Published on February 23, 2014
Max Angelo G. Terrenal Post-Graduate Medical Intern
Hypertensive disorders complicate 5 to 10% of all pregnancies
Hypertension complicating pregnancy 32.1% 18% Complications occurring in the course of labor, delivery or puerperium 41% 8.9% Post-partum Hemorrhage Pregnancy with abortive outcome Hemorrhage in early pregnancy
BP > 140 / 90
24-hour urine specimen > 0.3g or 300mg Spot urine sample +1 or > 30mg/mmol
Swelling of the hands and the face or leg edema after an overnight rest
1. Gestational Hypertension 2. Chronic Hypertension 3. Pre-eclampsia a. Mild/nonsevere b. Severe 4. Eclampsia 5. Preeclampsia syndrome superimposed on chronic hypertension
• • • • • BP > 140 / 90 mm Hg for first time during pregnancy No proteinuria BP returns to normal before 12 weeks postpartum Final diagnosis made only postpartum (+) epigastric discomfort or thrombocytopenia
• BP > 140/90 mm Hg prepregnancy 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
• BP > 140 / 90 mm Hg for first time during pregnancy • BP > 140/90 mm Hg prepregnancy or diagnosed before 20 weeks gestation • BP returns to normal before 12 weeks postpartum • Hypertension first diagnosed after 20 weeks' gestation and persistent after 12 weeks postpartum
• BP > 140/90 mm Hg after 20 weeks' gestation • Proteinuria > 300 mg/24 hours or > 1+ dipstick
< BP 160/110 mmHg < 2+ Proteinuria > 3+ Normal Serum Creatinine Marked Absent Thrombocytopenia Present Minimal Transaminase Elevation Marked >
Headache Visual Disturbances Upper Abdominal Pain Oliguria Pulmonary Edema Fetal-growth restriction
• Seizures that cannot be attributed to other causes in a woman with preeclampsia
• New-onset proteinuria > 300 mg/24 hours in hypertensive women but no proteinuria before 20 weeks' gestation
1. Placental implantation with abnormal trophoblastic invasion of uterine vessels 2. Immunological maladaptive tolerance between maternal, paternal (placental), and fetal tissues 3. Maternal maladaptation to cardiovascular or inflammatory changes of normal pregnancy 4. Genetic factors including inherited predisposing genes as well as epigenetic influences.
1. Termination of pregnancy with the least possible trauma to mother and fetus 2. Birth of an infant who subsequently thrives 3. Complete restoration of health to the mother
1. Weight 2. Proteinuria on admittance and at least every 2 days thereafter 3. Blood pressure readings 4. Measurements of plasma or serum creatinine and liver transaminase levels, and hemogram to include platelet quantification. 5. Evaluation of fetal size and well-being and amnionic fluid volume
Approximately 35% of women with gestational hypertension with onset at <34 weeks develop preeclampsia
• BP <140/100 mmHg • Proteinuria < 1,000mg 24hr or <2+ on dipstick • Platelet count > 120,000/mm • Normal fetal growth and testing • No indication for delivery
• Gestational age > 40 weeks • Gestational age > 37 weeks if there is • Bishop score > 5 • Fetal weight <10th percentile • Non-reactive non-stress test
• Gestational age 34 weeks and above with the presence of • • • • • Labor Rupture of membranes Vaginal bleeding Abnormal biophysical profile Criteria for severe preeclampsia • Expectant management should be considered for women remote from term who have mild preeclampsia
• BP at each visit – at least once weekly • Platelet count and liver enzymes at regular intervals • NST at regular intervals • Fetal growth every 2 to 3 weeks
• Anticonvulsants are not recommended • Anti-Hypertension meds only for increase in BP from baseline • Low dose aspirin and high dose calcium are not recommended
Symptoms CNS dysfunction Blurred vision, scotomata, altered mental status, headache Liver capsule distention or rupture Persistent RUQ and/or epigastric pain Signs Blood Pressure > 160/110 mmHg CVA Pulmonary Edema Cortical blindness Laboratory Findings Proteinuria >5g/24h or >3+ on 2 random urine samples Oliguria and/or renal failure Urine output <500mL/24h and/or serum creatinine > 1.2mg/dL HELLP syndrome Evidence of hemolysis (abnormal PBS, total bilirubin > 1.2mg/dL, LDH >600U/L) Elevated liver enzymes (ALT > 70U/L) Low platelets (<100,000/mm3) Hepatocellular Injury Serum transaminase levels >2 x normal Thrombocytopenia <100,000/mm3 Coagulopathy PT >1.4s, low platelet count and low fibrinogen (<300mg/dL)
The main objective in the management of severe preeclampsia must always be the safety of mother and the fetus
> 34 weeks AOG
1.Proteinuria 2.IUGR with good fetal testing 3.Blood pressure
• Abruptio placenta • Uteroplacental insufficiency • Increased premature deliveries • Increased cesarean section deliveries
• HELPP syndrome • Pulmonary edema • Eclampsia • Acute renal failure • DIC and thrombocytopenia • Cerebral hemorrhage
Before 23 weeks with severe preeclampsia 24 to 26 weeks, perinatal survival at 60% > 26 weeks almost 90%
4-7meq/L 4.8-8.4mg/dL 10meq/L 12mg/dL 12meq/L 17 20-25 2.0-3.5mmol/L Therapeutic prophylaxis CNS depression Respiratory Depression Coma Cardiac arrest Treatment with calcium gluconate or calcium chloride, 1 g intravenously, along with withholding further magnesium sulfate, usually reverses mild to moderate respiratory depression.
Fluid restriction with 80ml/h or 1ml/kg/h
BP > 160/110mmHg Target of 140-155/90-105mmHg
Labetalol Hydralazine Nifedipine IV Nicardipine 10 to 20mg IV, then 20-80mg q20-30 minutes 5mg IV or IM, then 5 to 10 every 20 to 40 minutes 10 to 30mg PO, q45 minutes Start at 0.1mg/mL with maximum of 10mg/hr Atenolol, ACEi, ARBs and diuretics should be avoided
• Indicated for lung maturity • Between 24-34 weeks • Betamethasone 12mg IM every 24 hours for 2 doses • Dexamethasone 6mg IM every 12 hours for 4 doses
• Control of seizure • Correction of hypoxia and acidosis • Control of blood pressure • Delivery after control of seizure
• Low dose aspirin (65-85mg) at bedtime everyday for 12 weeks until birth • ACEi and ARB are contraindicated • Anti-hypertensive therapy • Methyldopa 250-500mgPO BID-QID (max 2 g/day) • Labetalol 1000499mg PO BID0ID (max 1200mg/day) • Nifedipine 10-20mg PO BID-TID max, 120-180mg/day
• Hemolysis • Elevated liver enzymes • Low platelets
• Hemolysis • Abnormal peripheral smear • LDH > 600 IU.L • Bilirubin > 1.2mg/dL • Elevated liver enzymes • AST > 70 IU/L • Low platelets • Platelet count < 100,000/mL
Develops suddenly in rd Trimester or the 3 immediate Postpartum
• Malaise • Epigastric or RUQ pain • Nausea and vomiting
• Beyond 34 weeks AOG • Earlier • MOD • DIC • Liver infarction • Hermorrhage • Renal Failure • Nonreassuring fetal status
•MgSO4 •Control of hypertension •Stabilization of maternal condition
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Your responsibility. The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available.