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Hypertensive Disorders in Pregnancy: Presenter: Puteri Mo: DR Fatin Amirah
Hypertensive Disorders in Pregnancy: Presenter: Puteri Mo: DR Fatin Amirah
Hypertensive Disorders in Pregnancy: Presenter: Puteri Mo: DR Fatin Amirah
presenter : puteri
Mo : dr fatin amirah
• Definition • Definition
• Hypertension • Proteinuria
• Raised in blood pressure recorded at least • Screening test is by dipstick
• Have a sensitivity >90% using ≥ 1+
on two occasions at six hours apart, it may be
• However, the accuracy of dipstick compared
either:
• Diastolic BP greater than 90 mmHg or,
to 24 hours urine protein is highly variable
• Miss >300 mg/24 hours in up to 1:8 patients
• Systolic BP greater than 140 mmHg
• False negative up to 20%
• Measurement • Significant if ≥ 2+
• Should be measured in a sitting position or • Trace of ≥ 1+ should be regarded as equivocal
semi recumbent position (450 head up) • 24 hour urine collection and quantification
• T h e right arm should be used consistently • Significant if 24 hour urine protein > 300 mg
• A r m should be in a horizontal position at • Gold standard
the level of the heart • Labour intensive and slow
• Phase V us used in pregnancy • Spot urinary protein:creatinine ratio
• Phase IV is more difficult to detect and • Significant if > 30mg/mmol
has limited reproducibility • Good compromise
• Definition
• Severity of Hypertension
Mild hypertension
Moderate hypertension
Severe hypertension
• Mild hypertension
• B P is 140 to 149 mmHg systolic and/or 90 to 99 mmHg diastolic
• Moderate hypertension
• B P is 150 to 159 mmHg systolic and/or 100 to 109 mmHg diastolic.
• Severe hypertension
• B P is ≥160 mmHg systolic and/or ≥110 mmHg diastolic
Classifications
• Four Categories
• Gestational hypertension
• Pre-eclampsia / eclampsia
• Chronic hypertension
• Pre-eclampsia / eclampsia
superimposed on chronic hypertension
• Gestational hypertension • Chronic hypertension
• H P T that developed after 20th week of
• Presence of persistent
pregnancy, in labour or within 48 hours of
delivery without significant proteinuria hypertension, of whatever cause,
• Resolved by 12 weeks postpartum before the 20th week of pregnancy
• I f persist beyond 12 weeks chronic (in the absence of hydatiform
hypertension mole), or persistent hypertension
beyond six weeks postpartum.
• Pre-eclampsia / eclampsia
• Pre-eclampsia - New onset of HPT after 20th • Pre-eclampsia / Eclampsia
weeks of pregnancy, in labour or within 48 hours superimposed on chronic
of delivery, where the BP was previously hypertension
normal, accompanied by significant proteinuria • Usually difficult to make, but is
(>300 mg/24 hrs)
• Eclampsia – Occurrence of tonic-clonic
usually associated with worsening of
convulsion not cuased by coincidental the hypertension and the
neurological disoreders in a patient with pre- development of worsening
eclampsia proteinuria
Investigations
May be repeated at interval
Urine test
Coagulation profile
CTG
• General principle
•
In patient vs. out patient
•
Maternal evaluation
•
PET chart
•
Investigations
•
Fetal evaluation
•
Serial ultrasound for growth
•
AFI
•
Doppler
•
CTG
•
FKC
•
Plan for delivery – delivery will cure pre-eclampsia & gestational hypertension
Pre-Eclampsia - Diagnosis Pre-Eclampsia - Risk factors
Diagnosis
When systolic BP > 140 mmHg, DBP > 90mmHg in a woman known to be
normotensive prior to pregnancy
The diagnosis requires 2 such abnormal blood pressure measurements recorded at
least 6 hours apart
Significant proteinuria
Oliguria - <500mL/24 h
Thrombocytopenia - <100,000/mm3
Absent of Epigastric or right upper quadrant pain
Pulmonary edema
Persistent cerebral or visual
disturbances
Management
Investigations – What and how frequent?
Test for proteinuria
Investigations – What and how frequent?
Pre-eclampsia At least 4x per day At least 4x per day More than 4x per
day, depending on
circumstances
Management
Treatment – To treat or not?
Only offer antihypertensive Rx other than labetalol after considering side effect profiles for women, fetus and newborn baby
Alternative includes methyldopa and nifedipine
Management
Treatment – Drugs commonly used
Drugs Dosages
Labetalol Up to 1200 mg/day
Methyldopa (Aldomet) Up to 2250 mg/day
Prazocin Up to 15 mg/day
• Aim for BP <150 mmHg systolic & between 80 to 100 mmHg diastolic
• Combination therapy of drugs from different classes is possible
• Eg. Aldomet + Beta blocker
• Do not use:
• Thiazide diuretics – reduce plasma volume
• Highly selective beta blockers – causes IUGR
• ACE inhibitors – may cause IUFD
Management
Drugs used for acute hypertension
I V Hydralazine:
5mg IV bolus with additional 5mg
increments up to 20 mg every 20 – 30
mins.
I V Labetalol:
20-50mg over 2 mins.
Repeat after 15-30 mins.
Sublingual Nifedipine:
5mg sublingually
Usually starts working within 10 mins.
Can be repeated after 30 mins.
I V Diazoxide:
15 – 45 mg bolus
Repeat after 5 mins to a maximum of
300 mg.
Management
Prophylaxis against convulsion?
Consider giving intravenous magnesium sulphate to women with severe pre- eclampsia who are in a
critical care setting if birth is planned within 24 hours
Features of severe pre-eclampsia
Liver tenderness
HELLP syndrome
24 hours
Rate of titration adjusted
according to patient’s level of
consciousness
Phenytoin therapy
Phenytoin is only recommended
for prevention of convulsion. So
diazepam 10mg is to be given as
required for immediate control of
seizures
When to deliver?
a s soon as the woman’s condition
has stabilized, regardless of
gestational age
suggested within 12 hours of the
onset of convulsions Indications for caesarean section
1. unfavourable cervix
2. fetal heart rate abnormalities
How to deliver? 3. if vaginal delivery is not
anticipated within 12 hours ensure coagulopathy has been excluded
methods of delivery taking into before performing a caesarean section