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HYPERTENSIVE DISEASE OF PREGNANCY

Prof. Mehdi Hasan Mumtaz

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MATERNAL PHYSIOLOGY

Anaemia.

Hyperventilation.

Hypovolaemia.

Hyper-coagubility.

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HYPERTENSIVE DISEASE OF PREGNANCY

Pre-eclampsia.

Eclampsia.

HELLP syndrome.

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PRE-ECLAMPTIC TOXEMIA(PET)

TRIAD

Hypertension.

Proteinurea.

Oedema.

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SEVERE-PRE-ECLAMPSIADefinitions

BP> 140/90. Proteinurea >0.5 G/24h or

>2+ urine analysis+

Epigastric pain.Haedache.Visual disturbances.Clonus> 3beats.Platelet count <100x109.ALT>50IU/L.

OR

SPB = > 170DBP = > 110PROTEINUREA >0.5 G/24h OR > 2+ URINE ANALYSIS.

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HAEMODYNAMIC FINDINGSSevere Pre-eclampsia

Low plasma volume.

Low /Normal CO.

Low/ Normal CVP/PCWP.

myocardial contractility.

Low COP.

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ECLAMPSIA

Hypertension.

Protein urea.

Oedema.

Convulsion.

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HELLP SYNDROME

“Mos severe end of pre-eclamptic condition”

H – Haemolysis. EL - Liver enzyme. LP - Platelet count.

“Additional: Haemopoietic system”

“Liver involvement”

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PATHOLOGICAL FEATURES

Hypertension.

Renal functions.

Hypovolaemia.

Hypoproteinaemia.

Coagulation/fibrinolytic imbalance.

Cerebral irritability.

Placental perfusion.

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NORMAL PREGNANCY

Vasoconstriction

Platelet aggregations

Uterine activity

Utero-placental blood flow

Prostacyclin

Vasoconstriction

Platelet aggregations

Uterine activity

Utero-placental blood flow

Thromboxane

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PRE-ECLAMPSIA

Vasoconstriction

Platelet aggregations

Uterine activity

Utero-placental blood flow

Prostacyclin Vasoconstriction

Platelet aggregations

Uterine activity

Utero-placental blood flow

Thromboxane

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FLUID MANAGEMENT“Important”

Relatively Low PVLow PAWPCO

Endothelial damage. Low COP Excessive fluid therapy

fetal distress oligurea

risk pulmonary oedema

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MANAGEMENT

Definitive

Delivery of baby Delivery of

plaenta

Symptometic

Control Blood pressure. Convulsions. Fluid balance

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MANAGEMENT

SYMPTOMATICHIGH BLOOD PRESSURE

Dangers: Cerebral haemorrhage.Pul oedema

Objective: DBP 90-100mmHg<90 uteroplacentl

perfusion

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BLOOD PRESSURE

CAUTION. 4.5% HES 500ml preload.

Before IV anti-hypertensive.

EXCEPTION. Patient post delivery. Who has 4.5% HES already. DBP >120.

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BLOOD PRESSURE

HYDRALLAZINE 5mg/5min in 20 min.If BP 90-100 40mg/N-saline, 1-5mg/h.

IF AT 20min DBP >100 5mg/min in 20 min.If BP 100 40mg/N-saline, 1-5mg/h.

IF AT 20min DBP >100 LABETALOL 10-20mg IV/10min If DBP 90-100 or Total 220mg given

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BLOOD PRESSURE

Labetalol. 10-20mg boluses/15min.

If DBP 90-100.

Infusion 5mg/ml (0-160mg/hr).

Ca+ channel blockers.

Nitrates.

Adrenergic neuron blockers.

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ECLAMPSIA ROOM

Indications.1. Eclampsia.2. Hypertension > 170/110

+Proteinurea > 2+

3. Hypertension > 140/90Proteinurea 2+

+ One of the symptom/signs

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SYMPTOM/SIGNS

Headaches. Visual disturbances. Hyper-reflexia. Clonus (>3beats). Nausea & vomiting. Epigastric pain. Raised liver enzymes. Thrombocytopenia<100x10/L.

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“MONITORING” Eclampsia Room

ECG. NIBP. SPO2. Fluid balance. Urine output. CTG. CVP.

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CELL

CAPILLARY

EG

OSMOLALITY

Na+

COP

INTRACELLULAR INTERSTITIAL VASCULAR

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FLUID BALANCE

Restrict fluids.

(2000ml/24hrs)

Urine output <25ml/hr.

Pass CVP catheter.

CVP

Group A: CVP <4mmHg- underfilled.

Group B: CVP 4-8mmHg- optimialy

filled.

Group C: CVP >8mmHg- over filled.

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CVP GROUP - A.

Fluid challenge. HES 4.5% 100ml. Bring CVP 4-8.

GROUP - B. Fluid challenge careful. CVP 4-8. Urine O/P <25ml give dopamine..

GROUP - C. No pul oedema.

Dopamine 1-3g/kg/min. Pulmonary oedema present.

Frusemide 20mg. Refer to ICU.

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SEIZURE PROPHYLAXIS

“Severe pre-eclampsia”“Controversial”

Magnesium sulphate. Loading dose 4G.

Infusion 2G/hr.

Optimum level 2-4mmol/L.

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MAGNESIUM SULPHATEBlood Levels

Mgnesium (mmol/L)

0.7-1 2-4 >5 >7.5 >10

Effect

Normal Therapeutic range. Loss of reflexes. Respiratory

depression Cardiac arrest

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MAGNESIUM SULPHATE

Magnesium level >4 = dose (.5-1G/h)

Magnesium level <1.7=give 2G bolus.

dose 2.5G/h.

Magnesium level 1.7-2 continue 2G/h.

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MONITORING DURING MAGNESIUM INFUSION

Patellar reflex.

ECG.

SPO2.

Mgnesium level.

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MANAGEMENT MAGNESIUM TOXICITY

Loss of patellar reflex. Stop infusion. Measure level. Withold till reflex returns. Once reflex return – 1G/h.

SPO2 <90%. Give O2. Stop maintenance dose. Measure level. Inform anaesthetist.

Cardio-respiratory arrest. Stop infusion. CPR. Calcium gluconate. Intubation/ventilation.

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MAGNESIUM THERAPY

Considerations

Tocolytic effect.

Interaction – muscle relaxants.

Interaction – calcium antagonists.

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“INDICATIONS”ICU – ADMISSION

Severe coagulopathy or DIC.

Recurrent seizures.

Hypertension – poor control.

Persistant oligurea.

Pulmonary oedema + oligurea.

Compromised myocardial

function.

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MANAGEMENT

Definitive

Delivery of baby

Delivery of plaenta

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MANAGEMENTSevere Cases

Arrest & prevention of convulsion. Barbituates. Benzodiazepines. Megnesium SO4. Paralyse & IPPV.

Blood pressure. Hypertension – vasodilatation. Hypotension – inotropics.

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MANAGEMENTSevere Cases

Restoration of blood volume.

Low proteins. Colloids.

Colloid substitutes.

Progressive dehydration.

Replace out put.

Keep BV normal.

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ECLAMPSIA“Labour Room”

S.B.P. > 160 Torr. DBP > 110 Torr. Protein urea >5G/24h. Oligurea 500ml or less. Epigastric pain. Cyanosis. Pulmonary oedema. Convulsions.

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IN ICU

B. P. < 80 Torr.

Urine output – nil.

Convulsions.

Pulmonary oedema.

Cyanosis.

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ROUTINE

CVP Monitoring. Urinary

catheter. Nasogastric

catheter. Heavy sed with:

Valium. Pheno.

IPPV. Aemocel 500ml

daily

Blood 500ml/day.

Digitalise. Inotropes if

needed. Balance.

Negative 7-10day=10-14L

Ventilator off 3-4 day.

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IDEAL MANAGEMENT

Pass CVP catheter. Pass urinary catheter. Pass nasogastric tube. Replace obvious loss by crystaloids. Normalise blood volume by colloids. Remove excess fluids.

From ext vascular comp. By forced diuresis.

Keep the body in electrolyte balance.

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IDEAL MANAGEMENT

Routine investigations. Hb. HCT. Plasma proteins. Serum Na+ K+.

Monitoring. Urine output. ECG. BP. Pulse CVP.

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HELLP SYNDROME

H – Haemolysis. EL – elevated Liver enzyme

activity. LP - Platelet count.

“most sevre end of pre-eclamptic condition”

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CLINICAL FEATURES Epigastric pain. Upper abdominal tenderness. Proteinurea. Hypertension. Jaundice. Nausea & vomiting.

Haematuria. Oligurea. A T necrosis. Cortical necrosis. Pan-hypopituitarism. Actue liver rupture RDS.

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MANAGEMENT

Early diagnosis. Stbilization. Prompt delivery if.

Pre-eclampsia worsens. Worsening of hepatic renal functions. Severe thrombocytopenia. Gestational age at or beyond 32-

34wks. Evidence of foetal distess. Evidence of foetal maturity.

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MANAGEMENT

Pre-op investigations. Platelet count. PCV. Hb. PTT. Fibrinogen concentration. FDP. LFTs. Creatinine. Urea. Uric acid. X-ray chest.

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Platelet infusion if. <50000mm-3 cs. <20000mm-3 vag.D.

Blood transfusion if. B <10.0G/dl. Hb.

PPF. FFP. CVP. Urine output. Maternal blood glucose control. IPPV.