Transcript Hypertension in pregnancy

Hypertension in pregnancy
Hypertensive disorders complicate 3.7% of all
pregnancies and is a leading cause of maternal
and perinatal mortality and morbidity.
Identification of patients at high risk and timely
detection with proper management can prevent
life threatening complications.
Diagnosis-working group report(2000)
1)Gestational hypertensionBp >/= 140/90 mm of hG for first time during
pregnancy
No proteinuria
Bp returns to normal within 12 weeks
postpartum
So final diagnosis-only post partum
2)Pre-eclampsia
-minimum criteria bp>/=140/90 mm of hg after 20 weeks
gestation.
 Proteinuria >/= 300 mg /24 hrs
Increased certainity of pre-eclampsia
 Bp>/= 160/110 mm of hg
 Proteinuria 2g/24 hrs or >/=2+dipstick
 S.creatinine > 1.2 mg%(unless previously elevated)
 Platelets<100,000/cu.mm
 Microangiopathic hemolysis
 Elevated ALT/AST
 Persistent headache/cerebral/visual disturbances/persistent
epigastric pain.
3)eclampsia-seizures that cannot be attributed to other
causes in a woman with pre eclampsia
4)Superimposed preeclampsia(on chronic hypertension)
New onset proteinuria >/=300 mg/24 hrs but no
proteinuria before 20 weeks.
Sudden increase in proteinuria/BP/platelet
count<100,000/cumm if hypertension & proteinuria
before 20 weeks
5)Chronc hypertension-BP>/=140/90 mm of hg before
pregnancy or before 20 weeks gestation (excluding
hydatidiform mole/acute polyhydramnios)
OR
Hypertension first diagnosed after 20 weeks gestation
and persistent after 12 weeks post partum.
HISTORY
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Age –more common in young primigravidae and elderly
primigravidae >35 years(increased incidence of
hypertension with superimposed pre-eclampsia)
Poor socioeconomic status-poor antenatal care and poor
nurtition
Residence-high altitude-increased incidence of preeclampsia
Race-african american women are more prone
Obstetric history-parity-primigravidae,h/o pregnancy
complications like h.mole,multiple
pregnancy,polyhydramnios,rh-incompatibility,gestational
diabetes
Marital history-h/o new paternity
Past h/o any medical disorders-essential HT,chronic renal
disease,diabetes mellitus,endocrine disorders,connective
tissue disorders
Family h/o of pre-eclampsia/eclampsia in mother/siblings
h/o symptoms of pre-eclampsia(usually after 20th
week)
 h/o swelling of ankles which persists on rising
from bed in the morning
 Tightness of the finger ring
 Swelling may extending to face,abdomen,vulva or
whole body.
Ominous symptoms
 Headache-occipital/frontal,disturbed sleep
 Dimished output of urine
 Epigastric pain/vomiting-due to hepatocellular
ischemia/necrosis,edema,with stretching of
glissons capsule,subcapsular hge
 Blurring/dimness of vision,blindness-spasm of
retinal vessels,retinal edema,retinal
detachment,occipital lobe lesions(hypodensities
on MRI)
SIGNS
Abnormal weight gain-greater than 5
pounds/month or1 pound/week
 Edema-common feature in 80% of
normotensive pregnancies,so no longer
incloded in the definition of pre-eclampsia
 Mild edema-ignore
 Sudden,severe widespread edemapathological-may indicate imminent
eclampsia
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Blood pressure measurement-ideally woman should be
seated for 5 minutes before measuring BP with feet
supported on the ground & arm resting on a table at the
level of the heart.( Each cm above/below-0.8 mm hg
change in bp recording)
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BP recording in LLP-spuriously reduced by 10-15 mm of hg.
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The same arm should be used on each occasion
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Cuff should be of appropriate size (12 cm bladder width for
regular patients & 15cm for more obese women)
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Readings should be recorded to the nearest 2 mm of hg.
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Use korotkoff phase 5(disappearance of sound)
To diagnose HT in pregnancy BP should be >/=
140/90 mm of hg at 2 separate readings at least
4 hrs apart.
MAP=systolic BP+2* diastolic BP
3
MAP>/=105 mm of hg or ^ in MAP by 20 mmof
hg from previous is also diagnostic of HT in
pregnancy
Diastolic BP tends to rise first followed by the
systolic
P/A-the fundal height will be less than period of
gestation-oligohydramnios,iugr
Abdominal wall edema may be present-FHS may
be difficult to localise
Signs of IUD/abruption/preterm labour
Fundoscopic examination-retinal edema,arteriolar
constriction,alteration of normal vein to arteriole
diameter from 3:2 to 3:1,nicking of veins by the
arterioles
Patient may present with eclampsia in the antenatal
period(50%)
Eclamptic fit-premomitory stage,tonic stage,clonic
stage,stage of coma. Fits usually multiple
episodes at varying intervals/status epilepticus
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Premonitory stage-unconscious,twitching of the muscles of
face ,tongue and limbs,rolling f eyeballs-30 sec
Tonic stage-tonic spasm of all voluntary muscles with
opisthotonus,limbs flexed,hands clenched.respiration
ceases,tongue protrudes.cyanosis appears ,eyeballs are
fixed-30sec
Clonic stage-voluntary muscles undergo alternate
contractuion/relaxationbiting of tongue ,breathing
sterterous,blood stained frothy secretions fill
mouth,cyansis disappears gradually-1 to 4 min
Stage of coma-for brief period or lasyts till next
convulsion,pt may be in confused state foll seizure,coma
may occur without prior convulsion
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r/o other causes of convulsionsepilepsy/,hysteria,encephalitis,meningitis,poisoning,cerebral
malaria,neurocysticercosis,intracranial tumours
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o/e-temp raised,^ pulse,resp rate,BP
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Disoriention-cerebral haemorrhage
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Urine output-markedly decreased,haematuria with jaundice(HELLP
syndrome),anuria-b/l renal cortical necrosis
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Injuries-tongue bite,due to fall
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RS-basal crepitations- pulmonary edema(aspiration),signs of
hypostatic/infective pneumonia,pulmonary
embolism(cyanosis,resp distress)
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Shock-acute LVF-due to anoxia ,muscular exhaustion
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Generalised bleeding tendency-DIC
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Blindness
Tests of prediction
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on the abnormal vascular
responsivity/sympathetic overactivity
in women destined to develop HT
later in pregnancy.
 ROLL OVER TEST-28-32 weeks
 Positive predictive value-33%
 Positive roll over test indicates
abnormal angiotensin 2 sensitivity
 Angiotensin 2 infusion test
Early prenatal detection
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Increased prenatal visits during 3rd trimester
If overt hypertension(>140/90mm 0f hg)-admit
the patient and evaluate the severity of pih
Pts with new onset diastolic BP of 80-90 mm of
hg or wt gain>2 pounds/week should come for
return visit in 3-4 days
Once admitted-daily scrutiny for symptoms/signs
of imminent eclampsia
Daily wt chart
4th hrly BP chart
Clinical evaluation of fetal size,amniotic fluid
volume