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Hypertension in Pregnancy

Hypertension in Pregnancy. Ramon M. Gonzalez, MD Professor UST Medicine and Surgery. A 26y/o G1 21-22 weeks known hypertensive for 6 years was admitted because of severe hypertension VS- BP-200/100mmHg,

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Hypertension in Pregnancy

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  1. Hypertension in Pregnancy Ramon M. Gonzalez, MD Professor UST Medicine and Surgery

  2. A 26y/o G1 21-22 weeks known hypertensive for 6 years was admitted because of severe hypertension VS- BP-200/100mmHg, PR- 76/min, RR-20/min, T-36.5C. She was taking calcium channel blockers for her HPN which she was taking regularly.

  3. Hypertensive Disorders Complicating Pregnancy • Gestational Hypertension • Systolic BP≥ 140 or diastolic ≥ 90 mmHg for the first time after 20 weeks gestation • No proteinuria • BP returns to normal before 12 weeks postpartum • Final diagnosis made only postpartum • May have other signs or symptoms of preeclampsia

  4. Hypertensive Disorders Complicating Pregnancy • Preeclampsia • Minimum criteria • BP ≥ 140/90 mmHg after 20 weeks gestation • Proteinuria ≥ 300mg/24 hours or ≥ 1+ dipstick • Severe preeclampsia • BP ≥ 160/110 mmHg • Proteiunuria 2.0gms/24 hrs or ≥ 2+ dipstick • Serum creatinine > 1.2mg/dl • Platelets < 100,00/ul • Elevated LDH, ALT or AST

  5. Hypertensive Disorders Complicating Pregnancy • Eclampsia • Seizures that cannot be attributed to other causes in women with preeclampsia • Chronic Hypertension • BP ≥ 140/90 mmHg before pregnancy or diagnosed before 20 weeks gestation • Hypertension first diagnosed after 20 weeks gestation and persistent after 12 weeks postpartum

  6. Hypertensive Disorders Complicating Pregnancy • Superimposed Preeclampsia • New onset proteinuria ≥ 300mg/24 hrs in hypertensive women but no proteinuria before 20 weeks gestation

  7. Pregnancy 20-21 weeks, Chronic Hypertension

  8. Maternal Assessment • Duration of hypertension • Current therapy • Degree of BP control • Other medical complications

  9. Maternal Assessment • Serum creatinine • Quantification of urine proteins • ECG • Echocardiography • Blood chemistry

  10. What are the effects of chronic hypertension on pregnancy? • What is the management of chronic hypertension during pregnancy? • Can we prevent superimposition of preeclampsia ? • What is the management of chronic hypertension with superimposed preeclampsia?

  11. What are the effects of chronic hypertension on pregnancy?

  12. ORs for Fetal Complications: 1995-2008 Pregestational Diabetes ------------------------------------------------------------------------------------------- Variable With Chronic HPN W/O Chronic HPN ________________________________________________________ Stillbirth 4.30(3.81-4.85) 3.05(2.88-3.23) Poor fetal growth 2.66(2.40-2.94) 1.20(1.14-1.27) Spontaneous delivery 4.88(4.63-5.15) 2.90(2.83-2.90) <37weeks

  13. ORs for Maternal Complications: 1995-2008 Pregestational Diabetes -------------------------------------------------------------------------------------------- Variable With Chronic HPN W/O Chronic HPN __________________________________________________________ Preeclampsia 13.96 (13.29-14.66) 3.80 (3.69-3.91) CVA 7.14 (4.90-10.40 ) 1.85 (1.41-2.44) Acute renal failure 35.41 (28.39-44.16) 4.43 (3.57-5.48) Pulmonary edema 11.97 (7.86-18.24) 4.01 (3.07-5.25) Ventilation 11.87 (9.22-15.26) 3.34 (2.89-4.00) Cesarean delivery 5.75 (5.46-6.05) 3.33 (3.26-3.41) In- hospital mortality 6.02 (2.71-13.40) 2.58 (1.59-4.17)

  14. ORs for Fetal Complications: 1995-2008 Chronic Renal Disease ------------------------------------------------------------------------------------------- Variable With Chronic HPN W/O Chronic HPN ________________________________________________________ Stillbirth 7.29(5.59-9.52) 1.74(1.51-2.02) Poor fetal growth 7.94(6.67-9.44) 2.29(2.12-2.49) Spontaneous delivery 8.60(7.64-9.67) 2.25(2.15-2.35) <37weeks

  15. ORs for Maternal Complications: 1995-2008 Chronic Renal Disease --------------------------------------------------------------------------------------------- Variable With Chronic HPN W/O Chronic HPN __________________________________________________________ Preeclampsia 27.87(24.85-31.25) 3.28(3.10-3.47) CVA 13.73(6.63-28.44) 3.53(2.34-5.31) Acute renal failure 253.4(199.5-321.9) 62.40(54.37-71.63) Pulmonary edema 23.29(10.32-52.56) 9.06(5.84-14.06) Ventilation 19.29(11.36-32.76) 8.25(6.43-10.60) Cesarean delivery 5.73(5.03-6.53) 1.74(1.68-1.81) In- hospital mortality 27.02(8.72-83.73) 6.88(3.56-13.29)

  16. ORs for Fetal Complications: 1995-2008 Collagen Vascular Disease ------------------------------------------------------------------------------------------- Variable With Chronic HPN W/O Chronic HPN ________________________________________________________ Stillbirth 7.42(5.37-10.25) 2.74(2.35-3.20) Poor fetal growth 7.99(6.44-9.91) 3.87(3.55-4.22) Spontaneous delivery 7.19(6.22-6.30) 3.15(2.98-3.33) <37weeks

  17. ORs for Maternal Complications: 1995-2008 Collagen Vascular Disease --------------------------------------------------------------------------------------------- Variable With Chronic HPN W/O Chronic HPN __________________________________________________________ Preeclampsia 17.41 (15.09-20.09) 2.96 (2.76-3.18) CVA 23.00 (11.47-46.14) 7.60 (5.26-10.97) Acute renal failure 191.5 (141.4-259.4) 12.60 (8.88-17.88) Pulmonary edema 15.52 (4.92-48.90) 6.08 (3.46-10.69) Ventilation 26.29 (15.04-45.63) 11.09 (8.46-14.52) Cesarean delivery 4.38 (3.74-5.12) 1.89 (1.80-1.98) In- hospital mortality 88.81 (41.90-188.2) 23.81 (14.67-38.66)

  18. What is the management of chronic hypertension during pregnancy?

  19. Management • Blood pressure control • Fetal antepartum surveillance • Prevention of preeclampsia • Detection of preeclampsia

  20. Blood Pressure Control • Ca Channel Blockers • Adrenergic Blocking Agents • Vasodilators • Diuretics • ACE Inhibitors/ARB • contraindicated

  21. A randomized trial of tight vs. less tight control of mild essential and gestational hypertension in pregnancy • El Guindy, A.A. and Nabhan, A.F. (2008) • Journal of Perinatal Medicine • Women in the tight control group • Were less likely to develop severe hypertension (RR 0.32, 95% CI 0.14 to 0.74) • Delivered babies with older gestational ages (36.6 ±2.2 weeks vs 35.8 ± 2.2 weeks: P<0.05) • Fewer preterm deliveries (RR 0.52, 95%CI 0.28 to 0.99) • No significant differences between groups regarding stillbirth or IUGR

  22. Fetal Antepartum Surveillance • Fetal biometry • Nonstress test • Contraction stress test • Biophysical profile • Doppler velocimetry

  23. Can we prevent superimposition of preeclampsia?

  24. Preeclampsia • Pregnancy specific syndrome that can affect virtually every organ system. • Disorder of unknown etiology affecting 5-10% of all pregnancies. • In developed countries 16% of maternal deaths were due to hypertensive disorder. • POGS (2006)- 26.24% maternal deaths were due to hypertensive disorder.

  25. Pathogenesis • Vasospam • Increased resistance → hypertension • Endothelial cell damage → leakage of blood constituents, including platelets and fibrinogen • Decreased blood flow → ischemia of tissues → necrosis, hemorrhage and other end organ disturbances

  26. Pathogenesis • Endothelial cell activation • Increased pressor responses • Increased sensitivity to angiotensin II • Prostaglandin • Prostacyclin: thromboxane A2 ratio decreases • Nitric oxide • Decreased nitric oxide synthase expression • Endothelins • Potent vasoconstrictor which is increased in preeclampsia

  27. Cardiovascular System • ↑ Cardiac afterload • hypertension • ↑Cardiac preload • Diminished hypervolemia • ↑ intravenous crystalloids • Extravasation of intravascular fluid into the extracellular space • Pulmonary edema

  28. Blood Volume and Coagulation • Hemoconcentration • Hallmark of preeclampsia • Vasospasm and endothelial leakage • Thrombocytopenia • Hemolysis • Endothelial disruption • HELLP syndrome

  29. Kidneys • ↓ Glomerular filtration rate and renal plasma flow • ↑ Serum creatinine • ↑ Uric acid • Proteinuria • Oliguria • “Glomerular capillary endotheliosis” • Acute renal failure

  30. Liver • Hepatic infarction • Periportal hemorrhage • Hepatocellular necrosis • Elevations of AST/ALT • Hepatic hematoma • HELLP syndrome

  31. Brain • Headaches, visual symptoms • Convulsions • Intracerebral hemorrhage • Cortical and subcorticalpetechial hemorrhages • Subcortical edema

  32. Uteroplacental Perfusion Vasospasm ↓ Decreased uteroplacental perfusion ↓ Increased perinatal morbidity and mortality

  33. Prevention of Superimposed Preeclampsia • Systematic Review by Duley et al • 59 trials with 37,560 women given Aspirin • 17% reduction in the risk of preeclampsia (RR 0.83, 077-0.89), especially in high risk patients • 8% reduction in the relative risk of preterm birth (RR 0.92, 0.88-0.97) • 14% reduction in fetal and neonatal deaths (RR 0.86, 0.76-0.98) • 10% reduction in SGA babies (0.90, 0.83-0.98)

  34. Detection of Preeclampsia • BP monitoring • 24 hour urine proteins

  35. What is the management of chronic hypertension with superimposed preeclampsia?

  36. Management • Termination of pregnancy with the least possible trauma to mother and baby • Birth of an infant who subsequently thrives • Complete restoration of health to the mother

  37. Severe Preeclampsia • Clinical course is progressive deterioration in both maternal and fetal condition • Associated with high rates of maternal and perinatal morbidity and mortality

  38. Management of Severe Preeclampsia • Aggressive • High neonatal mortality and morbidity due to prematurity • Prolonged NICU stay • Long term disability • Expectant - Fetal death - Asphyxial damage in utero - Increased maternal morbidity

  39. Odendaal and associates • Aggressive vs expectant management • 58 patients, 20 were delivered w/in 48 hours • 20 aggressive, 18 expectant • 28-34 weeks • Betamethasone, MgSO4, Antihypertensive drugs • Maternal and fetal testing

  40. Sibai and colleagues • Aggressive vs expectant management • 28-32 weeks • 95 patients • Aggressive (n=46); expectant (n=49) • Bed rest, antihypertensives, MgSO4, betamethasone, maternal and fetal testing, laboratory exams

  41. Expectant Management • Prolongs pregnancy • Higher gestational age • Higher birth weight • Lower incidence of admission to NICU • Lower incidence of neonatal complication • No difference in the incidence of CS, abruptio placenta, HELLP syndrome and postpartum stay

  42. Guidelines for Expectant Management • Hospitalization in a tertiary hospital - Good facilities to monitor the mother and fetus - NICU facilities - Trained personnels • MgSO4 • Antihypertensives • Corticosteroids

  43. Maternal Assessment

  44. Maternal Assessment • Blood pressure measurement - Systolic – 140 – 155 mmHG - Diastolic – 90 – 105 mmHG • Daily 24 hour urine volume • Maternal symptoms • Search for imminent signs of eclampsia Sibai et al AmJOG 2007

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