Management of Hypertensive Disorders of Pregnancy (1).pptx

Mangment of hyptesion

1. Seminar on Management of Hypertensive Disorders of Pregnancy Presenters 1.Moges t. 2.Gibir s. 3.Leoulseged b. 4.Medan s. 5.Mathowos m. Moderator D r Endegena (R4)

2. OUTLINES INTRODUCTION DIAGNOSIS AND INVESTIGATIONS PATHOGENESIS AND CLINICAL MANIFESTATION MANAGEMENT PRINCIPLES PREVENTION OF CONVULSION CONTROLLING OF BP MANAGEMENT OF COMPLICATIONS AND TREATMENT RESPONSE DELIVERY TIMING

3. Introduction Hypertensive disorders include Preeclampsia gestational hypertension chronic hypertension complicate up to 10 percent of pregnancies. they are one member of the deadly triad —along with hemorrhage and infection.

4. Diagnosis of Hypertensive Disorders Hypertension is diagnosed when appropriately# taken blood pressure exceeds 140mmHg systolic and/or 90mmmHg of diastolic observed at least on two occasions 4hrs apart but not more than 7days apart

5. Gestational Hypertension Blood pressure ≥140/90 mmHg No protein in the urine (proteinuria )≥ 20 weeks pregnant No previous history of high blood pressure. 25 %-50% develop Preeclampsia Final diagnosis made only postpartum

6. Chronic Hypertension An elevated BP that is present prior to conception or is diagnosed before 20th week of gestation, or HTN that persist for more than 12wks postpartum. The frequency of chronic hypertension in pregnancy is estimated at 1% to 5%. Women with chronic hypertension are at increased risk for superimposed PE

7. Superimposed PE on Chronic HTN Criteria to diagnose preeclampsia in women with preexisting medical conditions Hypertension only ; proteinuria of >=300mg per 24hr or thrombocytopenia Hypertension plus proteinuria ; worsening of hypertension plus proteinuria and either new onset symptoms thrombocytopenia elevated liver enzymes

8. Pre eclampsia Is a multi-system progressive disorder characterized by new onset of hypertension and proteinuria or hypertension and significant end-organ dysfunction with or without proteinuria after 20 weeks of gestation in a previously normotensive woman. A pregnancy-specific syndrome that can affect virtually every organ system.

9. Cont ….. Proteinuria Two urine dipstick measurements of at least 1+ (30 mg per dL ) taken six hours apart; At least 300 mg of protein in a 24-hour urine sample A urinary protein/creatinine ratio of 0.3 or greater

10. Cont … Is identified in 5 to 8 percent of all pregnancies. Young and nulliparous women are particularly vulnerable, whereas older women are at greater risk for chronic hypertension with superimposed preeclampsia. The incidence of preeclampsia in nulliparas ranged from 3 to 10 percent. In multiparas, the incidence ranges from 2 to 5 percent.

11. Risk factors… Multifetal gestation Prim gravid CHTN A ge extremity Family hx of preeclampsia Obesity R enal disease P oor outcome in previous px

12. Theories associated with etiologies of preeclampsia Abnormal trophoblast invasion   Vascular endothelial damage Genetic predisposition Cardiovascular maladaptation    Immunologic phenomena    Coagulation abnormalities      Dietary deficiencies or excesses

13. In normal pregnancy Fetal trophoblast invade walls of spiral arteries . This disrupts their smooth muscle layer and converts them into venous-like channels Remodelling begins about 5-6 weeks and continues until around 20-22 weeks This allows blood supply to uterus to increase from 10-15 mls (pre-pregnancy) to 600-800 mls per minute to meet placental blood flow requirements at term

14. 1 st trimester (10-14wks) -Conversion of decidual segments of spiral arteriole by endovascular trophoblast migration. 2 nd trimester (16-20wks) - Changes of myometrial segments by subsequent waves.

15. Hypoperfused placenta Release factors (growth factors, Cytokines) Vascular endothelial cell activation Clinical manifestations of the disease

16. Criteria for Preeclampsia with Severity Features Preeclampsia SBP ≥160 mm Hg or DBP ≥110 mmHg on two occasions at least 4 hours apart. New-onset persistent cerebral symptoms: headaches or visual disturbances. Impaired liver function as indicated by abnormally elevated liver enzymes (at least twice the upper limit of normal. Severe , persistent right upper quadrant or epigastric pain that is unresponsive to medications and not accounted for by an alternative diagnosis; or both

17. Pulmonary edema (often develop in postpartum) Thrombocytopenia (platelet count <100000 ) Serum creatinine >1.1mg/ dl;or doubling in the patient’s base line C reatinine in absence of other renal diseases

18. Atypical preeclampsia Some patient with PE may present with signs of PE without HTN, - and it is referred to as atypical PE. G estational proteinuria or FGR plus one or more of the following Severity features of preeclampsia without hypertension: hemolysis, thrombocytopenia, elevated liver enzymes. Early signs and symptoms of PE-E syndrome earlier than 20 weeks. Late postpartum PE-E syndrome (>48 hours postpartum but less than six weeks after delivery).

19. Investigations CBC LFT , LDH RFT U/A 24hr urine protein Obstetrics U/S Serum electrolytes

20. Management principles of Pre-eclampsia Objectives Termination of pregnancy less possible trauma to the mother and the fetus. Birth of an infant who subsequently thrives Complete restoration of health to the mother Once Dx is made definitive Rx is delivery

21. Management based on classification Pre-eclampsia without severe features Pre-eclampsia with severe features

22. Pre-eclampsia without severe features Gestational age less than 37 weeks Twice weekly outpatient follow-up Monitor blood pressure fetal condition CBC liver& renal function test Counsel about the danger signs Orient on fetal movement counting

23. Gestational age ≥37complete weeks Delivery is recommended. Anticonvulsant during labor

24. Pre-eclampsia with severity features Antepartum General measures Prevent convulsion Control hypertension Delivery / expectant management in selected cases

25. General measures Admit the patient urgently Manage in left lateral position Setup IV line Monitor urine output Prepare equipment (airway, suction equipment, mask & bag, oxygen) Auscultate the lung bases for fine crepitation (furosemide 40 mg IV stat)

26. Prevention of Convulsions Mgso4 Diazepam Phenytoin

27. Magnesium sulfate I t is the drug of choice Because labor and delivery is a more likely time for seizures to develop. Usually given during labor and for 24 hours postpartum. candidates PE without severity features - intrapartum of postpartum PE with severity at any time

28. Mechanism of action Not clearly defined some proposed mechanisms of action include: 1 Reduced presynaptic release of the neurotransmitter glutamate. 2 Blockade of glutamatergic N-methyl-d-aspartate receptors. 3 Potentiation of adenosine action. 4 Improve calcium buffering by mitochondria. 5 Blockage of calcium entry via voltage-gated channels

29. Administration I t can be given C ontinuous IV infusion Intermittent IM injections

30. Continuous IV infusion Loading dose 4-6 gm in 100ml of IV fluid over 15-20 minutes. Maintenance 2 gm /hr in 100ml of maintenance infusion.

31. Intermittent IM injections Loading Magnesium sulfate 20% solution, 4g IV over 5 minutes. Follow promptly with 10 gm of 50% magnesium sulfate solution, 5 gm in each buttock as deep IM injection with 1mL of 2% lidocaine in the same syringe. If convulsion recurs after 15 minutes, give 2 gm magnesium sulfate (20% solution) IV over 5 minutes. Maintenance dose 5 gm magnesium sulfate (50% solution) + 1 mL lidocaine 2% IM every 4 hours into alternate buttocks. Continue for 24 hours after delivery or the last convulsion, whichever occurs last.

32. Note : Maintenance dose will be given only after assuring. Patellar reflex present Respiratory rate note depressed UOP greater than 100ml over 4 hr

33. Advantages Less costly Ease of administration Less CNS depressant Reduce the development of cerebellar 'palsy.

34. Side effects and toxicity Noses vomiting Fascial flushing Injection site irritation Decrease UOP Depress deep tendon reflex Respiratory depression Cardiac arrest CNS depression Hypotension

35. Cont….. But it toxicity related to its serum level Effect 4.8 Serum level (mg/dl) Therapeutic level 4.8-8.4 Depressed DTR 8.5-12 Respiratory depression 12-16 Cardiac arrest 18

36. Monitoring of toxicity Cheek patellar reflex Follow RR if >12 Bpm UOP if >100ml/4 Hr. Creatinine If patellar is absent , RR<16, UOP<30ml /hr with hold Mgso4 and administer calcium gluconate or Calcium chloride 1gm IV. If Cr is b/n 1.1 and 2.5 reduce maintenance dose by half. If Cr is >2.5 stop the maintenance dose.

37. Contraindications Heart block Myasthenia Gravis Severe Renal impairment Myocardial damage Addison disease Severe hepatitis

38. Other effects Neuron protection Toccolytic FHB abnormality

39. Dizepam Loading dose Diazepam10 mg IV slowly over 2 minutes If convulsion recur, repeat the same dose Maintenance dose Diazepam 40 mg in 500 ml IV fluids 30 drop /minute .

40. Phenytoin 20mg/kg IV at rate of 50mg /minute but cardiac monitoring and frequent vital signs are required ( if per fuse ). Loading 1gm IV Over 20 minutes Maintenance dose 200mg every 6 hr after 12 of the initial dose .

41. Blood pressure control

42. Cont'd Antihypertensives should be started if the systolic BP is 160 mmHg or higher and/or diastolic BP is 110 mmHg or higher. Hydralazine or labetalol is the drug of choice for acute control. NOTE: An important principle is to maintain BP above the lower limits of the normal.

43. Cont'd If blood pressure level is not in sever range(160/110 mmHg or more) and the patient doesn't have other severity feature of hypertensive diseases of pregnancy,patients are followed out patient. Blood pressure should be maintained with in the target range to avoid complications resulting from hypertensive crisis or further compromization of the already hypoxic uteroplacental vasculature.

44. Cont… Drugs used to control hypertension in pregnancy mainly are:- 1.Hydralazine 2.Labetalol 3.Nifedipine 4.Methyldopa

45. Acute Blood Pressure Control Hydralazine; Is Given as 5 mg IV slowly every 20 minutes until target blood pressure is maintained (systolic blood pressure <160 and diastolic blood pressure of <110 mmHg). The maximum dose is 30 mg per 24 hours.Its side effects include maternal hypotension,fetal bradycardia and allergic reactions.

46. Labetalol Oral treatment: Administer 200 mg; repeat dose after one hour until the treatment goal is achieved. The maximum dose is 1200 mg in 24 hours. Intravenous treatment: Administer 10 mg IV. If response is inadequate after 10 minutes, administer 20 mg IV. The dose can be doubled to 40 mg and then 80 mg with in10-minute intervals until desired BP is achieved.The total dose is 300 mg; then switch to oral treatment.

47. Labetalol It is contraindicated to patients with bronchial asthma,heart failure and cardiac conduction abnormalities like heart block. It is preferred to hydralazine in acutely lowering severly elevated blood pressure in that it has fewer side effects than hydralazine. Its side effects include maternal hypotension and bradycardia .

48. Nifedipine As alternative for acute therapy, administered as10 mg orally. Repeat dose after 30 minutes if response is inadequate until optimal blood pressure is reached. The maximum total dose is 30 mg in the acute treatment setting. For maintenance therapy10-20 mg PO bid is given.It is preferred to labetalol in quickly lowering blood pressure.

49. Methyldopa Administered as 250-750 mg every six to eight hours. The maximum dose is 3000 mg per 24 hour. This drug is mainly used for maintanig blood pressure with in the target range after blood pressure is controlled with short acting antihypertensive medications.

50. Complication Management of PE

51. Eclampsia Eclampsia is defined as the development of convulsions (generalized tonic- clonic ) or unexplained coma during pregnancy or postpartum in patients with signs and symptoms of PE. Eclampsia can develop antepartum, intrapartum (most of the time) or postpartum (in around 10% of cases, mostly within 48hr of delivery) Late postpartum eclampsia is defined as eclampsia that occurs after 48 hours but before 4 weeks of delivery .

52. Major Maternal Complications of Eclampsia Placental abruption Neurological Deficits Aspiration Pneumonia Pulmonary edema Cardiopulmonary Arrest Acute Renal Failure

53. Some of the recommended preventive therapies C lose monitoring (in-hospital or outpatient), U se of antihypertensive therapy to keep maternal BP below a certain level (< severe range or to normal values), T imely delivery, and prophylactic use of magnesium sulfate during labor and immediately postpartum in those considered to have PE Prophylactic MgSo4 is recommended only for women who are hospitalized with the established diagnosis of PE. NB, about 31-87% of eclampsia is considered unpreventable

54. MANAGEMENT OF ECLAMPSIA Treatment of eclampsia consists of: General measures Control of convulsions Blood pressure control Fluid balance Delivery & intrapartum/postpartum care

55. GENERAL MEASURES IN THE MANAGEMENT OF ECLAMPSIA Set up IV line & maintain intravascular volume Position the patient on her side (left lateral) & in Trendelenburg (head down) position. ensure open airway. Give oxygen by mask at 6 liters per minute. protect the woman from injury Place an indwelling catheter to monitor urine output. auscultate the lung bases hourly for crepitation . If the pulmonary edema occurs, withhold fluids & administer a diuretic. Administration of broad-spectrum IV antibiotics .

56. ANTICONVULSANT THERAPY Administer anticonvulsant drugs to stop the ongoing convulsion & prevent subsequent attack MgSO4 Magnesium sulphate is the drug of choice in the management of eclampsia ensure that respiratory rate is at least 12 per minute, patellar reflexes are present and urinary output is at least 30 ml per hour or 100 ml per 4 hours.

57. MAGNESIUM SULFATE SCHEDULES FOR SEVERE PRE-ECLAMPSIA AND ECLAMPSIA Loading dose Magnesium sulfate 20% solution, 4g IV over 5 minutes. Follow promptly with 10g of 50% magnesium sulfate solution, 5g in each buttock as deep IM injection with 1mL of 2% lidocainein the same syringe. If convulsion recurs after 15 minutes, give 2g magnesium sulfate (20% solution) IV over 5 minutes. Maintenance dose 5g magnesium sulfate (50% solution) + 1 mL lidocaine 2% IM every 4 hours into alternate buttocks. Continue treatment with magnesium sulfate for 24 hours. If there is respiratory arrest, assist ventilation and administer calcium gluconate 1g (10mL of 10% solution) IV slowly.

58. Diazepam Diazepam is an alternative, but it increases the risk of respiratory depression and newborn apnea. Loading dose Diazepam10mg IV slowly over 2 minutes If convulsion recur, repeat the same dose Maintenance dose Diazepam 40mg in 500ml IV fluids (N/S or Ringer's lactate) no of drops titrated to keep the woman

59. ANTI-HYPERTENSIVE THERAPY The therapeutic goal is to keep the diastolic blood pressure <110 mmHg (between 90 and 100mmHg & prevent cerebral hemorrhage). For drugs used as antihypertensive medication refer to management of severe pre-eclampsia above (use same drugs & doses ).

60. FLUID BALANCE Keeping strict input & output record is essential anddetermine serum electrolyte, if possible For unconscious patient, 5% DW & ringer's Lactate are infused for maintenance of nutrition & fluid balance during 24 hrs. Replace extra fluid loss when the patient becomes conscious & can drink, oral feeding of fluidis started.

61. DELIVERY Delivery should take place within 12 hours of onset of convulsions as soon as the woman's condition has stabilized, regardless of the gestational age

62. HELLP Syndrome is an acronym that refers to a syndrome in pregnant and postpartum individuals characterized by hemolysis with a microangiopathic blood smear, elevated liver enzymes, and a low platelet count.

63. PATIENT PRESENTATION Signs and symptoms U pper abdominal pain and the area may be tender on physical examination. N ausea, vomiting, and generalized malaise Thrombocytopenia-related bleeding Hypertension and proteinuria but both may be absent in patients with HELLP.

64. Classifications of HELLP syndrome Tennessee criteria Hemolysis (as least two of these): Peripheral smear ( schistocytes , burr cells) Serum bilirubin (≥1.2 mg/ dL ) Low serum haptoglobin Elevated liver enzymes Aspartate transaminase (AST) or alanine transaminase (ALT ) ≥ twice upper level or normal Lactate dehydrogenase ≥ twice upper level or normal Low platelets (<100,000/mm3 )

65. Classifications of HELLP syndrome Mississippi classification

66. Mississippi classification Vs Improvement after delivery Class 1 HELLP Improves after 14 days after delivery Class 2 Improves after 7 –10 days after delivery C lass 3 Improves after 3 –5 days after delivery

67. Management Delivery is the cornerstone of therapy for HELLP and is the only effective treatment. In pregnancies <34 weeks without severe complications, delivery can be delayed for 48 hours for antenatal corticosteroid administration. However expectant management is associated with a high risk of developing maternal complications without significant improvement in perinatal prognosis.

68. DELIVERY

69. A. Gestational age < 28 week Termination of pregnancy B. Gestational age ≥ 28 weeks and <34 weeks For expectant management: Transfer to maternity ward Follow vital signs every 4 hours CBC every other day Liver enzymes and creatinine twice weekly

70. DELIVERY A. Gestational age < 28 week Termination of pregnancy B. Gestational age ≥ 28 weeks and <34 weeks For expectant management: Transfer to maternity ward Follow vital signs every 4 hours CBC every other day Liver enzymes and creatinine twice weekly

71. Count.. Fetal kick count daily Fetal surveillance twice weekly Administer dexamethasone 6 mg IM every 12 hours for 2 days or betamethasone 12 mg daily for 2 days

72. Indications for delivery Failure to control hypertension with two antihypertensive drugs with a maximum dose in 48 hours. Persistent maternal severity symptoms (severe headache, visual changes and abdominal and/or epigastric pain with elevated liver enzymes). HEELP Syndrome

73. Count.. Eclampsia Pulmonary edema or left ventricular failure IUFD DIC Severe renal dysfunction

74. C. Gestation 34 to 37 Weeks: E xpectant management may be recommended, provided that uncontrolled maternal hypertension , worsening maternal status and fetal distress are absent and can be closely monitored.

75. D. Gestation after 37 Completed Weeks: For women with pre-eclampsia at term (≥ 37 weeks), regardless of severity features, deliveryis recommended.

76. INTRA PARTUM MANAGEMENT Absolute bed rest in left lateral position is essential. Antihypertensive drugs should be given as necessary to regulate diastolic bp between 90 &110mm Hg. Careful monitoring of FHB, maternal conditions & progress of labor. Pain management as required. Mgso4 administration .

77. POSTPARTUM MANAGEMENT Watch closely for at least 2 hours after delivery for complications such as shock, PPH & eclampsia. Anticonvulsive therapy should be maintained for 24 hrs to 48 hrs after delivery or the last convulsion, whichever occurs last . Continue anti-hypertensive therapy as long as the blood pressure is ≥ 110mmhg. Continue to monitor urine output & check for coagulation failure, LFT and RFT .

78. Postnatal follow-up of these cases is very important for T he treatment of hypertension DIC A cute renal failure P ulmonary edema

79. REFERENCES Williams obstetrics 26 th edition U ptodate online Obstetric protocol 2020

80. THANK YOU