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1、Hypertension in Pregnancy,Dr.Elwassiela Salih MD Obstetrician Gynecologist & Reproductive Endocrinologist Chief of the Department College of Medicine Taif University,OBJECTIVES,Be able to define hypertension in relationship to pregnancy Be able to classify hypertensive diseases in pregnant women Be
2、able to list criteria for the diagnosis of preeclampsia Be able to list criteria for the diagnosis of severe preeclampsia/HELLP syndrome Be able to discuss current management considerations Understand and discuss the effects of hypertension on the mother and fetus,Hypertension,Sustained BP elevation
3、 of 140/90 or greater Measurement taken while seated Arm at the level of the heart,Hypertensive Disease Associated with Pregnancy,Chronic Hypertension Gestational Hypertension Preeclampsia Eclampsia HEELP Syndrome,Hypertensive Disease Associated with Pregnancy,Chronic Hypertension Diagnosed before t
4、he 20th week or present before the pregnancy Gestational Hypertension Preeclampsia Eclampsia HEELP Syndrome,Hypertensive Disease Associated with Pregnancy,Chronic Hypertension Gestational Hypertension Criteria Develops after 20 weeks of gestation Proteinuria is absent Blood pressures return to norma
5、l postpartum Morbidity is directly related to the degree of hypertension Preeclampsia Eclampsia HEELP Syndrome,Overlap/Disease Progression,25%,Hypertensive Disease Associated with Pregnancy,Chronic Hypertension Gestational Hypertension Preeclampsia Criteria Develops after 20 weeks Blood pressure ele
6、vated on two occasions at least 6 hours apart Associated with proteinuria and edema May occur less than 20 weeks with gestational trophoblastic neoplasia Eclampsia HEELP Syndrome,Preeclampsia vs. Severe Preeclampsia,Criteria for Preeclampsia,Criteria for Severe Preclampsia,Previously normotensive wo
7、man 140 mmHg systolic 90 mmHg diastolic Proteinuria 300 mg in 24 hour collection Nondependent edema,BP 160 systolic or 110 diastolic 5 gr of protein in 24 hour urine or 3+ on 2 dipstick urines greater than 4 hours apart Oliguria 500 mL in 24 hours Cerebral or visual distrubances (headache, scotomata
8、) Pulmonary edema or cyanosis Epigastric or RUQ pain Evidence of hepatic dysfunction Thrombocytopenia Intrauterine growth restriciton (IUGR),Risk Factors for Preeclampsia,Nulliparity Multifetal gestations Maternal age over 35 Preeclampsia in a previous pregnancy Chronic hypertension Pregestational d
9、iabetes,Vascular and connective tissue disorders Nephropathy Antiphospholipid syndrome Obesity African-American race,Risk Factors,Hypertensive Disease Associated with Pregnancy,Chronic Hypertension Gestational Hypertension Preeclampsia Eclampsia Diagnosis of preeclampsia Presence of convulsions not
10、explained by a neurologic disorder Grand mal seizure activity Occurs in 0.5 to 4% or patients with preeclampsia HEELP Syndrome,Hypertensive Disease Associated with Pregnancy,Chronic Hypertension Gestational Hypertension Preeclampsia Eclampsia HELLP Syndrome A distinct clinical entity with: Hemolysis
11、, Elevated Liver enzymes, Low Platelets Occurs in 4 to 12 % of patients with severe preeclampsia Microangiopathic hemolysis Thrombocytopenia Hepatocellular dysfunction,Morbidity and Mortality from Hypertensive Disease,Hypertension affects 12 to 22% of pregnant patients Hypertensive disease is direct
12、ly responsible for approximately 20% of maternal mortality in the United State,Pathophysiology,Vasospasm Uterine vessels Hemostasis Prostanoid balance Endothelium-derived factors Lipid peroxide, free radicals and antioxidants,Pathophysiology,Vasospasm Predominant finding in gestational hypertension
13、and preeclampsia Uterine vessels Hemostasis Prostanoid balance Endothelium-derived factors Lipid peroxide, free radicals and antioxidants,Pathophysiology,Vasospasm Uterine vessels Inadequate maternal vascular response to trophoblastic mediated vascular changes Endothelial damage Hemostasis Prostanoi
14、d balance Endothelium-derived factors Lipid peroxide, free radicals and antioxidants,Pathophysiology,Vasospasm Uterine vessels Hemostasis Increase platelet activation resulting in consumption Increased endothelial fibronectin levels Decreased antithrombin III and 2-antiplasmin levels Allows for micr
15、othrombi development with resultant increase in endothelial damage Prostanoid balance Endothelium-derived factors Lipid peroxide, free radicals and antioxidants,Pathophysiology,Vasospasm Uterine vessels Hemostasis Prostanoid balance Prostacyclin (PGI2):Thromboxane (TXA2) balance shifted to favor TXA
16、2 TXA2 promotes: Vasoconstriction Platelet aggregation Endothelium-derived factors Lipid peroxide, free radicals and antioxidants,Pathophysiology,Vasospasm Uterine vessels Hemostasis Prostanoid balance Endothelium-derived factors Nitric oxide is decreased in patients with preeclampsia As this is a v
17、asodilator, this may result in vasoconstriction Lipid peroxide, free radicals and antioxidants,Pathophysiology,Vasospasm Uterine vessels Hemostasis Prostanoid balance Endothelium-derived factors Lipid peroxide, free radicals and antioxidants Increased in preeclampsia Have been implicated in vascular
18、 injury,Pathophysiologic Changes,Cardiovascular effects Hematologic effects Neurologic effects Pulmonary effects Renal effects Fetal effects,Pathophysiologic Changes,Cardiovascular effects Hypertension Increased cardiac output Increased systemic vascular resistance Hematologic effects Neurologic eff
19、ects Pulmonary effects Renal effects Fetal effects,Pathophysiologic Changes,Cardiovascular effects Hematologic effects Volume contraction/Hypovolemia Elevated hematocrit Thrombocytopeniz Microangiopathic hemolytic anemia Third spacing of fluid Low oncotic pressure Neurologic effects Pulmonary effect
20、s Renal effects Fetal effects,Pathophysiologic Changes,Cardiovascular effects Hematologic effects Neurologic effects Hyperreflexia Headache Cerebral edema Seizures Pulmonary effects Renal effects Fetal effects,Pathophysiologic Changes,Cardiovascular effects Hematologic effects Neurologic effects Pul
21、monary effects Capillary leak Reduced colloid osmotic pressure Pulmonary edema Renal effects Fetal effects,Pathophysiologic Changes,Cardiovascular effects Hematologic effects Neurologic effects Pulmonary effects Renal effects Decreased glomerular filtration rate Glomerular endotheliosis Proteinuria
22、Oliguria Acute tubular necrosis Fetal effects,Renal Effects,Decreased glomerular filtration rate Glomerular endotheliosis Proteinuria Oliguria Acute tubular necrosis,Pathophysiologic Changes,Cardiovascular effects Hematologic effects Neurologic effects Pulmonary effects Renal effects Fetal effects P
23、lacental abruption Fetal growth restriction Oligohydramnios Fetal distress Increased perinatal morbidity and mortality,Management,The ultimate cure is delivery Assess gestational age Assess cervix Fetal well-being Laboratory assessment Rule out severe disease!,Gestational HTN at Term,Delivery is alw
24、ays a reasonable option if term If cervix is unfavorable and maternal disease is mild, expectant management with close observation is possible,Mild Gestational HTN not at Term,Rule out severe disease Conservative management Serial labs Twice weekly visits Antenatal fetal surveillance Outpatient vers
25、us inpatient,Indications for Delivery,Worsening BP Nonreassuring fetal condition Development of severe PIH Fetal lung maturity Favorable cervix,Unfavorable Cervix,No contraindication to prostaglandin agents If 32 weeks, consider cesarean When favorable, oxytocin,Hypertensive Emergencies,Fetal monito
26、ring IV access IV hydration The reason to treat is maternal, not fetal May require ICU,Criteria for Treatment,Diastolic BP 105-110 Systolic BP 200 Avoid rapid reduction in BP Do not attempt to normalize BP Goal is DBP 105 not 90 May precipitate fetal distress,Characteristics of Severe HTN,Crises are
27、 associated with hypovolemia Clinical assessment of hydration is inaccurate Unprotected vascular beds are at risk, eg, uterine,Acute Medical Therapy,Hydralazine Labetalol Nifedipine Aldomet,Hydralazine,Dose: 5-10 mg every 20 minutes Onset: 10-20 minutes Duration: 3-8 hours Side effects: headache, fl
28、ushing, tachycardia, lupus like symptoms Mechanism: peripheral vasodilator,Labetalol,Dose: 20mg, then 40, then 80 every 20 minutes, for a total of 220mg Onset: 1-2 minutes Duration: 6-16 hours Side effects: hypotension Mechanism: Alpha and Beta block,Nifedipine,Dose: 10 mg po, not sublingual Onset:
29、5-10 minutes Duration: 4-8 hours Side effects: chest pain, headache, tachycardia Mechanism: CA channel block,Seizure Prophylaxis,Magnesium sulfate 4-6 g bolus 1-2 g/hour Monitor urine output and DTRs With renal dysfunction, may require a lower dose,Magnesium Sulfate,Is not a hypotensive agent Works
30、as a centrally acting anticonvulsant Also blocks neuromuscular conduction Serum levels: 6-8 mg/dL,Toxicity,Respiratory rate 12 DTRs not detectable Altered sensorium Urine output 25-30 cc/hour Antidote: 10 ml of 10% solution of calcium gluconate 1 v over 3 minutes,Treatment of Eclampsia,Few people di
31、e of seizures Protect patient Avoid insertion of airways and padded tongue blades IV access MGSO4 4-6 bolus, if not effective, give another 2 g,Alternate Anticonvulsants,Have not been shown to be as efficacious as magnesium sulfate and may result in sedation that makes evaluation of the patient more
32、 difficult Diazepam 5-10 mg IV Sodium Amytal 100 mg IV Pentobarbital 125 mg IV Dilantin 500-1000 mg IV infusion,After the Seizure,Assess maternal labs Fetal well-being Effect delivery Transport when indicated No need for immediate cesarean delivery,Other Complications,Pulmonary edema Oliguria Persis
33、tent hypertension DIC,HELLP Syndrome,He-hemolysis EL-elevated liver enzymes LP-low platelets,HELLP Syndrome,Is a variant of severe preeclampsia Platelets 100,000 LFTs - 2 x normal May occur against a background of what appears to be mild disease,Conservative Management,Controversial Steroids Require
34、s tertiary care Must have stable labs and reassuring fetal status May use antihypertensives,Prevention,Low dose ASA ineffective in patients at low risk Calcium supplementation is ineffective (2.0 g of calcium gluconate per day) No compelling evidence that either are harmful Recent study done with antioxidant (1,000mg VitC and 400mg VitE). Small study that needs to be confirmed.,SUMMARY,Criteria for diagnosis Laboratory and fetal assessment Magnesium sulfate seizure prophylaxis Timing and place of delivery,