This document summarizes hypertension in pregnancy, including gestational hypertension, preeclampsia, and chronic hypertension. It defines the conditions, discusses pathogenesis, risk factors, diagnosis, and management. Key points include:
1) Hypertension complicates 8% of pregnancies and is a major cause of maternal and neonatal morbidity and mortality.
2) Preeclampsia is diagnosed with new onset hypertension and proteinuria after 20 weeks gestation. It can range from mild to severe and is treated by delivering the baby and placenta.
3) Management involves monitoring blood work, urine output, fetal status and administering antihypertensive medications cautiously to minimize fetal exposure.
This document summarizes hypertension in pregnancy, including gestational hypertension, preeclampsia, and chronic hypertension. It defines the conditions, discusses pathogenesis, risk factors, diagnosis, and management. Key points include:
1) Hypertension complicates 8% of pregnancies and is a major cause of maternal and neonatal morbidity and mortality.
2) Preeclampsia is diagnosed with new onset hypertension and proteinuria after 20 weeks gestation. It can range from mild to severe and is treated by delivering the baby and placenta.
3) Management involves monitoring blood work, urine output, fetal status and administering antihypertensive medications cautiously to minimize fetal exposure.
This document summarizes hypertension in pregnancy, including gestational hypertension, preeclampsia, and chronic hypertension. It defines the conditions, discusses pathogenesis, risk factors, diagnosis, and management. Key points include:
1) Hypertension complicates 8% of pregnancies and is a major cause of maternal and neonatal morbidity and mortality.
2) Preeclampsia is diagnosed with new onset hypertension and proteinuria after 20 weeks gestation. It can range from mild to severe and is treated by delivering the baby and placenta.
3) Management involves monitoring blood work, urine output, fetal status and administering antihypertensive medications cautiously to minimize fetal exposure.
This document summarizes hypertension in pregnancy, including gestational hypertension, preeclampsia, and chronic hypertension. It defines the conditions, discusses pathogenesis, risk factors, diagnosis, and management. Key points include:
1) Hypertension complicates 8% of pregnancies and is a major cause of maternal and neonatal morbidity and mortality.
2) Preeclampsia is diagnosed with new onset hypertension and proteinuria after 20 weeks gestation. It can range from mild to severe and is treated by delivering the baby and placenta.
3) Management involves monitoring blood work, urine output, fetal status and administering antihypertensive medications cautiously to minimize fetal exposure.
Proteinuria ≥ 300 Most common medical disorder (8%) mg/day OR > +1 OR Major cause of maternal and neonatal Gestational Protein/ Crea ≥ 0.30 OR morbidity and mortality Hypertension – Gestational hypertension (6%) Thrombocytopenia + – Preeclampsia (5-8%) (<100,000) – Chronic Hypertension (3%) New onset of Impaired liver fxn – Superimposed preeclampsia (20- any of the 25%) following Renal Insufficiency
PGH Causes of Maternal Mortality (%) (> 1.1 Creatinine)
Classification Hypertension 28.67 26.91 8 38 0 31.58 Mild Preeclampsia – increase morbidity Infections 7.41 21 21 19 44.44 36.84 – increase mortality – rapid progression is possible Medical 28.31 54 54 24 27.78 0 Early onset Co-morbidities Definitions of terms Preeclampsia – increase morbidity Blood pressure – increase mortality – Mild: 140-159/90-109 – rapid progression is possible – Severe: ≥ 160/110 Early onset Proteinuria Co-morbidities – 300 mg protein in 24 hour urine Preeclampsia without severe features specimen Preeclampsia with severe features Gestational Hypertension Eclampsia Development of new, acute onset Originally described by Hippocrates hypertension after 19 weeks (2400 years ago) as: – Previously normotensive – headache accompanied by – SBP > 140 mmHg OR (not and/or) heaviness and convulsion during – DBP > 90 mmHg pregnancy – Persistent for 4 hours 1776: Thomas young Edinburg Scotland BP turns to normal < 6 weeks postpartum – Recognized that eclamptic Final diagnosis made only postpartum convulsion differed from non- pregnant seizure
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– Recommended prompt delivery Pathogenesis and venesection for patients with eclampsia to reduce uterine Preeclampsia Chronic Hypertension pressure on the iliac vessels Palcental Essential Pregnancy induced hypertension with: hypoperfusion/ – Hypertension / – Proteinuria ischemia presence of underlying – Pathologic edema disorder (renal, – Convulsions New onset parenchymal, renal hypertension vascular, endocrine Chronic Hypertension with proteinuria etc.) BP 140/90 mmHg or greater before Increase risk of IUGR Presents acute Major acute morbidity- pregnancy or diagnosed before 20 risk to mother secondary to the increased weeks not attributable to gestational and fetus risk of superimposed trophoblastic disease. preeclampsia Hypertension first diagnosed after 20 Greater risk for – well-established cause weeks and persistent after 12 weeks cardiovascular of cadiovascular postpartum disease later in morbidity and life mortality Classification Preeclampsia Superimposed preeclampsia (on Chronic hypertension) Widespread vascular endothelial New onset proteinuria in a woman with dysfunction and vasospasm with multi hypertension but with no proteinuria organ system clinical features such as: before 20 weeks – Hypertension Sudden increase in proteinuria or BP or a – Proteinuria platelet count of < 100, 000/mm3 in a – Cerebral and hepatic dysfunction woman with hypertension and Secondary to placental perfusions thus proteinuria before 20 weeks. lowering systemic BP and use of antihypertensive medications Criteria for Diagnosis of Preeclamsia with Severe Features Sustained SBP > 160 mmHg or DBP > 110 mmHg Proteinuria > 3 g/24 hrs or 3+ on urine dipstick Oliguria with urine output < 500 ml/24 hrs Serum creatinine > 1.2 mg/ dL Serum transaminase > 2x normal Lactate dehydrogenase >600 u/L Platelet count < 100,000/mm3 CNS disturbance (headache, altered vision) Pulmonary edema Evidence of fetal compromise (IUGR, olygohydramnios, abnormal umbilical artery)
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Maternal Factors for Preeclampsia (NICE Management of Preeclampsia Guidelines 2010) CBC High risk factors: Urinalysis Hypertensive disease in previous pregnancy Serum ALT and AST Chronic renal disease Creatinine Chronic hypertension Uric acid Diabetes mellitus LDH Autoimmune disease 24 hour urine protein PT, APTT and fibrinogen Moderate risk factors Maternal lifestyle: Fetal Surveillance – Obesity Assess status of the fetus (Biophysical – Smoking profile) Other maternal: Evaluate for growth restrictions – African-american race Doppler flow studies – Age > 40 years Cardiotocography (NST) Paternal obstetrics: – Paternity by male who fathered a Initiating Antihypertensive Medications previous preeclamptic pregnancy in Minimize fetal exposure to medication that another woman may have adverse effects – Paternity by male born from a Cochrane meta-analysis: preclamptic. Insufficient data to determine the benefits and risk of antihypertensive Mean Arterial Pressure (MAP) Test therapy for mild to moderate MAP = DBP + 1/3 (SBP- DBP) hypertension. Combined MAP @ 11-14 weeks + MF – ↓ risk of severe hypertension 62.5% of PE cases – no difference in outcomes of: MAP - 2 > 90 mmHg - ↑ Preeclampsia Preeclampsia MAP - 3 > 105 mmHg- ↑ Perinatal deaths Neonatal deaths Preterm births Prevention of Eclampsia SGA babies Low dose aspirin (80mg/day) Calcium supplementation (1 g daily) Safe BP target: 140-155/ 90-105 Low dose heparin Chronic hypertension and mild to Antioxidant supplementation moderately elevated BP before pregnancy Fish oil supplementation with no known target organ damage – Discontinue antihypertensive, Screening provided they are closely No clinically used screening test to predict monitored preeclampsia – Reinitiated if BP 140-150/90-100 Abnormal uterine artery doppler at first trimester (11-14 weeks) – Early onset of Eclampsia No single biochemical marker – PAPP-A – PP-13 – PIGF – VEGF
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Drugs for Gestational or Chronic HPN
Drug Dose Concerns/Comments
Preferred Agent 0.5-3 g/day in 2 divided Drug of choice Methyldopa (B) doses Adverse side effect – Postural hypotension – Sedation Second-line Agents 200-1200 mg/day in 2-3 Associated with IUGR Labetalol (C) divided doses Nifedipine (C) 30-120 mg/dl of a slow May inhibit labor and have symptomatic release preparation
Hydralazine (C) 50-300 mg/day in 2-4 May cause neonatal thrombocytopenia
divided doses B-receptor blockers Depends on specific – Decrease uteroplacental flow (C) agent – Impair fetal response to hypoxic stress – Risk of growth restrictions when started in 1st and 2nd trimester – Risk of neonatal hyperglycemia at higher doses Hydrochlorothiazide 12.5-25 mg/day May cause volume contraction and electrolyte disorders
For Urgent Control of severe HPN
Drug Dose Concerns/Comments Hydralazine (C) 5 mg IV or IM then 5-10 mg Drug of choice every 20-40 mins, infusion Adverse effects: 0.5-10 mg/hr; if no success – Tachycardia with 20 mg IV or 30 mg IM – Hypotension consider another drug – Headache – Decrease placental perfusion Contraindication: – Mitral valve – RHD – Coronary artery disease – Stroke Nifedipine (C ) Tablets recommended only Long acting preparation is preferred 10-30 mg PO, repeat in 45 although obstetrrics experience with short minutes if needed acting has been favourable It is not approved by the FDA Nicardipine Start at 1 mg/hr, maximum Used with caution if concomitantly used with of 10 mg/hr (D5W 90 cc + MgSo4 Nicardipine 10 mg in a Adverse effects: soluset- concentration 0.1 – Flushing mg/ml-10 ugtt/min – Headache increments of 1 mg/hr) – Reflex tachycardia – Uterine atony Labetalol ( C) 10-20 mg IV, then 20-80 mg Side effects: every 20-30 minutes. – IUGR MOA: Nonselective B- Maximum of 300 mg for – Fetal/neonatal bradycardia blocker/ alpha 1 infusion 1-2 mg/minute – Hypoglycemia in higher doses blocking activity Containdications: – Bronchial asthma – Congestive Heart Failure Joan CONSTANTIAM 2020 Doctor of Medicine - III Page 4 of 6 Management of Preeclampsia –CS: reserved for routine obstetric Objective: indications – Safety of the mother and delivery Should be delivered regardless of of healthy new born gestational age: Delivery is the only cure – Non reassuring fetal status Optimal management depends on the – Ruptured membranes gestational age and disease severity – In labor The further the pregnancy from term – Maternal distress the greater the impetus to manage the > 32 weeks and received course of patient medically steroid, should be delivered The severity of disease must be weighed against the risks of infant prematurity Criteria for Delivery Hospitalized and monitored carefully for Guidelines for Expedited delivery (within 72 development of worsening or hours) of patients with Preeclampsia complications Nonreassuring fetal heart status Bed rest Uncontrolled BP Should be delivered at: Oligohydramnios with AFI < 5cm ≥ 40 weeks AOG Severe IUGR in EFW < 5% ≥ 37 weeks AOG with favourable Oliguria (< 500/24 hr) cervix ( BS >5) Serum creatinine 1.5 mg/dL ≥ 37 weeks AOG Pulmonary edema Shortness of breath or chest pain with Patients having all of the following maybe pulse oximetry < 94% on room air. manage at home: Headache persistent and severe Ability to comply with Right upper quadrant tenderness recommendations Fundoscopic changes: hemorrhage or Diastolic pressure < 100 mmHg papilledema Systolic Pressure < 140 mmHg Development of HELLP syndrome Proteinuria < 1 gm/24 hr or < 2+ on Absent end diastolic or reversed dipstick umbilical artery flow on doppler Platelet count > 120,000 velocimetry. Normal fetal growth and testing Seizure Treatment and prophylaxis with Management of Mild Preeclampsia Magnesium sulfate Antepartum testing: ABC (airway, breathing and circulation) – NST, BPP 2x/week Magnesium Sulfate – Fetal growth monitoring every 2 – IM route: LD 4 g slow IV over 5- weeks 10 minutes and 10 grams deep – Doppler velocimetry IM (5 g on each buttocks), then 5 Delivery ≥ 34 weeks, ruptured gram IM every 4 hours until 24 membranes, abnormal fetal testing, hours after delivery progressive labor or FGR – IV route: LD 4 g slow IV followed Vaginal delivery byy IV infusion 2 g/hr Lorazepam and Phenytoin Management of Severe Preeclampsia Active seizure: After 34 weeks, delivery is appropriate. – IV Magnesium sulphate: first line – Vaginal delivery: attempted
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Prophylactic treatment: Baseline laboratory: – Magnesium sulphate: severe – Urinalysis preeclampsia – Urine culture – Serum creatinine Superimposed Preeclampsia – Glucose Antihypertensive treatment are – Electrolyte extrapolated from the evidence based Uncomplicated preexisting on CH and preeclampsia hypertension who are normotensive or Same drugs and dosage regimen for mildly hypertensive on medication may urgent control and oral maintenance continue their therapy or have their Corticosteroids at ≤ 34 weeks antihypertensive stopped or tapered MgSo4 as first line treatment of during pregnancy. eclampsia and prophylaxis Wihout severe features and with stable Postpartum Hypertenson maternal and fetal conditions expectant Antihypertensive agents may be management until 37 weeks required temporarily postpartum if Delivery soon after maternal hypertension is severe. stabilizations is recommended If pre pregnancy BP was normal, it is irrespective of gestation age for women reasonable to stop antihypertensive with SPE and complicated by any of the after 3 weeks to assess whether ff: treatment is indicated. – Uncontrollable severe Beta-blockers and calcium channel hypertension blockers enter breast milk but most – Eclampsia appear safe during lactation – Pulmonary edema – Abruption placenta Long Term Maternal Outcome – DIC Recurrent Preeclampsia – Nonreassuring FHR pattern Chronic hypertension (4 fold) Ischemic heart diesase (2 fold) Chronic Hypertension Stroke (2 fold) With complicated and secondary Venous Thromboembolism (2 fold) hypertension appear to be at greater All cause mortality (1.5 fold) risk for maternal and fetal complications benefit from antihypertensive therapy with goal of lower BP levels. Close fetal surveillance is warranted when there is uteroplacental vasculopathy With mild uncomplicated preexisting hypertension can be allowed to into spontaneous labor and deliver at term Possible adverse pregnancy outcomes are: – Superimposed preeclampsia – Abruption placenta – Preterm birth <37 weeks – IUGR
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