MedicalDisordersinPregnancy_Hypertension2004.pptx

Nursing

1. HYPERTENSIVE DISORDERS IN PREGNANCY

2. Objectives You should be able to : Define high blood pressure during pregnancy Define the spectrum of hypertensive disorders in pregnancy Describe the pathophysiology of hypertensive disorders in pregnancy List the maternal and fetal complications of hypertensive disoders during pregnancy. Describe the aspects of care of a hypertensive mother during: Antenatal period Labour postpartum

3. Definitions Chronic hypertension Hypertension before pregnancy or within 20 wks of POA Persists postpartum Pregnancy aggravated hypertension Chronic HT exacerbated by pregnancy Superimposed pre-eclampsia /eclampsia

4. Definitions Pregnancy induced hypertension occurs only after 20 wks of POA ↑BP without proteinurea gestational hypertension ↑BP + proteinurea ± oedema pre eclampsia Pre eclampsia + convulsions eclampsia

5. Pathophysiology of gestational hypertension ‘deficient placentation’ Relative lack of structural remodeling and dilatation of spiral arteries that occur at 8-18 wks of POA . ‘acute atherosis’ Aggregates of fibrin, platelets and lipid loaded macrophages block the spiral arteries. Inadequate uteroplacental circulation

6. Diagnosis – gestational hypertension What is high Blood pressure? SBP ≥ 140 mmHg DBP ≥ 90 mmHg on at least two occasions Blood pressure rise SBP ≥ 30 mmHg DBP ≥ 15 mmHg Mean arterial pressure ≥ 105 mmHg or a rise of ≥ 20 mmHg.

7. Diagnosis of pre-eclampsia Increased BP Proteinuria ≥ 300mg in 24 hours Oedema

8. Maternal vascular endothelial damage Endothelial cells – reduced prostacyclin Platelets - increased thromboxane → Vasospasm Vasospasm + endothelial damage – oedema (brain,lungs, liver,retina) Activation of clotting cascade – DIC, ↓platelets Kidney - glomeruloendotheliosis Pathopysiology of pre eclampsia

9. Risk factors for pre eclampsia Maternal Primigravidity Age < 20; >35 H/O pre eclampsia Obesity Medical disorders Chronic renal disease Chronic hypertension D.M. Antiphospholipid syndrome F/H of pre eclampsia Fetal/placental factors Advancing gestational age Multiple pregnancy H.mole triploidy

10. Classification of pre eclampsia Mild pre eclampsia Asymptomatic BP ≥140/90 but < 160/110 Proteinurea > 300mg/24hr but < 5g/24 hr.

11. Severe pre eclampsia Symptoms Persistent headache R/upper quadrant/epigastric pain Blurred vision/ scotomata Signs BP ≥160/110 mm/Hg Pulmonary oedema Brisk reflexes Ankle clonus

12. Sever pre eclampsia - investigations Proteinurea (≥ 5g/24 hr) Oliguria Thrombocytopaenia ↑ liver enzymes HELLP syndrome ↑ PCV Hyperuricaemia ↑plasma creatinine ↑ plasma Vwf ↑ fibrin D-dimer

13. Complications of pre-eclampsia Maternal CNS eclampsia Cerebral haemorrhage/oedema Cortical blindness Renal Renal cortical necrosis Renal tubular necrosis

14. Complications of pre eclampsia (ctd) Respiratory system Pulmonary oedema Liver Periportal necrosis Subcapsular haematoma HELLP syndrome Coagulation system DIC Microangiopathic haemolysis

15. Complications of pre eclampsia (ctd) Placenta Abruptio placentae Retroplacental bleeding

16. Complications of pre eclampsia (ctd) Fetal IUGR Fetal hypoxaemia IUD

17. Management of hypertension during pregnancy - antenatal period Chronic hypertension Exclude secondary causes Eg. Renal , C.V.S., connective tissue disorders Assess for secondary organ damage

18. Antenatal management Advice to mother Explain illness to mother Sequelae of uncontrolled HT Compliance with drugs Maintain kick count chart BP daily (twice /thrice a day) Monitor the weight Advice to report symptoms of pre eclampsia

19. Monitoring during the antenatal period Maternal Blood pressure weight Proteinurea Signs of severe pre eclampsia Fetal Growth scan – 3 rd trimester

20. Management of hypertension in pregnancy To control ↑ BP: Methyldopa Labetolol Nifedipine long acting formulation preferred. sublingual route unpredictable Other drugs – atenolol,clonidine.

21. Management of hypertension in pregnancy BP ≥160/110 mmHg I.V. Hydralazine I.V.labetolol Oral Nifedipine

22. Prophylaxis of convulsions Magnesium sulphate For the prophylaxis of eclamptic fits Prevents vasocontriction of cerebral vessels. Continue until 24 hrs. following the last fit or 24 hrs postpartum, whichever is longer. Route – I.V/I.M. Dose- loading dose, followed by a maintanance dose.

23. Magnesium sulphate (ctd) Monitoring; Regular assessment for features of toxicity Deep reflexes Respiratory rate Urine output

24. Management of an eclamptic fit Usually self limiting (1-2 mts ) Mg sulphate (I.V/I.M.) – along with monitoring since Mg sulphate can cause respiratory depression If prolonged General measures Positioning, securing airway and circulation Deliver the baby as early as possible

25. delivery When to deliver? Depends on Severity of HT condition Presence of complications of HT Fetal wellbeing How to deliver? Depends on POA State of cervix

26. delivery Monitoring of fluid balance if pre eclampsia is present. Oliguria/ pul. Oedema Avoid ergometrine during 3 rd stage of labour Exarcebates hypertension

27. Following delivery Continue to monitor B.P. monitor for signs of pre eclampsia mainly during the 1 st 48 hours. ( pre eclampsia and eclampsia can occur for the 1 st time following delivery) Discharge if no complications and the B.P. is stable. Educate mother to recognise symptoms of pre eclampsia