Hypertensive disorders in pregnancy

Int

Definition
Systolic BP 140 mmHg or Diastolic BP 90 mmHg Measure in sitting position Measure 2 time at least 6 hr interval

Epidemiology
Incidence 5-7 % of pregnant women 4% Mild preeclampsia 2% Severe preeclampsia

Risk factor
Primigravida Vascular disease eg. DM, obesity Family history of HT disorder in pregnancy Chorionic villi mass eg. Twin pregnancy, Hydratidiform mole, Hydrop fetalis

Pathophysiology
Angiotensin II sensitivity Endothelial cell activation Thromboxane A2 Prostacyclin, Prostaglandin E2

Vasoconstriction Vascular leakage Activate Coagulation factor

Systemic effect of preeclampsia

CVS increase peripheral vascular resistance RS pulmonary edema Neuro cerebral edema, ischemia Renal oliguria, proteinuria, ATN Liver ischemic necrosis, subcapsular hemorrhage Hemato DIC, thrombocytopenia Retina retinal arterial spasm, retinal detachment, transient blindness Placenta placental infarction

Symptom & Sign

Hypertension Excessive weight gain (> 1 kg/wk) Edema Headache Blurred vision Epigastric pain Hyperreflexia

Roll over test

Prediction of preeclampsia GA 28-32 wk DBP in Left lateral decubitus 5 min DBP in Supine 15 min 20 mmHg Higher in supine position => test +ve

Classification of Hypertensive disorders in pregnancy

1. Chronic HT
HT before pregnancy or GA 20 wk HT sustain > 12 wk postpartum Sign of Chronic HT eg. LVH HT, no proteinuria Not sustain > 12 wk postpartum HT, proteinuria (> 300 mg/day or 1+) HT after GA 20 wk (except mole, twin, fetal hydrop)

2. Gestational HT (Transient HT)

3. Preeclampsia

Classification of Hypertensive disorders in pregnancy

4. Eclampsia
Unidentified cause seizure in preeclampsia pt. Preeclampsia in Chronic HT pt. Proteinuria > 300 mg/day or significantly increase proteinuria SBP increase 30 mmHg or DBP increase 15 mmHg or Platelet < 100,000

5. Superimposed preeclampsia

Classification of preeclampsia
Finding BP Proteinuria Headache Blurred vision Epigastric pain Oliguria (<500 ml/day) Seizure Serum Cr Platelet Liver enz IUGR Pulmonary edema Mild preeclampsia < 160/110 mmHg < 2 gm/day (1+,2+) no no no no no normal normal Slightly elevated no no Severe preeclampsia 160/110 mmHg > 2 gm/day (3+,4+) yes yes yes yes yes elevated < 100,000 Markly elevated yes yes

Management of Mild preeclampsia

1. 2. 3. 4. OPD case, Admit if indicated Bed rest, sedatives eg. Diazepam High protein diet Investigation : CBC, UA, BUN, Cr, LFTs, uric acid, 24hr urine protein*(optional) 5. Close Monitor pt
BP q 4 hr, urine dipstick OD, BW 2 time/wk Clinical : headache, blurred vision, epigastric pain

Management of Mild preeclampsia

5. Monitor fetus
Fetal movement count, FHS NST 1-2 time/wk USG : EFW, presentation, AF

6. No diuretic or antihypertensive agents 7. Termination of pregnancy if

Term pregnancy Fetal compromise

Management of Severe preeclampsia

1. Admit and close monitor 2. Investigation : CBC, UA, BUN, Cr, LFTs, uric acid, 24hr urine protein*(optional) 3. Prevent seizure by give Magnesium sulfate
Loading dose 5 gm iv Maintenance 1-2 gm/hr continue until 24 hr postpartum

Management of Severe preeclampsia

Close monitor magnesium toxicity

Urine output > 30 ml/hr DTR > 1+ RR > 12 /min

10% Calcium gluconate 10 ml for Mg toxicity

4. BP control if DBP > 110 mmHg, give Hydralazine 510 mg iv repeat q 20 -30 min keep DBP 90-100 mmHg (Labetalol 20 mg iv, Nifedipine 10 mg oral, Nicardipine 1 mg iv)

Management of Severe preeclampsia

5. If GA > 34 wk, terminate pregnancy after Tx 4-6 hr 6. If GA 32-33 wk, assess maternal, fetal well being, corticosteriod for lung maturity, terminate if indicated or after Tx 48 hr 7. If GA 24-31 wk, assess maternal, fetal well being, corticosteriod for lung maturity, try conservative Rx, close monitoring 8. If GA < 24 wk, terminate pregnancy after 4-6 hr

Indication for termination of pregnancy

Maternal indication
Uncontrolled severe HT after maximum recommended dose at least 2 antihypertensive agents Eclampsia Pulmonary edema Abruptio placentae Oliguria (<0.5 ml/kg/hr) that does not resolve with fluid intake Signs of imminent eclampsia ( severe headache, blurred vision) Persistent epigastric or RUQ tenderness HELLP syndrome or Platelet counts < 100,000 Deterioration of renal function ( Cr > 1.4)

Indication for termination of pregnancy

Fetal indication
Repetitive late decelerations Severe variable decelerations Short term variability < 3 ms Biophysical profile 4 on 2 occasions at 4 hr EFW < 5th percentile Reversed EDF of umbilical artery Severe oligohydramnios

Management of Eclampsia
1. 2. 3. 4. Magnesium sulfate 2 gm iv Assess consciousness, neuro exam Assess fetal, maternal complication of seizure Termination of pregnancy after control seizure 1-2 hr

Management in Intrapartum
1. IV fluid, prevent dehydration, beware pulmonary edema 2. Close observe sign of impending eclampsia and sign of magnesium toxicity, BP q 1-2 hr 3. Adequate analgesia eg. Epidural block 4. Close observe sign of fetal distress, early ARM 5. Shorten second stage of labor eg. F/E 6. Notify Ped.

Management in Postpartum
1. 2. 3. 4. Close observe and MgSO4 iv for 24 hr Oxytocin iv drip, prevent uterine atony D/C if BP < 140/90, repeat BP at 2 wk Advice family planning

Management of Chronic Hypertension

1. Consult Med 2. Work up cause and assess severity 3. Antihypertensive agent if DBP > 110 mmHg Keep DBP 90-100 mmHg 4. Beware superimposed preeclampsia 5. Assess fetal well being

Prognosis
30-70 % recurrent in next pregnancy High recurrent rate in Chronic hypertension

Complication
Maternal Fetal Seizure complication Preterm birth Abruptio placentae Small for GA DIC DFIU HELLP syndrome Hypoxia Intracranial hemorrhage Birth injury Multiple organ failure

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