Hypertensive disorders of pregnancy II
Transcript of Hypertensive disorders of pregnancy II
Part I : Complications of Severe Pre-eclampsia
Part II : Chronic Hypertension in Pregnancy
Dr.Nadia Mudher Al-Hilli FICOG
Department of Obs&Gyn College of Medicine
University of babylon
Objectives of this lecture
• Learn the complicatios that might develop in a patient with severe PE & how to deal with them
• How to deal with a patient with eclamptic fit
• Understand the risk & complications of chronic HT in pregnancy
• Managing chronic HT in pregnancy
Complications of Preeclampsia
Complication of severe pre-eclampsia are:
• Eclampsia
• HELLP syndrome
• DIC
• Adult Respiratory Distress Syndrome (ARDS)
• Pulmonary oedema
• Acute renal failure
• Placental abruption
• Intrauterine growth restriction (IUGR)
• Intrauterine fetal death
Eclampsia: • defined as new-onset tonic-clonic seizure in
an otherwise healthy woman with hypertensive disorder of pregnancy
• 44% occur postnatally, 38% antepartum & 18% intrapartum.
• The pathophysiology
•is associated with high maternal and neonatal
morbidity and mortality.
Management: • General measures:
• Do not leave the patient alone
• Call for help
• Inform consultant
• Prevent maternal injury during convulsion
–Air way:
–Breathing:
–Circulation:
–Secure intravenous access
–Urinary catheter to assess urinary out put
–Fluid input/output chart & monitoring of BP every 15-30 min and other vital signs
anticonvulsant therapy • Magnesium sulphate: membrane stabilizer &
vasodilator & reduces intracerebral ischaemia
• Loading dose 4gm bolus iv over 15-20 min followed by continuous infusion of 1gm/hr for 24 hrs fron last fit or from delivery
signs of magnesium toxicity • loss of deep tendon reflexes
• respiratory depression
• cardiac standstill.
• So, the patient should be monitored hourly by patellar reflex, respiratory rate & oxygen saturation. & urine output
Mg sulphate indications in severe PE
• Consider the need for magnesium sulfate treatment, if 1 or more of the following features of severe pre-eclampsia is present :
• ongoing or recurring severe headaches • visual scotomata • nausea or vomiting • epigastric pain • oliguria and severe hypertension • progressive deterioration in laboratory blood tests
(such as rising creatinine or liver transaminases, or falling platelet count).
• Blood pressure should be controlled using intravenous hydralazin or labetolol
• limit maintenance fluids to 80 ml/hour unless there are other ongoing fluid losses (for example, haemorrhage)
• Delivery : Choose mode of birth according to the clinical circumstances and the woman's preference.
• Postpartum care : should be in critical care setting
• Transfusion of red cells, platelets, fresh frozen plasma and cryoprecipitate or fibrinogen concentrate are required as indicated clinically and by blood and coagulation tests.
• HELLP Syndrome: the association of haemolysis (H) elevated liver enzymes (EL) & low platelet count ( LP)
• DIC with low fibrinogen may coexist.
• Definitive treatment of severe pre-eclampsia and HELLP requires delivery of the fetus
• Give antenatal corticosteroid for fetal lung maturation.
Chronic Hypertension: • Effect 2-4 % of pregnant women. Over 90% of cases
are due to essential hypertension
• causes of chronic hypertension ( secondary) include:
• Chronic renal disease
• Renal artery stenosis
• Coarctation of the aorta
• Collagen vascular disease
• Pheochromocytoma
• Cushing's syndrome
• Conn's syndrome (primary hyperaldosteronism)
High-risk characteristics in women with CHT include:
• Maternal age >40 years
• Duration of hypertension > 15 years
• BP ≥160/110 mmHg
• Diabetes
• Renal disease
• Cardiomyopathy
• Connective tissue disease
• Coarctation of the aorta
• Previous pregnancy with perinatal loss
Preconception assessment & councelling:
• life style modification • anti-hypertensive therapy: • Physical examination • Investigations: renal function test, urinalysis, 24 h urine collection for protein excretion creatinine clearance CXR ECG echocardiography
Complications of CHT in pregnancy: • Superimposed PE
• Abruptio placentae
Antihypertensive therapy: reduces the risk of severe hypertension but does not reduce the risk of superimposed PE, preterm delivery or perinatal death
• diuretics decrease blood volume & cause undesirable physiological effect, congenital anomalies & neonatal complications.
• beta-blockers cause IUGR
• ACE inhibitors & angiotensin receptor blockers cause renal toxicity & increased risk of congenital abnormalities in the fetus & should be changed
Treatment of chronic hypertension Offer pregnant women with chronic
hypertension advice on:
• weight management
• exercise
• healthy eating
• lowering the amount of salt in their diet.
Continue with existing antihypertensive treatment if safe in pregnancy, or switch to an alternative treatment, unless:
• sustained systolic blood pressure is less than 110 mmHg or
• sustained diastolic blood pressure is less than 70 mmHg or
• the woman has symptomatic hypotension.
• Offer antihypertensive treatment to pregnant women who have chronic hypertension and who are not already on treatment if they have:
• sustained systolic blood pressure of 140 mmHg or higher or
• sustained diastolic blood pressure of 90 mmHg or higher.
• When using medicines to treat hypertension in pregnancy, aim for a target blood pressure of 135/85 mmHg . (NICE Guigelines 2019) https://www.nice.org.uk/guidance/ng133/resources/hypertension-in-pregnancy-diagnosis-and-management-pdf-66141717671365
• Consider labetalol to treat chronic hypertension in pregnant women.
• Consider nifedipine for women in whom labetalol is not suitable, or methyldopa if both labetalol and nifedipine are not suitable.
• Offer pregnant women with chronic hypertension aspirin 75–150 mg once daily from 12 weeks.
• Offer placental growth factor (PlGF)-based testing to help rule out pre-eclampsia between 20 weeks and up to 35 weeks of pregnancy, if women with chronic hypertension are suspected of developing pre-eclampsia.
Fetal monitoring in chronic hypertension: • carry out an ultrasound for fetal growth and
amniotic fluid volume assessment, and umbilical artery doppler velocimetry at 28 weeks, 32 weeks and 36 weeks.
• only carry out cardiotocography if clinically indicated.
• For women with chronic hypertension whose blood pressure is lower than 160/110 mmHg deliver after 37 weeks.
• After delivery continue follow up of BP & antihypertensive therapy as needed