HYPERTENSIVE DISORDERS IN PREGNANCY.pptx

HYPERTENSIVE DISORDERS

1. HYPERTENSIVE DISORDERS IN PREGNANCY PRESENTER – DR SHILPA M MODERATOR – DR NEHA

2. INTRODUCTION Hypertension is common medical disorder of pregnancy Affects 6% to 10% of pregnancies. Causes maternal mortality with hemorrhage Hypertensive disorders are an important risk factor for fetal complications preterm birth fetal growth restriction and/neonatal death

3. INTRODUCTION Anesthesiologist plays critical role in the management of hypertensive disorders in pregnancy Role- assessment of the severity of preeclampsia administration of anesthesia cardiovascular monitoring critical care multidisciplinary team -obstetricians cardiologists neonatologists midwives critical care specialists

4. INTRODUCTION Hypertensive disorders of pregnancy encompass Chronic hypertension Gestational hypertension Preeclampsia Preeclampsia superimposed on chronic hypertension Eclampsia Difficult to differentiate because the clinical presentation is similar Despite complex differences in their underlying pathophysiologies and prognoses.

5. CLASSIFICATION OF HYPERTENSIVE DISORDERS IN PREGNANCY National High Blood Pressure Education Program (NHBPEP) Classification done at 2000 C lassification updated in 2013 By American College of Obstetricians and Gynecologists (ACOG) They also published recemmendations for preeclmapsia management

6. Classification of Hypertensive Disorders in Pregnancy 1. Gestational hypertension 2.Preeclampsia a. Preeclampsia without severe features b. Severe preeclampsia c. Eclampsia • Chronic hypertension a.Chronic hypertension with superimposed preeclampsia

7. PATHOPHYSIOLOGY OF HYPERTENSIVE DISODERS IN PREGNANCY Poor invasion of the placental trophoblasts cells of maternal spiral arteries – major component of disorder Results in high resistance vessels instead of low resistance vessels Leads to limited distensibility of spiral arteries Restricting blood flow to placenta and fetus

8. PATHOPHYSIOLOGY OF HYPERTENSIVE DISODERS IN PREGNANCY

9. Nulliparity Pre-eclampsia in a previous pregnancy Age >40 years or <18 years Family history of pregnancy-induced hypertension Chronic hypertension Chronic renal disease Anti-phospholipid antibody syndrome or inherited thrombophilia RISK FACTORS FOR HYPERTENSION IN PREGNANCY

10. Vascular or connective tissue disease Diabetes mellitus (pre-gestational and gestational) Multi- fetal gestation High body mass index Hydrops-fetalis Unexplained fetal growth restriction RISK FACTORS FOR HYPERTENSION IN PREGNANCY

11. GESTATIONAL HYPERTENSION Affects approximately 5% of parturients . Definition of Gestational hypertension 1. presents as elevated blood pressure after 20 weeks’ 2. gestation without proteinuria 3. absence of chronic hypertension or systemic manifestations of preeclampsia 4.that resolves by 12 weeks postpartum Most cases of gestational hypertension develop after 37 weeks gestation.

12. GESTATIONAL HYPERTENSION 1/4 th of patients with gestational hypertension develops preeclampsia. D iagnosis of gestational hypertension can be made only in retrospect after delivery W hen the diagnosis of chronic hypertension can be excluded based on return to a normotensive state.

13. Maternal: Superimposed pre-eclampsia/ eclampsia in 15-20% of cases Foetal: Intrauterine growth retardation. Intrauterine foetal death. EFFECT OF CHRONIC HYPERTENSION ON PREGNANCY

14. PRE ECLAMPSIA Preeclampsia is defined as the new onset of hypertension and proteinuria after 20 weeks’ gestation The diagnosis of preeclampsia should also be considered in the absence of proteinuria when any of the following signs or symptoms of end-organ involvement are present: (1) persistent epigastric or right upper quadrant pain, (2) persistent cerebral symptoms (3) fetal growth restriction (4) thrombocytopenia (5) elevated serum liver enzymes.

15. EPIDEMIOLOGY Preeclampsia occurs in 3% to 4% of pregnancies Delivery of the infant and placenta - definitive treatment preeclampsia is a leading cause of preterm delivery Low-birth-weight preterm infants Preterm delivery indication for admission to NICU It is an indication for maternal peripartum admission to ICU

16. DIAGNOSTIC CRITERIA FOR PREECLAMPSIA Preeclampsia without Severe Features • Blood pressure greater than or equal to 140/90 mm Hg after 20 weeks gestation • Proteinuria (greater than or equal to 300 mg/24 hr , protein creatinine ratio greater than or equal to 0.3, or 1+ or greater on urine dipstick specimen)

17. DIAGNOSTIC CRITERIA FOR PREECLAMPSIA Severe Preeclampsia • Blood pressure greater than or equal to 160/110 mm Hg • Thrombocytopenia (platelet count less than 100,000/mm3 ) • Serum creatinine concentration greater than 1.1 mg/dL or greater than 2 times the baseline serum creatinine concentration • Pulmonary edema • New-onset cerebral or visual disturbances • Impaired liver function

18. DIFFERENCES BETWEEN EARLY- AND LATE-ONSET PREECLAMPSIA

19. ECLAMPSIA Eclampsia is central nervous system (CNS) involvement results in the new onset of seizures with preeclampsia DEFINATION Eclampsia is defined as the new onset of seizures or unexplained coma during pregnancy or the postpartum period with signs and symptoms of preeclampsia and without a preexisting neurologic disorder.

20. ECLAMPSIA EPIDEMIOLOGY Eclampsia can occur suddenly at any point in the puerperium most seizures occur intrapartum or within the first 48 hours after delivery. Late eclampsia is defined as seizure onset from 48 hours after delivery to 4 weeks postpartum

21. ECLAMPSIA The majority of eclamptic women have evidence of severe preeclampsia in 10% to 15% of cases hypertension is absent or modest and/or proteinuria is not detected. HELLP syndrome refers to the development of H- hemolysis, E-elevated liver enzymes, and L-low platelet count in a woman with P preeclampsia This condition may be a variant of severe preeclampsia

22. CHRONIC HYPERTENSION Chronic hypertension involves either (1) SBP of 140 mm Hg or higher and/or DBP of 90 mm Hg or higher presenting before pregnancy or before 20 weeks gestation (2) elevated blood pressure that fails to resolve after delivery. Chronic hypertension develops into preeclampsia 1/5 th of cases

23. CHRONIC HYPERTENSION SUPERIMPOSED WITH PREECLAMPSIA Occurs when preeclampsia develops before pregnancy with chronic hypertension Diagnosis new onset of proteinuria or a sudden increase in proteinuria or hypertension or both or other manifestations of severe preeclampsia appear Morbidity is increased for both the mother and fetus compared with preeclampsia alone.

24. HYPERTENSIVE DISORDERS OF PREGNANCY

25. REFERENCES MILLER S ANAESTHESIA 9 TH EDITION CHESTNUT S OBSTETRIC ANAESTHESIA 6 TH EDITION

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