Hypertensive disorders during pregnancy

1
(No Transcript)
2
Hypertensive disorders during pregnancy

• ?. ???? ???? ??????
• ??????? ???? ???? ?? ???? ???????
• ???? ???? / ?????
  ??????
• 9/10/2011

3
Definition and Classification
4
HYPERTENSION

• Definition Hypertension is two or more blood
  pressure readings of 140/90 mmHg at least 6
  hours apart in sitting position.

5
Gestational hypertension

• BP reading 140/90 mmHg for the first time
  during pregnancy.
• No proteinuria
• BP returns to normal within 12 weeks postpartum
• Final diagnosis is only made postpartum

6
Chronic hypertension

• Hypertension before pregnancy or diagnosed before
  20 weeks gestation
• Hypertension first diagnosed after 20 weeks
  gestation and persisting after 12 weeks
  postpartum

7
Pre-Eclampsia

• BP 140/90 mmHg or more after 20 weeks gestation
• Proteinuria 1 by urine dipstick or a total
  protein level 300 mg or more per 24 hour

8
Eclampsia

• Central nervous system involvement with the
  occurrence of convulsions that cannot be
  attributed to other causes

9
Predisposing factors

• Age
• Obesity
• Parity
• Socioeconomic status
• Genetic predisposition
• Obstetric complication
• Existing medical condition e.g. diabetes renal
  disease

10
Pathophysiological changes in pre-eclampsia

• Capillary leak causing edema, proteinuria and
  hemoconcentration
• Vasospasm causing hypertension, oliguria, organ
  ischemia, abruptio placentae and occurrence of
  convulsion
• Activation of coagulation causing
  thrombocytopenia the release of cytokines
  peroxidases causing more reduction in
  uteroplacental perfusion
• Release of vasoactive agents (PG, NO, Endothelin)
  causing reduced uteroplacental perfusion

11
Pathology

• Hemorrhage and necrosis in many organs, secondary
  to arteriolar constriction
• Glomerular capillary endotheliosis

12
Investigations

• Hematologic increased hematocrit level
  thrombocytopenia
• Hepatic impairment elevated liver enzymes
• Cardiopulmonary impairment left ventricular
  failure and pulmonary edema
• Fetal impairment IUGR, oligohydramnios,
  iatrogenic premature delivery and abruptio
  placenta , increased prenatal morbidity
  mortality

13
MANAGEMENT

• Early detection appropriate management are
  essential to improve maternal fetal outcome
• Timing of delivery in mild pre-elampsia
• gestation gt 38 weeks, termination of pregnancy
  yields better fetal maternal outcome
• 34-38 weeks expectant management
• Gestationlt 34 weeks expectant manegment
  admistration of glucocorticoid to accelerate
  fetal lung maturation.

14
Expectant management of pre-eclampsia

• Hospital addmition
• Bed rest
• Frequent BP measurement
• Laboratory investigations.
• Fetal evaluation by ultrasound
• Avoid giving antihypertensive diuretics
• Delivery if fetus reaches term or when any sign
  of maternal or fetal instability occures

15
Convulsion prophylaxis

• Intravenous magnesium sulphate to arrest and/or
  prevent convulsion. Loading dose is 6 gm diluted
  in 200 ml Ringer lactate over 20 min. Maintenance
  dose 2 gm /hour starting immediately after
  loading dose continue for 24 hour after
  delivery or after the last convulsion.
• Calsium gluconate 1gm i.v pushed over a few
  minutes may be administered to reverse magnesium
  sulphate toxicity

16
Antihypertensive therapy

• Anti-hypertensive therapy protect against
  occurrence of maternal intracranial hemorrhage
• Chronic therapy of moderate hypertension does not
  delay progression of the disease, prolong
  gestation, or reduce the risk of seizures
• The maternal BP should not reduced below 140/90
  mmHg because lower pressures may decrease
  utero-placental perfusion
• The most commonly used agents during pregnancy
  are Nifedipine, Labetalol, Hydralazine sodium
  nitroprusside

17
Termination of pregnancy

• Mode of delivery
• If the women is not in labor, examine the cervix,
  if the cervix is fit for induction, start
  induction of labor
• If the patient is in labor there is adequate
  progress as seen on the partograph with no fetal
  or maternal complications, continue vaginal
  delivery
• If there is an obstetric indication for CS
  delivery perform the procedure

18
Reference

• Dienstage JL, Isselbacher .Women's
  disorders.InFauci AS et al., eds .Harrison
  principles of internal medicine, 17 th ed.New
  York,McGraw-Hill, 2008413-416.

19
THANKS