1、HYPERTENSIVE DISORDERS IN PREGNANCY,Prof of Gyn&Obst. Mansoura Faculty of Medicine Egypt 2009,Prof.Mohammad Emam,Introduction,Hypertensive disorders of pregnancy are leading causes of maternal mortality. Worldwide: 50,000 women die each year. Egypt: 18% of maternal mortality.,Introduction,Homeostasi
2、s during normal pregnancy:is an example of the principle of priorities, where the pregnant women must alter her entire physiological and biochemical environment to provide conditions best suited for the fetus to whom she is hostess, that is the price of viviparity.,Introduction,In hypertension: many
3、 complex homeostatic modifications occur, some are harmful to the mother and fetus, while others are beneficial.,Definitions,Hypertension in pregnancy: Bl/P of 140/90 or more is abnormal. If there is a rise of 30 mmHg or more in the systolic blood pressure or 15 mmHg or more in the diastolic blood p
4、ressure In 2 occasions 6 hours apart.Mean arterial BP 105 mmHg .Systolic + 2 Diastolic Mean arterial BP = -3,Classifications,National High Blood Pressure Education Program Classification ( NHEP) 2000,Gestational hypertension. Preeclampsia (mild, severe). Eclampsia. Superimposed preeclampsia upon chr
5、onic hypertension. Chronic hypertension with pregnancy.,Definitions,Gestational hypertension: Hypertension for first time after 20 w, without Proteinuria. BP returns to normal before 12 weeks postpartum. Chronic hypertension with pregnancy: Hypertension antedates pregnancy and detected before 20 w,
6、& lasts more than 12 weeks postpartum.,Definitions,Preeclampsia: The development of hypertension and Proteinuria after 20 w May occur earlier in vesicular mole or twins.Eclampsia (in Greek= Flash of light): The occurrence of tonic-clonic convulsions (without any neurological disease) in a woman with
7、 pre-eclampsia.,Definitions,Superimposed pre-eclampsia: It is the new development of Proteinuria after 20 weeks gestation in a patient with chronic hypertension,Definitions,Proteinuria: 300mg/24 hours urine. +1 dipstick. Heavy Proteinuria : = 2gm/24 hoursor +2 in dipstick.,Preeclampsia,Epidemiology
8、of preeclampsia,Incidence: Is a disease of humans only. Is the most common medical disorder complicating pregnancy 5-15% Is the most common hypertensive disorder in pregnancy. More common in primigravidas and elderly multipara. More common in winter. More in black races.,Epidemiology,Risk factors: C
9、hronic hypertension. Chronic nephritis. Past history . Family history. Obesity. Multiple pregnancy.,Epidemiology ( risks),Polyhydramnios. Vesicular mole. Diabetes mellitus. Nulliparity.Teenage Pregnancy. Smoking. Stress,Etiology= theories,Genetic Predisposition. Free Radicals Theory In pre-eclampsia
10、 the levels of free radicals are higher than normotensive women leading to endothelial damage.,Oxidative stress,Antioxidant capacity,ROS synthesis,O2._ H2O2 ONOO_,Vitamin C SOD,Etiology= theories,Endothelial injury: Endothelin 1(potent vasoconstrictors).Nitric Oxide ( vasodilator action).Vascular En
11、dothelial Growth Factor (VEGF).,Etiology= theories,Prostaglandins: There is decrease in prostacyclin /TX A2 ratio leading to : vasoconstriction and tendency to thrombosis.,Etiology= theories,Inflammatory Factors: Pre-eclampsia is considered an inflammatory disease due to increased number of activate
12、d leukocytes in the maternal circulation. Immunological Factor: primigravidas Multipara with 1st pregnancy from a new husband. Abundant trophoblast ( vesicular mole and multiple pregnancy.,The Central Players (Hemostats) in PET,The Endothelium Neutrophils 3. Platelets 4. Coagulation system.Once one
13、is triggered Co- Workers are released (NO, PGs, ROS, Homosystein, etc),Triggers for PET,Genetic Modulators Pre-existing Vascular Pathology,Central players,CytokinesRos,The Constant Pathophysiological Changes,Is Vascular endothelial: Damage +Dysfunction+ Spasm,Pathology,PET is the clinical ice-berg t
14、ip manifestation of the disturbances in the maternal homeostasis, involving many systems and organs.,Multisystem Features Of Preeclampsia,Diagnosis,1) Prediction. 2)CL/P & Severity 3)Eclampsia,Diagnosis,I. Prediction: High risk factors. Rapid weight gain during the 2nd half of pregnancy (due to occu
15、lt edema). Any increase above 3/4 kg/week in late pregnancy is abnormal.,Tests for Prediction,Roll over test is positive (rise of diastolic blood pressure 20 mmHg or more after turning from left lateral to dorsal position).Increased pressor response.Uric acid: is elevated.Hypercalciuria.Doppler velo
16、cimetry to detect Uteroplacental hypo perfusion.,Diagnosis Of PET,Hypertension + Proteinuria= Two facets of a complex pathophysiological process,A): Signs: :,it is a disease of signs :2 cardinal signs + or - Edema: Hypertension: usually precedes Proteinuria, Proteinuria: detected by Boiling test. Qu
17、antitative assay. Dipstick test.,+ or - Edema,occult or manifest: The lower extremities. Abdominal wall, vulva or may be generalized anasarca.usually after hypertension.,Peripheral edema is not a useful diagnostic criterion,1) it is common in normal pregnancy.2) PET can occur without edema (dry type
18、).so its presence does not ensure a poor prognosis and its absence not ensure a favorable outcome.,B) Symptoms (non specific):,Headache. Blurring of vision. Nausea and vomiting. Epigastric pain (distension of the liver capsule) Oliguria or anuria,Severity Of Pre-eclampsia,The severity of pre-eclamps
19、ia is assessed by: The frequency and intensity of the signs and symptoms.The more the severity of PET, the more likely is the need to terminate pregnancy.,DD ,mild & severe PET,4) Diagnosis Of Eclampsia:,Eclamptic fit stages ( 4 stages): Premonitory stage (1/2 minute): Eye rolled up. Twitches of the
20、 face and hands. Tonic stage (1/2 minute): Generalized tonic spasm with episthotonus. Cyanosis. Tongue may be bitten between the clenched teeth.,4) Diagnosis Of Eclampsia:,Clonic stage (1-2 minutes): Convulsions . Tongue may be bitten.face is congested and cyanosed.conjunctival congestion.blood stai
21、ned froth from the mouth, Stertorous breathing,temperature may rise.involuntary passage of urine or stool. Gradually convulsions stop.,4) Diagnosis Of Eclampsia:,Coma: Variable duration due to respiratory and metabolic acidosis.Deep coma may occurs (cerebral hemorrhage). Labor usually starts shortly
22、 after the fit. Sometimes labor does not start and convulsions recur again the so called intercurrent eclampsia and carries a bad prognosis.,Classifications of Eclampsia,Intercurrent Eclampsia: eclampsia in which the eclamptic fits recur in the same pregnancy. Recurrent Eclampsia: eclampsia that rec
23、urs in subsequent pregnancy.,Classifications of Eclampsia,Ante partum (65%) with the best prognosis. Intrapartum (20%). Postpartum (15%) with the worst prognosis as it indicates extensive pathology and multisystem damage,Classifications of Eclampsia,1)Mild 2) Severe (Edens criteria): Coma 6 hours. T
24、emperature 39 (pneumonia or pontine hge) Systolic Bp 200 (risk of cerebral hge) Pulse 120/min ( acute heart failure). Anuria or Oliguria( renal failure). Respiratory rate 40/min( pneumonia) More than 10 fits (status eclampticus).,Investigations,A. Laboratory: Urine: 24 hour urine, Proteinuria. Kidne
25、y functions: serum creatinine, urea, creatinine clearance and uric acid. Liver functions: bilirubin, Enzymes (SGPT and SGOT). Blood: CBC, HCt , Hemolysis and Platelet count (Thrombocytopenia). Coagulation Profile: Bleeding and clotting time,Investigations,B. Instrumental Fundus Examination . C. Imag
26、ing techniques : CT scan for the brain. Ultrasonograghy . E. Doppler Velocimetry .,VI. Differential Diagnosis:,A. Hypertension With Pregnancy.B. Proteinuria With Pregnancy. C. Edema With Pregnancy:,VI. Differential Diagnosis:,D. Convulsions With Pregnancy: Eclampsia. Epilepsy. Hysteria. Meningitis a
27、nd Encephalitis. Tetanus. Tetany. Strychnine poisoning. Brain tumors. Uremic convulsions,VI. Differential Diagnosis:,E. Coma With Pregnancy: Hypoglycemic . Hyperglycemic coma Uremic coma. Hepatic coma. Alcoholic coma. Cerebral coma.,VI. Differential Diagnosis:,F. HELLP Syndrome: Acute fatty liver in
28、 pregnancy. Hepatitis. Thrombocytopenia purpura. Hemolytic Uremic syndrome.,Treatment,PREVENTION. Antepartum ttt. Proper antenatal care Expectant treatment. Control hypertension. Treatment of eclampsia . Prevention and control of convulsions. Termination of pregnancy . Intrapartum care. Postpartum c
29、are.,Prevention,Low dose aspirin: 75 mg/day. Decrease TxA2 (from Platelets). Not affect endothelial prostacyclin (PGI2 ) Calcium supplementation:Ca+ supplementation may increase the production of prostacyclin (PGI2 ) from endothelial cells.,The most effective preventive measures for OCCURANCE of pre
30、-eclampsia IS PREVENTION OF PREGNANCY “contraception”,Prevention,TTT of preeclampsia,Expectant Treatment . Control of Hypertension. Prevention of convulsions . Termination of pregnancy .,1) Expectant Treatment,Rest: Complete Physical and mental rest. Diet: Increase protein and carbohydrate with low
31、Na diet !. Sedation AND TRANQULIZER: Phenobarbitone & DIAZEPAAM. Observation ( MATERNAL & FETAL).,1) Expectant Treatment (Observation),Maternal: Blood pressure. Pulse and Respiratory rate. Urine output. Proteinuria. Any new symptoms. Investigations (creatinine, creatinine clearance, blood picture, c
32、oagulation profile,.)Fetal: fetal well-being,2) Control of Hypertension:,A)Parentral drugs: 1) Hydralazine: It is a peripheral VD. The best Antihypertensive drug used during Pre-eclampsia and Eclampsia. Dose: 5-10mg IV or IM as initial dose. Repeated every 20-30 minutes until blood pressure is contr
33、olled.,2)Control of Hypertension:,2) Labetalol (Trandate): and non selective - adrenergic blocker resulting in VD. Dose: 10-20mg IV . The dose can be doubled every 10 minutes if proper response is not achieved. 3) Diaz oxide (Hyperstat): Used in severe dangerous resistant hypertension as a last reso
34、rt. Dose: 50-150mg IV bolus dose. Repeated every 1-2 minutes until BP decreases.,2)Control of Hypertension:,A )Oral drugs: 1) -methyl DOPA (aldomet): It is the most commonly used.It is -adrenergic agonist causing depletion of catecholamine stores. Dose: 500mg 3-4 times/day orally. 2) Monohydralazine
35、 (Aprisoline): It is a weak Antihypertensive when given alone. It used in combination with - blockers to increase its efficacy and decrease its side effects.,2)Control of Hypertension:,3) - adrenergic blockers: Atenolol (tenormin) 50-100mg 4 times daily.Labetalol (Trandate) 10-20mg 3 times daily. 4)
36、 Prazocin (minipres): It is postsynaptic -adrenergic receptor blocker resulting in VD and reflex tachycardia. It is a weak Antihypertensive drug so used in combination with other drugs. 5) Calcium Channel Blocker: Nifedipine (adalat or Epilat) .,TTT of Preeclampsia,3)Prevention of convulsions ( vide
37、 infra ).4)Termination of pregnancy( vide infra),Treatment of Eclampsia,1)General and first aid measures: Isolation in a single, quite, semi dark room (eclampsia room). An efficient nurse should be present. The following equipments must be present Oxygen source. Airway. Suction apparatus. Bed with m
38、ovable head and legs with limb ties.,Treatment of Eclampsia,1) General and first aid measures( A &B &C &D cont ) Ensure patent airway with tracheal and bronchial suction. Put the patients in Trendlenburg position (to avoid aspiration of secretions) . Insert a catheter.Nasogastric tube may be inserte
39、d . Nothing by mouth and fluid chart.Full laboratory investigation.,Treatment of Eclampsia,2) Observation: Pulse, temperature, BP and RR. Level of consciousness. Duration of coma. Fetal heart sounds. Urine output and albuminuria . Number of convulsions,Treatment of Eclampsia,3) Sedation : Morphine 1
40、0-20mg IM then maintain by diazepam 10mg IV or IM/8 hours. Lytic cocktail 25mg chlorpromazine + 50mg phenergan + 100mg pethidine. Given in 500CC fluid over 4 hours . Can be repeated after 6 hours. Never give 3rd dose.,4) Control of Convulsions:,A) Magnesium Sulfate (MgSO4): It is the drug of choice.
41、 Mechanism: CNS depression. Mild VD. Mild diuresis. Inhibits platelet aggregation. Increase PGI2 synthesis.,Magnesium Sulfate (MgSO4):,It can be given IV (20%) or IM (50%) or SC (15%): The therapeutic level is 4-7mEq/L. The total dose of MgSO4 should not exceed 24 gms in 24 hours .The dose of MgSO4
42、is monitored by: Preserved patellar reflex. Respiratory rate 16/min. Urine output 100ml/4hours. Serum Mg+ level. Is stopped 24 hours after delivery.N.B Antidote is ca gluconate,Magnesium Sulfate (MgSO4):,IV regimen: initially 4-6 gm (20%) in 100ml solution . Given over 15-20 minutes.Then, 2 gm/hour
43、by IV drip. IM regimen: 10 gms of 50% solution are given deeply IM (5 gms in each buttock). Maintain with 5 gm/6 hours of 50% solution.,Side effects of MgSO4 (small safety margin),At a level of 8-10mEq/L patellar reflex is lost and starts myometrial inhibition. 10-15mEq/L respiratory depression. 15m
44、Eq/L cardiac depression. Curare like action. Synergistic effect with Ca+ channel blockers. Uterine inertia. Neonatal hypermagnesemia. Decreased beat to beat variability in FHS. Antidote : 10ml of 10 percent calcium gluconate,4) Control of Convulsions:,B ) Phyntoin (Epanutin):In severe pre-eclampsia
45、In imminent eclampsia . The dose is 15mg/kg.,4) Control of Convulsions:,C) Diazepam (Valium): This regimen is mainly for eclamptic patients. Initially 20-40mg IV slowly over 5 minutes. then 10-20mg/6hours. then the dose is adjusted at 10mg/hour to maintain drowsiness. Side effects: Neonatal low APGA
46、R score. Neonatal hyperbilirubinemia.,Modified Stroganoff method:The original Stroganoff method isMgSO4 6gm initially then 4 gm/4hours + 20mg morphine IM.,4) Control of Convulsions:,Treatment of Eclampsia,5) Control of hypertension (VIDE SUPRA) 6)Other drugs: Prophylactic digitalis to guard against
47、HF Antibiotic for infection. IV glucose 25% as a liver support, increases the urine output and improves Hemoconcentration.,Treatment of Eclampsia,7)Termination of Pregnancy Indications: Eclampsia. Retinal hemorrhage: by CS to avoid bearing down. Deteriorated cardiac, renal or liver functions. Severe
48、 PET not controlled after 24 hours. Mild PET reaching 38 weeks and not controlled. Expectant treatment reaching maturity. Deterioration of the fetal conditions. Other obstetric indications as CPD, malpresentations, APH,(by CS).,7)Termination of Pregnancy,Methods: As a rule vaginal delivery is safer
49、and better than CS. Artificial rupture of membranes and pitocin drip.CS.,Treatment of Eclampsia,8) Management during labor: With the onset of labor give IV hypotensives and sedation. The patient must be at rest with oxygen source and other equipments for treating fits. Maternal observation. Continuo
50、us electronic fetal monitoring.,8) Intrapartum management:,Epidural anesthesia is the best for both CS and vaginal delivery (provided that DIC is excluded). Avoid straining in the second stage. Shorten the 2nd stage by forceps or ventouse. No ergometrine Intrapartum.Management during CS: Best done 4-6 hours after the last fit (allow time for recovery from acidosis).,
