Hypertensive disorders in pregnancy e.ppt

Hypertensive disease in pregnancy

1. HYPERTENSIVE DISORDERS
IN
PREGNANCY
Prof. Dr. SUSHEELAMMA M.D,
J.J.M. Medical College
Davangere
Karnataka

2. Criteria for diagnosis
Maternal surveillance
Management of intrapartum pre-eclampsia
Management of severe hypertensive crisis.

3. CRITERIA FOR DIAGNOSIS OF PRE-ECLAMPSIA
Definition of hypertension in pregnancy :
•Blood pressure levels of > 140/90 mm Hg or at least two
occasions, 4-6 hours apart, beyond 20 weeks pregnancy; if
previous records are not available.
•A rise in systolic BP of at least 30 mm Hg and /or A rise in
diastolic BP of at least 15 mm Hg over previously known
blood pressure. (at present this criteria is not used)
•Diastolic BP > 110 mm Hg or, 2 consecutive measurements of
 90 mm Hg
•Rise of 20mm Hg in MAP over previous recording or when
MAP is  105 mm Hg is significant.

4. CRITERIA FOR DIAGNOSIS OF SEVERITY
Variable Mild Severe
1. Diastolic BP 90-100 mmHg  110 mmHg
2. Convulsions Absent Present
3. Blindness Absent Present
4. Headache Minimal Marked persistent
5. Visual symptoms Minimal Marked persistent
6. Pulmonary edema Absent Present
7. Oliguria Absent Present
8. Proteinuria Trace to 1+ Persistent 2+ or
more
9. Upper abdominal pain Absent Present
10. Thrombocytopenia Absent Present
11. Blood urea, serum
creatinine & uric acid
Normal Markedly elevated
12. SGOT, SGPT, LDH
levels
Normal Markedly elevated
13. Intravascular
hemolysis
Absent Present
14. Fetal distress Absent Present
15. Fetal growth
restriction
Absent Present

5. MATERNAL SURVEILLANCE :
Maternal weight - daily
Blood pressure - 4
th
hourly during day
Urine protein - 8
th
hourly daily.
Facial / Abdominal wall edema
Symptoms of impending eclampsia.
Laboratory studies
- Haematocrit & palatelet count - 2 times a week
- AST, ALT, Amylase - 2 times a week
- Creatinine, BUN, uric acid - 2 times a week.
- 24 hr. urine for total protein - 1 time a
week.
and creatinine clearance

6. “LIGHT IS THE TASK WHEN
MANY SHARE THE TOIL”
- ‘HOMER’

7. MANAGEMENT OF SEVERE HYPERTENSIVE CRISIS IN
PRE-ECLAMPSIA
Incidence : < 1% of PE-eclampsia patients
No precise definition for hypertensive crisis
Threshold parameters suggested are :
SBP  200 mm Hg
DBP  115 mm Hg
Pathophysiology :
1) Dilation of cerebnal arteries :
Markedly elevated arterial pressure
Decompensation of normal autoregulation of cerebral blood flow
Increase in cerebral blood flow
Produces encephalopathy with hypertensive crisis
2) Generalised arteriolar fibrinoid necrosis
3) Microangiopathic hemolytic anemia  deterioration of renal function
but CVA have occurred even below this levels

8. END ORGAN DAMAGE
Retinal detachment and / or hemorrhage, Congestive
cardiac failure, Myocardial infraction, Renal failure, Liver failure,
Placental abruption, Hypertensive encephalopathy.
CLINICAL FEATURES
Headache, Vomiting, Visual disturbances, Transient
paralysis, Convulsions, Stupor, Coma.
DIFFERENTIAL DIAGNOSIS
•Pheochromocytoma
•Renal vein thrombosis
•Clonidine withdrawal
•Acute flare of underlying collagen vascular disease
•Cocaine / mephentamine ingestion.

9. IMPLICATIONS OF SEVERE PREECLAMPSIA
MANAGEMENT PROTOCOL
I.Goals of therapy :
A.Control of severe hypertension (> 180-160/110 mm Hg).
B.Seizure prophylaxis/therapy.
C.Delivery of fetus and placenta.
D.Stabilization and correction of multisystem dysfunction.
II.Management protocol :
A.Control of severe hypertension: hydralazine 2.5 to 5.0 mg IV
every 20 minutes to maintain BP below above limits.
B.Seizure prophylaxis therapy: MgSO
4
IV loading does of 4 to 6
g over 20 minutes; then maintenance dose of 2 to 3g/hr IV.
C.Delivery of fetus and placenta: induction of labor (ARM,
oxytocin infusion, or prostaglandin cervical ripening) or LSCS
(for maternal or fetal indications).
D.Stabilization and correction of multisystem dysfunction.

10. IMPLICATIONS OF SEVERE PREECLAMPSIA
MANAGEMENT PROTOCOL (Cont)
III. Clinical laboratory tests :
A.Routine:complete blood count and platelet count, serum
creatinine, hepatic transaminase and lactate dehydrogenase,
urinalysis
B.Additional tests: fibrinogen, PT, PTT, uric acid and BUN, blood
type and screen/crossmatch, 24-hour urine for protein and
creatinine clearance.
IV. Consultation :
A.Routine: OB.GYN, maternal-fetal medicine, anesthesiology,
neonatology
B.Depending on clinical situation: critical care, neurology,
nephrology, pathology (blood bank).

11. MANAGEMENT
Aim : Avoidance of hypertensive encephalopathy and cerebro
vascular accident.
I.Correction of blood pressure :
Rapid and dramatic lowering to be avoided
Reduction by 20% to be achieved SBP :  140-150 mm
Hg DBP :  90-100 mm Hg
Pharmacologic management
Drugs – Hydralazine
– Labetalol
– Nifedipine
– Sodium nitroprusside
– Nitroglycerine
1
st
line therapy
Refractory to 1
st
line therapy

12. PHARMACOLOGIC MANAGEMENT OF ACUTE HYPERTENSIVE CRISIS
Recommended first line therapy
Drug Dosage Adverse effects Comments
HYDRALAZINE
Peripheral vaso
dilatation
Onset of action
IV – 10 mins
1 m – 10-30min
5mg IV/1m then 5-
20mg every 20-40min
or, 0.5 to 10mg/hr by
continuous infusion
till SBP: 140-150 mm
Hg
DBP : 90-100 mm Hg
Headache, Flushing,
Nausea Vomiting,
Tachycardia, possibly
ventricular arrythmias
•Be aware of
hypotension
•Adversely
effects utero
placental
perfusion
LABETALOL
and  blocker acts
on both peripheral
vasuclature and
heart
Onset of action
5-10 min
20mg IV then 20-80
mg every 20-30 mins
upto 300mg or 1-2
mg.min until desired
effect then stop or
decrease to 5mg / min
– continuous infusion
Flushing, Tingling of
scalp, Nausea
vomiting.
•Be aware of
hyptension
•Adversely
effect
uteroplacental
perfusion.

13. PHARMACOLOGIC MANAGEMENT OF ACUTE HYPERTENSIVE CRISIS
Recommended first line therapy
Drug Dosage Adverse effects Comments
NIFEDIPINE
Calcium channel
blocker causes
peripheral
vasodilatation and
decrease in
preipheral resistance
Onset of action
10-15 mins
5-10 mg orally,
repeat in 30 mins if
necessary then 10-
20mg orally every 3-
6 hrs.
Headache, Nausea,
flushing, inhibition of
labour, Tachycardia
•Avoid
sublingual route
•May have
synergestic
action with
magnesium
sulfate
Recommended second line therapy refractory to 1
st
line
SODIUM
NITROPRUSSIDE
Direct arteriolar
vasodilatation
Onset of action
0.5-5min
0.5-3mg/kg/min IV
infusion (not to
exceed 800 mg/min)
Cyanide toxicity,
nausea, vomiting may
cause fetal cyanide
toxicity
•Relatively
contraindicated
in pregnancy
•Use only in
critical care unit
with low-doses

14. II. DEFINITIVE MANAGEMENT :
Termination of pregnancy
Indication of termination :
1.Signs and symptoms of impending eclampsia
2.Premonitory symptoms of eclampsia
3.BP progressively increase at bedrest
4.Increase proteinusia
5.Impaired LFT
6.Thrombocytopenia
VAGINAL DELIVERY LSCS
Fetal condition good and cervix
favourable then
Induction of labour with IV
oxytocin and ARM
Preinduction ripening with PGs
Indications for LSCS
•Unfavourable Cx
•Failed induction
•Delivery before 32 weeks
•Impending eclampsia
•Viable fetus with fetal stress
•Associated obstetrical
complications

15. MANAGEMENT DURING LABOUR AND DELIVERY
•Rest : Patient should be in bed
•Sedatives : Inj pethidine 50mg/m
•Hypotensive drugs : if BP  110mmHg
•Monitor : BP, urinary output FHR
•In 1
st
stage : Low rupture of membranes
•In 2
nd
stage : Cut short by ventouse / forceps
•Withhold : Prophylactic ergometrine
•To give : Continuous oxytocin and/or carboprost
injection
•Prevent : PPH – even little blood loss may not be
tolerated
•Observe : For 48 hours for PPH, shock, oliguria, eclampsia
•Discharge : after BP has decreased and proteinuria disappears

16. A SIMPLE GESTURE
Everybody can be great …… because anybody can serve, you
don’t have to have a college degree to serve. You don’t have to
make your subject and verb agree to serve. You only need a
heart full of grace, a soul generated by love.
- Martin Luther King Jr.
Thank you