Hypertension Lecture For Cci 2013

Hypertensive Disorders in Pregnancy
Joseph U. Olivar MD, FPOGS, FPSMFM Department of OB-GYN Seamens Hospital FEU-NRMF Medical Center
Case
28 y/o, G1, 32 weeks came in for first prenatal check-up. BP of 130/90 mmHg. Repeat BP the next day 140/80 mmHg. Is the woman hypertensive?
YES OR NO?
Classification of Hypertensive Disorders complicating pregnancy (Working Group of the NHBPEP 2000):
Gestational Hypertension Preeclampsia Eclampsia Chronic Hypertension Superimposed Preeclampsia on Chronic hypertension
Gestational Hypertension
BP 140/90mmHg for the first during pregnancy after 20 weeks No proteinuria BP returns to normal <12 weeks postpartum May have other signs or symptoms of preeclampsia, for example, epigastric discomfort or thrombocytopenia
Eclampsia
Seizures that cannot be attributed to other causes in a woman with preeclampsia
CHRONIC HYPERTENSION
BP 140/90 mm Hg before pregnancy or diagnosed before 20 weeks' gestation not attributable to gestational trophoblastic disease;
or hypertension first diagnosed after 20 weeks' gestation and persistent after 12 weeks' postpartum
SUPERIMPOSED PREECLAMPSIA (ON CHRONIC HYPERTENSION) New-onset proteinuria 300 mg/24 hours in hypertensive women but no proteinuria before 20 weeks' gestation
A sudden increase in proteinuria or blood pressure or platelet count < 100,000/mm3 in women with hypertension and proteinuria before 20 weeks' gestation
Case
38 y/o, G5, 12 weeks came in for first prenatal check-up. BP of 180/110mmHg. Urine protein +4
Diagnosis?
Classification of Preeclampsia
Classification of Preeclampsia
Mild non-severe less severe Severe = preeclampsia + 1 of a series of complications
Criteria for the Diagnosis of Severe Preeclampsia
Symptoms
Symptoms of central nervous system dysfunction Blurred vision, scotomata, altered mental status, severe headache Symptoms of liver capsule distention or rupture Persistent right upper quadrant and/ or epigastric pain
Norwitz. Expectant management of severe preeclampsia remote from term. Am J Obstet Gynecol 2008 .
Signs
Blood pressure criteria 160/110 Eclampsia Pulmonary edema or cyanosis Cerebrovascular accident Cortical blindness IUGR (EFW < 5th percentile for age or < 10th percentile with evidence of fetal compromise
Laboratory findings Proteinuria

> 5 G per 24 hours or >/= 3+ on 2 random urine samples that are collected at least 4 hours apart
Oliguria and/ or renal failure

HELLP syndrome
Urine output < 500 mL per 24 hours and/ or serum creatinine > 1.2 mg/ dL Evidence of hemolysis (abnormal peripheral smear, total bilirubin >1.2 mg/ dL, LDH >600 U/L) Elevated liver enzymes (ALT >70 U/L) Low platelets (<100,000 platelets/ mm3 )
Laboratory findings
Hepatocellular injury
Liver enzymes 2x normal
Thrombocytopenia
< 100,000 platelet / mm3

Prolonged PT Low platelet count Low fibrinogen
Coagulopathy
Pathophysiology of hypertension in pregnancy

absent trophoblastic invasion of the uterine artery
vasospasm
hepatic ischemia
hepatic infarction hematoma
endothelial damage
edema
platelet consumption
hemolysis
liver rupture
Pathophysiology
brain liver kidneys
Hematology CBC - platelet count

Abruptio placenta Pulmonary edema
WHAT IS THE DEFINITIVE TREATMENT?
Delivery is the only cure for preeclampsia
Cunningham, Leveno. Pregnancy Hypertension. In: Williams Obstetrics, 23rd ed. 2010.
Main Objectives in the Management of Severe Preeclampsia

Safety of the mother
Forestall convulsion Prevent intracranial hemorrhage Avoid serious damage to vital organs
Deliver a healthy infant

When is the woman with severe preeclampsia delivered?

At 34 weeks short and long term neonatal age of outcomes are excellent Pregnancies 34 weeks of gestation gestation fetal survival is already similar
complicated by severe preeclampsia is to that of term gestation best managed by delivery after pulmonary lung maturity is maternal stabilization achieved
Level I
Grade A RCOG. The Management of Severe Preeclampsia. 2006
SURVIVAL BY GESTATIONAL AGE
Acute Morbidity by Gestational Age
Chronic Morbidity by Gestational Age
Severe Preeclampsia Remote from Term
Although delivery is always appropriate for the mother, it may not be optimal for the premature fetus ( 34 weeks )
Sarsam DS. Expectant versus Aggressive Management in Severe Preeclampsia Remote from Term. Singapore Med J. 2008.
Complications of Prematurity
RDS
IVH
NEC
Sepsis
Death
CASE
20 y/o G1 at 30 weeks with a BP of 150/90 mmHg was brought to the OPD because of bilateral pedal edema. Urinalysis done outside revealed a +4 protein and platelet count of 95,000. What is the best
management for this case?
A. B. C. D.
Admit, give MgS04, steroids, monitor BP Admit, give MgS04,steroids then deliver Admit, stabilize and deliver by CS Admit for induction of labor then give MgS04 postpartum
An Algorithm in The Management of Severe Preeclampsia ( < 34 weeks )
Sibai BM. Expectant Management of Preeclampsia AJOG June 2007
Admit to labor and delivery suite Maternal-fetal evaluation for 24 hours Magnesium sulfate for 24 hours Antihypertensives if systolic blood pressure >160 mmHg, diastolic blood pressure > 110 mmHg, or mean arterial pressure >125 mmHg
Magnesium sulfate in severe preeclampsia
Loading Dose:
4 grams IV 5 grams IM / buttocks
Maitenance Dose: 1-2 grams / hour
Case
20 y/o primi 36 weeks came in with a BP of 160/110 mmHg. 5mg hydralazine was given and repeat BP after 15 minutes revealed 170/100 mmHg. What meds at the ER will you give?
Case
30 y/o primi 32 weeks came in with a BP of 140/90 mmHg. She came from the lab with UA result CHON (+1); Ultrasound: SLIUP compatible with 28 weeks, 900 grams. Doppler of the UMA revealed absent end flow. Diagnosis? What meds will you give?
Case
25 y/o primi 37 weeks came in with a BP of 140/90 mmHg. She went to the laboratory to have her CBC done. After 6 hours she came back with a BP of 150/90 mmHg. Platelet count = 90,000. Diagnosis? What meds will you give?
Magnesium sulfate in severe preeclampsia Loading Dose:

Magnesium sulfate in severe preeclampsia Maintenance Dose:

1-2 grams / hour
Questions:
Level of Magnesium resulting to toxicity Is magnesium sulphate an antihypertensive?
therapeutic dose 4-7 meq/L loss of patellar 8-10 What are the 3 parameters tomeq/L monitor when reflexthe maintenance dose of MgS04? giving respiratory 12 meq/L depression What is the antidote for magnesium sulphate respiratory and > 12 meq/L toxicity? Cardiac Arrest
When is antihypertensive therapy indicated?
Antihypertensive treatment should be started in women with BP 160/110 mmHg. In a woman with other markers of potentially severe disease, treatment can be considered at lower degrees of BP
Grade C Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol 2000
Anti-hypertensive meds during pregnancy
Blood Pressure
160/110 mmHg
Purpose:
To prevent intracerebral hemorrhage

Update on the Use of Antihypertensive Drugs in Pregnancy. AHA, 2008
DRUG
LABETALOL
DOSE/ROUTE
COMMENTS
10-20 mg IV, then Not available locally 20 -80 mg every 30 min; max of 300 mg
5 mg IV or IM then 5 mg every 15 min; max of 20 mg Long experience of safety and efficacy; drug of choice
HYDRALAZINE
NIFEDIPINE
10-30 mg PO then Can be safely used 10mg every 45 min; with MgS04 max 50mg

DRUG
IV NICARDIPINE
DOSE/ROUTE
D5W 90 mL + Nicardipine 10 mg in soluset Concentration = 0.1 mg/ mL Start drip at 10 ugtts/min (equivalent to 1 mg/hr) Titrate every hour (increments of 1 mg/hr). Maximum dose 10 mg/hr Note: The IV infusion site must be changed every 12 hours
COMMENTS
Can be safely used with MgS04

DRUG
METHYDOPA (B) NIFEDIPINE
DOSE/ROUTE
Max of 3 grams per day 10 mg PO every 6 hours; max of 120 mg / day
COMMENTS
Drug of choice Slow or long acting preparations may be used; SL preparation no longer recommended Long experience with few adverse effects
HYPRALAZINE
50 mg every 8 hours; max 300mg per day
What blood pressure is the aim of antihypertensive therapy?
The aim of anti-hypertensive therapy is to keep the systolic BP between 140-155 and diastolic BP between 90-100 mmHg.
Grade C Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol 2000
Reminders: Diuretics are relatively contraindicated and reserved only for pulmonary edema Hyperosmotic agents (albumin) have the potential to promote edema formation in the lungs and brain
Any of the following present? Eclampsia Pulmonary edema
Acute renal failure Disseminated intravascular coagulation
Suspected abruptio placenta Non-reassuring fetal status Labor or rupture of membranes >34 weeks gestation
Any of the following present? Eclampsia Pulmonary edema Acute renal failure Disseminated intravascular coagulation Suspected abruptio placenta Non-reassuring fetal status Labor or rupture of membranes >34 weeks
YES
Magnesium sulfate and delivery
Any of the following present? Eclampsia Pulmonary edema Acute renal failure Disseminated intravascular coagulation Suspected abruptio placenta Non-reassuring fetal status Labor or rupture of membranes >34 weeks gestation NO
YES
HELLP syndrome
Persistent symptoms
HELLP Syndrome
H
hemolysis
LDH > 600 U/L total Bili > 1.2 mg/dL abnormal PBS SGPT > 70 U/L <100,000
EL LP
elevated liver enzymes low platelets
Any of the following present? Eclampsia Pulmonary edema Acute renal failure Disseminated intravascular coagulation Suspected abruptio placenta Non-reassuring fetal status Labor or rupture of membranes >34 weeks gestation NO
YES
HELLP syndrome Persistent symptoms
YES
Steroids
ANTENATAL CORTICOSTEROIDS Betamethasone Dexamethasone 12 mg IM q 24 hours x 2 doses 6 mg IM q 12 hours x 4 doses REDUCES

RDS IVH NEC Perinatal death Long term neurological problem
Any of the following present? Eclampsia Pulmonary edema Acute renal failure Disseminated intravascular coagulation Suspected abruptio placenta Non-reassuring fetal status Labor or rupture of membranes >34 weeks gestation NO HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelets) Persistent symptoms NO
YES
YES
Steroids
< 24 weeks
2432 weeks
MgSO4 for 24 hours Antihypertensives if needed Steroids Daily evaluation of maternalfetal condition Delivery if with indications Delivery at 33-34 weeks
33 34 weeks
Steroids Delivery 24 hours after completion of steroids
Magnesium sulfate during expectant management Loading Dose:

1-2 grams / hour Maintenance Dose: given for 24 hours
once a delivery decision is made and continued for 24 hours postpartum

Any of the following present? Eclampsia Pulmonary edema Acute renal failure Disseminated intravascular coagulation Suspected abruptio placenta Non-reassuring fetal status Labor or rupture of membranes >34 weeks gestation NO HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelets) Persistent symptoms
YES
YES
Steroids
< 24 weeks
2432 weeks
33 34 weeks
MgSO4 for 24 hours Antihypertensives if needed Steroids Daily evaluation of maternal-fetal condition Delivery if with indications Delivery at 33-34 weeks
Steroids Delivery after 48 hours
YES
YES
Steroids
< 24 weeks
2432 weeks
33 34 weeks
MgSO4 for 24 hours Steroids Delivery after 48 hours Antihypertensives if needed Steroids Daily evaluation of maternal-fetal condition Delivery if with indications Delivery at 33-34 weeks Hypertensive Disorders in Pregnancy
Maternal Evaluation
weigh patient daily
BP monitoring q 4 hours except between 12mn and 6am Labs: CBC with platelet count Creatinine Urinalysis 24 hour urine albumin
SGPT, SGOT
LDH, PBS, Total bilirubin
Fetal Evaluation
Baseline CTG
Grade B
Women in labor should have continuous EFM

Grade B
Biometry q 2 weeks, BPS 2x / week, doppler weekly and daily NST

Grade A
YES
YES
Steroids
< 24 weeks
2432 weeks
33 34 weeks
MgSO4 for 24 hours Antihypertensives if needed Steroids Daily evaluation of maternal-fetal condition Delivery if with indications Delivery at 33-34 weeks Hypertensive Disorders in Pregnancy
Indications for Delivery (24-32 weeks)

Variable Maternal Indication Persistent severe headache or visual changes; eclampsia
Pulmonary edema
Epigastric/RUQ pain with AST or ALT > 2 times the upper limits of normal Uncontrolled severe hypertension, despite maximum doses of antihypertensive agents
Oliguria (<500 cc/24 hours) or a serum creatinine level of 1.5 mg/dL

Persistent platelet count <100,000/mm3 Abruptio placenta, progressive labor and /or rupture of membranes
Indications for Delivery

Variable
Fetal Indication
Severe FGR (EFW < 5th percentile for gestational age)
Persistent severe oligohydramnios (AFI <5 cm)

Repetitive late or variable fetal heart rate decelerations Persistent BPP < 4 (evaluation 6 hours apart)
Umbilical artery Doppler imaging with reverse diastolic blood flow

Fetal death
What is the mode of delivery?
The mode of delivery should be determined after considering the presentation of the fetus and the fetal condition, together with the likelihood of success of induction of labor after assessment of the cervix
Grade C RCOG. The Management of severe preeclampsia. Evidence Based Clinical Guideline No. 10, 2006
How is postpartum hypertension managed?

Anti-hypertensives for BP 150/100 mmHg
Grade C
Anti-hypertensive agents
Grade C
Diuretics
Avoid NSAIDs
Grade A Grade C
YES
YES
Steroids
< 24 weeks
2432 weeks
33 34 weeks
Terminate pregnancy
Severe Preeclampsia < 24 weeks

High maternal morbidity
High perinatal morbidity and mortality

Pregnancy termination is recommended
Bombrys AE. Expectant Management of Severe Preeclampsia at less than 27 week gestation. Am J Obstet Gynecol, 2008.
YES
YES
Steroids
< 24 weeks
2432 weeks
33 34 weeks
Terminate pregnancy
CASE
20 y/o G1 at 30 weeks with a BP of 150/90 mmHg was brought to the OPD because of bilateral pedal edema. Urinalysis done outside revealed a +4 protein and platelet count of 95,000. What is the best
management for this case?
A. B. C. D.
Admit, give MgS04, steroids, monitor BP Admit, give MgS04,steroids then deliver Admit, stabilize and deliver by CS Admit for induction of labor then give MgS04 postpartum
Regarding management, how does severe preeclampsia differ from mild preeclampsia and gestational hypertension?
GH and Mild Severe A. Giving of MgS04 Preeclampsia Preeclampsia MgS04 34 weeks
B. AOG AOG at of delivery 37 weeks

delivery
160/110 mmHg Anti-HPN 160/110 mmHg C. Giving of antihypertensive
CASE
G1, 37 weeks, BP = 160/110 mmHg. Urine dipstick (-) protein. How will you manage the patient?
A. Give MgS04, antihypertensive and do antenatal fetal surveillance B. Give antihpn and proceed with induction of labor C. Give antihpn and send home once stable D. Give MgS04, antihypertensive and proceed with induction of labor
CASE
35 y/o G5P4 (4004), 28 weeks AOG, was brought to the ER due to tonic clonic convulsion. BP = 180/110 mmHg. Stat urine protein is +3. What is the
best management?
A. Give MgS04, steroids and antihpn B. Give MgS04, steroids and deliver by induction of labor C. Give MgS04, stabilize and deliver by CS D. Give MgS04, steroid, antihpn and do conservative management
21 y/o G1, 38 weeks, diagnosed with severe preeclampsia underwent induction of labor under continuous EFM. CTG suddenly revealed this IE: cephalic, fully dilated, station +5 trace. IE done: fully dilated, cephalic, station +3. Management?
A. B. C. D.
Proceed with CS Await delivery Do forceps Resuscitate
16 y/o G1, no PNCU, 1st consult at the OPD. AOG by LMP: 34 weeks. BP = 140/90 mmHg. FH: 24 cm, FHT: 140s. What is the best course of management?
A. B. C. D. Request for biometry and doppler studies Monitor bp, give methyldopa as home meds Give MgS04 and antihpn Admit for induction of labor
25 y/o G2, with severe preeclampsia is undergoing induction of labor. IE: 4cm. Baseline CTG revealed What statement/s is/are WRONG?
A. Intermittent auscultation every 15 minutes is acceptable B. Continuous CTG is done C. Hook to O2 and put to left lateral decubitus position D. All of the above
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Hypertension Lecture For Cci 2013

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Hypertensive Disorders in Pregnancy

Hypertensive Disorders in Pregnancy

Hypertensive Disorders in Pregnancy

Hypertensive Disorders in Pregnancy

Hypertensive Disorders in Pregnancy

Hypertensive Disorders in Pregnancy

Hypertensive Disorders in Pregnancy

Hypertensive Disorders in Pregnancy

Hypertensive Disorders in Pregnancy

Hypertensive Disorders in Pregnancy

Criteria for the Diagnosis of Severe Preeclampsia

Hypertensive Disorders in Pregnancy

Criteria for the Diagnosis of Severe Preeclampsia

Hypertensive Disorders in Pregnancy

Criteria for the Diagnosis of Severe Preeclampsia

Laboratory findings Proteinuria

Oliguria and/ or renal failure

Hypertensive Disorders in Pregnancy

Criteria for the Diagnosis of Severe Preeclampsia

< 100,000 platelet / mm3

Hypertensive Disorders in Pregnancy

Pathophysiology of hypertension in pregnancy

hepatic infarction hematoma

Hypertensive Disorders in Pregnancy

Hematology CBC - platelet count

Hypertensive Disorders in Pregnancy

WHAT IS THE DEFINITIVE TREATMENT?

Hypertensive Disorders in Pregnancy

Delivery is the only cure for preeclampsia

Hypertensive Disorders in Pregnancy

Main Objectives in the Management of Severe Preeclampsia

Deliver a healthy infant

When is the woman with severe preeclampsia delivered?

Hypertensive Disorders in Pregnancy

SURVIVAL BY GESTATIONAL AGE

Hypertensive Disorders in Pregnancy

Acute Morbidity by Gestational Age

Hypertensive Disorders in Pregnancy

Chronic Morbidity by Gestational Age

Hypertensive Disorders in Pregnancy

Severe Preeclampsia Remote from Term

Hypertensive Disorders in Pregnancy

An Algorithm in The Management of Severe Preeclampsia ( < 34 weeks )

Sibai BM. Expectant Management of Preeclampsia AJOG June 2007

Hypertensive Disorders in Pregnancy

Hypertensive Disorders in Pregnancy

Magnesium sulfate in severe preeclampsia

4 grams IV 5 grams IM / buttocks

Maitenance Dose: 1-2 grams / hour

Hypertensive Disorders in Pregnancy

Hypertensive Disorders in Pregnancy

Hypertensive Disorders in Pregnancy

Magnesium sulfate in severe preeclampsia Loading Dose:

Hypertensive Disorders in Pregnancy

Magnesium sulfate in severe preeclampsia Maintenance Dose:

Hypertensive Disorders in Pregnancy

Hypertensive Disorders in Pregnancy

When is antihypertensive therapy indicated?

Hypertensive Disorders in Pregnancy

Anti-hypertensive meds during pregnancy

To prevent intracerebral hemorrhage

Hypertensive Disorders in Pregnancy

Anti-hypertensive meds during pregnancy