PREGNANCY INDUCED HYPERTENSION

PIH

Gestational Hypertension or pregnancy-induced hypertension

Defined

as the

Development of new arterial hypertension in a pregnant woman after 20 weeks gestation

INCIDENCE
5

percent to 8 percent of all pregnancies. Young women First pregnancy Twin pregnancies Previous pre-eclmaptic pregnancy Diabetese Mallitus Chronic hypertension

Types
PIH

Pre-eclampsia

(Toxemia of pregnancy)

Mild Severe

Eclampsia HELLP

syndrome

PIH
MILD

BP 140/90
SEVERE

BP 160/110 or more

Characteristics of Pre-Eclampsia
Hypertension

Protienuria
Edema

PRIMARY CHARACTERISTICS
High

blood pressure 140/90 mm Hg or a significant increase in one or both pressures Proteinuria (300 mg or >/24 hours urine)
Or Urinolysis +++ or ++++

Edema

or recent rapid weight gain

ECLAMPSIA
Severe

form of PIH Women with eclampsia have seizures Occurance one in 1,600 pregnancies Develops near the end of pregnancy, in most cases.

HELLP syndrome
Complication

of severe pre-eclampsia or

eclampsia. group of physical changes: Breakdown of RBCs, Changes in the liver Low platelets

HELLP

H:

Haemolysis EL: Elevated Liver Enzymes LP: Low Platelets

HELLP
Diagnosis
Hemolysis
Blood smear
Bilirubin 1.2 mg/dl or more

Elevated

liver enzymes

SGOT (asperate aminotransferase) > 70 U/L Lactate dehydrogenase > 600 U/L

Low

Platelets
<100,000 per mm3

cause of PIH

unknown ???

Pathophysiology
Immunologic

response Endothelial Dysfunction Abnormal Prostaglandin Metabolism Platelet Dysfunction Calcium Coagulation factors Fatty metabolism Markers of angiogenesis

1-Immunologic response
Abnormal fetal-maternal antigen-antibody response Spermatozoa cause formation antibody or prostaglandins which cause VC Normally at 20 weeks, Maternal spiral arteries are invaded by trophoblast causing release of PGI and NO, this mechanism lacks in pre eclampsia >>>>high resistance low flow uteroplacental circulation

Endothelial cell dysfunction

in response to unknown factors Resulting in imbalance in the production of :PGI2 and EDRF(NO) >> Vasodialator & :TXA2 derived from platelets & endothelaium >>Vasoconstrictor ET-1: chorionic plate arteries constrictor, elevated in pre-eclampsia & pre term rupture of membrane

Platelet factor

Normally aggregating platelet release (serotonin) 5HT + 5HT receptors >> release of NO & Prostacyclin >> Angiotensin II >> improve uteroplacental blood flow
Loss

of 5-HT receptor prevents stimulation of angiotensin II release in pre eclampsia

CALCIUM

Instead of normal slow rise of intracellular Calcium concentration In Pre eclampsia Ca++ increases rapidly also enhanced by angiotensin II

(Sensitive indicator of subsequent development)

Other Factors

Coagulation factors disturbance between plasma ratio of von Willebrand factor and factor VIII Fatty metabolism increased free fatty uptake by liver hypertriglyceridemia Markers of angiogenesis FLT-I, VEGF (vascular endothelial growth factor)

RISK FACTORS for PIH

pre-existing

hypertension kidney disease Diabetes Mallitus PIH with a previous pregnancy Mother's age younger than 20 or older than 40 multiple fetuses (twins, triplets) Vascular Diseases

Why is pregnancy-induced hypertension a concern?

With high blood pressure there is an increase in the resistance of blood vessels. This may hinder blood flow in many different organ systems in the expectant mother including the liver, kidneys, brain, uterus, and

placenta.

Baby required to be delivered early, before 37 weeks gestation.

Complications
Maternal
DIC CCF with pulmonary edema Placental Abruption

Fetal
Pre-maturity Respiratory Distress IUG retardation

PPH
ARF Rupture of Liver

Oligohydromnios
Intracranial Hemorrhage Small for age

CVA, Seizures
Septic shock

Meconium aspiration
More Morbidity/Mortality

Symptoms of PIH
Neurological
Headach, Hyperexcitability, Intracranail hemorrhages, Visual distubances Seizers Cerebral edema

Pulmonary
Cardiovascular

Upper airway edema Pulmonary edema

Decreased intravascular volume Increased arteriolar resistance Hypertension, Heart failure

Hepatic
Renal Hematological

Impaired function, Hematoma,

Protienuruia, Decreased GFR

Elevated enzymes Rupture

Sodium retention Renal Failure

Coagulopathy Thrombocytopnia Platelet dysfunction Microangiopathic hemolysis

How is pregnancy-induced hypertension diagnosed

Increase in blood pressure levels but other symptoms help

Tests for pregnancy-induced hypertension may include

the following: blood pressure measurement urine testing assessment of edema frequent weight measurements eye examination (retinal changes ) Liver and Renal function tests Blood clotting tests

goal of treatment
To prevent the: Condition from becoming bad to worse Complications.

Treatment for pregnancy-induced

Specific treatment will be determined by the physician based on: pregnancy, overall health, and medical history extent of the disease Tolerance for specific medications, procedures, or therapies expectations for the course of the disease Patients opinion or preference

Obstetric Management

Bedrest (either at home or in the hospital) Hospitalization (specialized personnel and equipment) Magnesium sulfate (or other antihypertensives for PIH) Fetal monitoring may include: fetal movement counting - fetal kicks and movements change in the number/frequency: means fetus under stress. nonstress testing - measures the fetal heart rate in response to the fetus' movements. biophysical profile - combines nonstress test with ultrasound Doppler flow studies Continued laboratory testing of urine and blood (for changes that may signal worsening of PIH) Corticosteroids (help mature the lungs of the fetus) Delivery of the baby (if treatments do not control PIH or if the fetus or mother is in danger)

What antihypertensive medication is used in PIH ?

ANTIHYPERTENSIVES
Diuretic Beta Blocker ACE inhibitors Calcium /Angiotensin II receptor Channel Blocker antagonist Alpha Blockers

Caution

Not in late pregnancy

No Adversely effect fetal and neonatal blood pressure control, skull defects, oligohydromnios, toxicity

No Myocardial depressants

caution

Labetalol

Arteriolar dilator I/V Max 200 mg 2mg/min until satisfactory response Oral 200 mg BID upto 1200mg Vasodilator Causes tachycardia fluid retention Oral 25 mg BD IV 10mg in 10 ml saline in 20 minutes Isorbid dinitrate, Glyceryl trinitrate, isorbid mono nitrate

Hydralazine
(Apresoline)

Nitrates

Methyldopa
(Aldomet)

250 500 mg 2-3 times/day Centrally acting Alph 2 receptor agonist

0.5-1.5gm/kgmin Cyanide toxocity if treatment exceeds 3 days Vasodilator no myocardial depression 10-20mg BD

Sodium Nitropruside Nifedipine

(ADALET)

Alpha methyldopa 500 mg PO bid (up to 2 grams bid) Labetolol 200 mg PO bid (up to 1200 mg bid) Felodipine 5 mg PO daily (up to 20 mg daily) Hydrochlorothiazide

Not usually initiated in pregnancy due to volume depletion May be continued if on pre-pregnancy - consult with local expert opinion

Nifedipine XL 30 mg PO bid (up to 120 mg daily) Hydralazine 10 mg PO tid (up to 25 mg tid

GOAL
of

Antihypertensives
Blood

Pressure < 150/100

(much higher than non-pregnant goal)

Anti-hypertensives are not indicated for mild to moderate chronic Hypertension in pregnancy
BP

<150/100 does not reduce risk to fetus or prevent Preeclampsia

Antihypertensives benefit mother only do not reduce pregnancy complications

Pre-Operative Evaluation

Investigations ?

Blood complete picture Platelet count Coagulation assay, PT, APTT, Fibrinogen, D - dimer Serum Urea/creatinine Electrolytes Uric Acid LFTs Urinolysis, Microscopy, 24 Hours specimen for protien and creatinine clearence Type and screen Blood

Monitors

NIBP SaO2 Hourly deep tendon reflex Muscle strength Serial Magnesium Sulphate levels Foleys Catheter for urine volume Urine concentration Fetal heart Rate IBP CVP Persistent oligouria, difficulty in fluid management therapy in ante/post partum period, Pulmonary edema PA Severe eclampsia Left ventricular systolic function is markedly reduced CVP 92% versus PA 8%

What condition mandate immediate Delivery

Immediate Delivery
Severe

Hypertension Progressive thrombocytopenia Liver dysfunction Progressive Renal dysfunction Persistent headache Evidence of fetal jeopardy Premonitory signs of ECLAMPSIA

What drug therapy is the treatment of choice for Seizure prophylaxis

Diazepam Phenytoin

Magnesium

Sulphate

How to use Magnesium Sulphate

4

- 6 Grams in 20 minutes followed by 1-2 gram per hour

Monitor Urine output Respiratory rate Patellar reflexes Serum levels 4 hourly

Serum levels of Magnesium Sulphate

5 mEq/L 10 mEq/L
Therapeutic range

Loss of deep tendon reflexes Prolonged P-Q interval Widening QRS complexes

15 mEq/L 20 mEq/L

Respiratory Arrest Asystole

Role of Magnesium Sulphate

CNS depressant & Anticonvulsant CVS Mild Anti-hypertensive effect Neuromuscular Junction
Inhibits Ach release decrease membrane excitability augment Non and depolarizing muscle relaxant

Uterus
Mild relaxant effect on vascular & uterine smooth muscle Improve uterine blood flow

What are fetal effects of MgSO4

MgSO4

crosses the placenta

Neonatal depression
Respiratory Hyporeflexia Decreased beat to beat variability in heart rate

Treatment of Eclampsia

Stop convulsion (Thiopentone 50-100 mg) ABC Apply monitors (Pulse Oximeter, NIBP, ECG) I/V line Check BP repeatedly Administer MgSO4 Treat hypertension Deliver baby

Intraoperative Management

What type?

Analgesia/Anesthesia for patient with pre-eclampsia in labour

EPIDURAL

Superior pain relief Attenuate the hypertensive response to pain Reduce circulating level of catecholamines/hormones Improve intervillous blood flow Stable Cardiac output Increased Risk for C-section

Any Role of Prehydration

Prehydration with crystalloid compensate for decreased prelaod and after laod >>> ANP >> VD >>renal elimination of excess ECF AVOID if there is recent excessive weight gain (overhydration) Monitor for pulmonary oedema

Role of Bleeding time or Platelet count for EPIDURAL

BT

not useful

Skin bleeding time is not predictor for preeclamptic epidural vein bleeding

Platelet

count reliable
50-80,000

Commonly used Local Anaesthetics

Bupivacain
4 times potent then lignocain Onset 5 times longer then lignocain Fast in, slow out

Ropivacain
Single levorotatory isomer rather then racemic solution Less cardiotoxic

Levobupivacain
Single levorotatory isomer Less cardiotoxic

Lignocain
More Motor block More hypotension instant onset
Note: with adrenaline should not be used in severe preeclampsia

What type of anaesthesia for C Section

Spinal

General

Spinal Anaesthesia

Best even in severe pre-eclampsia GA Severe hypertensive response to intubation Risk of difficult intubation due to airway edema Epidural Less reliable anaesthesia than spinal Risk of trauma to epidural vein Risk of hypotension 6 times less in pre eclamptic pregnant woman .75% hyperbaric Bupivacain 11-12 mg with or without 15-20 g Fentanyl or morphine 100-200 g

General Anesthesia

Aspiration prophylaxis Thiopentone sodium induction Suxamethonium with cricoid pressure Attenute intubation response by deep anaesthesia & lignocain Smaller ETT 6-6.5 mm (airway edema) Nondepolarizing agent after recovery from suxamethonium Remember MgSO4 2/3 rd MAC for adequate depth of anaesthesia MgSO4 intra and Post op period IBP line for continuous blood pressure monitoring Anti HTN drugs

The End

Pathology of pregnancy, childbirth and the perpurium

Pregnancy abortive outcome Oedema, proteinuria and hypertensive disorders Other, predominantly related to pregnancy Maternal care related to the Fetus and amniotic cavity & possible delivery problems Complications of labour and delivery Ectopic pregnancy - Hydatidiform mole - Miscarriage Pregnancy-induced hypertension - Pre-eclampsia - Eclampsia - Gestational diabetes Hyperemesis gravidarum - Gestational pemphigoid Intrahepatic cholestasis of pregnancy Polyhydramnios - Oligohydramnios - Chorioamnionitis - Premature rupture of membranes - Amniotic band syndrome - Placenta praevia - Braxton Hicks contractions - Antepartum haemorrhage abruption Premature birth - Postmature birth - Cephalopelvic disproportion - Dystocia (Shoulder dystocia) - Fetal distress - Vasa praevia - Uterine rupture hemorrhage - Placenta accreta - Umbilical cord prolapse - Amniotic fluid embolism Puerperal fever - Peripartum cardiomyopathy Postpartum thyroiditis - Galactorrhea - Postpartum depression Fetal intervention - Fetal surgery

Maternal complications in the weeks after childbirth Complications related to the