Hypertensive emergencies in pregnancy
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Transcript of Hypertensive emergencies in pregnancy
SUMC | Nikita Joshi, MD ([email protected]) Slide 1 of 18
Hypertensive Emergencies in Pregnancy
Nikita K Joshi MDClinical Instructor of SurgeryEmergency MedicineStanford University Medical Center
@njoshi8
SUMC | Nikita Joshi, MD ([email protected]) Slide 2 of 18
Objectives
Diagnostic Criteria
End Organ Consequences
Medical Management
SUMC | Nikita Joshi, MD ([email protected]) Slide 3 of 18
Chronic (Preexisting)
HTN
Gestational HTN Preeclampsia Severe
Preeclampsia Eclampsia
Diagnostic Criteria
SUMC | Nikita Joshi, MD ([email protected]) Slide 4 of 18
Epidemiology
HTN disorders complicates 5-10% of
all pregnancies
Preeclampsia complicates 3-9% of
pregnancies in developed countries
Accountable for 10-15% of maternal
death in developed countries
Lo JO. Hypertensive disease of pregnancy and maternal mortality. Curr Opin Obstet Gynecol. 2013 Apr;25(2):124-32. PMID: 23403779.
SUMC | Nikita Joshi, MD ([email protected]) Slide 5 of 18
Morbidity and Mortality
HTNCADCVA
ESRD
IUGRSGAHTNCAD
Maternal Neonatal
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Maternal History Family History Fetus
Primipaternity Smoking
Risk Factors
Uzan J. Pre-eclampsia: pathophysiology, diagnosis, and management. Vasc Health Risk Manag. 2011;7:467-74. PMID: 21822394.
SUMC | Nikita Joshi, MD ([email protected]) Slide 7 of 18
Preeclampsia
Unknown Etiology
Challenges in Prevention, Screening, Diagnosis, Treatment
Disease of Multiple Theories
Lack of animal model
Roberts JM. If we know so much about preeclampsia, why haven’t we cured the disease? J Reprod Immuol. 2013 Sep;99(1-2):1-9. PMID 23890710.
SUMC | Nikita Joshi, MD ([email protected]) Slide 8 of 18
Current TheoryAbnormal Placentation
Fetal Cytotrophoblasts fail to adopt invasive
endothelial phenotype
Invasion of spiral arteries is shallow
Remain small-caliber resistance vessels
Vikse BE. Preeclampsia and the Risk of End-Stage Renal Disease. NEJM. 2008. Aug 21;359(8):800-9. PMID: 18716297.
SUMC | Nikita Joshi, MD ([email protected]) Slide 9 of 18
Abnormal Placentation Endothelial Dysfunction
VasoconstrictionActivation of coagulation cascade
Loss of fluid from intravascular space
Decreased organ perfusionInflammationHemorrhage
Ischemia
Pathophysiology
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End Organ Consequence
Liverreduced hepatic
blood flow leads to ischemia and
periportal hemorrhage
CardiopulmCapillary leakage
leading to nondependent edema, pulm
edema
KidneyGlomerular
capillary endotheliosis and vasospasm reduce
GFR
CranialVasospasm leading
to headache, seizures, CVA
PlacentaPlacental abruption
FetusGrowth
restriction, oligohydramnios
HemePlatelet level
proportional to severity of disease
VisionRetina artery
constriction,visual changes
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Intubation
Magnesium
BP Control
Medical Management
Delivery
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Hypertensive Therapy
LabetalolBeta > Alpha Blocker
Vasodilation10-20 mg IVP
1-2 mg/min up to 300 mg
HydralazineVascular smooth muscle
relaxer5 mg IVP
0.5-10 mg/hr
SUMC | Nikita Joshi, MD ([email protected]) Slide 13 of 18
Evidence Review
Cochrane Review 2013
35 Randomized Control Trials3573 Women included
Not enough evidence to show which drug is most effective
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Treatment Algorithm
Uzan J. Pre-eclampsia: pathophysiology, diagnosis, and management. Vasc Health Risk Manag. 2011;7:467-74. PMID: 21822394.
SUMC | Nikita Joshi, MD ([email protected]) Slide 15 of 18
Magnesium
Prevention & Treatment of
Seizures
Fetal neural protection for
preterm delivery
Short-term prolongation of pregnancy
(48 hrs)
2013 Committee Opinion
SUMC | Nikita Joshi, MD ([email protected]) Slide 16 of 18
Mechanism of Action
VasculatureCa2+ Antagonist
Smooth muscle relaxationVasodilation
Relieve vasospamDecreased vascular
resistance
Anticonvulsant NMDA AntagonistDecreases effect of
glutamateLimits neuronal depolarization
Increases seizure threshold
Cerebral EndotheliumCa Antagonist
Decrease stress fiber contraction
Decrease paracellular BBB permeability
Limits cerebral edema
Euser AG. Magnesium sulfate for the treatment of eclampsia: a brief review. Stroke. 2009. Apr;40(4):1169-75. PMID: 19211496.
SUMC | Nikita Joshi, MD ([email protected]) Slide 17 of 18
Future Directions
Medical Management
Warrington JP. Recent advances in the understanding of the pathophysiology of preeclampsia. Hypertension. 2013 Oct;62(4):666-73. PMID: 23897068.
End Organ Consequences
Diagnostic Criteria
SUMC | Nikita Joshi, MD ([email protected]) Slide 18 of 18
References• Abalos E. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database of Systematic
Reviews. 2007 (1), CD0002252.• Berg CJ. Pregnancy-Related mortality in the United States, 1998-2005. Obstet Gynecol. 2010. Dec;116(6):1302-1309.• Duley L. Magnesium sulphate and other anticonvulsants for women with pre-eclampsia. Cochrane Database Syst Rev. 2010 Nov 10;
(11):CD000025.• Duley L. Magnesium sulphate versus phenytoin for eclampsia. Cochrane Database Syst Rev. 2010 Oct 6;(10):CD000128.• Duley L. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database Syst Rev. 2013 Jul31;7:CD001449.• Euser AG. Magnesium sulfate for the treatment of eclampsia: a brief review. Stroke. 2009. Apr;40(4):1169-75. PMID: 19211496.• Lo JO. Hypertensive disease of pregnancy and maternal mortality. Curr Opin Obstet Gynecol. 2013 Apr;25(2):124-32. PMID: 23403779.• Roberts JM. If we know so much about preeclampsia, why haven’t we cured the disease? J Reprod Immuol. 2013 Sep;99(1-2):1-9.
PMID 23890710.• Rosser ML. Preeclampsia: an obstetrician’s perspective. Adv Chronic Kidney Dis. 2013 May;20(3):287-96. PMID: 23929395.• Samadi AR. Maternal hypertension and associated pregnancy complications among african-american and other women in the United
States. Obstet Gynecol. 1996. Apr;87(4):557-63. PMID: 8602308.• Uzan J. Pre-eclampsia: pathophysiology, diagnosis, and management. Vasc Health Risk Manag. 2011;7:467-74. PMID: 21822394.• Vikse BE. Preeclampsia and the Risk of End-Stage Renal Disease. NEJM. 2008. Aug 21;359(8):800-9. PMID: 18716297.• Warrington JP. Recent advances in the understanding of the pathophysiology of preeclampsia. Hypertension. 2013 Oct;62(4):666-73.
PMID: 23897068.