PREGNANCY INDUCED HYPERTENSION BY ABIE ASCHALE DEMISSIE.pptx

THIS IS PROPERTY OF ABIE

1. Pregnancy induced hypertension Prepaired by: ABIE ASCHALE (BSC, ECCN) BY ABIE ASCHALE 1 7/5/2024 Department of emergency and critical care nursing

2. Content Introduction Risk factors Pathophysiology Classification Diagnosis Management Complications ICU admission criteria and management BY ABIE ASCHALE 2 7/5/2024

3. Objectives Define hypertension and PIH state Risk factors for PIH Diagnosis of PIH Classification Discuss Diagnosis Discuss Management option for PIH List the Complications of PIH Identify ICU admission criteria and management for PIH BY ABIE ASCHALE 3 7/5/2024 At the end of this session students are expected to:

4. INTRODUCTION What is hypertension ? Stages of hypertension ? Types of hypertension? 7/5/2024 BY ABIE ASCHALE 4

5. INTRODUCTION conti ……… ( ACC/ AHA) ; 2017 Normal blood pressure Systolic <120 mmHg and diastolic <80 mmHg Elevated blood pressure – Systolic 120 to 129 mmHg and diastolic <80 mmHg Hypertension: •Stage 1 – Systolic 130 to 139 mmHg or diastolic 80 to 89 mmHg •Stage 2 – Systolic at least 140 mmHg or diastolic at least 90 mmHg If there is a disparity in category between the systolic and diastolic pressures, the  higher value   determines the stage. 7/5/2024 BY ABIE ASCHALE 5

6. Isolated systolic hypertension vs I solated diastolic hypertension 7/5/2024 BY ABIE ASCHALE 6 White-coat hypertension - office/clinic BP (≥140/90 mmHg), but normal at home or work. Masked hypertension - BP is normal at a clinic or office visit but elevated at other times, more difficult to diagnose- WHY most typically diagnosed by 24-hour ABPM or automated home BP monitoring INTRODUCTION conti ………

7. PIH Pregnancy induced hypertension is defined as a rise in BP> 140/90 mmHg after the 20th week of gestation measured twice at least six hours apart or a single measurement of diastolic BP>110mmHg. Exce ption Gestational Trophoblastic diseases (GTD) and multiple pregnancy. Why ? 7/5/2024 BY ABIE ASCHALE 7

8. unique to human pregnancy(PE) Complicates 7-10% of pregnancies 70% Preeclampsia-eclampsia 30% Chronic hypertension Eclampsia 0.05% incidence 20% of Maternal Deaths Cause of 10% of Preterm birth Etiology unknown 7/5/2024 BY ABIE ASCHALE 8 INTRODUCTION conti ………

9. Risk factors A past history of preeclampsia Multifetal pregnancy - 20 percent Nulliparity – family history  Advanced maternal age < 18 or < 35 yrs. 7/5/2024 BY ABIE ASCHALE 9 Pre- existing medical conditions: Pregestational diabetes underlying kidney or vascular disease Obesity abnormal lipid metabolism Chronic hypertension

10. 7/5/2024 BY ABIE ASCHALE 10 pathophysiology The pathophysiology of preeclampsia likely involves both maternal and fetal/placental factors Abnormal development of the placenta Immunologic factors Genetic factors Environmental and maternal susceptibility factors Preexisting maternal vascular/metabolic/kidney/autoimmune disease

11. 11 A normal invasion of the spiral arterioles by the cytotrophoblast cells  reduced uteroplacental perfusion      placental ischemia (lack of oxygen and nutrients)  release of placental factors   endothelial dysfunction in the maternal circulation Endothelial dysfunction  inner lining of the blood vessels becomes impaired and unable to produce enough  vasodilators  (substances that relax the blood vessels) such as  nitric oxide and prostacyclin.   This results in  increased vascular resistance and hypertension Endothelial dysfunction  to increased production of   vasoconstrictors  (substances that narrow the blood vessels) such as  endothelin  and  thromboxane  increase the  sensitivity of the blood vessels to angiotensin II, a hormone that regulates blood pressure and fluid balance

12. 7/5/2024 BY ABIE ASCHALE 12

13. The increased vascular resistance and hypertension affect the  renal function  and cause  proteinuria  (protein in the urine),  edema  (swelling), and  reduced glomerular filtration rate  (GFR).  The increased blood pressure and endothelial dysfunction also affect the  brain , the  liver , and the  coagulation system . The placental ischemia and the maternal hypertension also affect the  fetal growth and development .  The reduced blood flow and oxygen delivery to the placenta can cause  intrauterine growth restriction  (IUGR),  fetal distress , and  premature birth image 7/5/2024 BY ABIE ASCHALE 13

14. 7/5/2024 BY ABIE ASCHALE 14 PRE ECLAPSIA GESTATION AL HTN MILD Pre existing HTN ECLAPSIA SEVER

15. Classification 7/5/2024 BY ABIE ASCHALE 15

16. 1. Gestational hypertension BP > 140/90 or more after the 20th week of gestation without significant proteinuria. Gestational hypertension may represent pre-eclampsia prior to proteinuria or chronic hypertension previously unrecognized 7/5/2024 BY ABIE ASCHALE 16

17. 2. Pre-eclampsia Pre-eclampsia BP > 140/90mmHg Presence of significant proteinuria of > 300 mg/24 hours urine specimen OR > 1+ protein (equivalent to approximately 100mg/dl) on dipstick in at least two randomly collected urine specimen at least 6 hours apart Based on degree of hypertension or proteinuria and involvement of other organ systems 7/5/2024 BY ABIE ASCHALE 17

18. 7/5/2024 BY ABIE ASCHALE 18 1. Mild pre-eclampsia The mild form of pre-eclampsia is diagnosed when the Systolic and diastolic blood pressure is between 140-160 and 90-110mmHg respectively without signs of severity.

19. 2. Severe pre-eclampsia Severe blood pressure elevation: BP > 110 ∕160mmHg measured twice at least six hours apart OR A single measurement of diastolic BP >120mmHg Proteinuria > 5gm/24 hours or >3+ in randomly collected urine Pulmonary edema Kidney function impairment- Serum creatinine >1.1 mg/Dl HELLP syndrome 7/5/2024 BY ABIE ASCHALE 19

20. 7/5/2024 BY ABIE ASCHALE 20

21. Elevated Liver Enzymes (HELLP syndrome) - Disseminated intravascular coagulation (DIC) - Headache, visual disturbance and right upper abdominal pain - Oliguria (<400ml in 24hours or 30ml/hour) - Intrauterine growth restriction (IUGR) - Cardiac decompensation, Pulmonary edema, cyanosis 7/5/2024 BY ABIE ASCHALE 21

22. 3. Eclampsia Eclampsia is the development of new-onset seizures (generalized tonic clonic type), superimposed upon Preeclampsia, in a woman between 20 weeks of gestation and 4 weeks postpartum. Eclampsia is the convulsive manifestation of preeclampsia absence of other causative conditions ( eg , epilepsy, cerebral arterial ischemia and infarction, intracranial hemorrhage, drug use Any convulsion occurring during pregnancy is eclampsia unless proven otherwise . 7/5/2024 BY ABIE ASCHALE 22

23. diagnosis History Physical examination laboratory 7/5/2024 BY ABIE ASCHALE 23

24. management 7/5/2024 BY ABIE ASCHALE 24 objectives Control hypertension Prevent convulsion Prevent complication Deliver viable fetus

25. GENERAL PRENCIPLES Stabilization of air way, breathing and circulation is the initial step. Always anticipate difficult airway in pregnant patients. Two large-bore intravenous cannula (14G or 16G) should be placed to administer fluids. The Foley catheter should be placed to monitor urine output. Nurse in the left lateral position (30° wedge to the right hip) to prevent supine hypotension syndrome 7/5/2024 BY ABIE ASCHALE 25

26. 7/5/2024 BY ABIE ASCHALE 26 Non pharmacologic - Bed rest at home in the lateral decubitus position. - Frequent evaluation of fetal well being - Maternal well being i.e. BP , laboratory - Advise patient to immediately report whenever they develop symptoms of severity such as headache, epigastric pain, blurring of vision etc - Plan termination of pregnancy at term. - If the disease progresses to severe range, manage as severe case. Management of mild pre-eclampsia Most patients are asymptomatic and can be managed conservatively. Such patients are not candidates for urgent delivery.

27. Pharmacologic 7/5/2024 BY ABIE ASCHALE 27 BP control Arterial pressure not greater than 160/110 mmHg in preeclampsia can increase the risk of complication, and it should be controlled. Goal of BP control is 15–25% reduction in the mean arterial pressure, and Reduction of pressure to normal levels (<140/90 mmHg) should be avoided as it may compromise placental perfusion. Methyldopa , 250-500mg P.O., 8 to 12 hourly Nifedipine , 10-40mg P.O., BID OR slow release 30-60mg daily N.B. Advise patient

28. 7/5/2024 BY ABIE ASCHALE 28 Preeclampsia and Eclampsia B. BP CONTROL

29. 1. Labetalol Dosage 20 mg IV gradually over 2 minutes. If BP remains above target level at 10 minutes, give 40 mg IV over 2 minutes. If BP remains above target level at 20 minutes, give 80 mg IV over 2 minutes. Cumulative maximum dose is 300 mg. If target BP is not achieved, switch to another class of agent. Hold dose if heart rate <60 beats per minute. A continuous IV infusion of 1 to 2 mg/minute can be used instead of intermittent therapy or started after 20 mg IV dose. 7/5/2024 BY ABIE ASCHALE 29

30. 2 . Hydralazine 7/5/2024 BY ABIE ASCHALE 30 Repeat BP measurement at 20-minute intervals: If BP remains above target level at 20 minutes, give 5 or 10 mg IV over 2 minutes, depending on the initial response. Cumulative maximum dose is 20 to 30 mg per treatment event. Initial dose - 5 mg IV gradually over 1 to 2 minutes.* Less predictable than with IV labetalol.

31. 3. Nifedipine * I mmediate release- 10 mg orally. Repeat BP measurement at 20-minute intervals: If BP remains above target at 20 minutes, give 10 or 20 mg orally, depending on the initial response. If BP remains above target at 40 minutes, give 10 or 20 mg orally, depending on the previous response. 7/5/2024 BY ABIE ASCHALE 31

32. C. Control Seizure 7/5/2024 BY ABIE ASCHALE 32

33. FIRST LINE - Magnesium sulphate A loading dose 4gm as 20% solution IV over 10-15 minutes followed by 10gm as 50% IM injection divided on two sides of the buttock, Maintenance dose 5gm every 4 hours as 50% concentration over 2minutes, 2gm IV as 50% solution over 2minutes if convulsion recurs. Reduce the maintenance dose by half if there are signs of renal derangement during labor and for the first 24 hours postpartum 33

34. Monitor toxicity Loss of deep tendon reflexes Respiratory depression Loss of patellar reflex If seizures recur while the patient is receiving magnesium, a repeat (2g) bolus of magnesium may be given. Infusion dose should be reduced in case of renal dysfunction. Serum magnesium level should be monitored Discontinue magnesium sulfate 24 h after delivery or after last seizer 7/5/2024 BY ABIE ASCHALE 34

35. d. Delivery  The definitive treatment for eclampsia is prompt delivery;  7/5/2024 BY ABIE ASCHALE 35

36. 7/5/2024 BY ABIE ASCHALE 36

37. 7/5/2024 BY ABIE ASCHALE 37 Maternal Complications DIC(3%), Renal failure  (4%) Adult respiratory distress syndrome (3%). HELLP syndrome  3%, severe PE  4-12% with Uncontrolled Hypertension Risk of Cerebro -vascular Accident Liver failure (Liver rupture)

38. 7/5/2024 BY ABIE ASCHALE 38 Pulmonary oedema 2%(adult RDS) Pulmonary hemorrhage Placental abruption Eclampsia (risk of aspiration pneumonia)

39. Prematurity IUGR Utero-placental insufficiency Oligohydramnios Respiratory distress syndrome Placental abruption 7/5/2024 BY ABIE ASCHALE 39 Acute fetal distress IUFD Caesarean section, Admission to SCUBU/NICU Fetal complications

40. ICU admission criteria for sever conditions The criteria for ICU admission for preeclampsia and depending on the severity of the condition, the availability of resources, and the clinical judgment of the obstetrician and the intensivist. 7/5/2024 BY ABIE ASCHALE 40

41. some common indicators may warrant ICU admission are BP > 160/110 mmHg or higher, despite adequate antihypertensive therapy. Severe proteinuria (> 4+ on dipstick or 5 g in 24 hours). Oliguria (UO < 20-30 ml/ hr ) or AKI (cr. >1.3 mg/dl). S igns of HELLP syndrome Epigastric pain, headache, visual disturbances, or altered mental status (signs of cerebral edema or ischemia). Seizures or coma (eclampsia). Pulmonary edema, signs of fluid overload or cardiopulmonary dysfunction. Fetal distress or IUGR (signs of placental insufficiency or abruption). 7/5/2024 BY ABIE ASCHALE 41

42. Goal of ICU care AND role of nurse Blood pressure control with intravenous antihypertensive a Magnesium sulfate infusion for seizure prophylaxis and treatment Fluid management with careful assessment of the fluid balance, urine output, and hemodynamics. Fetal monitoring with continuous cardiotocography, ultrasound, and biophysical profile Steroid administration for fetal lung maturation if the gestational age is less than 34 weeks and delivery is anticipated within 7 days.  7/5/2024 BY ABIE ASCHALE 42

43. summery PIH) a condition where a pregnant woman develops high blood pressure after 20 weeks of pregnancy. It can affect the mother’s organs and the baby’s growth and development. PIH can also lead to serious complications such as pre-eclampsia, eclampsia, and HELLP syndrome. PIH is diagnosed by measuring blood pressure and checking for protein in the urine. Treatment options depend on the severity of the condition and the stage of pregnancy. Some common treatments include bed rest, medication, and early delivery.  PIH usually goes away after childbirth 7/5/2024 43

44. References Overview of pregnancy induced hypertension– UpToDate ,2024 Protocol R. 3 : Classification of hypertension in pregnancy. 2012; Melkie DA, Internist, Teferra DE, Pediatrician, Assefa DM, Oncologist, et al. Food , Medicine and Healthcare Administration and Control Authority of Ethiopia Standard Treatment Guidelines For General Hospital Diseases Investigations Good Prescribing & Dispensing Practices for Better Health Outcomes. Fmhaca Addis Ababa. 2014;(3):360. Brown MA, Magee LA, Kenny LC, Karumanchi SA, McCarthy FP, Saito S, et al. Hypertensive disorders of pregnancy: ISSHP classification, diagnosis, and management recommendations for international practice. Hypertension. 2018;72(1):24–43. Braunthal S, Brateanu A. Hypertension in pregnancy: Pathophysiology and treatment. SAGE Open Med. 2019;7. Gouveia, I., Costa, C., Cunha, P.  et al.  Pre-eclampsia in the intensive care unit: indicators of severity and hospital outcome.  Crit Care   9  (Suppl 1), P216 (2005). https://doi.org/10.1186/cc3279 7/5/2024 BY ABIE ASCHALE 44

45. 7/5/2024 BY ABIE ASCHALE 45

46. 7/5/2024 BY ABIE ASCHALE 46

47. አመሰግናለሁ 7/5/2024 BY ABIE ASCHALE 47