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PIH

PIH. 高雄榮總婦產部 李如悅. Preview. Obstetrics deadly triad: hemorrhage, infection, preeclampsia Incidence: 3.7-5% 16% of 3201 pregnancy-related deaths in the United States from 1991-1997. TABLE 34-1 Diagnosis of Hypertensive Disorders Complicating Pregnancy. Gestational hypertension

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PIH

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  1. PIH 高雄榮總婦產部 李如悅

  2. Preview • Obstetrics deadly triad: hemorrhage, infection, preeclampsia • Incidence: 3.7-5% • 16% of 3201 pregnancy-related deaths in the United States from 1991-1997

  3. TABLE 34-1 Diagnosis of Hypertensive Disorders Complicating Pregnancy • Gestational hypertension BP≧ 140/90mm Hg for first time during pregnancy No proteinuria BP returns to normal < 12 weeks’ postpartum Final diagnosis made only postpartum May have other signs or symptoms of preeclampsia, for example, epigastric discomfort or thrombocytopenia

  4. Preeclampsia Minimum criteria • BP ≧ 140/90mm Hg after 20 weeks’ gestation, 2 measurements a minimum of 6 hours apart • Proteinuria ≧ 300 mg/24 hours or ≧ 1+ dipstick of two urine specimens collected at least 4 hours apart

  5. Increased certainty of preeclampsia • BP ≧ 160/110 mg Hg • Proteinuria 2.0 g/24 hours or ≧ 2+ dipstick • Serum creatinine > 1.2 mg/dL unless known to be previously elevated • Platelets < 100,000/mm3 • Microangiopathic hemolysis (increased LDH or schistocytes or helmet cells on peripheral blood smear) • Elevated ALT or AST • Persistent headache or other cerebral or visual disturbance • Persistent epigastric pain

  6. Eclampsia Seizures that cannot be attributed to other causes in a woman with preeclampsia • Superimposed Preeclampsia (on chronic hypertension) New-onset proteinuria ≧ 300mg/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/mm3 in women with hypertension and proteinuria before 20 weeks’ gestation

  7. Chronic Hypertension • BP ≧ 140/90 mm Hg 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

  8. Etioloty

  9. Abnormal trophoblastic invasion • In normal implantation • uterine spiral arteries undergo extensive remodeling as they are invaded by endovascular trophoblasts

  10. In preeclampsia • Incomplete trophoblastic invasion • Decidual vessels, not myometrial vessels, become lined with endovascular trophoblasts

  11. Immunological factors • Preeclampsia is immune mediated. • The microscopic changes at the maternal-placental interface are suggestive of acute graft rejection • Atherosis is demonstrated in blood vessels.

  12. The vasculopathy and the inflammatory changes • Inflammatory changes are a continuation of the placental causes. • These then serve as mediators to provoke endothelial cell injury. • To cause a series of oxidative stress, TNF-α, interlukins, endothelins • PGI2 ↓; TXA2 ↑

  13. Pathogenesis • Vasospasm • Endothelial cell activation • Increased pressor responses X: gestational age Y: the dosage of angiotensin II for inducing hypertension Blue line: preeclampsia group Black line: normal pregnancy women

  14. Prediction and prevention

  15. Roll-Over test (hypertensive reponse after laterally recumbent to supine position) • Uric acid • Fibronectin • Coagulation activation • Positive predictive value<40% • Routine prenatal examination

  16. Prevention • Dietary manipulation salt restriction, Calcium supplementation, fish oil capsules (of no use) • Antioxidants: vit C or E, significant reduction of preeclampsia (17% vs 11%) • Low-dose aspirin: ineffective

  17. Management

  18. 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

  19. The most important information that the obstetrician has for successful management is precise knowledge of the age of the fetus

  20. 在每一次產前檢查都會測量血壓以及檢查尿蛋白，以期早期發現 PIH or preeclampsia • 對於輕微的 PIH 病人可以在家中臥床休息，以降血壓藥物控制血壓，並於門診追縱治療即可。一旦血壓持續上升或有 severe preeclampsia 的症狀出現時，則需要住院觀察及治療

  21. 對於 preeclampsia 的病人需要安排下列的檢查，以評估病人目前的狀況： • (1) CBC＋platelet • (2) Blood chemistry screening • (3) Urine analysis • (4) 24 小時 urine protein • (5) 眼底檢查

  22. (6) Coagulation profile (PT，PTT，FDP，Fibrinogen，Bleeding time) • (7) 每星期 1-2 次 NST • (8) 每星期至少一次 sonographic screening 以了解胎兒生長情況 • (9) Blood flow study (Waveform study)

  23. (10) Severe preeclampsia 病人需要記錄 intake 及 output • (11) 使用 MgSO4 的病人要記錄尿量、注意呼吸速率、以及肌腱反射, serum Mg2+ level (4-7mEq/dL; 4.8-8.4mg/dL) • (12) 有肺水腫或需要補充體液時，最好能有 central line 或 Swan-Ganz cather以監測 CVP 或 PCWP

  24. 在治療方面首先要控制血壓及 Vital sign。如果血壓很高，超過 160/100 mmHg 以上時，可以給 Apresoline 5-10mg IV push，15-20-minute interval, 20 分鐘後再 recheck 血壓; 如果需要，可以再給一個dose。

  25. 在口服降血壓藥方面，目前認為 Apresoline (Hydralazine) 以及 Aldomet (Methyldopa) 可以安全地用在孕婦，有效地降低血壓。一般使用的劑量為Apresoline 10mg tid，最高劑量為 300 mg/day; Aldomet 250 mg bid - tid，最高劑量可以用到 2000mg/day。

  26. 其它的降血壓藥，如 Adalat (Ca blocker)、Tenormin (β-blocker)等，有人主張仍可用孕婦，但也有人認為對胎兒會有不良影響，仍未有定論，但ACE inhibitor 如 Capoten，Renitec 絕不可使用 (renal toxicity)

  27. 原則上，血壓控制的目標在140/90mmHg，但是血壓的下降不可太快，最好是 step by step，否則降低子宮的血流，反而影響胎盤的 perfusion 造成胎兒窘迫的現象。

  28. 在 severe preeclampsia 和 eclampsia 的病人可以使用 MgSO4 IV infusion來預防或控制 convulsion。 • 要特別強調的是 MgSO4 的作用在於anticonvulsion而非降低血壓。

  29. 一般會先給 4gm (2 Amp) 作為 loading dose，再以 1-2gm/hr的速率 IV infusion 作為 maintenance dose (可用 5 Amp 加 在400cc 5% G/W keep 50-100cc/hr ，或 10 Amp 加在 300cc 5% G/W keep 25-50cc/hr)。 • 生產後， MgSO4 仍要繼續使用 24 小時，以防止產褥期的 eclampsia 發生。鎂離子的 safty range 很窄，theraputic level 大約在 4-7mEq/l(4.8-8.4mg/dL)

  30. Clinical presentation of MgSO4 overdose • 9.6-12mg/dL: loss of deep tendon reflexes • 12-18mg/dL respiratory paralysis • 24-30mg/dL cardiac arrest

  31. Calcium gluconate 1gm IV 5-10 mins for life-threatening symptoms of magnesium toxicity

  32. Eclampsia • Preeclampsia complicated by generalized tonic-clonic convulsions • Fatal coma without convulsions • Major complication placenta abruption:10%, neurological deficits:7%, aspiration pneumonia:7%, pulmonary edema:5%, cardiopulmonary arrest4%, acute renal failure:4%, maternal death 1%

  33. Treatment the same as severe preeclampsia

  34. 何時要中止懷孕﹖

  35. 這是一個需要多方考慮的問題。如果病人只是血壓稍高，或是可以用降血壓藥物控制在正常範圍，而且胎盤功能正常、胎兒生長情況良好，可以等到足月再生產這是一個需要多方考慮的問題。如果病人只是血壓稍高，或是可以用降血壓藥物控制在正常範圍，而且胎盤功能正常、胎兒生長情況良好，可以等到足月再生產 • 門診追蹤

  36. 如果胎盤功能降低、血流阻力明顯升高(UA S/D ratio>3)，或胎兒生長停滯(IUGR)，對於 severe preeclampsia 的病人首先要降低血壓、控制 vital sign，等情況穩定後儘快生產; 如果發生 eclampsia，在 convulsion 控制下來以後就應該立刻中止懷孕

  37. The way of delivery • The decision to expedite delivery does not mandate immediate cesarean birth • A prolonged induction is best avoided • Scheduled C/S for women with severe preeclampsia when GA<30 wks and low Bishop score

  38. Long-term consequences

  39. Women who have had preeclampsia are more prone to hypertensive complications in future pregnancies. • Multiparous women with eclampsia tend to have higher risk in cardiovascular diseases than nullipara

  40. Recurrent pregnancy hypertension were at increased risk for chronic hypertension  Women experiencing normotensive births in subsquent pregnancy have a reduced risk for remote HTN

  41. Repeated pregnancy serves as a screening test for future HTN • Preeclampsia does not cause chronic hypertension

  42. The End Thanks for your attention!

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