Pregnancy Induced Hypertension

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Pregnancy Induced Hypertension

• Prof. Duan Tao,M.D.
• Shanghai 1st Maternity and Infant Hospital

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Pregnancy Induced Hypertension

• Definition
• Toxemia
• Gestosis
• Preeclampsia-Eclampsia
• Pregnancy Induced Hypertension
• EPH Syndrome

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Theories about causes

• Still Unknown
• Utero-placental ischemia
• Neuro-endocrinologyPGI2/TXA2
• Immunology-hereditary
• Chronic DIC

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Theory

• Primipaternity
• Robillard PY. Eur J Obstet Gynecol Reprod Biol,
  1999.
• Dekker 392 multiparous PIH women , 22-25 have
  new partners, 3.4 in control group.

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My Theory

• Trigger off theory
• The open Shield in Chicago
• Lying In Hospital

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Diagnosis

• Hypertension of pregnancy
• BP ? 140 / 90 mmHg ALONE
• or WITH mild oedema (after 20wks of gestation)

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Diagnosis

• American Way
• Preeclampsia
• I) Mild preeclampsia
• BP ? 140/90mmHg, but lt160/110mmHg,
• Edema mild
• Proteinuria Trace / 1

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Diagnosis

• II) Severe preeclampsia
• BP ? 160/110 mmHg
• Edema marked
• Proteinuria 2 or more

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Diagnosis

• With headache,visual disturbances, abdominal
  pain, oliguria, thrombocytopenia, bilirubin,
  liver enzymes, creatinine, foetal growth
  retardation, pulmonary oedema
• Eclampsia
• Severe preeclamsia with CONVULSION

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Diagnosis

• Chinese way
• Mild preeclampsia
• BP ? 140/90mmHg, but lt150/100mmHg,
• or with an elevation of 30/15 mmHg
• Edema and/or
• Proteinuria Trace

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Diagnosis
Moderate preeclampsia BP ? 150/100mmHg, but
lt160/110mmHg, Edema and/or Proteinuria 1
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Diagnosis
Severe preeclampsia BP ? 160/110mmHg Edema
and/or Proteinuria 24
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Pathophysiology

• Vasospasm haemorrage necrosis end organ
  changes
• Reduced placental perfusion? IUGR foetal
  death
• Increased cardiac output
• Increased extra cellular fluid volume

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Pathophysiology

• Haemoconcentration
• Hypercoagulability-DIC - reduced clotting factors
  - bleeding
• Reduced GFR oligouria - anuria
• No electrolytic imbalance

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Pathophisiology

• Serious Complications
• Hellp syndrome
• Abruptio placentae
• Pulmonary oedema
• Acute renal failure

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Pathophysiology

• Serious Complications
• Cerebral haemorrhage
• Visual disturbances blindness
• Hepatic rupture
• Electrolytic imbalance
• Postpartum collapse

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Differential Diagnosis

• Chronic hypertension essential / renal / others
• Mostly obese, elderly, parous likely to be on
  antihypertensive drugs
• Usually preexists / appears early (lt20wks)
  persists postpartum
• End organ damage maybe present

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Differential Diagnosis

• Diagnostic confusion
• 10 of 24(42) women initially thought to have had
  eclampsia were later found to have had other
  cerebro-vascular pathology-hypertensive
  encephalopathy, cerebral hemorrhage, or cerebral
  infarction. Suspected eclampsia, unresponsive to
  Mgso4 therapy warrants a prompt neuroimaging
  study.
• Am J Obstet Gynecol. 19971761139-1148

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OBJECTIVES OF MANAGEMENT

• Cure / prevent progression -
• Close monitoring
• Reduce blood pressure -tatrget- 140/90mmHg
• Promote foetal maturity
• Prolong pregnancy (34 - 36 weeks)
• To achieve foetal maturity ? termination
• Delivery- best day, best way best place
• Prevent / manage complications

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MATERNAL MONITORING

• Look for appearance of ominous features
• Daily- record b.P 4 times, monitor urine output
  test for proteinuria quali. / Quant
• Alt.Day- body weight
• Every 4th day- uric acid, platelet count, liver
  function
• Weekly- creatinine

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FOETAL MONITORING

• Daily - clinical foetal monitoring - fhs, fundal
  ht. Abdominal girth, amniotic fluid, foetal
  movement count, C.T.G
• Ultrasound - on admission then 3 weekly for
  foetal biophysical parameters, placenta and
  amniotic fluid volume
• Dopller ultrasonography for placental blood flow
  velocity every 4th day
• L/s ratio for maturity

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Anticonvulsion

• The history of MgSO4
• Magnesium sulfate in the treatment of eclamptic
  convulsion
• 1)It was first used to control tetanic
  convulsions in early 1900s. The modern obstetric
  use of Mgso4 was first popularized by Pritchard
  IM 10 g load, then 5g/4hrs (1955)

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Anticonvulsion

• 2)Zuspan recommended continuous intravenous
  infusion 4g load, then 1g/hr (1966)
• ( This regimen was used in the United States
  before 1980s,and is currently used in Europe and
  South Africa, it was found to produce levels less
  than 4.8mg/dl in the majority of women treated).

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Anticonvulsion

• 3)Sibai modified IV infusion 6g load, then 2g/hr
  (1981)
• 4)Pritchard recommended that the appropriate
  serum levels of Mgso4 for treatment of eclamptic
  convulsions were 3.5-7 Meq /L(or
  4.2-8.4mg/dl)(1979)

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Anticonvulsion

• 5)Magnesium level mg/dl 1.2x magnesium level
  Meq/L
• 6)If the patients were treated according to the
  recommended regimen, 10 of the eclamptic
  seizures will recur

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Anticonvulsion

• The usage of MgSO4
• 1)15-22.5g/d 1.5-2g/hr
• 2)I.M.Vs I.V.
• 3)I.V./day,I.M./night
• 25 MgSO420ml2Lidocaine 2ml
• 4)The effect of MgSO4BP/ Proteinuria /Edema
• Attentionspatellar reflex /respiratory/ urine
  output

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Anticonvulsion

• Phenytoin (Europe way)
• If contraindications of MgSO4 exist, use
  Phenytoin. Loading dose 15 mg/kg at 40 mg/min
  with continous monitorization of the cardiac
  function and BP every 5 minutes. The therapeutic
  range is 10-20 µg/ml.

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Sedatives

• Diazepam10mg IV
• Pethedine100mg
• Chloropramazine50mg

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Antihypertensives

• Apresolinea blocker/25mg5GS 500ml
• CaptoprilACE II blocker,banned because of fetal
  damage.
• NifedipineCalcium channel blocker , quick/short
  lasting, 10mg q6h.

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Antihypertensives

• Labetalolaandß blocker,
• 50-100mg5GS 500ml
• Nitroprusside sodiumVery potent, but with toxic
  effect.
• 50mg5GS 500ml
• Rigitinea-blocker,first choice for PIH patients
  with cardiac disease.
• 10-40mg5GS 500ml

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Caveats for antihypertensive therapy

• 1)There is great individual variability in
  response to these drugs, and they do not lower
  blood pressure predictably, precisely, or
  smoothly.
• 2)Lowering blood pressure too rapidly or
  excessively may produce fetal distress,
  particularly in the setting of IUGR or an
  abnormal fetal heart rate tracing.

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Caveats for antihypertensive therapy

• 3)Epidural anesthesia will lower the blood
  pressure approximately 15, frequently abrogating
  the need for antihypertensive medication.
• 4)The gravida with chronic renal insufficiency
  has hypertension that is more difficult to
  control, in part due to volume expansion.

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Caveats for antihypertensive therapy

• 5) Severe hypertension without proteinuria should
  prompt a urine screen for cocaine.
• 6)With prolonged unconsciousness, papilledema,
  lateralizing signs, seizures on magnesium
  sulfate, or seizures more than 48 hours after
  delivery, a CT scan should be performed to rule
  out intracranial hemorrhage.

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Volume Expansion

• Choice between crystalloid and colloid.
• Diuresis
• Furosemide10-20mg/iv
• Mannitol20 250ml,within 15-20

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Management of Eclampsia

• Mafia Look
• protocol for managing eclampsia
• 1)Convulsions are controlled or prevented with a
  loading dose of 6 g Mgso4 in 100ml 5dextrose in
  Ringers lactated solution, given over 15
  minutes, followed by a maintenance dose of 2g/hr,
  the dose is adjusted according to patellar
  reflexes and urine output in the previous 4-hour
  period.

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Management of Eclampsia

• 2)Diuretics, plasma volume expanders, and
  invasive hemodynamic monitoring are not used.
• 3)Induction and/or delivery is initiated within 4
  hours after maternal stabilization.

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Management of Eclampsia

• 4)Mgso4 is continued for 24 hrs after delivery
  or, if postpartum, 24 hrs after the last
  convulsion. In some cases, the infusion may be
  continued for longer.
• Witlin and Sibai. Hypertensive diseases in
  pregnancy. In Medicine of the fetus and mother,
  2nd ed. Reece EA, Hobbins J (eds). Philadelphia,
  PA. Lippincott-Raven, 1998, 997-1020.

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Hint

• DAMMCALD
• D Diazepam A Apresoline
• M MgSO4 M Mannitol
• C Chlorpremazine A Antibiotics
• L Lasix D Digitalis

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DELIVERY
TREATMENT
BEST DAY - WHEN ?
1 ) at 36 weeks - in all controlled cases 2 )
after 32 weeks - for foetal salvage Decreased
foetal movement Severe IUGR with
oligohydramnios Late deceleration with poor
variability Reversed umbilical diastolic blood
flow
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DELIVERY
TREATMENT
BEST DAY - WHEN ?
3) any time - if progressive in spite of
treatment, when - Bp gt160 /100 mmHg Urine
output lt 400 ml / 24 hours Platelet count lt
50,000 / cmm Serum creatinine increases
progressively Ldh gt1000 iu / l
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DELIVERY
TREATMENT
BEST WAY - HOW ?
1 ) Induction with oxytocin -after 36 weeks If
foetal condition is good Cervix is favourable /
cerviprime Application of forceps / ventouse
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DELIVERY
TREATMENT
BEST WAY - HOW ?
2 ) By C-S If termination before 36 weeks In
cases of maternal / fotal jeopardy Anaesthesia -
general / epidural / spinal better left to
anaesthetist
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DELIVERY
TREATMENT
Best place - where ? High-risk pregnancy unit /
tertiary hospital / well equipped hospital
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POSTPARTUM
TREATMENT
1 ) PPH - be prepared to face it Uterine atony /
DIC - FDP/bleeding disorder Oxytocics / uterine
massage / packing / uterine artery ligation /
internal iliac artery ligation / hysterectomy
2 ) neonatal care - Presence of
paediatrician is a must Incubator is helpful
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POSTPARTUM
TREATMENT
3 ) Drugs - Judicious use of
antihypertensives, iv fluids, diuretics,
diazepam in the first 48 hours
4) Follow up for 6 weeks
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TORCH Syndrome

• Why TORCH?
• T Toxoplasma
• O Others(Treponema pallidum,syphilis)
• R Rubella Virus
• C Cytomegalo Virus
• H Herpes Simplex Virus

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TORCH Syndrome

• Characteristics
• Mother---Minimal/Flu-like
• Fetus---Fatal/malformatiom
• Risk Population
• Way of fetal Infection
• 1.Intrauterine infection
• 2.Birth canal infection
• 3.Postpartum infection

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TORCH Syndrome

• Effect on the mother minimal
• Effect on the fetus
• 1. Toxoplasma
• Abortion,fetal death,cranial
  malformation,neural dysfunction.
• 2. Others(Treponema pallidum, syphilis)
• Abortion,fetal death,congenital
• syphilis

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TORCH Syndrome

• 3. Rubella Virus
• Congenital rubella syndrome(CRS),
• CRS triade cardiovascular malformation,
  congenital cataract, deaf.
• 4. Cytomegalo Virus
• Abortion,fetal death,neural and cardiovascular
  malformation.

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TORCH Syndrome

• 5. Herpes Simplex Virus
• IUGR,cranial malformation,neonatal infection
• Diagnosis
• 1.History and Symptoms
• 2.Lab Test antibodies/PCR

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TORCH Syndrome

• Management
• 1.Therapeutic abortion
• 2.Drugs
• The existing problems

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HELLP SYNDROME

• What is HELLP?
• H hemolysis
• EL elevated liver enzyme
• LP low platelet count
• Severe complication of PIH

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HELLP SYNDROME

• Effect on the mother
• Effect on the fetus
• Clinical manifestation
• Diagnosis and differential diagnosis
• Management

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Antiphospholipid Syndrome

• Characteristics
• 1. anticardiolipin antibody ()
• lupus coagulant ()
• 2.Symptoms like thrombosis, recurrent
  spontaneous abortion, thrombocytopenia

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Antiphospholipid Syndrome

• Clinical manifestation
• Diagnosis
• Management
• 1.aspirin
• 2.heparin
• 3.steroids

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Thank U !

• Prof. Duan Tao, M.D.