4 is contraindicated or not available 1 vial diazepam contains 10mg/2ml Given iv diazepam 10mg bolus over 1-2 minutes followed by 40mg in D5% slow infusion so that patient become sedated

54. 3. Maternal and fetal monitoring Maternal Fetal Sign and sx of impending eclampsia Ultrasound Blood pressure CTG Reflexes and clonus Doppler Urine protein

55. 4. Fluid management Beware of iatrogenic pulmonary oedema in preeclampsia/eclampsia Due to damage endothelial linings of the capillary—3 rd space loss Can cause pulmonary edema Total fluid/ day : 80mls/ hr (1ml/kg/ hr ) Maintain urine output: (0.5-1ml/kg/ hr ) If confirmed pulmonary edema -iv frusemide 40mg, oxygen administration

56. 5. Timing of delivery Delivery is decided by O&G team based on: -Patients condition -Gestational age In preeclampsia or eclampsia, the definitive treatment is delivery If delivery to be delayed and gestational age less than 34 weeks - IM dexamethasone 12mg 12hours apart for 1day If the gestation is 34 weeks or more, consider delivery if crisis recur

57. Reference CPG Management of Hypertension, 5 th edition Training Manual on Hypertensive Disorder in pregnancy, 3 rd edition The hypertensive disorders of pregnancy: ISSHP classification, diagnosis and management recommendations for international practice Hypertension in pregnancy: diagnosis and management, NICE guideline HSNZ O&G protocol https://www.sciencedirect.com/science/article/pii/S0735109720362987