Hypertensive Disorders in Pregnancy.pptx

all about hypertensive disorders

1. Hypertensive Disorders in Pregnancy Pre – eclampsia

2. Introduction Hypertensive disorders of pregnancy remains as one of the common causes of mortality among woman in Malaysia. Accounted for 14.1% of total maternal death between 1997-2000(Confidential Enquiry of Maternal Mortality, Malaysia 2005) Carry risk for the woman such as eclampsia, DIVC, intracranial bleeding, VTE, pulmonary oedema, heart failure, abruptio placentae and death. Most develop for the first time in the second half of the pregnancy. Carry risk for the baby: higher rate of perinatal mortality, preterm birth and low birth weight.

3. Eclampsia: Convulsive condition associated with pre-eclampsia. Pre-eclampsia: New hypertension presenting after 20 weeks with significant proteinuria. Severe pre-eclampsia: Pre-eclampsia with severe hypertension and/or with symptoms, and/or biochemical and/or haematological impairment. Significant proteinuria: urinary protein : creatinine ratio >30mg/mmol or 24 hour urine collection >300mg/day.

4. Risk factors for pre-eclampsia Moderate First pregnancy Age ≥ 40 years Pregnancy interval > 10 years BMI ≥ 35 kg/m2 at first visit Family history of pre-eclampsia Multiple pregnancy

5. Risk factors for pre-eclampsia High Risk Hypertensive disease during previous pregnancy Chronic kidney disease Autoimmune disease such as systemic lupus erythematosis or antiphospholipid syndrome Type 1 or type 2 diabetes Chronic hypertension

6. If at least 2 moderate risks factors or one high risk factor for PET Advise woman to take aspirin 75 mg/day from 12 weeks until birth **NICE Hypertension in pregnancy August 2010

7. Outline of Management of Pre-eclampsia (PET) Antihypertensives: Aim for BP<150/80-100mmHg. First-line: Amlodipine, labetalol (oral, IV) Second-line: Nifedipine, methyldopa Monitor BP every 4 hours, hourly if severe HPT. Check FBC, PT/PTT, BUSE, Se Creatinine, Se Uric acid.

8. Outline of Management of Pre-eclampsia (PET) Fetal Monitoring: USS for fetal growth + AFI + Umbilical artery doppler every 2 weekly. CTG: at diagnosis and repeat if reduced fetal movement, PV bleeding, abdo pain, deterioration of maternal condition Steroids: IM dexamethasone 12mg BD for 2 doses if considering delivery within 7 days (24 to 36 weeks) for fetal lung maturity.

9. Outline of Management of Pre-eclampsia (PET) Timing of delivery: Determine by several factors: Severe refractory hypertension Deteriorating maternal or fetal conditions. Availability of neonatal care. Completion of corticosteroid. After 37+0 weeks: recommend birth within 24-48 hours.

10. Indications for MgSO4 Give intravenous magnesium sulphate if woman with severe hypertension or severe pre-eclampsia has or previously had eclamptic fit. Consider giving intravenous magnesium sulphate* if birth planned within 24 hours in woman with severe pre-eclampsia.

11. Features of Severe Pre-Eclampsia Severe hypertension and proteinuria or mild or moderate hypertension and proteinuria with at least one of: severe headache problems with vision such as blurring or flashing severe pain just below ribs or vomiting Papilloedema signs of clonus (≥ 3 beats) liver tenderness HELLP syndrome platelet count falls to < 100 x 10 9 /litre abnormal liver enzymes (ALT or AST rises to > 70 iu /litre).

12. MgSo4 regime Loading dose of 4 g given intravenously over 5 minutes, followed by infusion of 1 g/hour for 24 hours. Further dose of 2–4 g given over 5 minutes if recurrent seizures. *The Eclampsia Trial Collaborative Group (1995)Which anticonvulsant for women with eclampsia?Evidence from the Collaborative Eclampsia Trial.Lancet 345:1455–63.

13. Outline of Management of Pre-eclampsia (PET) Fluid balance: limit fluid to 2L/day (total) Mode of delivery: according to clinical circumstances and woman’s preference.

14. Breastfeeding: No known adverse effects: labetalol, nifedipine, enalapril, captopril, atenolol, metoprolol. Insufficient evidence on safety: ARBs, amlodipine, ACE inhibitors other than enalapril & captopril. Next pregnancy? Risk of PET: ranges from 1 in 14 to 1 in 2. If birth before 34 weeks: 1 in 4. If birth before 28 weeks: 1 in 2.