Hypertensive disease during pregnancy

What is hypertension during pregnancy?

 is defined as a diastolic blood pressure of 90 mmHg
or more or systolic blood pressure of 140mmhg or
more
 Rise of BP by >30 systolic or >15 diastolic .
 abnormally high blood pressure is often
accompanied by proteinuria.
 Severe hypertension is >169mm Hg systolic and or
diastolic >109 mm Hg.
 Requires admission and urgent Rx
 What is protein urea?

is defined as an excessive amount of protein

in the urine.
 Protein urea cont…
Proteinuria during pregnancy is diagnosed
when either of the following is present:
1) >300ml/l/24 hrs
2) > 1+ protein as easured with a urine dipistick
3) 0.3g/L or more in random clean catch specimen
 Cont…
Proteinuria during pregnancy may also be
caused by:
 A urinary tract infection or by renal disease .
Contamination of the urine by a vaginal discharge or
leucorrhoea.
 Classification of hypertension during
pregnancy
The classification of hypertension during
pregnancy depends on:
1. Whether the hypertension started before or after
the 20th week of pregnancy.
2. Whether or not proteinuria is also present
 Classifaction of …
The common forms of hypertension during
pregnancy are:
1. Pre-eclampsia (gestational proteinuric
hypertension).
2. Gestational hypertension.
3. Chronic hypertension.
4. Chronic hypertension with superimposed
pre-eclampsia.
5. Eclampsia.
 1. Pre-eclampsia
Sustained hypertension with protein urea
after 20wks of pregnancy and with evidence
of other organ involvement.
Patho physiology of Pre Eclampsia
• Placental tissue
– In healthy pregnancies cytotrophoblast infiltrates
the decidual portion of the uterine spiral arteries In
order to increase maternal blood flow to the
placenta
– In patients destined to develop pre Eclampsia this
fails to occur
– This results in placental hypo perfusion
– These changes occur at <16 weeks gestation but
the pre Eclampsia may not be manifest until much
later in the pregnancy
 Pathophysiology cont…
 Hypoperfusion of the Placenta
 Becomes worse as pregnancy progresses
The abnormal uterine vasculature is unable to
accommodate the normal rise in blood flow to the
fetus/placenta that occurs with increasing
gestational age.
Late placental changes consistent with ischemia
include atherosis , fibrinoid necrosis, thrombosis,
sclerotic narrowing of arterioles, and placental
infarction
Sign and syptoms of pre-eclamcia
Headache
Blurring of vision
Epigestric pain
Low platelet count
Signs of cerebral irritation
• Brisk reflexes, clonus
 S&s cont….
Abnormal liver enzymes(alanine
aminotransferes,aspartate
aminotransferes,gamma glutamyl
transpeptidase.
Generalised Oedema
Placental insufficiency
 IUGR
 Predisposing factors for PE
Maternal
 Primigravidity
Family history
 Age
 Chronic hypertension
Hypertensive renal disease
Diabetes with vascular disease
 Predisposing factor…
multiple pregnancy
Migraine before pregnancy
Patients over 34 years
 Predisposing cont…
 Fetal
 Multiple pregnancy
Hydatidiform mole
 Hydrops fetalis
 Diabetes with macrosomia
 Classification of pre-eclamcia
1) MILD PRE-ECLAMPSIA:
A diastolic blood pressure of 90 - 109 mmHg and
proteinuria.
 Classification cont…
2. SEVERE PRE-ECLAMPSIA:
 A diastolic BP of 110mm Hg or more on 2 occasions,
4 hours apart, or 120mm Hg or more on1 occasion,
and proteinuria
 Complication of pre-eclamcia
 MATERNAL
Renal -acute renal failure
Liver- liver failure [hypo gastric pain]
 Cardiac- congestive heart failure
 Cerebral -convulsions
 Complication…
 Haematological Disseminated intravascular
coagulation
Abruption revealed or concealed
FETAL.
Placental insufficiency IUGR Intrauterine growth
retardation.
 Premature delivery .
 Management -Pre-eclampsia
THE ONLY EFFECTIVE Rx IS DELIVERY
 when to deliver patient with pre-eclamsia
 Patients who have a gestational age of 36 weeks or more
• If the patient has a favourable(“ripe”)cervix, a
surgicalinduction can be done
• If cx is not ripened ripening" the cervix witha very low dose
of oral misoprostol (Cytotec) or prostaglandin E2
 Control blood pressure with anti
hypertension drugs
Antihypertensive:
 alpha/Beta-blockers: Labetolol (Trandate) 100-
200mg tds
Methyldopa 250-500 mg tds/qid
 Hydralazine 20-40 mg qid or by infusion
Nifedipine 10-20 mg bd
 Diuretics - NO PLACE [unless heart failure]
SINCE PRE-ECLAMPSIA IS ASSOCIATED WITH
HYPOVOLAEMIA
 Moniter fetal condition
Fetal distres is common in preclamsia
 Follow fetal heartbeat with stetoscope or
CTG
 Mngt of sever pre-eclamsia
 The main aimsof management are to:
1. Prevent eclampsia, by giving magnesium
sulphate.
2. Prevent intracerebral haemorrhage,by
decreasing the blood pressure
 Mgt..step
Step 1)
 intravenous infusion
 300 mlof the intravenous infusionis given rapidly
over half anhour.
Thereafter, the infusion is given slowly, at a rate of 80
mlper hour.
magnesium sulphateis administered
 Mgso4 admini..
 Loading dose
(i) Give 4 g of 20 % mgso4 slowly
intravenously over10 minutes.
 Prepare the 4 g by adding 8 ml 50% magnesium
sulphate (i.e. 2 ampoules) to 12 ml sterile water.
(ii) Then give 5 g (i.e. 10 ml 50% magnesium
sulphate) by deep intramuscular injection into
each buttock.
 Mgso4 admini cont…
If convulsion occur in 15 minutes of loading dose
give 2g mgso4
Maintaining dose
Magnesium sulphate 5 g is given with 1ml of 1%
lidocaine 4 hourly by deep intramuscular
injection into alternate buttocks.
 Mgt…
Step 2) measuring BP
 If the diastolic blood pressure is still 110 mg
Hg or higher
 Give dihydralazine by intramuscular
injection or nefidipine.
 Mgt…
If the blood pressure drops too much, intravenous
Ringer's lactate is administered rapidly
 Mgt…
 Step 3)
• foley's catheter is inserted into the patient's
bladder, to monitor the urinary output.
 Adverse effect and overdose of mgso4

 respiratory depression-decreased
respiratory rate .
 cardiac depression
 decreased urine output
 Before giving the next maintenance dose
1) check patellar reflex
2) count RR
3) measure urine output-normal is 30ml
per hour
 What should be done if adverse and over
dose effects of mgso4 occur?
• Intubate and ventilate the patient
• Give 10 ml of 10% calcium gluconate slowly
intravenously
THNK YOU