Presentation1 preeclampsia.pptx and Hypertension in pre

Hypertension in pregnancy
Preclampsia with or without features
Eclampsia

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2. OUTLINE I ntroduction E pidemiology D efinition C lassification M anagement P ost partum and post natal care

3. INTRODUCTION Hypertension is a sign of underlying pathology, which may be pre-existing or appears for the first time during pregnancy. Identification of this clinical entity and effective management play a significant role in the outcome of pregnancy. HDP are a common cause of maternal and perinatal morbidity and mortality. HDP range from isolated hypertension in a previously normotensive woman to severe hypertension with abnormal laboratory values or symptoms indicative of multiorgan dysfunction.

4. EPIDEMIOLOGY The incidence of hypertensive disorders of pregnancy increased from 16.30 million to 18.08 million globally, with a total increase of 10.92 % from 1990 to 2019 Chronic hypertension occurs in up to 22% of women of child bearing age ,with the pevalence varying according to age ,race and BMI. In Ghana ,HDP has been noted as one of the leading causes of maternal deaths for well over a decade. An HDP prevalence of 21.4% has been reported with gestational hypertension and preeclampsia/eclampsia in the majority.

5. DEFINITION defined as systolic BP 140mmhg and /or diastolic bp 90mmhg on two different occasions 4-6 hours apart. O r a single systolic BP 160mmhg and /or a diastolic BP 110mmhg P roteinuria - 300mg per 24-hr urine collection or protein:creatinine ratio 0.3 or urine dipstick 1+  

6. CLASSIFICATION Chronic (pre existing ) hypertension G estational hypertension P reeclampsia without severe features P reeclampsia with severe features C hronic hypertension with superimposed preeclampsia E clampsia H ELLP syndome

7. C ase scenario 1

8. C hronic hypertension C hronic HTN-htn diagnosed or present before pregnancy or on at least 2 occasions before 20wks of gestation or if first diagnosed during pregnancy and persists for at least 12 weeks post partum.

9. C ase scenario 2

10. G estational hypertension G estational htn-new onset htn after 20 weeks of gestation in a previously normotensive individual.

11. Mgt of chronic and gestational. htn H istory P hysical exam I nvestigations treatment

12. cont C hronic htn with superimposed preeclampsia --any of these features in a patient with chronic htn A sudden increase in bp that was previously well controlled or an escalation of antihypertensive therapy to control BP N ew onset of proteinuria or a sudden increase in proteinuria in a patient with known proteinuria before or early in pregnancy S ignificant new end organ dysfunction consistent with preeclampsia after 20 weeks of gestation or postpartum

13. C ase scenario 3

14. preeclampsia P reeclampsia –new onset htn after 20 weeks of gestation in a previously normotensive individual with protenuria . P reeclampsia with severe features- ---systolic bp 160mmhg and /or dbp 110mmhg on 2 occasions at least 4 hrs apart Thrombocytopenia Impaired lft Severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by alternative diagnoses Persistent cerebral or visual disturbances Pulmonary edema Progressive renal insufficiency HELLP syndome – H emolysis, E levated L iver enzymes and L ow P latelets.  

15. P reeclampsia-Risk factors High Moderate Prior history of pre eclampsia Nulliparity Multiple gestation Obesity (BMI>30) Chronic hypertension Family history of pre eclampsia (mother or sister) Pregestational diabetes Age 35 or older Renal disease Autoimmune disease (SLE and APS) Primigravidae –teenagers Previous abruptio or unexplained intrauterine death

16. pathophysiology Placental implantation with abnormal trophoblastic invasion of uterine vessels Immunological maladaptative tolerance between maternal, placental and fetal tissues Maternal maladaptation to cardiovascular or inflammatory changes of normal pregnancy Genetic factors including inherited predisposing genes and epigenetic influences Circulating factors (angiogenic and anti-angiogenic factors)

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19. C linical features S ymptoms signs Asymptomatic elevated BP Severe headache oliguria Dizziness epigastric tenderness Blurred vision brisk reflexes Flashes of light ankle clonus Nausea and vomiting edema Palpitations decreased fundal height Epigastric pain

20. Complications of Preeclampsia Maternal Fetal Stroke or brain injury fetal growth restriction Eclampsia prematurity and its complications Amaurosis fugax fetal distress Retinal detachment stillbirth Pulmonary oedema Heart failure Renal failure (AKI) - Acute tubular necrosis Liver dysfunction/failure Subcapsular haematoma Preterm delivery Placental abruption HELLP syndrome

21. investigations Blood tests FBC - look at HB, Haematocrit and Platelets BUE/Cr - look at Creatinine Uric acid levels Liver enzymes – AST & ALT >twice the normal Clotting profile Urine Tests RE/CS - Protein: Creatinine ratio from spot test >30 significant 24 hr protein excretion >300 mg/day significant

22. I nvestigations cont. Imaging USG - fetal growth restriction , oligohydramnios, fetal hydrops (rare) Uterine and umbilical artery doppler- (Absent /reversed end diastolic flow)

23. M anagement Depends of on the following Severity of the condition: maternal and fetal condition Gestational age The definitive treatment is to deliver the placenta The timing of delivery is based on a careful balance of maternal and fetal risks

24. M anagement of preeclampsia without severe features Principles of Management If maternal/fetal condition is stable and the gestational age is less than 34 weeks, conservative management is indicated Conservative Management Control of hypertension Prevention of eclampsia: Monitoring of maternal condition Fetal surveillance Deliver when gestational age is at least 34 weeks or fetal and maternal condition deteriorates

25. Maternal Monitoring BP 4 hourly, Daily urine testing, LFTs and RFTs weekly MagSO4 may or may not be given to prevent fits

26. Management of fetal condition Dexamethasone to mature fetal lungs:12mg 12hourly 2doses Fetal kick count Ultrasound for fetal weight(?IUGR}, liquor volume 3weekly Weekly CTG tracing

27. I f GA >34weeks A dmit C ontrol the bp while running the investigations M onitor maternal and fetal well being P repare to deliver baby If there is no obstetric contraindication to vaginal delivery, induce labour Monitor labour with CTG or pinard stethoscoope ¼ to ½ hrly intervals C/S if fetal distress develops

28. M gt of preeclampsia with severe features A dmit C ontrol the bp while running the investigations M onitor maternal and fetal well being M gso4 protocol P repare to deliver baby If there is no obstetric contraindication to vaginal delivery, induce labour Monitor labour with CTG or pinard stethoscoope ¼ to ½ hrly intervals C/S if fetal distress develops D elivery should between 24hrs

29. M gso4 protocol (pritchard ) M gso4 protocol –pritchard Loading dose- 14g - Give 4g as 20mls of 20% iv over 5min - Then immediately followed by 10g as 20mls of 50% im,5g in each buttock - If convulsion persists within 30mins of administering mgso4 give im diazepam 10mg stat, after 30 mins give 2g as 10mls of 20% iv over 10min- if the woman is large give 4g

30. Maintainace dose - give 5g as 10mls of 50% im every 4hrs on alternate buttock till delivery or 24 hours after the last fit B efore maintenace dose id given check for signs of toxicity . tendon reflexes are present (knee jerk) 2. urine output is at least 100mls in the last 4hrs (25-30mls per hr ) oliguria <0.5ml/kg/hr <400mls in 24hrs 3. the respiratory rate is at least 16 cycles per min

31. P revention of preeclampsia H igh risk women P revious preeclampsia/eclampsia Boh related to hypertension ( iufd ) Aspirin and calcium Aspirin 150mg nocte between 12 and 16 weeks until 36weeks gestation A daily dose of 1.5g-2g(in 2 or 3 divided doses)

32. E clampsia- a generalised seizure in a patient that cannot be attributed to other cases

33. pathophysiology T heory of vasogenic edema L oss of cerebral autoregulation

34. C linical features Few warning signs may be present Imminent eclampsia – a significant portion of patients may report these before onset of seizures headache epigastric pain, liver rupture in some cases visual disturbances, blindness in severe cases hyper- reflexia clonus Eclampsia can occur antepartum, intrapartum or postpartum.

35. management Core Principles of Eclampsia Management Prevention of maternal injury during convulsion Life support after fits: airway, breathing, circulation (ABC) Control of seizures with magnesium sulphate ( MgSO ₄) Control of hypertension Delivery: CS or vaginal delivery: Once eclampsia has occurred CONSERVATIVE MANAGEMENT IS NOT INDICATED D elivery should be within 8 hours

36. C ont. scenarios Fits have stopped, patient is fully conscious and stable Fits have stopped but patient is drowsy, semiconscious or unconscious Patient still fitting

37. cont Emergency,call for help Venous access with large bore cannular 14 or 16 Control BP (hydralazine or nifedipine or labetolol ) Administer MgSo4 protocol to prevent recurrence of fits Assess patient and deliver

38. 2nd scenario. Fits have stopped but patient is drowsy, semiconscious or unconscious Emergency, call for help. ABC Ensure that the airways are patent and patient is breathing well Venous access 14-16 gauge cannular Auscultate the lungs Control BP Prevent recurrence of fits (MgSo4) Monitor urine output Monitor BP Do the test above Deliver as soon as patient is stabilized

39. 3rd scenario . Patient still fitting Emergency. Call for help Ensure that the patient does not injure her self Do not over restrain eg by tying Keep her on a mattress on the floor, or just on the floor clear of any objects that may cause injury Tilt the head laterally and if on the bare floor keep the head firm so that she does not hit the head several times on the hard floor Do not force anything into the mouth while she is fitting. This may cause injury, choking, or push the tongue back to cause airway obstruction

40. C ont. As soon as the fits cease, clear the airway, insert airway, get iv access Administer MgSo4 protocol Pass catheter to monitor urine output Control BP Deliver as soon as the patient is stabilized

41. S tatus eclampticus ICU management 0.5g of thiopentone sodium dissolved in 20ml of 5% dextrose, given very slowly IV ,under strict supervision of an intensivist/anesthesiologist I f it fails , intubation

42. P ostpartum and postnatal care Women who develop threatening signs or eclampsia after delivery need referral to tertiary center or facility with specialist care and ICU. After caesarean section – wound care, antibiotics, analgesia Patients with hypertension during pregnancy should stay in hospital after delivery until BPs are well controlled. Patients with chronic hypertension can be switched to the drugs they used before pregnancy Persistent hypertension – chronic hypertension – refer to hypertension clinic/physicians

43. conclusion Pre-eclampsia and eclampsia are among leading causes of maternal mortality and morbidity Pre-eclampsia is a multisystem usually progressive disorder They are also a major cause of adverse pregnancy outcome: Still Births, preterm delivery, abruptio placentae etc Vigilance during antenatal care will detect some cases of pre-eclampsia Vigilance during delivery and post-delivery is also important as most cases occur intrapartum and postpartum Adherence to principles of care leads to favourable outcomes

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