Hypertensive Disorders in Pregnancy

1. Hypertensive Disorders in Pregnancy Dr. SAJDA ALRUBAIE CONSULTANT OBSTETRICIAN & GYNECOLOGIST PROF. BASRAH MEDICAL COLLEGE

2. Hypertensive Disease Associated with Pregnancy • Chronic Hypertension • Gestational Hypertension • Preeclampsia • Eclampsia • HEELP Syndrome

3. Chronic Hypertension • Blood Pressure ≥ 140/90 before 20 weeks of gestation Or • Persistence of hypertension beyond 12 weeks after delivery.

4. Gestational Hypertension • Blood Pressure ≥ 140/90 on two or more occasions - in a previously normotensive patient - after 20 weeks gestation - without proteinuria - returning to normal 12 weeks after delivery • Almost half of these develop preeclampsia syndrome

5. Preeclampsia superimposed on Chronic Hypertension • New-onset 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 <100000 /cmm in women with hypertension and proteinuria before 20 weeks’ gestation • More adverse outcome than preeclampsia alone

6. Preeclampsia • New onset of hypertension & proteinuria in a previously normotensive woman • after 20 weeks of gestation • Returning to normal after 12 weeks of pregnancy. • Edema not a part of diagnosis now. Eclampsia : • New onset of seizures or unexplained coma during pregnancy or postpartum period in patients with pre-existing preeclampsia and without pre-existing neurological disorder.

7. Risk Factors of Preeclampsia • Preconception - Partner related • Nulliparity • limited exposure to paternal sperms -Non partner related • History of Preeclampsia in previous pregnancy • Advanced maternal age • Family history of Preeclampsia • History of placental abruptio, IUGR, fetal death • Non hispanic black race

8. Risk factors contd.. -Maternaldisease related • Obesity, BMI>35 doubles the risk • Hypertension • Diabetes • Thrombotic vascular diseases -Behaviour- • Smoking : - preventive -Pregnancy associated- • Multiple gestation • Molar pregnancy

9. PATHOGENESIS • Exact mechanism unknown, disease of theories. • ABNORMAL PLACENTATION 2. Inflammatory mediators ↓PGI2 ↑TXA2 Vasoconstriction Platelet aggregation ↑Vasopressor response ↑uterine activity

10. Abnormal trophoblastic invasion

11. 3. GENETIC - Family history of pre eclampsia: genetic origin Mutations in Complement Regulatory Protein gene - Genes assoc • Exposure to sperms of different partner • long term exposure to paternal antigen in sperms of same partner- protective • activated auto antibodies to angiotensin receptor-1 AA-AT1activate AT1 receptorsincreased sensitivity to angiotensins  hypertension 4. IMMUNOLOGIC

12. Fetal & maternal risks Fetal • IUGR • Oligohydramnios • Placental infarcts • Placental abruption • Prematurity • Uteroplacental insufficiency • Perinatal death Maternal • CNS seizures & stroke • DIC • ↑↑ CS • Renal failure • Hepatic failure or rupture • Death DR SALWA NEYAZI ASS. PROF.KSU CONSULTANT OBGYN

13. Haematology • Hemoconcentration (pts with anemia may appear to have normal hematocrit) • Thombocytopaenia  most common • Platelet count correlates with disease severity and incidence of abruptio placentae • DIC due to activation of coagulation cascadeoverconsumption of coagulants and platelets spontaneous haemorrhage.

14. Hepatic • HELLP syndrome • Periportalhaemorrhage • subcapsular bleeding • hepatic rupture: 32% maternal mortality

15. Renal Decreased GFR - oliguria - renal failure - uric acid, creatinine is elevated Glomerulopathy - proteinuria

16. Uteroplacental circulation • Uteroplacental insufficiency • Fetal complications: - hypoxia -IUGR -Prematurity -IUD -Placental abruption

17. SYMPTOMS & SIGNS • Edema of the face & hands. • Headache • Visual disturbance • Epigastric pain • ↑ BP • Exaggerated reflexes • Proteinuria

18. Prevention • Regular Antenatal checkup: rapid gain in weight rising blood pressure edema proteinuria/deranged liver or renal profile • Low dose Aspirin in High risk group: ↑PGs and↓TXA2 • Calcium supplementation: no effects unless women are calcium deficient • Antioxidants- Vitamin C and E • Nutritional supplementation: zinc, magnesium, fish oil, low salt diet

19. Management

20. Gestational HTN at Term • Delivery is always a reasonable option if term • If cervix is unfavorable and maternal disease is mild, expectant management with close observation is possible

21. Mild Gestational HTN not at Term • Rule out severe disease • Conservative management • Serial labs • Twice weekly visits • Antenatal fetal surveillance • Outpatient versus inpatient

22. Indications for Delivery • Worsening BP • Non reassuring fetal condition • Development of severe PIH • Fetal lung maturity • Favorable cervix

23. Unfavorable Cervix • No contraindication to prostaglandin agents • If < 32 weeks, consider cesarean • When favorable, oxytocin

24. preclampsia

25. Obstetrics management 1. Maternal evaluation : Hemoglobin and hematocrit platelet count : decreased, if < 100000 coagulation profile LFTs : indicated in all patients KFTs : raised (S.urea creatinine is decresaed in Normal pregnancy) Urine Routine : proteinuria

26. Manegement OBJECTIVES • Terminaton of pregnancy with the least possible trauma to the mother & fetus • Birth of an infant who subsequently thrives • Complete restoration of health to the mother 1- Hospitalization • Women with new onset BP ≥ 140/90 • Worsening BP • Development of proteinuria in addition to existing BP

27. Lines of management • Anticonvulsant therapy • Antihypertensive therapy • Termination of pregnancy

28. Anticonvulsant therapy Seizure Prophylaxis • Routinely used in severe PE • Magnesium sulphate: most commonly used • Initiated with onset of labor till 24h postpsrtum • For caesarean, started 2hrs before the section till 12hrs postpartum

29. Side effects of MgSO4 • Maternal : flushing, headache, muscle weakness, pulmonary edema decrease patellar reflexes , respiratory depression , cardiac arrest • Neonatal: lethargy, hypotonia, respiratory depression

30. Magnesium levels Monitoring • Normal Serum levels- 1.7- 2.4 mg/dl • Therapeutic range- 5- 9mg/dl • Patellar reflex lost- >12mg/dl • Respiratory depression- 15-20 mg/dl • Cardiac arrest- >25mg/dl

31. Management of MgSO4 Toxicity • Stop infusion • Intravenous Calcium 10 ml 10% over 10 minutes • Endotracheal intubation in respiratory depression

32. Antihypertensive therapy Mild PET • There is no benefit of antihypertensive therapy • Reduction in the maternal BP with labetalol or nifedipineIUGR • ACI contraindicated  IUGR, boney malformations, limb contracture, PDA, pulmonary hypoplasia, RDS, hypotension &death Severe PET Antihypertensive therapy is used to control BP untill the Pt delivers or in preterm for 48 hrs to allow time for glucocorticoid administration for fetal lung maturity then delivery

33. Acute Medical Therapy • Hydralazine: 5-10 mg every 20 minutes • Labetalol: 20mg, then 40, then 80 every 20 minutes, for a total of 220mg • Nifedipine: 10 mg po, not sublingual • Nitroprusside • Diazoxide • Clonidine 1 mg po

34. HELLP syndrome Diagnosis: • Hemolysis: • Peripheral smear • ↑bilirubin >1.2mg/dL, • Elevated liver enzymes: • SGOT> 70 IU/L • Low platelets

35. Management of HELLP syndrome • Immediate hospitalisation • Stabilise mother • antihypertensives • anti seizure prophylaxis • correct coagulation abnormalities • Assess fetal condition- FHR, doppler ultrasound, biophysical profile

36. HELLP contd.. • Ultimate goal: • >34 wks gestation deliver • <34wks expectant management if stable maternal and fetal conditions • Platelet transfusion if: <40,000/mm3 before cesarean <20,000/mm3 before delivery

37. Termination of pregnancy Indications • Term pregnancy with mild or severe PET • Severe PET regardless of the gestational age Warning signs  headache , visual disturbance, epigastric pain, oliguria • Eclampsia Pt must be stabilized & delivered immediately Preterm with mild PET  Assess fetal wellbeing by NST, Doppler Methods of termination • IOL with prostaglandines to ripen the Cx followed by IV oxytocin • Elective CS  Severe PET with unfavorable Cx

38. ECLAMPSIA Epidemiology • 0.1- 5.5 per 10,000 pregnancies • Decreasing incidence with time • Antepartum(50%): mostly in third trimester • Intrapartum(30%): • Postpartum(20%): usually within 48hours, fits beyond 7days generally rules out eclampsia

39. Risk factors Maternal age less than 20 years Multigravida Molar pregnancy Triploidy Pre-existing hypertension or renal disease Previous severe Preeclampsia or Eclampsia Nonimmune hydrops fetalis Systemic Lupus Erythematosus

40. Clinical features • Eclamptic convulsions are epileptiform and consist of four stages • Premonitory stage: twitching of muscles of face, tongue, limbs and eye. Eyeballs rolled or turned to one side, 30s • Tonic stage: opisthotonus, limbs flexed, hands clenched, 30s • Clonic stage: 1-4 min, frothing, tongue bite, stertorous breathing • Stage of coma: variable period.

41. Management • 1.call for help • 2.put the patient in a left lateral position remove the clothes and protect the tongue • 3.artificial airway • 4.blood should be taken for basal investigations • 5.folley’s catheter • 6.MgSO4 • 7.diazepam 10mg slowly and diluted which can repeated after 10 minutes • 8. antihypertensive therapy • 9.obstetrical examination to decide the mode of delivery then deliver the patient