Hypertensive Disorders of Pregnancy Blok 25
-
Upload
ali-husain-abdul-kadir -
Category
Documents
-
view
225 -
download
0
Transcript of Hypertensive Disorders of Pregnancy Blok 25
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
1/37
HYPERTENSIVE DISORDERS OFPREGNANCY
Adrian Setiawan, M.D.
Department of Obstetrics andGynecology,Faculty of MedicineKRIDA WACANA CHRISTIAN UNIVERSITY
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
2/37
General Classification
Preeclampsia or Eclampsia (hypertension andproteinuria unique to pregnancy)
Chronic hypertension Chronic hypertension with superimposed
preeclampsia
Gestational or transient hypertension(National Institutes of Health Working GroupReport on High Blood Pressure in Pregnancy,2000.
Adopted by ACOG ,2002)
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
3/37
Diagnosis of Hypertension
Blood pressure readings vary depending onmaternal position and the gestational age ofthe pregnancy.
Tends to be lower in the LLD position, higherin the sitting position.
In the supine position some elevatedpressure, some have supine hypotension dueto compression of the vena cava by theuterus.
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
4/37
Arterial blood pressure normally declinesduring 1st and 2nd trimester
The diagnosis of hypertension should bereserved for patients with a systolic greaterthan or equal to 140 mmHg or a diastolicgreater than or equal to 90 mmHg.
BP should be taken in the sittting or lateraldecubitus position after woman has rested atleast 10 minutes.
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
5/37
PREECLAMPSIA
A syndrome unique to pregnancy, characterized bythe new onset of hypertension and proteinuria in thelatter half of gestation divided into mild and severepreeclampsia.
Classically affecting the first pregnancy, but alsooccurs in multiparas or change in husband
Two criteria for diagnosis of preeclampsia : the BP 140/90 mmHg and development of new onset
proteinuria after 20th wks AOG. Proteiunuria defined as 0.3 gram protein in a 24
hour urine collection ,
usually correlates 30 mg/dl (+1 on dipstick)
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
6/37
Criteria for Severe
Preeclampsia BP 160/110 mmHg at rest on two occasions
at least 6 hr apart
Proteinuria 5 gram in a 24 h urine collectionor qualitative +3
Oliguria (< 500 ml in 24 hr)
Cerebral or visual disturbances Pulmonary edema or cyanosis
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
7/37
Epigastric or right upper quadrant pain
Impaired liver function (elevated liver
enzyme) Thrombocytopenia
Fetal growth restriction
(ACOG, Practice Bulletin No.33, Washington,DC,2002)
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
8/37
Eclampsia
Is the presence of tonic clonic seizures in awoman with preeclampsia that cannot beattributed to other causes.
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
9/37
Chronic Hypertension
The diagnosis of chronic hypertensionrequires at least one of the following : knownhypertension before pregnancy, developmentof hypertension before 20 weeks gestation,or, in cases in which hypertension is firstnoted during pregnancy, persistence of
elevated blood pressures greater than 12weeks postpartum.
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
10/37
Chronic Hypertension with
Superimposed Preeclampsia The diagnosis of gestationla hypertension is
made if hypertension without proteinuria firstappears after 20 weeks gestation or within 48 to
72 hours after delivery and resolves by 12 weekspostpartum.
The diagnosis of gestational hypertension canonly be made in retrospect, if the pregnancy has
been completed without the development ofproteinuria and if the blood pressure hasreturned to normal before the 12 weekpostpartum.
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
11/37
Etiology Preeclampsia /
Eclampsia Preeclampsia is called a disease of theories,
because genetic,immunologic,vascular,hormonal, nutritional, and behavioral factorshave all been proposed as causes. No singledefinitive cause has been identified and theorigins of the disease are considered to be
multifactorial.
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
12/37
Placental ischemia, or hypoxia appears to becentral to the development of the diseaseand has been attributed to failure of thecytotrophoblasts to adequately invade theuterine spiral arteries and establish the lowresistance uteroplacental circulation
characteristic of normal pregnan
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
13/37
It is postulated that uteroplacental ischemiaresults in oxidative stress leading toproduction and release of toxins that enterthe circulation and cause widespreadinflammation, endothelial dysfunction andactivation of the coagulation system.
Endothelial dysfunction leads to imbalancebetween different classes of locally producedvasoconstrictors and vasodilators.
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
14/37
Endothelial changes also appear to involve arelative deficiency in the production of nitricoxide, a vasodilator and inhibitor of plateletaggregation along with increased production ofendothelin-1. Endothelin 1 is an extremelypotent vasoconstrictor and activator platelets.
The net effect of these processes would bespread vasoconstriction leading to hypoxic and
ischemic damage in different vascularbeds,systemic hypertension, the HELLPsyndrome or DIC and worsening placentalischemia.
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
15/37
Pathophysiology
Generalized vasospasm
GFR and renal blood flow are significantly
lower Damage of glomerular membranes ,
increasing their permeability to proteins andleading to proteinuria.
Cerebral vascular resistance is high inpatients with PE and Eclampsia
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
16/37
Pathology
Lack of decidualization of the myometrialsegments of the spiral arteries
Glomerular capillary endotheliosis Ischemia, hemorrhage and necrosis in many
organs, presumably secondary to arteriolarconstriction.
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
17/37
Clinical and laboratory
manifestations
Weight gain and edema
Elevation of blood pressure
Proteinuria Increase serum uric acid concentration
Thrombocytopenia
Liver function : elevated serum enzyme levels(alanine aminotransferase and aspartateaminotransferase)
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
18/37
Retroplacental hemorrhage or abruptio
Visual disturbance
Laboratory : CBC, platelet count,LDH,Ureum, creatinin and uric acid, urinalysis 24hour urine for protein and creatinine, liverfunction tests.
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
19/37
Evaluation and management
Delivery is the only definitive cure forpreeclampsia and eclampsia after a period ofstabilization, regardless of the gestationalage of the fetus.
Seizure prophylaxis : magnesium sulfate
Antihypertensive therapy : hydralazine,
labetalol, nifedipine, methyldopa
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
20/37
MANAGEMENT OF PREECLAMPSIA
ADEQUAT AND PROPER PRENATAL CARE
IDENTIFICATION OF WOMEN AT HIGH RISK
EARLY DETECTION BY THE RECOGNATION OF CLINICAL
SIGNS AND SYMPTOMS
THE PROGRESSION OF CONDITION TO SEVERE STATE
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
21/37
MATERNAL AND PERINATAL OUTCOME IN WOMEN WITH MILD
PREECLAMPSIA, > 36 WEEKS GESTATION ARE USUALLY
FAVOURABLE
MATERNAL AND PERINATAL OUTCOMES DEPEND ON :
GESTATIONAL AGE AT TIME OF DISEASE ONSET
SEVERITY OF DISEASE
QUAITY OF MANAGEMENT
PRESENCE OR ABSENCE OF PRE-EXISTING MEDICAL
DISORDERS
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
22/37
MILD PREECLAMPSIA
AMBULATORY CAREBED REST : NOT NECESSARILY
REGULAR DIET, NO SALT RESTRICTION
PRENATAL VITAMINNO OTHER MEDICATION : ANTI HYPERTENSIVE,
SEDATIVE, DIURETICS
ANTENAL VISIT : EVERY WEEK
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
23/37
HOSPITAL CARE
PERSISTENT HYPERTENSION MORE THAN 2 WEEKS
PERSISTENT PROTENURIA MORE THAN 2 WEEKS
ABNORMAL LABORATORY TEST
ABNORMAL FETAL GROWTH
ONE OR MORE SIGN AND SYMPTOM SEVERE PE
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
24/37
OBSTETRIC MANAGEMENT
GESTATIONAL AGE < 37 WEEKS
~ SIGN AND SYMPTOM ARE NOT WORSENED
MAINTAIN UNTIL TERM
GESTATIONAL AGE > 37 WEEKS
~ WAIT UNTIL THE ONSET OF LABOR
~ CERVIX IS FAVORABLE, INDUCTION OF LABOR
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
25/37
SEVERE PREECLAMPSIA
MEDICAL TREATMENT
OBSTETRIC MANAGEMENT :
CONSERVATIVE : - PREGNANCY 37 WEEKS
ACTIVE : - PREGNANCY 37 WEEKS
- FETAL INDICATION- MATERNAL INDICATION
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
26/37
MEDICAL TREATMENT :
HOSPITALIZE
TOTAL BED REST
FLUID THERAPY : RINGER LACTATE, DEXTROSE 5%.
Mg SO4 IV
ANTI HYPERTENSION :
HYDRALAZINLABETALOL
NIFEDIPINE : 10 20 mg / ORALLY EVERY - 1 H,
MAX : 120 mg / 24 Hours
DIURETIC : NOT RECOMMENDED ANTI OXYDANT : N-ACETYL CYSTEIN
CORTICOSTEROID + LUNG MATURITY 34 WEEKS
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
27/37
OBSTETRIC MANAGEMENT
CONSERVATIVE MANAGEMENT:
GOAL : TO IMPROVE INFANT OUTCOME,
WITHOUT COMPROMISING THE MOTHER
PREGNANCY 37 WEEKS, IMPENDING ECLAMPSIA (-)
ACTIVE MANAGEMENT : TO TERMINATE THE PREGNANCY
INDICATION
FETAL : - PREGNANCY 37 WEEKS
- IUGR AND ABNORMAL
BIOPHYSICAL PROFILE
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
28/37
MATERNAL : - PERSISTENT HYPERTENTION- IMPENDING ECLAMPSIA
- COMPLICATION : HELLP SYNDROME,
ABRUPTIO PLAC., OLIGURIA
ROUTE OF DELIVERY :
VAGINAL DELIVERY IS PREFERABLE THAN CS.
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
29/37
ECLAMPSIA : PE + CONVULSION
BASIC MANAGEMENT :
CONTROL THE AIRWAY, BREATHING, CIRCULATION (ABC)
STABILIZE THE MOTHER
CONTROL CONVULSION
CORRECT MATERNAL HYPOXEMIA / ACIDEMIA
PREVENT COMPLICATION : HYPERTENSION CRISIS
TERMINATE PREGNANCY
MEDICAL TREATMENT :
SAME AS SEVERE PREECLAMPSIA
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
30/37
COMPLICATION : P.E AND ECLAMPSIA
MOTHER
BABY
HELLP SYNDROME
LIVER RUPTURED
PULMONARY EDEMA
RENAL FAILURE
ABRUPTIO PLACENTAE
DIC
CEREBROL VASCULER ACCIDENT
MATERNAL DEATH
IUGR
PREMATURE LABOR
INTRA CRANIAL HAEMORRHAGE
CEREBRAL PALSY
PNEUMO THORAX
IUFD
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
31/37
HELLP SYNDROME
FIRST DISCRIBED BY WEINSTEIN 1982:
ACRONYM OF : H : HEMOLYSIS
EL : ELEVATED LIVER ENZYM
LP : LOW PLATETLED COUNT
INCIDENCE : 2%-12% AMONG PATIENTS WITH
PREECLAMPSIA.
30% OCCURS IN POSTPARTUM
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
32/37
CRITERIA DIAGNOSTIC
LABORATORY FINDING:
HEMOLYSIS
ABNORMAL PERIPHERAL SMEAR : SCHISTOCYTES ANDBURR CELLS
TOTAL BILIRUBIN LEVEL > 1,2 mg/Dl
LACTATE DEHYDROGENASE LEVEL > 600 /L
ELEVATED LIVER FUCTION
SGOT LEVEL 70 / L (LDH)
LACTATE DEHYDROGENASE LEVEL > 600 /L
LOW PLATELET COUNT
PLATELET COUNT < 100.000/m3
THE LABORATORY DIAGNOSTIC CRITERIA USED AT THE UNIVERSITY OF TENNESSEE
DIVISION OF MATERNAL FETAL MEDECINE, MEMPHIS TN. WITLIN AND SIBAI (1999)
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
33/37
CLASS I : PLATELET 50.000/m3
WITH : LDH
600 U/L
SGOT 40 U/L
CLASS II : PLATELET 50.000/m3 - < 100.000/m3
WITH : LDH 600 U/L
SGOT
40 U/L
CLASS II : PLATELET 50.000/m3 - < 150.000/m3
WITH : LDH
600 U/L
SGOT 40 U/L
CLASSIFICATION BASED ON PLATELET COUNT
(MISSISIPPI):
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
34/37
MANAGEMENT OF HELLP SYNDROME
MATERNAL STABILISATION IS THE MAYOR PRIORITY
BEGIN WITH A STANDART MANAGEMENT OF SEVERE
PREECLAMPSIA
HELLP SYNDROME IS NOT AN INDICATION FOR CS
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
35/37
MEDICAL MANAGEMENT
SAME AS SEVERE PREECLAMPSIA
WHEN THROMBOCYTE COUNT IS < 50.000 mm3, 10 UNITS
OF THROMBOCYTE OR FRESH WHOLE BLOOD MUST BE
GIVEN
WHEN PATIENT IS COMATOUS, SHE MUST BE TAKEN TO
THE ICU
WHEN THROMBOCYTE COUNTS IS < 50.000/mm3
FIBRINOGEN LEVEL, PROTHROMBINE TIME, PARTIAL
THROMBOPLASTIN TIME, D-DIMMER MUST BE CHECKED
TO FIND DIC
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
36/37
OBSTETRIC MANAGEMENT
WHEN MOTHERS IS STABLE TERMINATE THE
PREGNANCY OR CONSERVATIVE MANAGEMENT.
CONSERVATIVE MANAGEMENT CAN BE DONE
WHEN :
THE BLOOD PRESSURE < 160/110 m g
THE OLIGURIA RESPONSE TO FLUID
REPLACEMENT
THERE IS NO EPIGASTRIC PAIN
THE GESTATIONAL AGE IS < 34 WEEKS
-
8/10/2019 Hypertensive Disorders of Pregnancy Blok 25
37/37