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A Case History of Hypertension in Pregnancy

A Case History of Hypertension in Pregnancy. Max Brinsmead MB BS PhD April 2014.

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A Case History of Hypertension in Pregnancy

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  1. A Case History of Hypertension in Pregnancy Max Brinsmead MB BS PhD April 2014

  2. Carol is a 36-year old Intensive Care Nurse who has been trying to have a baby for 5 years. She conceives spontaneously and commences antenatal care in Sydney. During a “weekend away” in Coffs Harbour she comes to Maternity feeling a little unwell and asks to have her BP checked. It is 160/105. The midwife starts a CTG and asks that you come to see this patient.

  3. Carol is pregnant with a BP of 160/105 • Is this preeclampsia or pregnancy-induced hypertension • How urgent is this review • What further history do you require • Preeclampsia is sustained hypertension in the 2nd half of pregnancy accompanied by evidence of some other organ involvement. Returns to normal after 3m • Not urgent, but symptoms are worrying… • This pregnancy. Other pregnancies. Personal and Family medical history. Social circumstances. Symptoms.

  4. Carol with a BP of 160/105 • Gestation is 33 weeks by dates and early scans • Never pregnant before. • All tests thus far, including PAPP-A for triploidy, are normal. • Had “nephritis” aged 6 years but recovered after 6 weeks. • Mother is hypertensive on medication • Married to another nurse. Non smoker. Usually fit and healthy but just “feels unwell and thought her BP might be up”. • BP in the first trimester was 105–115/60–75 and was 130/80 one week ago.

  5. Carol G1P0 at 33 weeks with a BP of 160/105 • What further information do you require • What tests are desirable • Would you admit this patient to the antenatal ward? • Repeat BP after resting. Cardiovascular and pregnancy examination. Test urine for protein • FBC, UEC, LFTs, Urate, Proteinuria quantification, UMCS • Pregnancy ultrasound • YES

  6. Carol G1P0 at 33 weeks BP 160/105 • Cardiovascular exam is normal apart from accentuated 2nd heart sound. Mild generalized oedema noted. • Symphysis-fundal height 29 cm • Knee jerks are active but there is no sustained clonus • Oedema is no longer regarded as a sign of preeclampsia • Because oedema is a “good sign” in pregnancy • This uterus is small for dates • It is normal to have 1-2 beats of clonus but sustained clonus is a sign of imminent eclampsia

  7. Carol G1P0 at 33 weeks BP 160/105 • Ward test proteinuria + • HB 128 Hct 0.36 Platelets 231 • UEC and LFT’s normal. S Creatnormal. Urate0.38 • 24-hr urine protein 0.25G (normal <0.3G) • UMCS – no red/white cells or casts. Culture negative • Estimated Fetal Weight (EFW) by ultrasound <10th centile with evidence of head-sparing IUGR. Reduced amniotic fluid index. Umbilical UA Dopplers 95th centile

  8. Estimated Fetal Weight by Ultrasound • Is made by ultrasonic measurements of head biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and Femur Length (FL) • Has an error of not less than ± 20% • Fetal growth restriction is either generalised (symmetrical) or head-sparing (asymmetrical) • Asymmetrical IUGR arises from a redirection of cardiac output to support vital brain growth

  9. Amniotic Fluid • Is largely composed of fetal urine • It’s volume is a reflection of fetal urine output • Which, in turn, is a reflection of fetal cardiac output/function, fetal oxygenation and welfare • Will be absent if there is renal agenesis or urine output obstruction • Is often expressed as the Amniotic Fluid Index (AFI)

  10. Umbilical Artery Doppler Study • Upper panel represents peak (systolic) and trough (diastolic) flow often expressed as S/D ratio • Lower panel is constant flow through a uterine vein • UA Doppler reflects downstream placental resistance • Is the 1st change to occur with placental disease

  11. Umbilical Artery Doppler changes with Gestation

  12. Abnormal UA Doppler Flows When flow ceases in the diastolic phase (AEDF) the S/D ratio is very high (∞) Flow may even reverse in the diastolic phase (RDF) as shown opposite

  13. Carol G1P0 33 weeks BP of 160/105 but no significant proteinuria. Clinical and scan evidence of IUGR • Is this preeclampsia • Why is that an important diagnosis • YES • Preeclampsia is an unpredictable disease with significant maternal and fetal mortality and morbidity

  14. Systems involved in Preeclampsia • Renal • Significant proteinuria • Renal failure biochemistry • Oliguria • Hepatic • Elevated transaminases • Epigastric or RUQ pain • Haematological • Thrombocytopenia • Haemolysis • DIC • CNS • Eclampsia or stroke • Hyperreflexia with sustained clonus • Severe headache or visual disturbance • Cardiovascular • Pulmonary oedema • Placental • IUGR • Abruption

  15. Carol 33 weeks with preeclampsia in hospital. BP rises to 180/110 at 6 pm with dull headache. No sustained clonus • Does this hypertension require treatment • Why • What drug will you use • What BP would you aim to achieve • Yes • Risk of eclampsia, cerebral haemorrhage and pulmonary oedema • Aldomet or Labetalol with a loading dose • Reduce BP to 120-150/80-100 so as not to further compromise uterine blood flow

  16. Carol 33 weeks with preeclampsia. Over the next 2 days her BP continues to rise, especially at night • What measures can you use to control the BP • How will you monitor fetal wellbeing on a daily basis • Use drugs to maximum possible doses. Then add in other drugs from a different class • For example, Aldomet + Labetalol + Nifedipine + Prazosin • Fetal movement charts and non stress cardiotocography (CTG)

  17. Antenatal (Non stress) CTG • 10–40 min of continuous FHR • Tocograph for fetal movements + maternal trigger • Is an assessment of fetal CNS and cardiac oxygenation • High negative predictive value when “reactive"

  18. Carol now 34 weeks. BP difficult to control. She develops severe epigastric pain and vomiting. • What is the most likely diagnosis • What causes the pain • What tests may be useful • Deteriorating preeclampsia with a significant risk of fits • Acute liver swelling stretches its capsule. Maybe subcapsularhaematoma • AST 240, ALT 115 (NR <70)

  19. Carol 34 weeks with uncontrolled hypertension and epigastric pain. Ultrasound shows no further fetal growth and AEDF with Doppler of the umbilical arteries. • How will you CURE this patient • What steps may be desirable on behalf of the baby • DELIVERY • A course of steroids to promote fetal lung maturation

  20. Carol 34 weeks with severe preeclampsia and fetal compromise requires delivery • How can you deliver this patient • Describe the pros and cons of each method • Induction of labour best for mother but baby may not tolerate the hypoxic stress of contractions. Cervix may be unfavourable. • Caesarean quick and best for baby but riskier for mother and may compromise her future deliveries

  21. As preparations are being made for a Caesarean Carol has a grand mal seizure. You are present as it commences… • What do you do • First aid is more important than drugs • Protect from injury • Secure an airway • Administer oxygen • Then secure IV access • IV MgSO4 loading dose and maintain by infusion

  22. Carol 34 weeks has had an eclamptic fit. MgSO4 continues by infusion. Her BP is 180/120. • What drugs are useful now to lower BP • What are the risks from the MgSO4 and how is that avoided • IV Hydrallazine or Diazoxide used most in Australian practice • Risk of respiratory and cardiac arrest. Monitor urine output, respirations, O2 saturation, knee jerks and serum Mg levels

  23. Carol undergoes urgent Caesarean section and is transferred to Intensive Care for postoperative care • How long should the MgSO4 infusion continue • What are the problems that may arise from intensive care • Not less than 24 hours after delivery • Separation of mother and infant interferes with bonding and lactation. • Insomnia and stress to Carol and her relatives. • May increase the risk of thromboembolism

  24. The baby weighs 1800g and has signs of IUGR. • What is the most common neonatal problem for this baby • How is it avoided • Hypoglycaemia due to depleted glycogen liver stores • Monitor blood glucose levels. Early feeding by suckling or D-tube or IV glucose may be required

  25. The baby does well. Carol’s BP still requires treatment postpartum. • When would expect recovery of renal or hepatic dysfunction • How about the hypertension • What drugs are used in the control of hypertension • 24-72 hours but renal/hepatic function may get worse before it gets better • Keep BP <150/100, drugs may be required for 6-12 weeks • Any antihypertensive drug can be used (but some patients don’t respond to ACE inhibitors)

  26. Carol’s BP is normal off all medication by 6 weeks. Tests for autoimmune disease and thrombophilia are negative • What is the risk that she will develop preeclampsia in a subsequent pregnancy • How could that risk be reduced • Is Carol at risk of hypertension in the future • 50 – 66% • Low dose aspirin (100 mg daily preferably commencing in the 1st trimester) reduces risk by >17% • Also use Ca supplements 1.5G/day • YES

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