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Pregnancy induced hypertension is the elevation of blood pressure during pregnancy

1. SEMINAR PRESENTATION ON HYPERTENSIVE DISORDERS IN PREGNANCY AMBO UNIVERSITY, HEALTH CENTER STUDENTS GROUP 3

2. GROUP MEMBERS 1.ADINEW KASSAHUN 2.JOHN 3.SENA SHELEMA 4.MARTHA SILESHI 5.HAWI DAMENE 6.TESSEMA MAMO 7.ABDI 8.HERMELA G/GIORGIS

3. Objectives At the end of this session we will be able to : Define hypertensive disorders of pregnancy Classify hypertensive disorders of pregnancy Differentiate the types of hypertensive disorders of pregnancy Discuss the management of HDP Manage preeclampsia eclampsia syndrome Administer anticonvulsants and antihypertensive

4. Hypertensive disorders of pregnancy (HDP) Hypertension: A SBP≥ 140 mmHg, DBP≥ 90 mmHg or both in two occasions taken 4 hours or more apart; or a single blood pressure recording of ≥160/110 mmHg

5. Cont …..d Hypertensive disorders: is the third leading cause of maternal mortality in Ethiopia. complicate 5-10% of pregnancies. is the cause of 9-26% of global maternal mortality. is the cause of a significant proportion of preterm deliveries as well as maternal and neonatal morbidity.

6. Classification of HDP Gestational hypertension : H ypertension without proteinuria (or other signs of preeclampsia) developing after 20 weeks of gestation in a previously normotensive woman . D efinitive evidence for the preeclampsia syndrome does not develop and hypertension resolves by 12 weeks postpartum.

7. Cont…d 2. Preeclampsia and E clampsia syndrome Preeclampsia : new onset of hypertension and proteinuria after 20 weeks of gestation in a previously normotensive woman. Eclampsia : grand mal seizure or coma in a woman with preeclampsia.

8. Cont…d Preeclampsia syndrome superimposed on chronic hypertension Is diagnosed when preeclampsia occurs in a patient with preexisting chronic hypertension (primary or secondary hypertension that precedes pregnancy or is present on at least two occasions before the 20 th  week of gestation or persists longer than 12 weeks postpartum).

9. Con…..d 4. Chronic hypertension: Hypertension that antedates pregnancy; is present before 20 weeks of gestation; or persists after 12 weeks postpartum.

10. Diagnostic Criteria Hypertension: is diagnosed BP ≥ 140/90 mm Hg measured 2 times with at least 4hours interval but no more than 7 days Gestational hypertension : new onset of BP > 140/90 mmHg after 20 weeks in previously normotensive women and no proteinuria & no severe features of preeclampsia .

11. Cont …..d Pre- eclampsia : New onset of hypertension (BP >140/90mmHg) and ≥ 300 mg protein in a 24-hour urine specimen or Protein: creatinine ratio ≥ 0.3 or 2+ on dipstick in a woman without history of proteinuria (Dipstick >1+ persistent) if other methods not available

12. Diagnostic Criteria … Pre- eclampsia : The new onset of HTN and significant end-organ dysfunction with or without proteinuria after 20 weeks of gestation or postpartum. Thrombocytopenia (platelet count <100,000/microliter) Renal insufficiency (serum creatinine of >1.1mg/ dL ) Impaired liver function (liver AST or ALT levels at least twice the normal) Pulmonary edema Persistent cerebral or visual symptoms (headache, visual disturbances)

13. Pre- eclampsia Preeclampsia is best described as a pregnancy-specific syndrome that can affect virtually every organ system. New-onset of hypertension after 20 weeks of gestation and Proteinuria > 300mg in a 24hour urine or 2+ on dipstick in a woman without history of proteinuria Note: Proteinuria can indicate other conditions (severe anemia, kidney disease, or UTI) as well as contamination by vaginal discharge, blood, or amniotic fluid. However , PE&E is the most common cause of proteinuria in pregnancy

14. Cont…d Preeclampsia is Classified in to : Mild or non severe preeclampsia DBP remains < 110mmHg, SBP< 160mmHg Proteinuria No other symptoms, signs or laboratory findings of severe preeclampsia. Severe pre- eclampsia PE with severity features

15. Severe Preeclampsia New-onset of elevated BP: SBP ≥ 160 mmHg OR DBP ≥ 110 mmHg or Clinical Features of SPE includes any one or more of the following Headache : increasing frequency, unrelieved by regular analgesics Visual changes such as blurred vision or photophobia Epigastric or RUQ pain (hepatocellular necrosis, ischemia, and edema that stretches Glisson capsule. Elevated transaminase (ALT or AST)

16. CONT…. Thrombocytopenia (Platelets count of < 100,000/ μ L) Elevated serum creatinine ( Creatinine > 1.1 mg/ dL or 2x of baseline) Pulmonary edema (difficulty of breathing and/or rhales heard on lungs) Fetal growth restriction Oliguria (< 400 ml urine passed in 24 hours

17. Cont… Atypical pre- eclampsia is any clinical presentation of pre eclampsia occurring before 20 weeks of gestation and/or after 48 hours post partum

18. Eclampsia Preeclampsia + convulsion R efers to the occurrence of a tonic- clonic seizure in a patient with preeclampsia in the absence of other neurologic conditions that could account for the seizure. Seizures that cannot be attributed to other causes in woman with preeclampsia Seizures are generalized and may occur antepartum, intra partum and post partum

19. Risk factors for preeclampsia Null parity Preeclampsia in a previous pregnancy (8 fold) Age >40 years or Multiple pregnancy Molar pregnancy Family history of pre eclampsia Pre existing vascular disease Chronic hypertension chronic renal disease DM High body mass index (Obesity) Black race Low socio economic status

20. Etiopathogenesis The mechanisms by which pregnancy incites or aggravates hypertension remain unsolved . HDPs are more likely to develop in women with the following characteristics: Exposure to chorionic villi for the first time Exposure to a super abundance of chorionic villi, as with twins or hydatidiform mole Preexisting conditions associated with endothelial cell activation or inflammation (diabetes or renal or CV disease) Are genetically predisposed to hypertension developing during pregnancy.

21. Etiology Of suggested mechanisms to explain the cause of preeclampsia, primary ones include: Abnormal trophoblastic invasion of Uterine vessels Immunological intolerance between maternal and feto -placental tissues Maternal maladaptation to cardiovascular or inflammatory changes of normal pregnancy Genetic factors including inherited predisposing genes and epigenetic influences

22. Management: The basic management objectives for any pregnancy complicated by preeclampsia are: Prevent convulsion Termination of pregnancy with the least possible trauma to mother and fetus Birth of an infant who subsequently thrives Complete restoration of health to the mother. Termination of pregnancy is the only cure for preeclampsia.

23. Management of Mild pre eclampsia Management depends on GA (before & after 37weeks) Gestational age <37weeks Monitor BP, U/A, BPP, CBC, fetal condition twice weekly Counsel about the danger signals (symptoms and signs of severe pre- eclampsia ) Encourage the woman to eat a normal diet (salt restriction should be discouraged) Orient on fetal movement counting (kick chart) daily No medications (do not give anticonvulsants, anti hypertensives , sedatives)

24. Management of Mild pre eclampsia … If follow-up as an outpatient is not possible, admit the woman to the hospital and: Monitor blood pressure (twice daily), and urine output & weight (daily) Auscultation of FHB & kick chart daily Do not give medications Urine protein, fetal condition twice weekly . Do not give diuretics (diuretics are harmful & only indicated for use in pre- eclampsia with pulmonary edema or congestive heart failure )

25. Cont… If the woman's condition remains stable continue monitoring. If there are signs of growth restriction, consider early delivery. If not, continue hospitalization and terminate the pregnancy at 37 weeks.

26. Management of Mild pre eclampsia … Gestational age ≥37complete weeks Delivery is recommended. Plan delivery when the cervix is favorable (but before going post term, better not beyond 40wks) At term, women are induced if there are no contraindications to vaginal birth. If there are signs of fetal compromise, assess the cervix & expedite delivery. Administer anticonvulsant during labor

27. Management of Severe pre- eclampsia The steps of management include: General measures : Supporting the specific treatments Prevent convulsion - with magnesium sulfate or valium/diazepam Control hypertension Delivery as soon as possible

28. General Measures… Admit the patient urgently, preferably to the labor ward Manage in left lateral position Setup IV line & infuse maintenance fluids Monitor urine output and maintain urine output at >30 ml/hr. Maintain a strict fluid balance chart Prepare equipment for convulsion management at bed side (airway, suction equipment, mask & bag, oxygen) Never leave the patient alone- if convulsion occurs, aspiration may cause death

29. Cont… Monitor vital signs, FHB & reflexes hourly Auscultate the lung bases for fine crepitation. If they occur, withhold fluids &administer a diuretic (furosemide 40 mg IV stat) The immediate treatment should include managing symptoms: Anti emetic - for nausea & vomiting to minimize maternal discomfort Anti pain - for RUQ pain, headache etc

30. Anticonvulsant therapy (seizure prophylaxis) Give Magnesium sulfate In all severe pre- eclamptic mothers during admission & continued during period of evaluation & observation for 24 hours . Diazepam : may be used as alternative, if MgSO4 is not available

31. Control hypertension Administration of antihypertensives should be started if the systolic blood pressure is 160 mmHg or higher and/or the diastolic blood pressure is 110 mmHg or higher. Hydralazine or labetalol is the drug of choice for acute control. Note : The therapeutic goal is to keep the diastolic blood pressure <110 mmHg (between 90 and 100mmHg & prevent cerebral hemorrhage

32. Plan for Delivery Gestational age < 28 weeks : T ermination of pregnancy is recommended after thorough counseling. Expectant management is not recommended A dminister MgSo4 , antihypertensive Gestational age 28 to 34 weeks : E xpectant management is recommended Provided that uncontrolled maternal hypertension, maternal danger signs and fetal distress are absent

33. Cont… E xpectant management : Transfer to maternity ward Follow vital signs every 4 hours CBC every other day Liver enzymes and creatinine twice weekly 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

34. Cont… Indications for delivery are : Failure to control hypertension with two anti hypertensive 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) HELLP Syndrome Eclampsia Pulmonary edema or left ventricular failure IUFD DIC Severe renal dysfunction

35. Expectant management… Give magnesium sulfate: stop MgSo4 after 24hours if: If the clinical picture is not worsening, premonitory signs of eclampsia are absent Signs of severe pre- eclampsia are not persistent Terminate pregnancy at GA of 34wks or fetal & maternal status deteriorates

36. Cont… GA of 34 to 36wks+6days Termination of pregnancy is recommended But can be expectant if uncontrolled maternal hypertension, worsening maternal status and fetal distress are absent and can be closely monitored At term after 37 weeks: F or women with pre- eclampsia at term (>/=37 weeks), regardless of severity features, giving birth is recommended If vaginal birth is not anticipated within 24hours C/S is recommended

37. Cont… MODE OF DELIVERY Depends on gestational age, fetal condition, presentation, cervical condition & maternal condition. Indication for Cesarean Section Unfavorable cervix (firm, thick, closed) esp. in seriously ill patients Poor progress of labor If patient has not entered active labor within 8 hours of induction of labor Evidence of fetal distress or other obstetric indications

38. Cont… Intra Partum Management Absolute bed rest in LLP is essential Antihypertensive drugs should be given as necessary to regulate diastolic blood pressure between 90 &110mm Hg Careful monitoring of FHB, maternal conditions & progress of labor Pain management as required

39. Cont… Postpartum Management Watch closely for at least 2hrs after delivery for complications such as shock, PPH & eclampsia Anticonvulsive therapy should be maintained for 24hrs 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, RFT Postnatal follow-up of these cases is very important for the treatment of hypertension & possible complications such as DIC, acute renal failure and pulmonary edema.

40. Eclampsia Seizures that cannot be attributed to other causes in a woman with preeclampsia. The following are often seen during an eclamptic convulsion: Rolling and bulging eyes Twitching of face and hand muscles Clenching of the fists and teeth Violent contractions of the muscles Foaming at the mouth Noisy breathing Women may lose consciousness after convulsions.

41. Management Treatment of eclampsia consists of: General measures Control of convulsions-to stop ongoing convulsion & prevent subsequent convulsion Blood pressure control Fluid balance Delivery & intrapartum /postpartum care

42. Cont… If the seizure is witnessed : Shout for help- mobilize personnel Airway : Turn woman onto her side to prevent aspiration. Ensure her airway is open Breathing : If the woman is not breathing, A ssist ventilation using Ambubag and mask. Supplemental O2 via a face mask (6L/min ) Circulation : If pulse is absent, begin cardiac massage . Protect from injury but do not restrain Do not put anything in her mouth. Do not leave her alone.

43. Cont… Secure IV line and infuse IV fluids (N/S) Management of severe hypertension, if present Prevention of recurrent seizures if eclampsia is diagnosed →MgSo4 Catheterize the bladder to monitor urine output Never leave the woman alone!! Evaluation for prompt delivery. Delivery must occur within 12 hours of onset of convulsions in eclampsia .

44. If the cause of convulsions has not been determined, manage as eclampsia and continue to investigate other causes. DDx : C erebral malaria Meningitis Hypoglycemia previous seizure disorder head injury or intracranial space occupying lesions have to be ruled out

45. Cont… Atypical eclampsia : is eclampsia occurring before 20 weeks of gestation and/or after 48hours post partum, but less than four weeks postpartum.

46. Managements … Seizure prophylaxis In all pre- eclamptics during labor & continued for 24 hrs after delivery. In all severe pre- eclampsia during admission & continued during period of evaluation & observation. Magnesium sulfate is the drug of choice for preventing & treating convulsions in severe pre- eclampsia & eclampsia . Diazepam can be used if Mgso4 is not available Has greater risk of neonatal respiratory depression

47. Management… NB : It is difficult to predic t who will develop seizure. It is not directly related to degree of hypertension or level of proteinuria (BP is not a reliable predictor of the risk of seizures, some may seize with blood pressure of 140/90). A small proportion of women with eclampsia may have normal blood pressure.

48. Anti- Convulsant Therapy Administer anticonvulsant drugs to prevent repeated attacks Should be initiated during labor & continued for 24 hrs after delivery and in all severe preeclamptics during admission & continued during period of evaluation & observation. Generally MgSo4 is indicated in case of: Severe pre eclampsia Pre eclampsia intra partum and post partum (regardless of severity) Eclampsia

49. Magnesium sulfate schedules for SPE&E Loading dose 4 gm MgSo4 as 20% solution IV over 5min (mix 8ml of 50% MgSo4 + 12ml of N/S) Follow promptly with 10 gm of 50% MgSo4 solution, 5 gm (10ml) in each buttock as deep IM injection with 1mL of 2% lignocaine in the same syringe or 2ml of 1% lidocaine . Tell the women feeling of warmth will be felt when given MgSo4 If convulsions recur after 15 minutes, give 2 gm magnesium sulfate (20% solution) IV over 5 minute

50. MgSo4 Protocol… Maintenance dose or continuation: 5gm MgSo4 (50% solution) + 1mL lignocaine 2% IM every 4hours into alternate buttocks. Continue treatment with MgSo4 for 24 hours after delivery or the last convulsion, whichever occurs last.

51. Mgso4 Toxicity Monitoring Before repeat administration, ensure that: Respiratory rate is at least 12 per minute (monitor every 1 hourly) Patellar reflexes are present (monitor every 1 hourly) Urinary output is at least 30 ml per hour or at least 100 ml over 4 hours Withhold or delay drug if: Respiratory rate falls below 12 per minute. Patellar reflexes/DTR are absent or depressed discontinue & closely monitor the patient Urinary output falls below 30mL per hour over preceding 4 hours.

52. Mgso4 Toxicity Monitoring… Keep antidote ready : In case of respiratory arrest: Give calcium gluconate 1g (10mL of 10% solution) IV slowly until respiration begins to antagonize the effects of magnesium sulfate . Assist ventilation (bag and mask, anesthesia apparatus, intubation ) NB: MgSo4 can be restarted with half of the standard dose if respiratory rate returns to normal and if the urine out put is adequate with normal serum creatinine level.

53. Diazepam Loading dose Diazepam 10mg IV slowly over 2 minutes Maintenance dose Diazepam 40mg in 500 ml IV fluids (N/S or Ringer's lactate) no. of drops titrated over 6-8 hours to keep the woman sedated but arousable . Don’t give more than 100 mg in 24 hours Long-term continuous IV administration increases the risk of respiratory depression

54. Anti Hypertensive therapy Note : An important principle is to maintain blood pressures above the lower limits of normal . Hydralazine 5–10 mg IV (is a peripheral vasodilator, with an onset of action 10–20 minutes, and the dose can be repeated in 20minutes. Drug of choice for acute therapy (arteriolar dilator with rapid onset iv) If BP is not controlled after administering a total of 20mg another agent should be used Cautions -hypotension with fetal compromise (start with 5 mg iv test dose).

55. Cont…d Labetalol : 10mg by slow IV push If response is inadequate after 10min, give additional 20 mg IV Increase the dose to 40 mg and then 80 mg if satisfactory response is not obtained after 10 minutes of each dose The maximum total dose is 300 mg; then switch to oral treatment 2 00 mg every six to 12 hours (max of 1200mg per 24hrs )

56. Cont.… Labetalol o ral treatment : 200mg repeated after 1hour until the treatment goal is achieved Maximum dose is 1200 mg in 24 hours Note : Women with CHF, hypovolemic shock or predisposition to bronchospasm (asthma) should not receive labetalol.

57. Cont… Nifedipine : 5–10 mg orally/sublingually Is a calcium channel blocker that can be used as an alternative for acute therapy The dose can be repeated in 30 minutes, as needed. Then continue as 10-20 mg PO every 12hours (max 120mg per 24hrs) For maintenance therapy 10-20mg PO bid Note : There is concern regarding a possibility for an interaction with magnesium sulfate that can lead to hypotension.

58. Methyldopa Is the drug of choice for maintenance therapy Is a centrally acting α:-receptor agonist Methyldopa has a long history of safe use in pregnancy , well tolerated & has a minimal side effect There is some concern regarding ability to control blood pressure (additional drug may be needed) Administer 250 mg every six to eight hours The maximum dose is 3000 mg per 24 hours .

59. Complications of pre- eclampsia If untreated it is associated with high maternal and perinatal mortality and morbidity. Eclampsia Abruptio placenta Acute renal failure Hepatic failure and rupture of sub capsular hematoma DIC HELLP syndrome Cerebral hemorrhage Pulmonary edema and heart failure Intrauterine growth restriction prematurity and death and fetal complications.

60. Contents of PE&E emergency kit: MgSO4 50%—at least 16 g as supplied locally Lignocaine 2%—at least 1 ampule Sterile water or normal saline for dilution One tourniquet Three 20-mL syringes with IM needles Alcohol prep pads Gloves—at least 2 pairs IV needle and tubing 500 mL IV bag normal saline Calcium gluconate —at least 1 g

61. Gestational Hypertension BP > 140/90mmHg for the first time during pregnancy (≥20 weeks of gestation) No proteinuria BP returns to normal before 12weeks postpartum Final diagnosis is made only postpartum

62. Gestational Hypertension…. Gestational hypertension is a temporary diagnosis for hypertensive pregnant women who do not meet criteria for preeclampsia or chronic hypertension. The diagnosis is changed to: Preeclampsia , if proteinuria develops Chronic hypertension , if blood pressure elevation persists ≥12 weeks postpartum Transient hypertension of pregnancy , if blood pressure returns to normal by 12 weeks postpartum Thus , reassessment up to 12 weeks postpartum is necessary to establish a final definitive diagnosis.

63. Gestational Hypertension…. Manage on an outpatient basis: Monitor blood pressure, urine (for proteinuria) and fetal condition weekly . Counsel the woman and her family about danger signals indicating pre- eclampsia or eclampsia . Severe gestational hypertension: BP ≥160/110 mmHg is treated with antihypertensive agents to reduce the risk of a maternal cerebrovascular event .

64. Gestational Hypertension…. Give women with severe gestational hypertension peripartum magnesium sulfate for seizure prophylaxis. If blood pressure worsens, manage as mild pre- eclampsia . I f spontaneous labor has not occurred before term, induce labor at term (around 40wks of GA).

65. Preeclampsia Superimposed on Chronic Hypertension Preeclampsia that occurs in a woman with a pre-existing chronic hypertension. New-onset of proteinuria > 300 mg/24 hours in hypertensive women but no proteinuria before 20 weeks’ gestation. A sudden increase in proteinuria or blood pressure or platelet count < 100,000/L in women with hypertension and proteinuria before 20 weeks’ gestation. Tend to be more severe & more often accompanied by FGR

66. Chronic Hypertension BP > 140/90 mmHg before pregnancy or diagnosed before 20 weeks’ gestation not attributable to gestational trophoblastic disease or Hypertension first diagnosed after 20 weeks’ gestation and persistent after 12 weeks postpartum . The goal of treatment of hypertension is to minimize the risk of maternal cardiovascular or cerebrovascular events. Untreated mild hypertension over the course of a pregnancy is unlikely to affect this risk, but untreated severe hypertension could result in a stroke.

67. Cont…d Blood pressure should not be lowered below its pre-pregnancy level. If on antihypertensive medication before pregnancy and her BP is well-controlled, continue the same medication if acceptable in pregnancy or change to the one safely used in pregnancy. Monitor fetal growth and condition If no complications, induce labor at term (>37wks).

68. Preventions of Preeclampsia There are no reliable clinical and biochemical tests for the prediction of preeclampsia But WHO, 2016 suggested that: In areas where dietary calcium intake is low, calcium supplementation during pregnancy (at doses of 1.5–2.0 g elemental calcium/day) is recommended for the prevention of preeclampsia for all women, but particularly those at high risk of preeclampsia.

69. WHO, 2016 …… Low-dose acetylsalicylic acid (aspirin, 75 mg) should be initiated before 20wks (if possible, as early as at 12) weeks of gestation for women at high risk of developing pre- eclampsia . Women at high risk if they have one or more of the following risk factors: previous severe pre- eclampsia diabetes , chronic hypertension, renal disease Obesity autoimmune disease and multiple pregnancies. Eclampsia can be prevented by early detection, effective treatment of preeclampsia and timely delivery.

70. Thank you!