HYPERTENSIVE DISORDER IN PREGNANCY


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anil    on Mar 01, 2012 Says :

Hypertension in pregnant women is quite common.
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1 :
2 : HYPERTENSIVE DISORDERS IN PREGNANCY by Dr Ku Adniza Ku Adnan KKGC/KK Yan 20 Julai 2011
3 : Etiology & Definition Complicates 10-20% of pregnancies Elevation of BP =140 mmHg systolic and/or =90 mmHg diastolic, on two occasions at least 6 hours apart.
4 : AETIOLOGY OF PIH Result of abnormal placentation Cause unknown – may be due to altered genetic or immunologic influences A syndrome of generalised endothelial dysfunction Untreated – generalised vasospasm result in tissue hypoxia and organ failure
5 : DEFINITION OF HYPERTENSION SBP of ? 140 mmHg and/or ? 90 mmHg taken after a period of rest on two occasion
6 : Rise of SBP of 30 mmHg and/or rise of DBP of 15 mmHg compared to pre-pregnancy level No longer recognized as hypertension However need close observation especially if proteinuria and hyperuricaemia are also present (3rd edition CPG Hypertension 2008)
7 : CLASSIFICATION OF HDP Pregnancy Induced Hypertension (PIH) - HPT after 20th week of pregnancy - may be associated with proteinuria a) Gestational HPT – PIH without proteinuria b) Pre-eclampsia (PE) – PIH with proteinuria c) Eclampsia – PIH with convulsions 2) Chronic HPT – essential or secondary 3) Chronic HPT with superimposed pre- eclampsia * Unclassified HPT – HPT found at first antenatal visit after 20 weeks gestation
8 : Prenatal Care for Chronic Hypertensives Electrocardiogram should be obtained in women with long-standing hypertension. Baseline laboratory tests Urinalysis, urine culture, and serum creatinine, glucose, and electrolytes Tests will rule out renal disease, and identify comorbidities such as diabetes mellitus. Women with proteinuria on a urine dipstick should have a quantitative test for urine protein.
9 : Proteinuria ?UTI must be excluded ?defined as 300 mg/24 hours urine collection or 1 gm/L or more in 2 occasions 6 hours apart ?quantifying proteinuria by dipstix is convenient + - 0.3 gm/L ++ - 1.0 gm/L +++ - 3.0 gm/L ++++ - >20gm/L
10 : Oedema commonly seen in pregnancy in severe PIH – generalised fluid accumulation due to endothelial damage weight gain of > 1.0 kg/week may indicate increasing severity of PIH
11 : Severity of PIH Mild - BP >140/90 - no proteinuria b) Severe – BP ?160/110 on two occasions 6 hours apart - proteinuria 3+ or > 3 gm/L - oliguria <400 ml/24 hours - headache, cerebral or visual disturbances, epigastric pain, hyper-reflexia,pulmonary oedema, impaired LFT, increased se Creatinine>1.2 mg/L, retinal haemorrhages,exudates or papilloedema, thrombocytopenia, IUGR
12 : Coding system All patient should be appropriately coded according to MOH guideline on Mx. Of High Risk Cases in pregnancy
13 : High Risk Mothers Maternal age <20 and >35 years Nulliparity Previous h/o HDP Multiple gestation Polyhydramnios Non – immune fetal hydrops Underlying renal disease Chronic HPT 9. Diabetes Mellitus 10. Gestational Trophoblastic disease 11. Low socio-economic status 12. Pregnancies with different partners 13. Excessive weight gain 14. Rh incompatibility
14 : COMPLICATIONS OF PRE-ECLAMPSIA Central nervous system – cerebral oedema, cerebral h’ge, transient cortical blindness, serious retinal detachment Cardiovascular System- hypertension, APO, cardiac failure Pulmonary System- APO, aspiration pneumonia Liver- congestion, haemorrhage, infarction, rupture Kidney- glomeruloendotheliosis, nephrotic syndrome, ARF Blood- thrombocytopenia, DIVC Uterus, skin & Mucosa- placental abruptio, oedema, petechia,laryngeal oedema Foetus – IUGR, Prematurity, IUD
15 : Management of Mild HDP Management at Health Clinic/Hospital without Specialist must be done by FMS/M&HO or MO in O&G 1) criteria for selection for ambulatory care - BP ? 140/90 and less than 150/100 - no proteinuria - no signs or symptoms of impending eclampsia - no excessive weight gain - no intra-uterine growth retardation
16 : Maternal surveillance blood pressure urine for albumin weight gain signs/symptoms of impending eclampsia biochemical investigations: platelet count, haematocrit, se uric acid,se creatinine, 24 hour urine protein
17 : Fetal surveillance fundal height fetal heart fetal movement chart serial ultra-sound for - growth parameters (BPD, FL, AC, HC) and amniotic fluid index
18 : Treatment for Chronic Hypertension Avoid treatment in women with uncomplicated mild essential HTN as BP may decrease as pregnancy progresses. May taper or discontinue meds for women with BP less than 120/80 in 1st trimester. Reinstitute or initiate therapy for persistent diastolic pressures >95 mmHg, systolic pressures >150 mmHg, or signs of hypertensive end-organ damage. Medication choices = Oral methyldopa and labetalol.
19 : Anti-hypertensive therapy patients with BP 140/90 mmHg without any complications, may not require treatment anti HPT may be considered when BP persistently above SBP 140 mmHg / DBP 90 mmHg
20 : Referral to hospital at any time referral to hospital with specialist should be made when there is any deviation from the above criteria all cases of mild HDP must deliver in hospital
21 : Indication for in-patient management symptomatic patient patient’s with complication for observation of patient’s condition for at least 24-48 hours for blood pressure stabilisation planning of obstetric management timing of delivery
22 : Timing of delivery aimed at 38 - 40 weeks if at any time the maternal and fetal condition is compromised, early delivery is mandatory
23 : Management of severe HDP Definition: SBP ? 160 or DBP ? 110 on two occasions 6 hours apart proteinuria 3+ or 3.0gm/L oliguria symptoms of impending eclampsia pulmonary oedema increased se creatinine > 1.2 mg/dl retinal h’ge, exudates or papilloedema thrombocytopenia IUGR
24 : Management at home and health clinic ? patient should be referred to hospital immediately with red coding ? arrange for transport and accompany the patient to hospital ? if patient is on antiHPT continue therapy ? set-up IV drip with normal saline for administration of drugs for resuscitation if the need arise
25 : Management at hospital without specialist ? manage in high dependancy area while waiting for transfer to hospital with specialist ? maintain IV drip with normal saline ? monitor BP, PR, RR and fetal HR every 15 minutes ? if DBP > 110 mmHg, set-up IV Hydrallazine 25 mg in 500 ml hartman’s /N/S. start at 5-10 dpm, increase by 5 dpm every 15 minutes till DBP around 90 mmHg ? insert foley’s catheter and record urine output
26 : ……..cont…….. ? consult O&G specialist nearby ? inform the husband or next of kin ? transfer to the nearest hospital with specialist
27 : Obstetric Management ? if gestation is < 34 weeks, there is a place to prolong the pregnancy to as near as 36 weeks, provided no danger to mother and the fetus ? if gestation is 34 weeks or above, consider delivery ? delivery - aim for vaginal delivery
28 : Treatment of Preeclampsia Definitive Treatment = Delivery Major indication for antihypertensive therapy is prevention of stroke. Diastolic pressure =105-110 mmHg or systolic pressure =160 mmHg Choice of drug therapy: Acute – IV labetalol, IV hydralazine, SR Nifedipine Long-term – Oral methyldopa or labetalol
29 : Antihypertensive Drugs Commonly Used In Pregnancy
30 : HELLP Syndrome H - Hemolysis E Elevated Hepatic Transaminases L L Low Platelets (Thrombocytopenia < 100,000/mm3) P
31 : HELLP SYNDROME 1. Usually an indication for delivery 2. May occur without appreciable HTN 3. Is indicative of multisystem disease
32 : ECLAMPSIA occurance of convulsion in association with features of pre-eclampsia Incidence in UK: 4.9 of 100,000 maternities 44% postnatal, 38 % antepartum, 18% postpartum In Malaysia, 1/3rd of mortality from HDP had eclampsia ECLAMPSIA
33 : Classically occurs in 2nd half of pregnancy – 10 days after delivery 20% of women are normotensive and 30% has no premonitory proteinurea Prevention : early detection and treatment of PE
34 : SYMPTOMS AND SIGNS OF IMPENDING ECLAMPSIA Severe frontal headache Vomiting Blurring of vision Epigastric pain Hyper-reflexia Severe hypertension
35 : Goals of treatment to treat convulsions and prevent recurrence to control the BP to stabilise the mother to deliver the fetus
36 : Management General Management ? call for assistance / red alert system ? keep airway open. Remove any dentures. Give O2 ? patient to be put in left lateral position, and no pillow ? head in extended and lower position ? suck off excessive secretion in the mouth/throat ? give deep IM MgSO4 or valium
37 : set-up 2 IV lines, Ix: GXM 2 pint blood, platelet count, BT, CT, LFT, renal function if DBP >110 mmHg, start IV Hydrallazine, to reduce DBP to around 90 mmHg ? monitoring : * BP every 10-15 minutes * level of consciousness * maintain and auscultate lungs 4-6hrly * strict I/O chart * put CBD and ensure output > 30 ml/hr * blood Ix-bleeding profile, renal profile, LFT, GXM blood
38 : All cases of eclampsia should have the baby delivered regardless of gestation after BP is controlled
39 :

 

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