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Hypertensive disorders in pregnancy by Dr. Ranjana

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National Vice President FOGSI - 2017 Founder President ISOPARBPrayagraj2021-25 ICOG Governing CouncilMember 2021-25 ExecutiveMember,NationalISOPARB2023-25 President AOGS (Allahabad)2013 2017 Organising Chairperson,National FOGSIConference Scientific Sangam Prayagraj 2023 Obstetric Dilemmas Prayagraj 2022 BOH The Trilogy Delhi 2017 Organising Secretary, National FOGSI Conference-SAVMA-2016, Allahabad 2016 NationalAwards- FOGSI Achiever Award 2022 FOGSI Dheera Award 2022 FOGSI - Dr D.K Tank Reproductive Healthcare Promotion Trophy AICOG 2015 FOGSI Smriti Mylan Award Save theGirl Child AICOG 2013 Faculty at National, Intl conferences, IMA XL refreshercourse 2022-23and webinars Delivered theprestigious Dr Prabha Malhotra Oration 2023,UPCOG Lucknow Author of many articles and chapters in various books and journals. Co-convener of FOGSI GCPR on epilepsy in pregnancy Senior Consultant &Director RanjanaHospital, Prayagraj (MS,DGO,FICOG)
Overview of managing Hypertensive Disorders in Pregnancy Speaker: Speaker: DR. RANJANA KHANNA
Classification of hypertension in pregnancy American College of Obstetricians and Gynaecologists' Task Force on Hypertension in Pregnancy Gestational Preeclampsia Eclampsia Superimposed preeclampsia Chronic
Classification of hypertension in pregnancy 140 mm Hg systolic or 90 mm Hg diastolic on two separate occasions at least 4 hours apart occurring after 20 weeks gestation. Transient diagnosis with normalization of BP by 12 weeks postpartum BP of 140 mm Hg systolic or 90 mm Hg diastolic predating conception Identified prior to 20 weeks gestation Persists > 12 weeks postpartum Use of antihypertensive medications before pregnancy Gestational hypertension Chronic hypertension
Classification of hypertension in pregnancy Preeclampsia Occurring after 20 weeks of pregnancy BP 140 mm Hg systolic or 90 mm Hg diastolic or higher Proteinuria 0.3 grams protein or higher in a 24-hour urine specimen OR +1 per dipstick OR P/C ratio > 0.3 mg/dL Or in the absence of proteinuria, new onset HT with the new onset of any of the following: Thrombocytopenia, renal insufficiency, impaired liver function, Pulmonary edema, cerebral or visual symptoms Eclampsia Presence of new onset grand mal seizures in a pregnant woman with preeclampsia Rule out idiopathic seizure disorder or other central nervous system pathology such as intracranial hemorrhage, bleeding arteriovenous malformation, ruptured aneurysm
Classification of hypertension in pregnancy Superimposed preeclampsia New onset in a woman with hypertension prior to 20 weeks Sudden increase in proteinuria if already present in early gestation Sudden increase in BP Development of HELLP syndrome Development of headache, scotomata, or epigastric pain
HDP are common and complicate obstetric practice in India Incidence of preeclampsia in hospital practice in India varies from 5% to 15% Incidence of eclampsia is about 1.5% Hypertension in pregnancy: Fast figures
Aetiopathogenesis
MANAGEMENT Gestational Hypertension
A. Antepartum Management Mother evaluation CBC with platelet count Serum creatinine LFT Urine protein (24-hr collection or protein/ creatinine ratio) Symptoms of severe preeclampsia Fetal evaluation USG for fetal weight & Amniotic fluid index Non-stress test Biophysical profile if NST is nonreactive Initial Evaluation
B. Antepartum Management Kick count: Daily USG: Every 3 weeks Amniotic Fluid volume: Once weekly NST: Weekly (GHT), Twice weekly (Preeclampsia) Blood pressure at every visit Evaluate Proteinuria (GHT) Laboratory: CBC, Liver enzymes, Serum creatinine (once week) Fetal Evaluation Mother evaluation Continued Evaluation
C. Antepartum Management Women are instructed to report symptoms of severe preeclampsia (headache, visual changes, epigastric pain, shortness of breath) Advised to immediately come to hospital if they develop persistent symptoms, abdominal pain, contractions, vaginal spotting, rupture of membranes, or decreased fetal movements Advice to Patients
Pure Gest. Hypertension in 6% of pregnant females. 1/3 may develop pre eclampsia. In absence of PET maternal & fetal outcomes are usually normal. Initial tt is lifestyle & diet modifications.Diet low in fat & salt & rich in calcium is recommended. Relative bed rest & light exercises are advised. BP is monitored once or twice weekly. MANAGING GESTATIONAL HYPERTENTION
Frequent ANC visits advised every 15 days till 34 weeks & then once a week. Proteinuria checked at each visit. If BP not controlled start antihypertensives.. Labetalol, nifedipine, hydralazine are usual drugs. Fetal monitoring by USGGrowth assessment,liquor volume & doppler studies done to see for FGR.. Induction of labor done after 37 weeks to terminate pregnancy. MANAGING GESTATIONAL HYPERTENTION
Management of Preeclampsia
Goal of Treatment To maintain a safe blood pressure To monitor the mother for deteriorating disease To monitor the fetus for signs of placental dysfunction and growth restriction Integrated Blood Pressure Control 2016
Primiparity Previous preeclamptic pregnancy Chronic HT/Renal disease H/o Thrombophilia Multifetal pregnancy In vitro fertilization Famliy h/o preeclampsia Diabetes mellitus Obesity SLE Advanced age (>40 years) ACOG 2017 Clinical risk factors for Preeclampsia
Where dietary Ca intake is low,1.5-2 gm of elemental calcium is given daily. WHO recommends Ca as early as possible starting in first trimester. 150mg asprin started from 14 wks gestation. PREVENTION
SCREENING. 1DOPPLER STUDIES ( Uterine a pusatility index,diastolic notch ). 2BIOCHEMICAL MARKERS- soluble fms-like tyrosine kinase 1(sFlt-1 ), placental growth factors & soluble endoglin (sEng ) 3MATERNAL CHARACTERISTICS- age, past history PRE ECLAMPSIA
Severity of Preeclampsia Preeclampsia with the absence of severe manifestations often has been characterized as mild. It should be noted that this characterization can be misleading: even in the absence of severe disease, morbidity and mortality are significantly increased. Therefore, the term Pre-eclampsa without severe features be used instead.
Severe Features of Preeclampsia SBP of >160 mm Hg or DBP > 110 mm Hg on two occasions at least 4 hours apart while the patient is on rest (unless antihypertensive therapy is initiated before this time) Thrombocytopenia (Platelet count <100,000/microliter) Impaired liver function . Progressive renal insufficiency (serum creatinine concentartion > than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease) Pulmonary edema New-onset cerebral or visual disturbances Any of these findings
Complications of Preeclampsia ARDS Pulmonary edema Cardiomyopathy Generalized edema Cardiorespirat ory Eclampsia Cerebral hemorrhage PRES Altered metal status Neurological Acute tubular necrosis Acute kidney injury Glomerular endotheliosis Renal Periportal inflammation Hepatic dysfunction Hepatic hematoma Acute fatty liver of pregnancy Hepatic Thrombocytopenia DIC Microangiopathic hemolysis Venous thromboembolism Hematological Abbreviations:- ARDS: Adult respiratory distress syndrome, PRES: Posterior reversible leukoencephalopathy syndrome, DIC: Disseminated intravascular coagulopathy
When to initiate antihypertensive therapy Recommends commencing therapy when blood pressure exceeds 150/100 mmHg Recommend treatment only for blood pressure over 160/110 mmHg WHO guideline specified that the evidence is not yet sufficient to determine which strategy is preferable, but ongoing study will clarify this issue in the near future Avoid reducing the blood pressure below the lower limits (110/80 mmHg) which would lead to a risk of placental underperfusion
Although it is recommended to start anti hypertensives at150/100mmhg but common practice is to start when BP is 140/90.. DRUGS used are LABETALOL100-400mg BD or TDS ( max 1200). NIFEDIPINE10-20mg BD or TDS ( max 120mg). HYDRALAZINE25-50mg BD (max 200mg) Combination of these drugs gives good control. TREATMENT
A Cochrane review of four randomized trials that compared bed rest with no rest in pregnant women with mild HY found insufficient evidence to provide guidance for clinical practice Bed rest not to be prescribed Bed rest Cochrane Database of Systematic Reviews 2007/2011 A. Antepartum Management
Cochrane Database of Systematic Reviews 2007/2011 Timing of Delivery Less than 37 0/7 weeks of gestation Beyond 37 0/7 weeks of gestation Expectant management with maternal and fetal monitoring is suggested Delivery rather than continued observation is suggested B. Intrapartum Management
Universal use of magnesium sulphate therapy in preeclampsia without severe features is not recommended. Certain signs and symptoms are premonitory to seizures and should be considered for initiation of magnesium sulfate therapy. Magnesium sulphate therapy should be initiated if there is progression to severe disease. Magnesium Sulfate Prophylaxis B. Intrapartum Management
Treatment of severe disease a. Severe hypertension b. Severe preeclampsia
Defined as > or = 160/110mmHg..Even without pre eclampsia it is a serious condition. Requires parenteral antihypertensive tt or oral nifedipine.IV Labetalol & hydralazine are first choice. Induce labour if >37 weeks. If <34 weeks give steroids. Can give steroids upto 36 wks.Postpartum BP is measured for 2 days daily, then twice or thrice a wk.till it becomes normal.( 2 days to 2 weeks ). Gestational hypertension is strongly associated with development of Chronic Hypertension in later life. SEVERE HYPERTENTION
An updated Cochrane systematic review of 35 trials that involved 3,573 women found no significant differences regarding either efficacy or safety between hydralazine and labetalol, or between hydralazine and any calcium channel blocker Theoretical concern exists that the combined use of nifedipine and magnesium sulfate can result in excessive hypotension and neuromuscular blockade Cochrane Database of Systematic Reviews 2013 A. Severe Hypertension
B. Severe Preeclampsia Maternal & Fetal Monitoring during expectant management Maternal assessment Vital signs, fluid intake, and urine output should be monitored at least every 8 hours. Symptoms of severe preeclampsia should be monitored atleast every 8 hours. Presence of contractions, rupture of membranes, abdominal pain, or bleeding should be monitored atleast every 8 hour. Laboratory testing should be performed daily. Fetal monitoring Kick count and NST with uterine contraction monitored daily Biophysical profile twice weekly Serial fetal growth should be performed every 2 weeks and umblical artery doppler studies should be performed every 2 weeks fetal growth restriction is suspected.
B. Severe Preeclampsia Women with Severe Preeclampsia receiving expectant management at 34 0/7 weeks or less of gestation Corticosteroid treatment result in Less frequent RDS Neonatal death Intraventricular hemorrhage Corticosteroids for Fetal Lung Maturity
50%67% reduction in the risk of seizures Reduction in the risk of maternal death May have some benefit to the baby Dose: 4 g loading dose with a maintenance infusion of 1 g/h Monitoring: Observation of urine output, respiratory rate, and deep tendon reflexes Magnesium sulfate prophylaxis The Lancet 2002 B. Severe Preeclampsia
Timing of Delivery <34 0/7 weeks of gestation Stable maternal-fetal conditions Continuation of pregnancy should be undertaken only at facilities with adequate maternal and neonatal intensive care resources >34 0/7 weeks of gestation Unstable maternal-fetal conditions Delivery soon after maternal stabilization is recommended Delivery decision should not be based on the amount of proteinuria or change in the amount of proteinuria B. Severe Preeclampsia
Observe in labor and delivery for first 24-48 hours Corticosteroids, MgSO4 prophylaxis and antihypertensive medications Ultrasonography, monitoring of fetal heart rate, symptoms, and laboratory tests. Delivery Corticosteroids for fetal maturation Delivery after 48 hours Delivery once maternal condition is stable Achievement of 34 0/7 weeks of gestation New onset contraindications to expectant management abnormal maternal-fetal test results Labor or premature rupture of membranes Expectant management Facilities with adequate maternal and neonatal intensive care resources, feta viability- 33 6/7 weeks of gestation, inpatient only and stop MgSO4, daily maternal- fetal tests, vital signs, symptoms and blood tests, oral antihypertensive drugs. Are there additional expectant complications? 33 5/7 weeks of gestation, persistent symptom, HELLP, FGR, severe oligohydramnios, reversed end diastolic flow, labor or premature, rupture of membrane, significant renal dysfunction. Contraindications to continued expectant management Eclampsia, Pulmonary edema, Disseminated IV coagulation, Uncontrollable severe hypertension, Nonviable fetus, Abnormal fetal test results, Abruptio placentae, Intrapartum fetal demise. Yes Yes Yes Management of severe preeclampsia at less than 34 weeks of gestation
Eclampsia
Eclampsia Occurrence of generalized tonic clonic convulsions or coma in women with preeclampsia which cannot be attributed to other causes Maternal mortality 4-6% Perinatal loss 45% Incidence may be 1-55 of all pregnancies in India
Stabilize mother through the application of a standardized ABCDE (airway, breathing, circulation, disability and evaluate) approach If eclamptic seizure not terminated by itself, magnesium sulphate should be commenced as soon as possible Further bolus of magnesium sulphate may be given, and the maintenance infusion may be increased to 2 g/h Hypertension should be controlled as discussed previously Management
Recurrent seizures may warrant intubation and paralysis in order to maintain oxygenation. Fetal bradycardia will be seen in cardiotocography but seizure and BP control is the primary intervention. As soon as mothers condition is stable she should be delivered by most expedient route may be achievable vaginally, but will most commonly be by Caesarean section. Management
HELLP Syndrome
HELLP Syndrome Severe pre-eclampsia complicated by haemolysis, elevated liver enzymes and low platelets. Occurs in about 12% of pregnancies complicated by Pre- eclampsia or Eclampsia. Laboratory findings- Haemolysis Abnormal peripheral smear Total bilirubin >1.2mg/dL LDH >600IU/L Raised liver enzymes like AST (SGOT) >70 IU/L Platelet count < 100,000
Management of HELLP syndrome Stabilize the mother Control BP Prevent seizures Evaluate fetus for well being Determine optimal timing and route of delivery as early as possible Provide continuous monitoring and management during postpartum period And all the parturients should receive MgSO4 Alternative therapies dexamethasone 10 mg IV q 12 h when Platelets < 100000 Platelets for active bleeding or if <20000 Plasmapheresis (limited success)
Future Health Risks and Screening
Future Health Risks and Screening Women who have had hypertensive complication in pregnancy - receive postnatal counselling regarding the management of future pregnancies. Women with Gestational hypertension - risk of recurrence of hypertension in the next pregnancy is 16%47% and of preeclampsia is 2%7%. Women with Preeclampsia - o Risk of recurrence is 16% if delivered at term, 25% if they delivered < 34 weeks and 55% if they delivered < 28 weeks o Advised to book early in their next pregnancy o Consideration of starting low-dose aspirin as prophylaxis o Women on long-term antihypertensive therapy should be counselled to stabilize blood pressure before conceiving o Should have more frequent blood pressure and urine dipstick monitoring o Delivered < 34 weeks - screened for Anti-phospholipid syndrome.
Future Health Risks and Screening Associated adverse outcomes demonstrated by meta-analysis o Increased risk of cardiovascular disease o Chronic hypertension o Venous thromboembolism and o Cerebrovascular disease Simple lifestyle modification suggested by obstetric team and primary care physician to help reduce future risk are: o Weight loss o Smoking cessation o Low salt and o Regular exercise
DEFINITIVE TREATMENT OF HYPERTENTION IN PREGNANCY IS DELIVERY
Hypertensive disorders in pregnancy by Dr. Ranjana
Hypertensive disorders in pregnancy by Dr. Ranjana

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Hypertensive disorders in pregnancy by Dr. Ranjana

  • 1. National Vice President FOGSI - 2017 Founder President ISOPARBPrayagraj2021-25 ICOG Governing CouncilMember 2021-25 ExecutiveMember,NationalISOPARB2023-25 President AOGS (Allahabad)2013 2017 Organising Chairperson,National FOGSIConference Scientific Sangam Prayagraj 2023 Obstetric Dilemmas Prayagraj 2022 BOH The Trilogy Delhi 2017 Organising Secretary, National FOGSI Conference-SAVMA-2016, Allahabad 2016 NationalAwards- FOGSI Achiever Award 2022 FOGSI Dheera Award 2022 FOGSI - Dr D.K Tank Reproductive Healthcare Promotion Trophy AICOG 2015 FOGSI Smriti Mylan Award Save theGirl Child AICOG 2013 Faculty at National, Intl conferences, IMA XL refreshercourse 2022-23and webinars Delivered theprestigious Dr Prabha Malhotra Oration 2023,UPCOG Lucknow Author of many articles and chapters in various books and journals. Co-convener of FOGSI GCPR on epilepsy in pregnancy Senior Consultant &Director RanjanaHospital, Prayagraj (MS,DGO,FICOG)
  • 2. Overview of managing Hypertensive Disorders in Pregnancy Speaker: Speaker: DR. RANJANA KHANNA
  • 3. Classification of hypertension in pregnancy American College of Obstetricians and Gynaecologists' Task Force on Hypertension in Pregnancy Gestational Preeclampsia Eclampsia Superimposed preeclampsia Chronic
  • 4. Classification of hypertension in pregnancy 140 mm Hg systolic or 90 mm Hg diastolic on two separate occasions at least 4 hours apart occurring after 20 weeks gestation. Transient diagnosis with normalization of BP by 12 weeks postpartum BP of 140 mm Hg systolic or 90 mm Hg diastolic predating conception Identified prior to 20 weeks gestation Persists > 12 weeks postpartum Use of antihypertensive medications before pregnancy Gestational hypertension Chronic hypertension
  • 5. Classification of hypertension in pregnancy Preeclampsia Occurring after 20 weeks of pregnancy BP 140 mm Hg systolic or 90 mm Hg diastolic or higher Proteinuria 0.3 grams protein or higher in a 24-hour urine specimen OR +1 per dipstick OR P/C ratio > 0.3 mg/dL Or in the absence of proteinuria, new onset HT with the new onset of any of the following: Thrombocytopenia, renal insufficiency, impaired liver function, Pulmonary edema, cerebral or visual symptoms Eclampsia Presence of new onset grand mal seizures in a pregnant woman with preeclampsia Rule out idiopathic seizure disorder or other central nervous system pathology such as intracranial hemorrhage, bleeding arteriovenous malformation, ruptured aneurysm
  • 6. Classification of hypertension in pregnancy Superimposed preeclampsia New onset in a woman with hypertension prior to 20 weeks Sudden increase in proteinuria if already present in early gestation Sudden increase in BP Development of HELLP syndrome Development of headache, scotomata, or epigastric pain
  • 7. HDP are common and complicate obstetric practice in India Incidence of preeclampsia in hospital practice in India varies from 5% to 15% Incidence of eclampsia is about 1.5% Hypertension in pregnancy: Fast figures
  • 10. A. Antepartum Management Mother evaluation CBC with platelet count Serum creatinine LFT Urine protein (24-hr collection or protein/ creatinine ratio) Symptoms of severe preeclampsia Fetal evaluation USG for fetal weight & Amniotic fluid index Non-stress test Biophysical profile if NST is nonreactive Initial Evaluation
  • 11. B. Antepartum Management Kick count: Daily USG: Every 3 weeks Amniotic Fluid volume: Once weekly NST: Weekly (GHT), Twice weekly (Preeclampsia) Blood pressure at every visit Evaluate Proteinuria (GHT) Laboratory: CBC, Liver enzymes, Serum creatinine (once week) Fetal Evaluation Mother evaluation Continued Evaluation
  • 12. C. Antepartum Management Women are instructed to report symptoms of severe preeclampsia (headache, visual changes, epigastric pain, shortness of breath) Advised to immediately come to hospital if they develop persistent symptoms, abdominal pain, contractions, vaginal spotting, rupture of membranes, or decreased fetal movements Advice to Patients
  • 13. Pure Gest. Hypertension in 6% of pregnant females. 1/3 may develop pre eclampsia. In absence of PET maternal & fetal outcomes are usually normal. Initial tt is lifestyle & diet modifications.Diet low in fat & salt & rich in calcium is recommended. Relative bed rest & light exercises are advised. BP is monitored once or twice weekly. MANAGING GESTATIONAL HYPERTENTION
  • 14. Frequent ANC visits advised every 15 days till 34 weeks & then once a week. Proteinuria checked at each visit. If BP not controlled start antihypertensives.. Labetalol, nifedipine, hydralazine are usual drugs. Fetal monitoring by USGGrowth assessment,liquor volume & doppler studies done to see for FGR.. Induction of labor done after 37 weeks to terminate pregnancy. MANAGING GESTATIONAL HYPERTENTION
  • 16. Goal of Treatment To maintain a safe blood pressure To monitor the mother for deteriorating disease To monitor the fetus for signs of placental dysfunction and growth restriction Integrated Blood Pressure Control 2016
  • 17. Primiparity Previous preeclamptic pregnancy Chronic HT/Renal disease H/o Thrombophilia Multifetal pregnancy In vitro fertilization Famliy h/o preeclampsia Diabetes mellitus Obesity SLE Advanced age (>40 years) ACOG 2017 Clinical risk factors for Preeclampsia
  • 18. Where dietary Ca intake is low,1.5-2 gm of elemental calcium is given daily. WHO recommends Ca as early as possible starting in first trimester. 150mg asprin started from 14 wks gestation. PREVENTION
  • 19. SCREENING. 1DOPPLER STUDIES ( Uterine a pusatility index,diastolic notch ). 2BIOCHEMICAL MARKERS- soluble fms-like tyrosine kinase 1(sFlt-1 ), placental growth factors & soluble endoglin (sEng ) 3MATERNAL CHARACTERISTICS- age, past history PRE ECLAMPSIA
  • 20. Severity of Preeclampsia Preeclampsia with the absence of severe manifestations often has been characterized as mild. It should be noted that this characterization can be misleading: even in the absence of severe disease, morbidity and mortality are significantly increased. Therefore, the term Pre-eclampsa without severe features be used instead.
  • 21. Severe Features of Preeclampsia SBP of >160 mm Hg or DBP > 110 mm Hg on two occasions at least 4 hours apart while the patient is on rest (unless antihypertensive therapy is initiated before this time) Thrombocytopenia (Platelet count <100,000/microliter) Impaired liver function . Progressive renal insufficiency (serum creatinine concentartion > than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease) Pulmonary edema New-onset cerebral or visual disturbances Any of these findings
  • 22. Complications of Preeclampsia ARDS Pulmonary edema Cardiomyopathy Generalized edema Cardiorespirat ory Eclampsia Cerebral hemorrhage PRES Altered metal status Neurological Acute tubular necrosis Acute kidney injury Glomerular endotheliosis Renal Periportal inflammation Hepatic dysfunction Hepatic hematoma Acute fatty liver of pregnancy Hepatic Thrombocytopenia DIC Microangiopathic hemolysis Venous thromboembolism Hematological Abbreviations:- ARDS: Adult respiratory distress syndrome, PRES: Posterior reversible leukoencephalopathy syndrome, DIC: Disseminated intravascular coagulopathy
  • 23. When to initiate antihypertensive therapy Recommends commencing therapy when blood pressure exceeds 150/100 mmHg Recommend treatment only for blood pressure over 160/110 mmHg WHO guideline specified that the evidence is not yet sufficient to determine which strategy is preferable, but ongoing study will clarify this issue in the near future Avoid reducing the blood pressure below the lower limits (110/80 mmHg) which would lead to a risk of placental underperfusion
  • 24. Although it is recommended to start anti hypertensives at150/100mmhg but common practice is to start when BP is 140/90.. DRUGS used are LABETALOL100-400mg BD or TDS ( max 1200). NIFEDIPINE10-20mg BD or TDS ( max 120mg). HYDRALAZINE25-50mg BD (max 200mg) Combination of these drugs gives good control. TREATMENT
  • 25. A Cochrane review of four randomized trials that compared bed rest with no rest in pregnant women with mild HY found insufficient evidence to provide guidance for clinical practice Bed rest not to be prescribed Bed rest Cochrane Database of Systematic Reviews 2007/2011 A. Antepartum Management
  • 26. Cochrane Database of Systematic Reviews 2007/2011 Timing of Delivery Less than 37 0/7 weeks of gestation Beyond 37 0/7 weeks of gestation Expectant management with maternal and fetal monitoring is suggested Delivery rather than continued observation is suggested B. Intrapartum Management
  • 27. Universal use of magnesium sulphate therapy in preeclampsia without severe features is not recommended. Certain signs and symptoms are premonitory to seizures and should be considered for initiation of magnesium sulfate therapy. Magnesium sulphate therapy should be initiated if there is progression to severe disease. Magnesium Sulfate Prophylaxis B. Intrapartum Management
  • 28. Treatment of severe disease a. Severe hypertension b. Severe preeclampsia
  • 29. Defined as > or = 160/110mmHg..Even without pre eclampsia it is a serious condition. Requires parenteral antihypertensive tt or oral nifedipine.IV Labetalol & hydralazine are first choice. Induce labour if >37 weeks. If <34 weeks give steroids. Can give steroids upto 36 wks.Postpartum BP is measured for 2 days daily, then twice or thrice a wk.till it becomes normal.( 2 days to 2 weeks ). Gestational hypertension is strongly associated with development of Chronic Hypertension in later life. SEVERE HYPERTENTION
  • 30. An updated Cochrane systematic review of 35 trials that involved 3,573 women found no significant differences regarding either efficacy or safety between hydralazine and labetalol, or between hydralazine and any calcium channel blocker Theoretical concern exists that the combined use of nifedipine and magnesium sulfate can result in excessive hypotension and neuromuscular blockade Cochrane Database of Systematic Reviews 2013 A. Severe Hypertension
  • 31. B. Severe Preeclampsia Maternal & Fetal Monitoring during expectant management Maternal assessment Vital signs, fluid intake, and urine output should be monitored at least every 8 hours. Symptoms of severe preeclampsia should be monitored atleast every 8 hours. Presence of contractions, rupture of membranes, abdominal pain, or bleeding should be monitored atleast every 8 hour. Laboratory testing should be performed daily. Fetal monitoring Kick count and NST with uterine contraction monitored daily Biophysical profile twice weekly Serial fetal growth should be performed every 2 weeks and umblical artery doppler studies should be performed every 2 weeks fetal growth restriction is suspected.
  • 32. B. Severe Preeclampsia Women with Severe Preeclampsia receiving expectant management at 34 0/7 weeks or less of gestation Corticosteroid treatment result in Less frequent RDS Neonatal death Intraventricular hemorrhage Corticosteroids for Fetal Lung Maturity
  • 33. 50%67% reduction in the risk of seizures Reduction in the risk of maternal death May have some benefit to the baby Dose: 4 g loading dose with a maintenance infusion of 1 g/h Monitoring: Observation of urine output, respiratory rate, and deep tendon reflexes Magnesium sulfate prophylaxis The Lancet 2002 B. Severe Preeclampsia
  • 34. Timing of Delivery <34 0/7 weeks of gestation Stable maternal-fetal conditions Continuation of pregnancy should be undertaken only at facilities with adequate maternal and neonatal intensive care resources >34 0/7 weeks of gestation Unstable maternal-fetal conditions Delivery soon after maternal stabilization is recommended Delivery decision should not be based on the amount of proteinuria or change in the amount of proteinuria B. Severe Preeclampsia
  • 35. Observe in labor and delivery for first 24-48 hours Corticosteroids, MgSO4 prophylaxis and antihypertensive medications Ultrasonography, monitoring of fetal heart rate, symptoms, and laboratory tests. Delivery Corticosteroids for fetal maturation Delivery after 48 hours Delivery once maternal condition is stable Achievement of 34 0/7 weeks of gestation New onset contraindications to expectant management abnormal maternal-fetal test results Labor or premature rupture of membranes Expectant management Facilities with adequate maternal and neonatal intensive care resources, feta viability- 33 6/7 weeks of gestation, inpatient only and stop MgSO4, daily maternal- fetal tests, vital signs, symptoms and blood tests, oral antihypertensive drugs. Are there additional expectant complications? 33 5/7 weeks of gestation, persistent symptom, HELLP, FGR, severe oligohydramnios, reversed end diastolic flow, labor or premature, rupture of membrane, significant renal dysfunction. Contraindications to continued expectant management Eclampsia, Pulmonary edema, Disseminated IV coagulation, Uncontrollable severe hypertension, Nonviable fetus, Abnormal fetal test results, Abruptio placentae, Intrapartum fetal demise. Yes Yes Yes Management of severe preeclampsia at less than 34 weeks of gestation
  • 37. Eclampsia Occurrence of generalized tonic clonic convulsions or coma in women with preeclampsia which cannot be attributed to other causes Maternal mortality 4-6% Perinatal loss 45% Incidence may be 1-55 of all pregnancies in India
  • 38. Stabilize mother through the application of a standardized ABCDE (airway, breathing, circulation, disability and evaluate) approach If eclamptic seizure not terminated by itself, magnesium sulphate should be commenced as soon as possible Further bolus of magnesium sulphate may be given, and the maintenance infusion may be increased to 2 g/h Hypertension should be controlled as discussed previously Management
  • 39. Recurrent seizures may warrant intubation and paralysis in order to maintain oxygenation. Fetal bradycardia will be seen in cardiotocography but seizure and BP control is the primary intervention. As soon as mothers condition is stable she should be delivered by most expedient route may be achievable vaginally, but will most commonly be by Caesarean section. Management
  • 41. HELLP Syndrome Severe pre-eclampsia complicated by haemolysis, elevated liver enzymes and low platelets. Occurs in about 12% of pregnancies complicated by Pre- eclampsia or Eclampsia. Laboratory findings- Haemolysis Abnormal peripheral smear Total bilirubin >1.2mg/dL LDH >600IU/L Raised liver enzymes like AST (SGOT) >70 IU/L Platelet count < 100,000
  • 42. Management of HELLP syndrome Stabilize the mother Control BP Prevent seizures Evaluate fetus for well being Determine optimal timing and route of delivery as early as possible Provide continuous monitoring and management during postpartum period And all the parturients should receive MgSO4 Alternative therapies dexamethasone 10 mg IV q 12 h when Platelets < 100000 Platelets for active bleeding or if <20000 Plasmapheresis (limited success)
  • 43. Future Health Risks and Screening
  • 44. Future Health Risks and Screening Women who have had hypertensive complication in pregnancy - receive postnatal counselling regarding the management of future pregnancies. Women with Gestational hypertension - risk of recurrence of hypertension in the next pregnancy is 16%47% and of preeclampsia is 2%7%. Women with Preeclampsia - o Risk of recurrence is 16% if delivered at term, 25% if they delivered < 34 weeks and 55% if they delivered < 28 weeks o Advised to book early in their next pregnancy o Consideration of starting low-dose aspirin as prophylaxis o Women on long-term antihypertensive therapy should be counselled to stabilize blood pressure before conceiving o Should have more frequent blood pressure and urine dipstick monitoring o Delivered < 34 weeks - screened for Anti-phospholipid syndrome.
  • 45. Future Health Risks and Screening Associated adverse outcomes demonstrated by meta-analysis o Increased risk of cardiovascular disease o Chronic hypertension o Venous thromboembolism and o Cerebrovascular disease Simple lifestyle modification suggested by obstetric team and primary care physician to help reduce future risk are: o Weight loss o Smoking cessation o Low salt and o Regular exercise
  • 46. DEFINITIVE TREATMENT OF HYPERTENTION IN PREGNANCY IS DELIVERY