Hypertensive disorders of pregnancy
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Transcript of Hypertensive disorders of pregnancy
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Interesting case
11/24/2011
Warawut suttison , GP
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• A pregnant woman , 19 yrs• History taking from patient and her husband• CC : seizure 30 min PTA
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• OB-GYN Hx :– G1P0 GA 35 wks by U/S – ANC x 8 at private clinic : normal
• PH :– No underlying disease– No drug allergy
• FH :– No history of seizure
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• PE :– General appearance : confusion– Vital sign : BP 140/100 mmHg , RR 22 /min ,
BT 38.1 c , PR 120 /min– HEENT : pink conjunctiva , anicteric sclera– Heart and lungs : equal breath sound , normal S1S2 ,
no murmur– Abdomen : HF - , position : ROA , FHS : 160 , uterine
contraction : can’t evaluate , EFW : 2500 gram– PV : not done
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Provisional diagnosis
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Hypertensive Disorders of Pregnancy
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I. Introduction
• Hypertensive disorders complicate 5 to 10 percent of all pregnancies, and together they form one member of the deadly triad
• In developed countries, 16 percent of maternal deaths were due to hypertensive disorders
Ref : William obstetric 23rd edition,2009
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II. Diagnosis
• Hypertension is diagnosed empirically when appropriately taken blood pressure exceeds 140 mm Hg systolic or 90 mm Hg diastolic
• women who have a rise in pressure of 30 mm Hg systolic or 15 mm Hg diastolic should be seen more frequently
Ref : William obstetric 23rd edition,2009
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III. Classification and Definitions
Ref : William obstetric 23rd edition,2009
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Ref : William obstetric 23rd edition,2009
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III. Classification and Definitions
• Gestational Hypertension• Preeclampsia and eclampsia syndrome• superimposed Preeclampsia on chronic
hypertension• Chronic hypertension
Ref : William obstetric 23rd edition,2009
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II. Classification and Definitions
• 1. Gestational Hypertension:– Systolic BP 140 or diastolic BP 90 mm Hg for first
time during pregnancy – No proteinuria – BP returns to normal before 12 weeks postpartum – Final diagnosis made only postpartum – May have other signs or symptoms of
preeclampsia, for example, epigastric discomfort or thrombocytopenia
Ref : William obstetric 23rd edition,2009
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• 2. Preeclampsia and eclampsia syndrome• Preeclampsia:
Minimum criteria:– BP 140/90 mm Hg after 20 weeks' gestation – Proteinuria 300 mg/24 hours or 1+ dipstick
Ref : William obstetric 23rd edition,2009
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Increased certainty of preeclampsia :– BP 160/110 mm Hg – Proteinuria 2.0 g/24 hours or 2+ dipstick – Serum creatinine >1.2 mg/dL unless known to be previously
elevated – Platelets < 100,000/L – Microangiopathic hemolysis—increased LDH – Elevated serum transaminase levels—ALT or AST – Persistent headache or other cerebral or visual disturbance – Persistent epigastric pain
Ref : William obstetric 23rd edition,2009
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• Eclampsia:– Seizures that cannot be attributed to other causes
in a woman with preeclampsia
Ref : William obstetric 23rd edition,2009
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Ref : William obstetric 23rd edition,2009
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• 3. Superimposed Preeclampsia 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 < 100,000/L in women with hypertension and proteinuria before 20 weeks' gestation
Ref : William obstetric 23rd edition,2009
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• 4. Chronic Hypertension:– BP 140/90 mm Hg before pregnancy or diagnosed
before 20 weeks' gestation not attributable to gestational trophoblastic disease
or– Hypertension first diagnosed after 20 weeks'
gestation and persistent after 12 weeks postpartum
Ref : William obstetric 23rd edition,2009
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Investigation
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• UA (15/11)– Color : yellow– Appearance : clear– glu ,ketone– alb : neg– RBC : 2-3– WBC : 5-10– Epi : 5-10
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• CBCHb 12.4 Hct 38.2 WBC 23000Plt 430000 PMN 66 Lymph 26 MCV 78
• Coagulogram PT 9(11.2) PTT 28.1(29.2)INR 0.83
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• Blood chemistryBUN 5 , Cr 0.9Electrolyte : Na 136 K 2.8
HCO3 22.3 Cl 104LFT : pro 7.9 alb 3.8 glob 4.1
DB 0.06 TB 0.47 SGOT 19 SGPT 10 ALP 136
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Diagnosis
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• Management– Non-severe preeclampsia– severe preeclampsia– eclampsia
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Non severe preeclampsia• Admit• Bed rest• Monitoring for symptoms of pre-eclampsia ; daily kick counts• Body weight once a day• Blood pressure check every 6 hours , no antihypertensive drug
not shown to improve perinatal outcome• Laboratory testing: baseline 24-hour urine protein collection
at least 3 days• Non-stress test/biophysical profile• Termination
termclinical worsing (severe PIH)
Ref : Johns Hopkins Manual of Gynecology and Obstetrics, The, 3rd Edition
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Severe preeclampsia
• Principle1. Seizure prophylaxis2. Antihypertensive therapy3. Delivery
Ref : William obstetric 23rd edition,2009
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Severe preeclampsia
• 1. Seizure prophylaxis
Ref : William obstetric 23rd edition,2009
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Severe preeclampsia
• Seizure prophylaxis• LD : Give 4 g of magnesium sulfate diluted in 100 mL of
IV fluid administered over 15–20 min• MD :Begin 2 g/hr in 100 mL of IV maintenance infusion.• Monitor for magnesium toxicity:
The patellar reflex is present,Respirations are not depressed, andUrine output the previous 4 hr exceeded 100 mL
• Magnesium sulfate is discontinued 24 hr after deliveryRef : William obstetric 23rd edition,2009
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Severe preeclampsia
• Antihypertensive therapy• The three most commonly employed in North
America and Europe are hydralazine, labetalol, and nifedipine
• 1. nifedipine Dosage :– (soft capsule) 10 mg sublingual– (film-coat tablet) 10 mg oral
Ref : William obstetric 23rd edition,2009
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Severe preeclampsia
• 2. hydralazine Dosage : 5 mg IV
Ref : William obstetric 23rd edition,2009
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Severe preeclampsia
• Delivery– 1. induction– 2.route of delivery
Ref : William obstetric 23rd edition,2009
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Ecclampsia
• Management– Control of convulsions – Intermittent administration of an antihypertensive
medication – Avoidance of diuretics unless there is obvious
pulmonary edema– Delivery of the fetus to achieve a "cure."
Ref : William obstetric 23rd edition,2009
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Thank you