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Hypertension in pregnancy
1.
2. A 36 year old leady from AL-Mabeala G8P7, LMP:
15/5/2012 at 37weeks of gestation, EDD:
20/2/2013 referred from HC for evaluation of High
blood pressure in the last 5 days, avg of BP 130/90
mmHg. K/C/O PIH on labetalol.
3. P/C Hx:
She complains of headache since 2 weeks which is bilateral, sharp in
nature, progressive, intermittent, aggravated by waking, not relived by
paracetamol, and it disturbing her daily activity. The headache
associated with nausea, vomiting, dizzenss, palpitation, fatigability,
labiality of mood. But there is no history of fall or visual disturbance or
abnormal movements. She sleeps well.
At the same episode she developed cough which was intermittent,
continuous all the day, productive of yellow sputum, small amount,
no blood, no foul smell. It is Associated with difficulty in breathing in
exertion. No audible sounds or fever.
Also she complains of abdominal pain and cramps (labour pain).
And she noticed that her leg start to be swelling in the last two days
markedly.
She denied any urinary symptoms (pain, burning sensation, UTI
symptoms). Bowel habits are normal. No vaginal discharge or leaking.
4. OBS Hx:
G8P7, all her previous pregnancies were uneventful (SVD,
normal baby weight, no complications) except for the last
pregnancy were she developed high BP at 37+ weeks of
gestation and she was induced.
After Last pregnancy she
developed low Hb post partum
(Hb 6mg/dL with blood loss 100 mL) received 2 units of blood
post delivery.
Current pregnancy: all her antenatal scans were normal, all
booking investigations were normal.
Booking Hb was 10,7 mg/dL; at 32-34 Hb was 8,8 mg/dL
OGCT: 7.5
Anomaly scan normal
Lat scan on 2/2/2013: cephalic, AFI: 12cm, Doppler normal, efw
3.2Kg
5. PMH/PSH:
-she was admitted on 30/1/2013 due to leg pain, Doppler done normal,
her Bp at that admission were normal
-no HTN, DM
-no surgery was done for her
Mediaction Hx:
PIH in labetalol
Family Hx:
No consanguinity ,
Futher with HTN and DM, bronchial asthma
(sister, and a brother)
Social History:
Housewife, husband is driver, good socioeconomic status, no history of
smoking or Alcohol consumption. No history of contact with sick people.
Allergic Hx:
Unremarkable
6. At admission:
Patient looks well oriented, alert, not in distress or pain.
Her vitals: pulse 84/min, BP 120/80, rechecked after 1
hr 140/87 mmHg, temp 36.8
General assessment: bilateral leg edema
Chest Examination: chest with wheeze bilaterally, no
crepition
CVS: normal
Abdominal examination: distended abdomen,
abdominal wall thick uterus relaxed, cephalic
presentation
CTG: normal
Scan: liquor normal, Doppler normal, AFI 12 cm, efw
3.2Kg
7. Blood tests:
CBC: Hb (9.5 g/dL), Hcrts low, MCV low, platelet normal, WBC (14,5 high),
neutophils(10.1 high)
CRP:
7.6 mg/L >>> high
: low urea (2.2 mmol/L), Na, CL-, K+, creatinine are all normal
U&E
: normal enzymes, low albumin (25 g/L)
LFT
Uric acid
: 190 normal
Ferritin in serum/plasma (2/2/2013):
Folate & vitB12:
normal
ECHO: normal
Chest x-ray: normal
10 ug/L low
8. Management:
Continue BP monitoring
Treat chest condition IV augmentin and regular
6hourly salbutamol nebulizer
Patient discharged after two days of
admission with:
Oral antibiotics (augmentin), Haematinic, and
Methyldopa 250mg TID
For admission on 12/2/2013 for IOL on 13/2/2013
Informed sos
10. In pregnancy
Increase Aldosterone increase blood
volumes increase HR (15 beats/min more
than usual), SV, CO (50%, mostly during the
first trimester).
Increase progesteron smooth muscle
relaxation and overall vasodilation
systemic vascular resistance drops
Diastolic BP decreases between 12–26 wks
Diastolic BP increases again to pre-
pregnancy levels by 36 weeks
11. Pregnancy-induced hypertension (PIH) is a
syndrome of hypertension with or without
proteinuria and edema, with the clinical
manifestation usually occurring late in pregnancy
and regressing after delivery of the conceptus.
Hypertension is the most common medical
problem encountered during pregnancy,
complicating 2-3% of pregnancies.
12. Classification:
Gestational or transient HTN
Chronic HTN
Chronic HTN with superimposed
preeclampsia
Preeclampsia/ eclampsia
13. HTN without proteinuria first appears after 20 weeks
of gestation or within 48-72 hour after delivery and
resolves by 12 weeks Postpartum.
Is a retrospective diagnosis Thus, reassessment up
to 12 weeks postpartum is necessary to establish a final
definitive diagnosis.
14.
Most will have essential HTN but small percent
will have secondary HTN due to renal, vascular
and endocrine causes.
16. Difficult to distinguish it from poorly controlled
chronic HTN especially if women is not seen until
after 20th wk of gestation
Carries a worse prognosis than does either
condition alone.
17. A syndrome unique to pregnancy where new HTN
and proteinuria developed in the latter half of
gestation.
More common in primigravida
If occur in the early second trimester hydatidiform
mole or chriocarcinoma should be considered
18.
New development of HTN (sBP>=140mmHg,
dBP>=90 mmHg) in previously normo-tensive
women after 20 weeks of gestation
New onset proteinuria after 20weeks of gestation
(protein in urine > 0.3g in timed 24-hour urin
collection
Usually correlqted with urinanalysis >30mg/dL and urine
dipstick +1.
Divided into mild and severe
Presence of one of the following considered as
severe:
21. Maternal personal risk factors for preeclampsia
First pregnancy
New partner/paternity
Age younger than 18 years or older than 35 years
History of preeclampsia
Family history of preeclampsia in a first-degree
relative
Black race
Obesity (BMI ≥30)
Interpregnancy interval less than 2 years or longer
22. Maternal medical risk factors for preeclampsia
Chronic hypertension, especially when secondary to such
disorders as hypercortisolism, hyperaldosteronism, or renal artery
stenosis
Preexisting diabetes (type 1 or type 2), especially with
microvascular disease
Renal disease
Systemic lupus erythematosus
Obesity
Thrombophilia
History of migraine
Use of selective serotonin uptake inhibitor antidepressants
(SSRIs) beyond the first trimester
23. Chronic HTN, immune mediate vascular damage, obesity,
DM, dyslipidemia cause placental ischemia and
hypoxia
Release of toxins and Cytokines in the blood causing
widespread of inflammatory process
Endothelial dysfunction
Occur due to imbalance between vasodilators (PGE,
prostacysline, NO) and vasoconstrictors (PGF, trombaxan
and endotheline I)
Net results of this is vasoconstriction and
increase PVR
Systemic HTN, DIC, HELLP syndrome, and
placental ischemia
24. Generalized vasospasm
Lower renal flow and glomerular filtration rate
Proteinuria
oliguria
Decreased cerebral blood flow
Activation of coagulation system ….
HELLP syndrome
25. In most women, sign and symptoms first become
apparent after 34 weeks of gestation
10 % of women, preeclampsia develop before
34 weeks of gestation
5 %, preeclampsia is first recognized postpartum
usually within 48 hours of delivery
26. mild hypertension
(≥140/90 and <160/110 mm Hg) and mild
proteinuria (<5 grams in 24 hours), usually
accompanied by peripheral edema.
Most patients have only
About 25 percent develop one or more of the
following nonspecific findings:
27. Severe hypertension (systolic blood pressure ≥160 mm Hg or
diastolic ≥110 mm Hg on two occasions at least six hours
apart)
Persistent and/or severe headache,
Visual abnormalities (photophobia, blurred vision, or
temporary blindness [rare])
Upper abdominal or epigastric pain
Nausea, vomiting
Oliguria
Dyspnea, retrosternal chest pain
Fetal growth restriction
Oligohydramnios
Altered mental status
28. Atypical presentation
include any of the following:
Onset of signs/symptoms at usuallyweeks of a complete or
is <20 associated with
partial molar pregnancy.
gestation
Hypertension or proteinuria (but not both) with or
without characteristic signs and symptoms of
severe preeclampsia
Delayed postpartum onsetmay be observed in 15 percent of
or exacerbation of
patients with HELLP syndrome
disease (>2 days postpartum) patients with eclampsia. and in
some
29.
Vessels are less sensitive to angiotensine
Earliest sign of preclampsia
Occur due to endothelial dysfunction EVF
accumulation
INF is low explain why diuretics are not indicated
in preeclampsia
Hypovolemia and hemeconsentration
30.
Occur after days or weeks from onset of fluid
retenstion
High diastolic usually due to increase PVR
Occur after days or weeks from onset of BP
elevation
Occur due to afferent vasoconstriction damage to
the capsular membrane.
Increase uric acid is the earliest sign of renal
involvement
31.
Thrombocytopenia is the most common abnormality
DIC or HELLP syndrome may occur
Focal hemorrhages and infraction of liver may occur RUQ pain,
elevated liver enzymes(AST & ALT) , epigastric pain
Haemolysis may increase bilirubin
Uteroplacental vasospasum and ischemia decrease blood
perfusion IUGR, oligohydroamnious, fetal heart abnormalities
Placenta abruption or hemorrhage if extensive infraction
Visual disturbance blurred vision, spots
Hyperreflexia and irritability
32. In general, clinical evaluation should include the mother and
fetus
RUQ pain, headache and visual disturbances are potentially
•
ominous symptoms requiring immediate assessment
-central nervous system
headache
-visual disturbances – blurring,
scotomata
tremulousness, irritability, -hyperreflexia
Hematologic
-bleeding, petechiae
Hepatic
-UQ or epigastric pain
severe nausea and vomiting
-urine output and colour
:
non-dependent edema (i.e. hands and face)
•fetal movement
•fetal heart rate tracing – NST
•biophysical profile
-ultrasound for growth
-Doppler flow studies
33. hemoglobin, platelets, blood film
PTT, INR, fibrinogen, D-dimer – especially if surgery
or regional anesthetics are planned
ALT, AST, LDH, bilirubin
proteinuria, creatinine, uric acid
24-hour urine collection for total protein and
creatinine clearance
36. Hemolysis, Elevated Liver enzymes, Low Platelets
Pathogenesis unknown
Affects 20% of women with severe preeclampsia
Presents >27 weeks GA (11% sooner)
up to 30% of cases present AFTER delivery and with no
prevoius signs of hypertension
Epigastric, RUQ or chest pain, N/V, symptoms of
preeclampsia (headache, blurred vision, thirst) ±
jaundice Atypical presentations: asymptomatic reduction
in platelet count, “flu-like” symptoms.
37.
AST (70-663 U/L), total bilirubin slightly increased, low
platelet count (7-99), elevated LDH
elevated D-dimers,
tissue polypeptide antigen (TPA)
fragmented RBCs on smear
Liver biopsy (rarely done): periportal hemorrhage and
fibrin deposition with periportal necrosis, macro- and
microvesicular fatty deposits (NOT pericentral as in
AFLP)
Supportive care (in ICU) and prompt delivery
38. The definitive treatment of preeclampsia is delivery
to prevent development of maternal or fetal
complications from disease progression
Whether or not to deliver the fetus is based upon
gestational age, the severity of preeclampsia, and
maternal and fetal condition.
39. Three important Qs, the clinician should ask:
The goal of management
40. Labour should be induced in the absence of obstetric
indication for cessarian delivery
Continuous maternal-fetal monitoring
Seizure prophylaxis and control of hypertension
Other potenital maternal problems that may develop
are oliguria, pulmonary edema, HELLP syndrome
41. Degree of
hypertension
Mild
hypertension
(140/90 to 149/
99 mmHg)
Moderate
hypertension
(150/100 to 159/
109 mmHg)
Severe hypertension
(160/110 mmHg or
higher)
Admit to
hospital
yes
yes
yes
Treat
No, because it
does not reduce
or prevent
progression of
preeclampsia
With oral labetalol
With oral labetalol
as
first-line treatment to
keep:
diastolic blood
pressure between
80–100 mmHg
systolic blood
pressure less than
150 mmHg
as
first-line treatment to
keep:
diastolic blood
pressure between
80–100 mmHg
systolic blood
pressure less than
150 mmHg
42. Degree of
Mild hypertension
hypertensio (140/90 to 149/
n
99 mmHg)
Moderate
hypertension
(150/100 to 159/
109 mmHg)
Severe hypertension
(160/110 mmHg or
higher)
Measure
blood
pressure
At least four times a
day
At least four times
a day
More than four times a
day, depending on
clinical circumstances
Blood tests
Monitor using the
following tests twice
a
week: kidney
function,
electrolytes, full
blood
count,
transaminases,
bilirubin
Monitor using the
following tests
three
times a week:
kidney
function,
electrolytes, full
blood count,
transaminases,
bilirubin
Monitor using the
following tests three
times a week: kidney
function, electrolytes,
full
blood count,
transaminases, bilirubin
43. Manage pregnancy in women with pre-eclampsia
conservatively 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:
44. Recommend birth for women who have pre-eclampsia
with severe hypertension after 34 weeks when their blood
pressure has been controlled and a course of
corticosteroids has been completed (if appropriate).
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.
Recommend birth within 24–48 hours for women who
have pre-eclampsia with mild or moderate hypertension
after 37 +0 weeks.
45. Magnesium sulfate
Given during the intrapartum period and continued
for about 24 hr after delivery
Unproved benefits for mild preeclampsia
Severe preeclampsia ….given on admission
If determined not to delivered …it can be stopped,
restarted intrapartum and continued 24 hr
postpartum or until there is evidence of resolution of
the disease
46. IV or IM
Type of treatment IV
IM
Prophylactic
loading
4 g over 15-20 min 5 g in 100 ml fluid
Maintenance
2 g/hr
5 g /4 hr infusion
47. It is excreted exclusively through the kidneys
Serial assessments of urine output, deep tendon
reflexes and respirations are important for detecting
signs of magnesium toxicity
every 6 hr
Toxicity can occur even in a patient with apparently
normal renal function
48.
49. Toxicity is treated by stopping infusion and
administering calcium gluconate, 10 ml of a 10 %
solution, IV and resuscitative measures if
necessary
50. Fluids:
Fluid balance should be monitored closely to avoid
excessive administration
Maintenance fluids of 80 mL/hour are often adequate
in the absence of ongoing fluid loss, such as
bleeding.
Antihypertensive medication:
Severe hypertension is treated with
intravenous labetalol or hydralazine or
oral nifedipine.
51. On the basis of the recent evidence, nitric oxide
agents may be beneficial in the prevention of
preeclampsia. Randomized controlled trials initiated
in the first trimester and using long-acting nitrates
are needed in high-risk women to validate these
findings.
Kalidindi M, Velauthar L, Khan K, Aquilina J. The role of nitrates in the prevention of preeclampsia: an update. Curr
Opin Obstet Gynecol. 2012 Dec;24(6):361-7. doi: 10.1097/GCO.
Low-dose aspirin decreases the incidence of
preeclampsia among nulliparous women,
primarily through its effect in those who have
elevated systolic blood pressure initially. This
treatment does not decrease perinatal morbidity
but increases the risk of abruptio placentae
Sibai BM, Caritis SN, Thom E, et al. Prevention of preeclampsia with low-dose aspirin in healthy, nulliparous
pregnant women. The National Institute of Child Health and Human Development Network of Maternal-Fetal
Medicine Units
.
52. Obstetric emergency
Is the presence of tonic clonic seizures in a women with
preeclampsia that cannot be attributed to other causes
Eclamptic seizures can also occur before the development
of classic signs of preeclampsia
53. When evaluating cases of atypical eclampsia its
important to consider other causes of seizures such
as:
underlying seizure disorder hypertensive encephalopathy
metabolic abnormalities (hypoglycemia, hyponatremia)
CNS hemorrhage
Thrombosis
Mass
Infection
54. IOL or cessarian birth during the acute phase may
aggravate the disease
Stabilize the pt before delivery
Once hypoxia is corrected, convulsion controlled and
diastolic blood pressure brought down to 90 to 100
mmHg, delivery should be expedited preferably by
the vaginal route
55. Gather equipment (airway, suction, mask and bag,
oxygen) and give oxygen at 4-6 L per minute.
Protect the woman from injury
Start an IV line and infuse IV fluids (maintenance
dose: 80 ml/hr or 1ml/kg/hr) after the convulsion.
Give anticonvulsive drugs (start a loading dose of
magnesium sulphate by preparing 4 g of 50%
magnesium sulphate solution given slowly IV over
10-15 minutes.
56. If magnesium sulphate is not available, loading dose
of diazepam can be given if convulsion recur,
repeat the loading dose).
her left side to reduce risk
of aspiration of secretions, vomit and blood.
Position the woman on
Aspirate the mouth and throat as necessary.
Monitor vital signs (pulse, blood pressure, and
respiration), reflexes and fetal heart rate hourly.
emergency case to a secondary
care institute.
Refer as an
