Hypertensive disorders in Pregnancy

By Amir and Rafiza

Types of Hypertension
Pre-existing hypertension (chronic) Elevated BP before pregnancy or in the first 20 weeks. May be due to essential HPT, renal disease, connective tissue disorders and other rare causes. Pre-eclampsia Elevated BP of 140/90mmHg or greater in 2nd half of pregnancy and were normotensive before this Rise of 25mmHg over diastolic level in non-pregnant state or in 1st half pregnancy

Aetiology of pre-eclampsia
Cause of the condition remains unknown but there is a pre-disposition in certain groups:
Primigravid patients Increased risk with age Family history of pre-eclampsia/HPT Pre-existing HPT Multiple pregnancy Diabetic pregnancy Hydatidiform mole Severe rhesus sensitisation

Pathophysiology
Normal pregnancy: trophoblast invades the maternal spiral arteries and converts these vessels into LOW resistance arteries (increase perfusion). In pre-eclampsia, this process is defective (increase resistance). Placental ischemia is thought to lead to widespread activation/dysfunction of the maternal vascular endothelium that results in enhanced formation of endothelin and thromboxane, increased vascular sensitivity to angiotensin II, and decreased formation of vasodilators such as nitric oxide and prostacyclin. Therefore there is widespread systemic disturbance

System CVS Renal system

Pathophysiology Increased peripheral resistance. Fall in plasma proteins due to renal dysfunction hypovolemia and tissue edema. Impaired renal function (both glomerular and tubular dysfunction). Proteinuria (>300mg in 24 hours) and raised plasma urate levels (>0.35mmol/L)

Clotting system Falling platelet levels and changes in clotting factors. May proceed to disseminated intravascular coagulation with micro-angiopathic hemolysis secondary to small vessel blockage anemia and presence of fragmented red cells in peripheral blood. Raised level of fibrin degradation products are found.

Liver damage

Subcapsular haemorrhage and areas of necrosis in peri-portal region of liver lobules. Epigastric tenderness and elevated enzymes. HELLP syndrome: combination of DIC and liver damage in severe pre-eclampsia.
Headache, visual disturbance and abdominal pain may indicate progression towards eclampsia. First two reflect the effects of hypertensive encephalopathy as well as epileptiform fit. In normal pregnancy, there is reduction in sensitivity to vasopressor effects of angiotensin. Does not occur in high proportion of cases which eventually develops pre-eclampsia.

CNS (eclampsia) Renin angiotensin system

Management of Chronic HPT and PIH

Algorithm for chronic HPT

Chronic hypertension and PIH (first line therapy)

Methyldopa Is a centrally acting alpha- adrenergic agonist that inhibit vasoconstricting impulses from medullary vasoregularoty centre. Total daily dose of 500 mg administered n 2-4 divided dose. Max effect of 4-6 hrs Excreted by kidney Side effect: sedation and postural hypotension Hemolytic anemia is indication to stop medication. Is a alpha 1- adrenergic and non selective beta- adrenergic blocker. Ratio of 7:1( beta:alpha) Safe during preg, because lack teratogenic and crosses placenta at small amt. Side effect: SGA

Labetolol

nifedipine

Is a calcium channel blocker A tocolytic agent and also a HPT tmrt Dose of 30mg once daily. Must be used cautiously for pt receiving mg sulphate becz the neuromuscular blocking action of mg maybe potentiated by simultaneous calcium channel blokade.

Contraindicated drugs
ACE causes fetal hypocalvaria, renal defects, anuria, fetal and neonatal death. Diuretic eg: furosemide, hydrochlorothiazide Beta blocker Causes fetal bradycardia, growth retardation, neonatal hypoglycemia

Prognosis
Close monitoring for dev of fetal growth restriction and superimposed preeclampsia is indicated.

Preeclampsia
Mild preeclampsia BP 140/90mmHg but < 160/110mmHg on 2 occasion at least 6hr apart while pt is on bed rest. Proteinuria 300mg/24hr but <5g/24hr asympt Severe preeclampsia
BP 160/110mmHg on 2 occasion at least 6hr apart while pt is on bed rest Proteinuria 5g/24hr Cerebral or visual disturbances Pul edema or cyanosis Epigastric/RUQ pain Impaired liver function Thrombocytopenia Fetal growth restriction

Mild preeclampsia
delivery Gestational age of 40 weeks delivery is indicated Gestational age of 37- 40 weeks cervical status has to be assessed. If favorable, induction is initiated. If not favorable, peri-induction cervical ripening agents are used. -plus bed rest, antepartum fetal surveillance and BP monitoring 4-6 hr daily.
Administered if gestational age <34 weeks. For fetal lungs maturity -To do amniocentesis(pul maturity study) Fetal growth is assessed with ultrasound 3-4 weeks once.

corticosteroid

Management of Severe preeclampsia & Eclampsia

Like a flash of lightning

Aims:
Control the fits by relieving the generalized vascular spasm and decreasing the sensitivity of the brain to the stimuli Reduce blood pressure to prevent cerebral haemorrhage Deliver the fetus

Observations and investigations

Maternal Fetal

1. BP should be measured every 15-20 minutes 2. Oxygen saturation should be monitored continuously 3. Urine output measured hourly 4. Urea and electrolytes, FBC, LFT and coagulation screen at least every 24 hours

1. Ultrasound biophysical assessment (fetal maturity and estimate of fetal size) 2. Continuous cardiotocography

Magnesium sulphate
Reduces risk of recurrent seizures by
Relieving vasospasm Inducing cerebral vascular dilatation

Increases release of prostacyclin

Improves uterine blood flow Inhibits platelet activation Protects endothelial cells from injury

MgSO4 treatment for eclampsia Loading dose MgSO4 4g IV over 5 to 15 minutes Maintenance dose MgSO4 1g per hour in solution of 5g in 500mL normal saline

Maintenance dose should be continued until 24 hours after last seizure OR if there is Mg toxicity. Repeat fits may be treated by using further boluses of MgSO4 or diazepam

Mg Toxicity Respiratory arrest Respiratory depression (<14 per min)

Management Intubate, ventilate and stop MgSO4 infusion. Give 1g calcium gluconate IV (antidote) O2 by mask, calcium gluconate 1g IV, maintain clear airway

Absent patellar reflexes If respiration normal, stop MgSO4 infusion until reflexes return. If respiration is depressed, treat for this condition. Poor urinary output (<100mL in 4 hours) If no signs of Mg toxicity, reduce rate of IV infusion to 0.5g/h and monitor fluid balance

Other treatments
Hypotensive therapy
Hydralazine, 5mg over 15 minutes and repeated to max dose of 20mg Labetalol infusion also has a role in second line agent

Fluid balance
Fluid overload and pulmonary edema may develop: standard fluid regimes should be used and monitored. CVP line may be required to assess fluid balance and aid management

Delivery
Timing of the delivery depends on
Rate of deterioration of mothers condition Maturity of pregnancy

 <34 weeks controversial

to administer corticosteroid and do amniocentesis to monitor fetal lung maturity. give mother antihypertensive agent- continuous monitoring of mother BP <160/105mmHg

33-35 weeks
amniocentesis to check for fetal pul maturity. If mature, proceed with delivery. If not mature, administer corticosteroid and delay delivery to 24-48 hr.

>36 weeks- immediate delivery if indicated.

 If eclamptic fit occurs and if baby is alive and viable, delivery should be done often by Caesarean section. If cervix if favourable, then induction of labour can still be considered, particularly in parous women.

 Depending on coagulation status: prophylaxis of DVT should be considered. Compression stockings should be provided.

Case Scenario

Case
Name: Nur Ellyza Age:28 y.o Race:Malay G1P0A0 LNMP:5th Dec 2010 EDD:12th Sept 2011 POA:35th W+3 Date of Admission: 12th Aug 2011 Date of Clerking:15th Aug 2011

 c/o HPT since 20th week of gestation -After the 20th week, her BP was 145/90mmHg. -She monitored her BP for 2 weeks and resolve. -During the 35th week of gestational, her BP increases to 145/90mmHg and was admitted to HPJ -complained her urine was dirty since 12th Aug. -she complained of headaches -no RUQ/ epigastric pain -no oligouria -no blurring of vision

 Missed her period for 1 month and did a UPT which was +ve. Did booking at KK in Presint 3 No sympt of early preg such as hyperemesis gravidarum. Quickening was felt at 24th week(early jun) Still able to feel fetal movement (10x in a day) Unplanned preg No MOGTT was performed.

 Duirng 14th week preg laparascopy was done for right and left emdometriocycst. Never preg before. Both family has HPT. Does not take contraceptive pills. Menarche at age 12 which is regular every month with duration of 7/28. Heavy flow for first 2-3 days with 4 pads used fully soaked. Dysmenorhea but no meds taken.

 Taking -Vit c -b complex -folic acid No other trad/over the counter med. Lives with Husband at Putrajaya. Working at Complex E. Not a smoker and does not consume alcohol. Husband is a statistician and a smoker of 3 sticks per day. Smokes outside the house.

PE
Pulse: 80 bpm BP: 138/79mmHg Palm is pale Capillary refill is good( < 2sec) X jaundice Conjunctiva is slightly pale No angular stomatitis No central cyanosis Oral hygiene is good and well hydrated Bilateral pitting edema until the knee level

 Abd is distended with a gravid uterus as presence of Linea Nigra and Stria Gravida. There is a surgical scar presence at right upper quadrant which measures 1cm and left loin which measures 2cm. Estimated fundus height is 34 weeks which is corresponding to POA. However it measures 28 cm. There is single fetus in oblique lie with breech presentation. Head is not engage. Was not able to appreciate fetus back Liquor is not adequate. Estimated fetal weight is 2.18kg.

IX
FBC
LFT Renal Profile

HB (12) Platelet- Normal

Alanine Posphatase 129 ( 35- 104) Creatinine normal Chloride 109.3 (98-106) Uric acid 344 (142-339) Prothrombine time 9.0 Protein 1+ Leucocyte 3+

24 hour urine Protein Coagulation Profile Urine Feme

doppler

RI: 0.63 PI:1.03 Bpd:8.91=36w Hc:32-24 = 26w 3d Ac:283=31w Fl:6.66=34w2d Efw:2.18kg Afi:7

PLAN
T Labetolol 100mg tds Monitor BP (not > than 160/110) Watch for Impending Eclampsia sympt For LSCS at 36 weeks Keep NBM

Thank you