Transcript gonzales - Philippine Heart Association
Hypertension in Pregnancy
Ramon M. Gonzalez, MD Professor UST Medicine and Surgery
A 26y/o G1 21-22 weeks known hypertensive for 6 years was admitted because of severe hypertension VS- BP-200/100mmHg, PR- 76/min, RR-20/min, T-36.5C. She was taking calcium channel blockers for her HPN which she was taking regularly.
Hypertensive Disorders Complicating Pregnancy
•
Gestational Hypertension
– Systolic BP≥ 140 or diastolic ≥ 90 mmHg for the first time after 20 weeks gestation – No proteinuria – BP returns to normal before 12 weeks postpartum – Final diagnosis made only postpartum – May have other signs or symptoms of preeclampsia
Hypertensive Disorders Complicating Pregnancy
•
Preeclampsia
–
Minimum criteria
• BP ≥ 140/90 mmHg after 20 weeks gestation • Proteinuria ≥ 300mg/24 hours or ≥ 1+ dipstick –
Severe preeclampsia
• BP ≥ 160/110 mmHg • Proteiunuria 2.0gms/24 hrs or ≥ 2+ dipstick • Serum creatinine > 1.2mg/dl • Platelets < 100,00/ul • Elevated LDH, ALT or AST
Hypertensive Disorders Complicating Pregnancy
•
Eclampsia
– Seizures that cannot be attributed to other causes in women with preeclampsia •
Chronic Hypertension
– BP ≥ 140/90 mmHg before pregnancy or diagnosed before 20 weeks gestation – Hypertension first diagnosed after 20 weeks gestation and persistent after 12 weeks postpartum
Hypertensive Disorders Complicating Pregnancy
•
Superimposed Preeclampsia
– New onset proteinuria ≥ 300mg/24 hrs in hypertensive women but no proteinuria before 20 weeks gestation
Pregnancy 20-21 weeks, Chronic Hypertension
Maternal Assessment
• • • • Duration of hypertension Current therapy Degree of BP control Other medical complications
Maternal Assessment
• • • • • Serum creatinine Quantification of urine proteins ECG Echocardiography Blood chemistry
1. What are the effects of chronic hypertension on pregnancy?
2. What is the management of chronic hypertension during pregnancy?
3. Can we prevent superimposition of preeclampsia ?
4. What is the management of chronic hypertension with superimposed preeclampsia?
What are the effects of chronic hypertension on pregnancy?
ORs for Fetal Complications: 1995-2008
Pregestational Diabetes
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Variable With Chronic HPN W/O Chronic HPN
________________________________________________________ Stillbirth Poor fetal growth 4.30(3.81-4.85) 2.66(2.40-2.94) 3.05(2.88-3.23) 1.20(1.14-1.27) Spontaneous delivery 4.88(4.63-5.15) 2.90(2.83-2.90) <37weeks
ORs for Maternal Complications: 1995-2008 Pregestational Diabetes
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Variable With Chronic HPN W/O Chronic HPN
__________________________________________________________ Preeclampsia 13.96 (13.29-14.66) 3.80 (3.69-3.91) CVA 7.14 (4.90-10.40 ) 1.85 (1.41-2.44) Acute renal failure Pulmonary edema Ventilation 35.41 (28.39-44.16) 4.43 (3.57-5.48) 11.97 (7.86-18.24) 4.01 (3.07-5.25) 11.87 (9.22-15.26) 3.34 (2.89-4.00) Cesarean delivery 5.75 (5.46-6.05) 3.33 (3.26-3.41) In- hospital mortality 6.02 (2.71-13.40) 2.58 (1.59-4.17)
ORs for Fetal Complications: 1995-2008
Chronic Renal Disease
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Variable With Chronic HPN W/O Chronic HPN
________________________________________________________ Stillbirth Poor fetal growth 7.29(5.59-9.52) 1.74(1.51-2.02) 7.94(6.67-9.44) 2.29(2.12-2.49) Spontaneous delivery 8.60(7.64-9.67) 2.25(2.15-2.35) <37weeks
ORs for Maternal Complications: 1995-2008 Chronic Renal Disease
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Variable With Chronic HPN W/O Chronic HPN
__________________________________________________________ Preeclampsia 27.87(24.85-31.25) 3.28(3.10-3.47) CVA 13.73(6.63-28.44) 3.53(2.34-5.31) Acute renal failure Pulmonary edema Ventilation 253.4(199.5-321.9) 19.29(11.36-32.76) Cesarean delivery 5.73(5.03-6.53) In- hospital mortality 27.02(8.72-83.73) 62.40(54.37-71.63) 23.29(10.32-52.56) 9.06(5.84-14.06) 8.25(6.43-10.60) 1.74(1.68-1.81) 6.88(3.56-13.29)
ORs for Fetal Complications: 1995-2008
Collagen Vascular Disease
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Variable With Chronic HPN W/O Chronic HPN
________________________________________________________ Stillbirth Poor fetal growth 7.42(5.37-10.25) 7.99(6.44-9.91) 2.74(2.35-3.20) 3.87(3.55-4.22) Spontaneous delivery 7.19(6.22-6.30) 3.15(2.98-3.33) <37weeks
ORs for Maternal Complications: 1995-2008 Collagen Vascular Disease
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Variable With Chronic HPN W/O Chronic HPN
__________________________________________________________ Preeclampsia 17.41 (15.09-20.09) 2.96 (2.76-3.18) CVA 23.00 (11.47-46.14) 7.60 (5.26-10.97) Acute renal failure Pulmonary edema Ventilation 191.5 (141.4-259.4) 15.52 (4.92-48.90) 26.29 (15.04-45.63) Cesarean delivery 4.38 (3.74-5.12) In- hospital mortality 88.81 (41.90-188.2) 12.60 (8.88-17.88) 6.08 (3.46-10.69) 11.09 (8.46-14.52) 1.89 (1.80-1.98) 23.81 (14.67-38.66)
What is the management of chronic hypertension during pregnancy?
Management
• Blood pressure control • Fetal antepartum surveillance • Prevention of preeclampsia • Detection of preeclampsia
Blood Pressure Control
• • • • • Ca Channel Blockers Adrenergic Blocking Agents Vasodilators Diuretics ACE Inhibitors/ARB –
contraindicated
A randomized trial of tight vs. less tight control of mild essential and gestational hypertension in pregnancy
• • • El Guindy, A.A. and Nabhan, A.F. (2008)
Journal of Perinatal Medicine Women in the tight control group
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Were less likely to develop severe hypertension (RR 0.32, 95% CI 0.14 to 0.74)
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Delivered babies with older gestational ages (36.6 ±2.2 weeks vs 35.8 ± 2.2 weeks: P<0.05)
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Fewer preterm deliveries (RR 0.52, 95%CI 0.28 to 0.99)
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No significant differences between groups regarding stillbirth or IUGR
Fetal Antepartum Surveillance
• Fetal biometry • Nonstress test • Contraction stress test • Biophysical profile • Doppler velocimetry
Can we prevent superimposition of preeclampsia?
Preeclampsia
• • • • Pregnancy specific syndrome that can affect virtually every organ system.
Disorder of unknown etiology affecting 5-10% of all pregnancies.
In developed countries 16% of maternal deaths were due to hypertensive disorder.
POGS (2006)- 26.24% maternal deaths were due to hypertensive disorder.
Pathogenesis
•
Vasospam
– Increased resistance → hypertension – Endothelial cell damage → leakage of blood constituents, including platelets and fibrinogen – Decreased blood flow → ischemia of tissues → necrosis, hemorrhage and other end organ disturbances
Pathogenesis
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Endothelial cell activation
– Increased pressor responses • Increased sensitivity to angiotensin II – Prostaglandin • Prostacyclin: thromboxane A2 ratio decreases – Nitric oxide • Decreased nitric oxide synthase expression – Endothelins • Potent vasoconstrictor which is increased in preeclampsia
Cardiovascular System
• • • ↑ Cardiac afterload – hypertension ↑Cardiac preload – Diminished hypervolemia – ↑ intravenous crystalloids Extravasation of intravascular fluid into the extracellular space – Pulmonary edema
Blood Volume and Coagulation
• • • • Hemoconcentration – – Hallmark of preeclampsia Vasospasm and endothelial leakage Thrombocytopenia Hemolysis – Endothelial disruption HELLP syndrome
Kidneys
• • • • • • • ↓ Glomerular filtration rate and renal plasma flow ↑ Serum creatinine ↑ Uric acid Proteinuria Oliguria “Glomerular capillary endotheliosis” Acute renal failure
• Hepatic infarction • Periportal hemorrhage • Hepatocellular necrosis • Elevations of AST/ALT
Liver
• Hepatic hematoma • HELLP syndrome
Brain
• • • • • Headaches, visual symptoms Convulsions Intracerebral hemorrhage Cortical and subcortical petechial hemorrhages Subcortical edema
Uteroplacental Perfusion
Vasospasm ↓ Decreased uteroplacental perfusion ↓ Increased perinatal morbidity and mortality
Prevention of Superimposed Preeclampsia
• • Systematic Review by Duley et al 59 trials with 37,560 women given Aspirin –
17% reduction in the risk of preeclampsia (RR 0.83, 077-0.89), especially in high risk patients
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8% reduction in the relative risk of preterm birth (RR 0.92, 0.88-0.97)
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14% reduction in fetal and neonatal deaths (RR 0.86, 0.76-0.98)
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10% reduction in SGA babies (0.90, 0.83-0.98)
Detection of Preeclampsia
• BP monitoring • 24 hour urine proteins
What is the management of chronic hypertension with superimposed preeclampsia?
Management
• Termination of pregnancy with the least possible trauma to mother and baby • Birth of an infant who subsequently thrives • Complete restoration of health to the mother
Severe Preeclampsia
• Clinical course is progressive deterioration in both maternal and fetal condition • Associated with high rates of maternal and perinatal morbidity and mortality
Management of Severe Preeclampsia
•
Aggressive
•
Expectant
- Fetal death - High neonatal mortality and morbidity due to prematurity - Asphyxial damage in utero - Prolonged NICU stay - Increased maternal morbidity - Long term disability
Odendaal and associates
• • • • • • Aggressive vs expectant management 58 patients, 20 were delivered w/in 48 hours 20 aggressive, 18 expectant 28-34 weeks Betamethasone, MgSO4, Antihypertensive drugs Maternal and fetal testing
Sibai and colleagues
• • • • • Aggressive vs expectant management 28-32 weeks 95 patients Aggressive (n=46); expectant (n=49) Bed rest, antihypertensives, MgSO4, betamethasone, maternal and fetal testing, laboratory exams
Expectant Management
• Prolongs pregnancy • Higher gestational age • Higher birth weight • Lower incidence of admission to NICU • Lower incidence of neonatal complication • No difference in the incidence of CS, abruptio placenta, HELLP syndrome and postpartum stay
Guidelines for Expectant Management
• Hospitalization in a tertiary hospital • • • - Good facilities to monitor the mother and fetus - NICU facilities Trained personnels MgSO4 Antihypertensives Corticosteroids
Maternal Assessment
Maternal Assessment
• • • • Blood pressure measurement Systolic – 140 – 155 mmHG - Diastolic – 90 – 105 mmHG Daily 24 hour urine volume Maternal symptoms Search for imminent signs of eclampsia Sibai et al AmJOG 2007
Maternal Assessment
• • • CBC with platelet counts Serum creatinine Liver function test – AST/ALT – Lactate dehydrogenase Sibai et al AmJOG 2007
Fetal Assessment
Fetal Assessment
• • • • • Fetal kick counts NST Biophysical profile scoring Umbilical artery Doppler studies Assessment of fetal growth
Maternal Indications for Delivery in Women With Severe Preeclampsia
• • • • Persistent severe headache or visual changes; eclampsia Pulmonary edema Uncontrolled severe HPN Epigastric pain/RUQ pain with AST or ALT >2 times the upper limit of normal Sibai et al AmJOG 2007
Maternal Indications for Delivery in Women With Severe Preeclampsia
• • • • • Oliguria (<500ml/24hr) HELLP syndrome Platelet counts <100,000/mm3 Deterioration of renal function (serum creatinine >/=1.5 mg/dl) Suspected abruptio placenta, progressive labor, and/or rupture of membranes Sibai et al AmJOG 2007
Fetal Indications For Delivery In Women With Severe Preeclampsia
• • • • • Repetitive late or severe variable deceleration Biophysical profile
Mode of Delivery
• Vaginal delivery - Inducible cervix - No fetal distress • Cesarean section
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