Definitions
Chronic hypertension is hypertension that is present at the booking visit or before 20 weeks or if the woman is already taking antihypertensive medication when referred to maternity services. It can be primary or secondary in aetiology.
Eclampsia is a convulsive condition associated with pre-eclampsia.
HELLP syndrome is haemolysis, elevated liver enzymes and low platelet count.
Gestational hypertension is new hypertension presenting after 20 weeks withoutsignificant proteinuria.
Pre-eclampsia is new hypertension presenting after 20 weeks with significant proteinuria.
Severe pre-eclampsia is pre-eclampsia with severe hypertension and/or with symptoms,and/or biochemical and/or haematological impairment.
Significant
proteinuria is defined in recommendation
Severity of hypertension
Mild hypertension diastolic blood pressure 90–99 mmHg, systolic blood pressure 140–149 mmHg.
Moderate hypertension diastolic blood pressure 100–109 mmHg, systolic blood pressure150–159 mmHg.
Severe hypertension diastolic blood pressure 110 mmHg or greater, systolic blood pressure 160 mmHg or greater
Etiology
Normal implantation , uterine spiral arteries undergo extensive remodeling as they are invaded by endovascular trophoblasts
Incomplete
invasion (decidual vessels , not myometrial vessels) causes preeclampsia
Pathophysiology
CNS
Thrombosis
of arterioles, microinfarcts, and petechial hemorrhage
Cerebral
edema: increased intracranial pressure
EEG:
nonspecific abnormality (75% in eclamptic patient)
Eyes
Serous
retinal detachment
Cortical
blindness
Pulmonary system
Pulmonary
edema
Aspiration
of gastric contents: the most dreaded complications of eclamptic seizures
Kidneys
Glomeruloendotheliosis
and Swelling of the glomerular capillary endothelium
Decreased
GFR
Proteinuria
Increase of
plasma uric acid, creatinine,
Liver
The spectrum
of liver disease in preeclampsia is broad
Subclinical
involvement
Rupture of
the liver or hepatic infarction
HELLP
syndrome: hemolysis, elevated liver enzymes and low platelets
CVS
Generalized
vasoconstriction, low-output, high-resistance state
Untreated
preeclamptic women are significantly volume-depleted
Capillary
leak
Cardiac
ischemia, hemorrhage, infarction, heart failure
Blood
Volume:
reduced plasma volume
Normal
physiologic volume expansion does not occur
Generalized
vasoconstriction and capillary leak
Hematocrit
Coagulation
Isolated
thrombocytopenia: <150,000/ml
Microangiopathic
hemolytic anemia
DIC (5%)
HELLP syndrome: in severe preeclampsia
schistocytes on the peripheral blood smear
lactic dehydrogenase > 600 u/L
total bilirubin > 1.2 mg/dl
aspartate aminotransferase >70 U/L
platelet count <100,000/mm3
Placenta
Acute
atherosis of spiral arteries: fibrinoid necrosis of the arterial wall, the
presence of lipid and lipophages and a mononuclear cell infiltrate around the
damaged vessel----vessel obliteration---- placental infarction
IUGR or stillbirth
Placental abruption
Chronic hypertension
Three types
1. Essential HT
Essential
hypertension is defined by a blood pressure greater than or equal to 140mmHg
systolic and/or 90mmHg diastolic confirmed before pregnancy or before 20
completed weeks gestation without a known cause.
2. White coat HT
3. Secondary HT
Important secondary causes of chronic hypertension in pregnancy include:
·
Chronic
kidney disease e.g. glomerulonephritis, reflux nephropathy, and adult polycystic kidney disease.
·
Renal
artery stenosis
·
Systemic
disease with renal involvement e.g. diabetes mellitus, systemic lupus erythaematosus.
·
Endocrine
disorders e.g. phaeochromocytoma, Cushing’s syndrome and primary
·
hyperaldosteronism.
·
Coarctation
of the aorta.
Gestational Hypertension
Gestational hypertension is characterised by the new onset of hypertension after 20 weeks gestation without any maternal or fetal features of preeclampsia, followed by return of blood pressure to normal within 3 months post-partum.
The earlier
the gestation at presentation and the more severe the hypertension, the higher
is the likelihood that the woman with gestational hypertension will progress to
develop preeclampsia or an adverse pregnancy outcome.
Preeclamsia
Preeclampsia
is a multi-system disorder unique to human pregnancy characterized by
hypertension and involvement of one or more other organ systems and/or the fetus.
Raised blood pressure is commonly but not always the first manifestation.
Raised blood pressure is commonly but not always the first manifestation.
Proteinuria is the most commonly recognized additional feature after hypertension but should not be considered mandatory to make the clinical diagnosis.
A diagnosis of preeclampsia can be made when hypertension arises after 20 weeks gestation and is accompanied by one or more of the following signs of organ involvement:
Renal involvement
Significant proteinuria – a spot
urine protein/creatinine ratio ≥ 30mg/mmol Serum or plasma creatinine > 90
μmol/L
Oliguria: <80mL/4 hr
Haematological involvement
Thrombocytopenia <100,000 /µL
Haemolysis: schistocytes or red cell
fragments on blood film, raised bilirubin, raised lactate dehydrogenase
>600mIU/L, decreased haptoglobin
Disseminated intravascular
coagulation
Liver involvement
Raised serum transaminases
Severe epigastric and/or right upper
quadrant pain.
Neurological involvement
Convulsions (eclampsia)
Hypereflexia with sustained clonus
Persistent, new headache
Persistent visual disturbances
(photopsia, scotomata, cortical blindness, posterior reversible encephalopathy
syndrome, retinal vasospasm)
Stroke
Pulmonary oedema
Fetal growth restriction (FGR)
Preeclampsia superimposed on chronic
hypertension
Superimposed preeclampsia
Pre-existing
hypertension is a strong risk factor for the development of preeclampsia.
Superimposed
preeclampsia is diagnosed when a woman with chronic hypertension develops one
or more of the systemic features of preeclampsia after 20 weeks gestation.
Symptoms of preeclamsia (impending symptoms):
·
severe
headache
·
problems
with vision, such as blurring or flashing before the eyes
·
severe
pain just below the ribs
·
vomiting
·
sudden
swelling of the face, hands or feet
Risk factors and prevention of gestatinal hypertension and preeclamsia
Advise women
at high risk of pre-eclampsia to take 75 mg of aspirin daily from
12 weeks
until the birth of the baby.
Women at high risk are those with any of the following:
·
hypertensive
disease during a previous pregnancy
·
chronic
kidney disease
·
autoimmune
disease such as systemic lupus erythematosis or antiphospholipid
·
syndrome
·
type
1 or type 2 diabetes
·
chronic
hypertension.
Advise women with more than one moderate risk factor for pre-eclampsia to
take 75 mg
of aspirin daily from 12 weeks until the birth of the baby.
Factors indicating moderate risk are:
·
first
pregnancy
·
age
40 years or older
·
pregnancy
interval of more than 10 years
·
body
mass index (BMI) of 35 kg/m2
·
or
more at first visit
·
family
history of pre-eclampsia
·
multiple
pregnancy.
Evaluation of Hypertension in
Pregnancy
History
Identification
and Complaint
Impending
symptoms
FM /abdominal
pain/PV bleeding
Past Medical
Hx, Past Family Hx
Past
Obstetrical Hx, Past Gyne Hx
Social Hx
Medications,
Allergies
Prenatal
serology, blood work
Assess for
Hypertension in Pregnancy risk factors
Physical
Vitals
Edema
Vision
Cardiovascular
Respiratory
Abdominal = Epigastric pain, RUQ pain
Neuromuscular
and Extremities = Reflex, Clonus
Fetus =
Leopold’s, FHB
Investigation for gestational hypertension
Any woman
presenting with new hypertension after 20 weeks gestation should be assessed
for signs and symptoms of preeclampsia.
Initially,
assessment and management in a day assessment unit may be appropriate.
If features
of preeclampsia are detected, admission to hospital is indicated. The presence
of severe hypertension, headache, epigastric pain, oliguria or nausea and
vomiting are ominous signs which should lead to urgent admission and management,
as should any concern about fetal wellbeing.
The
following investigations should be performed in all women with new onset
hypertension after 20 weeks gestation:
1. Spot urine albumin
2. Full blood count
3. Creatinine, electrolytes, urate
4. Liver function tests
5. Ultrasound assessment of fetal
growth, amniotic fluid volume and umbilical artery Doppler assessment.
Management of chronic hyper tension
In pregnant women with uncomplicated chronic hypertension aim to keep
blood
pressure lower than 150/100 mmHg.
Do not offer
pregnant women with uncomplicated chronic hypertension
treatment to
lower diastolic blood pressure below 80 mmHg.
Offer
pregnant women with target-organ damage secondary to chronic
hypertension
(for example, kidney disease) treatment with the aim of keeping
blood
pressure lower than 140/90 mmHg.
Management of gestational hypertension
Preeclampsia is a progressive disorder that will inevitably worsen if pregnancy continues.
Current therapy
does not ameliorate the placental pathology nor alter the pathophysiology or
natural history of preeclampsia.
Delivery is the definitive management and is
followed by resolution, generally over a few days but sometimes much longer.
Timing of birth in gestational HT
Do not offer birth before 37 weeks to women with gestational hypertensionwhose blood pressure is lower than 160/110 mmHg, with or without antihypertensive treatment.
For women
with gestational hypertension whose blood pressure is lower than
160/110 mmHg
after 37 weeks, with or without antihypertensive treatment,
timing of
birth, and maternal and fetal indications for birth should be agreed
between the
woman and the senior obstetrician.
Offer birth
to women with refractory severe gestational hypertension after a
course of
corticosteroids (if required) has been completed.
Timing of delivery in preeclamsia
Manage pregnancy in women with pre-eclampsia conservatively (that is, do not
plan
same-day delivery of the baby) until 34 weeks.
Offer birth
to women with pre-eclampsia before 34 weeks, after discussion with
neonatal and
anaesthetic teams and a course of corticosteroids has been
given if:
·
severe
hypertension develops refractory to treatment
·
maternal
or fetal indications develop as specified in the consultant plan
Offer birth
to women who have pre-eclampsia with mild or moderate
hypertension
at 34+0 to 36+6 weeks depending on maternal and fetal condition,
risk factors
and availability of neonatal intensive care.
Control of HT
Labetalol is
the 1st line drug , but its expensive and availability is restricted
in Sri Lanka .
Table 1
Drugs which can be used to control blood pressure during pregnancy
Drugs
|
Dose
|
Action
|
Contraindication
|
Practice points
|
Methyl
Dopa
|
250- 1000mg tds
|
Central
|
Depression
|
Slow onset of action over 24
hours, dry mouth, sedation,
depression, blurred vision
Withdrawal effects: rebound
hypertension
|
Labetalol
|
100- 400mg qds
|
Blocker
with
mild
alpha
vasodilator
effect
|
Asthma, chronic
airways limitation
|
Bradycardia, bronchospasm,
headache, nausea, scalp
tingling (labetalol only) which
usually resolves within 24
hours
|
Nifedipine
|
20-60mg bd
|
Ca channel
antagonist
|
Aortic stenosis
|
Severe headache in first 24
hours
Flushing, tachycardia,
peripheral oedema,
constipation
|
Prazosin
|
0.5-5 mg qds
|
Alpha blocker
|
Orthostatic
hypotension
especially after first
dose
|
|
Hydralazine
|
25-50 mg qds
|
Vasodilators
|
Flushing, headache, nausea,
lupus-like syndrome
|
Table
2.Drugs used to control severe HT
Dose
|
Route
|
Onset of action
|
Adverse effect
|
|
Labetalol
|
20 -80mg
Max 80mg
|
IV bolus over 2 min, Repeat every 10
mins prn
|
Maximal effect usually occurs within 5
minutes after each dose
|
Bradycardia:
Hypotension
Fetal Bradycardia
|
Nifedipine
|
10-20MG tablet
Max 40mg
|
Oral
|
30-45 minutes
Repeat after 45 minutes
|
Headache
Flushing
|
Hydralazine
|
10mg
(First dose 5mg if fetal compromise])
Max 30mg
|
IV bolus, repeat every 20mins
|
20 min
|
Flushing
Headache
Nausea
Hypotension
Tachycardia
|
Diazoxide
|
15-45mg
Max 300mg
|
IV rapid bolus
|
3-5 mins, repeat after 5 mins
|
Flushing
Warmth along Injection site
Hypotension
|
Eclamsia
Preeclampsia
complicated by generalized tonic-clonic convulsions
Appear
before , during , or after labor
Most common
in last trimester
1/3 of
eclamsia occur in the postpartum.
Usually
begin in facial twitch , entire body rigid , generalized muscle contraction ,
jaw open & close violently
Major complications
Cerebrovascular
hemorrhage
placental
abruption
aspiration pneumonia
pulm edema
arrest
ARF
death
Pathophysiology
Pulmonary
edema from aspiration pneumonitis or heart failure
Death from
massive cerebral hemorrhage
Hemiplegia
from sublethal hemorrhage
Blindness
from retinal detachment or occipital lobe ischemia & edema
Persistent
coma due to uncal herniation
Rarely
eclampsia followed by psychosis
Diferential diagnosis
epilepsy
encephalitis
meningitis
cerebral
tumor
cysticercosis
ruptured
cerebral aneurysm
management
A,B,C management
Control BP
Control fits
Delivery of the baby
Controlling fits
Mgso4 is the 1st line drug
Dose 4g IV over 20min followed by infusion of 1g /h.
Continue infusion for 24 h from delivery or from last fits .
Effective anticonvulsant without producing CNS depression in
either mother or infant .Not given to treat HT
Monitor for mg toxicity
Toxicity:
·
Diminished
or loss of patellar reflex
·
Diminished
respiration
·
Muscle
paralysis
·
Blurred
speech
·
Cardiac
arrest
Reversal of toxicity
Reversal of toxicity:
Slow i.v . 10% calcium gloconate
Oxygen supplementation
Cardiorespiratory support
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