Hypertension in pregnancy
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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.

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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 hypertension-

Bp >/= 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)Chronchypertension-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
HISTORY

  • 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 pre-eclampsia

  • 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
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 edema-pathological-may indicate imminent eclampsia


  • 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)

  • BP recording in LLP-spuriously reduced by 10-15 mm of hg.

  • The same arm should be used on each occasion

  • Cuff should be of appropriate size (12 cm bladder width for regular patients & 15cm for more obese women)

  • Readings should be recorded to the nearest 2 mm of hg.

  • 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


  • 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


  • r/o other causes of convulsions-epilepsy/,hysteria,encephalitis,meningitis,poisoning,cerebral malaria,neurocysticercosis,intracranial tumours

  • o/e-temp raised,^ pulse,resp rate,BP

  • Disoriention-cerebral haemorrhage

  • Urine output-markedly decreased,haematuria with jaundice(HELLP syndrome),anuria-b/l renal cortical necrosis

  • Injuries-tongue bite,due to fall

  • RS-basal crepitations- pulmonary edema(aspiration),signs of hypostatic/infective pneumonia,pulmonary embolism(cyanosis,resp distress)

  • Shock-acute LVF-due to anoxia ,muscular exhaustion

  • Generalised bleeding tendency-DIC

  • Blindness


Tests of prediction
Tests of prediction convulsions-epilepsy/,hysteria,encephalitis,meningitis,poisoning,cerebral malaria,neurocysticercosis,intracranial tumours

  • Based 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
Early prenatal detection convulsions-epilepsy/,hysteria,encephalitis,meningitis,poisoning,cerebral malaria,neurocysticercosis,intracranial tumours

  • 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


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