Williams 34 Hypertensive disorders in pregnancy (2)

1. Williams 34Hypertensive disorders in pregnancy (2) 부산백병원 산부인과 R3 박영미

2. Management • Long-term consequences

3. Management • Basic management objectives • Termination of pregnancy with the least possible trauma to mother and fetus • Birth of an infant who subsequently thrives • Complete restoration of health to the mother • The most important information -> Precise knowledge of the age of the fetus

4. Early prenatal detection • The protocol of Parkland hospital • Return visits at 3 to 4 day intervals ① New onset diastolic blood pressure (81-89 mmHg) ② Sudden abnormal weight gain (more than 2 pounds per week during the third trimester)

5. The protocol of Parkland hospital • Outpatient surveillance is continued unless supervene ① Overt hypertension ② Proteinuria ③ Visual disturbances ④ Epigastric discomfort

6. Antepartum hospital management • Hospitalization is considered • New onset hypertension, especially if there is persistent or worsening hypertension • Development of proteinuria

7. A systemic evaluation • Daily scrutiny for clinical findings : headache, visual disturbances, epigastric pain, rapid weight gain • Weight on admittance and every day thereafter • Analysis for proteinuria on admittance and at least every 2 days thereafter • Blood pressure readings in the sitting position with an appropriate size cuff every 4 hours (except between midnight and morning)

8. A systemic evaluation • Measurement of plasma or serum creatinine, hematocrit, platelets, serum liver enzymes (the frequency to be determined by the severity of hypertension) • Frequent evaluation of fetal size and amnionic fluid volume either clinically or with sonography

9. In mild preeclampsia • Reduced physical activity throughout much of the day is beneficial • Absolute bed rest is not necessary • Sedatives and tranquilizers are not prescribed • Ample, but not excessive, protein and calories should be included in the diet • Sodium and fluid intakes should not be limited or forced -> if these observations lead to a diagnosis of severe preeclampsia, further management is the same as eclampsia

10. Termination of pregnancy • Delivery is the cure for preeclampsia • The prime objectives • To forestall convulsion • To prevent intracranial hemorrhage • To prevent serious damage to vital organs • To deliver a healthy infant

11. ▶ Indicative sign of convulsion ① Headache ② Visual disturbances ③ Epigastric pain ④ Oliguria ▶ Severe preeclampsia -> Anticonvulsant -> Antihypertensive therapy -> Followed delivery

12. In milder preeclampsia • Hesitation to deliver the fetus because of prematurity • Assesments of fetal well-being and placental function • Nonstress test • Biophysical profile • Lecithin-sphingomyelin ratio in amnionic fluid

13. In moderate or severe preeclampsia • Delivery is usually advisable • Labor should be induced by intravenous oxytocin • Preinduction cervical ripening with a prostaglandin or osmotic dilator • Cesarean delivery, whenever.. • Labor induction almost certainly will not succeed • Attempts at induction have failed

14. Near term, milder degrees of preeclampsia • With a soft, partially effaced cervix • Observation is more risk to the mother and fetus than dose induction of labor by carefully monitored oxytocin infusion • The cervix is firm and closed • Not likely to be the above case • The hazards of cesarean delivery may be greater than that of allowing the pregnancy to continue under close observation until the cervix is more suitable for induction

15. Elective cesarean delivery • Labor induction to effect vaginal delivery has traditionally been considered to be in the best interest of the mother • Several concerns have led some practitioners to advocate cesarean delivery • Unfavorable cervix precluding successful induction of labor • Perceived sense of urgency because of the severity of preeclampsia • The need to coordinate neonatal intensive care

16. Antihypertensive drug therapy • Sibai (1987) : Randomized study to evaluate the effectiveness of labetalol (200 nulliparous, 26~35 weeks) • Women given labetalol : Significantly lower mean blood pressures • Mean pregnancy prolongation, gestational age at delivery, birth-weight : No differences

17. The cesarean delivery rates, the number of infants admitted to special care nurseries : Similar • Growth restricted infants : Twice as frequent in women given labetalol

18. # The use of ACEI during the second and third trimesters should be avoided : oligohydramnios : fetal growth restriction : bony malformation : limb contractures : persistent patent ductus arteriosus : pulmonary hypoplasia : respiratory distress syndrome : prolonged neonatal hypotension : neonatal death

19. Delayed delivery with severe preeclampsia • Severe preeclampsia are usually delivered without delay • In recent years, a different approach in the treatment of women with severe preeclampsia remote from term • The aim of improving infant outcome without compromising the safety of the mother • Careful daily, more frequent monitoring of the pregnancy in the hospital with or without drugs to control hypertension

20. Randomized controlled trial of Sibai (1994) : severe preeclampsia in 95 women, 28-32weeks • Expectant management • Bed rest • Either oral labetalol or nifedipine • Aggressive management • Glucocorticoid administration for fetal lung maturation -> Pregnancy was prolonged for a mean of 15.4 days in the expectant management group with an improvement in neonatal outcome

21. Vigil-De Gracia (2003) : 129 women at 24 to 34 weeks with either severe or superimposed preeclampsia • Treatment with delayed delivery • Bed rest • Magnesium sulfate for 48 hours • Bolus doses of antihypertensive medications to control blood pressures exceeding 160/110 mmHg • Volume expansion • Dexamethasone to promote fetal maturation

22. Indications for delivery • Uncontrollable blood pressure • Fetal distress • Placental abruption • Renal function deterioration • HELLP syndrome • Persistent severe symptoms • Attainment of 34 weeks gestation • The result • The average pregnancy prolongation was 8 day • No maternal death • 6 stillbirths • 11 placental abruptions • 28 infants diagnosed with growth restriction

23. Hall (2000) : 360 women with severe preeclampsia before 34wks • The result • Mean duration : 11 days • Placental abruption : 20% • Pulmonary edema : 2% • Eclampsia : 1.2% # We are reluctant to advise clinicians that it is safe to expectantly manage women with persistent severe hypertension, significant hematological, cerebral, liver abnormalities due to preeclampsia

24. Glucocorticoids • To enhance fetal lung maturation • Dose not seem to worsen maternal hypertension • Decrease in the incidence of respiratory distress • Improve fetal survival

25. The randomized clinical trial (1999) : 218 women with severe preeclampsia, 26-34wks • The result • Neonatal complications were decreased significantly when betamethasone was given compared with placebo • respiratory distress • intraventricular hemorrhage • death • But • 2 maternal death • 18 stillbirths

26. High risk pregnancy unit • In 1973, at Parkland Hospital • The result • The majority of women have a beneficial response by disappearance or improvement of hypertension • Theses women are not “cured” : nearly 90% have recurrent hypertension before or during labor

27. Provider costs are slight compared with the cost of neonatal intensive care for a preterm infant • Relatively simple physical facility • Modest nursing care • No drugs other than iron and folate supplement • The very few laboratory test that are essential

28. Home health care • If hypertension abates within a few days -> Further hospitalization is not warrnated • Mild to moderate hypertension, without proteinuria -> Managed at home -> Continue as long as : the disease dose not worsen : fetal jeopardy is not suspected

29. Outpatient management • Sedentary activity throughout the greater part of the day • Instructed in detail about reporting symptoms • Daily blood pressure monitoring • Weight and spot urine protein : three times weekly • A home health nurse visited : twice weekly • Women were seen weekly in the clinic • In a study from Parkland Hospital (1995) -> Although, perinatal outcomes were similar -> the development of severe preeclampsia was more common in the home treated women than in hospitalized women

30. Eclampsia • Eclampsia : preeclampsia complicated by generalized tonic-clonic convulsions • Major complications • Placental abruption (10%) • Neurological deficits (7%) • Aspiration pneumonia (7%) • Pulmonary edema (5%) • Cardiopulmonary arrest (4%) • Acute renal failure (4%) • Maternal death (1%)

31. The time of onset • Convulsions appear before, during, after labor -> eclampsia is designated as antepartum, intrapartum, postpartum • Most common in the last trimester • Increasingly more frequent as term approaches • In more recent years, increasing shift toward the postpartum period • Consideration with the onset of convulsions more than 48hours postpartum

32. Convulsion • The convulsive movements usually begin about the mouth in the form of facial twitchings • After a few seconds, the entire body becomes rigid in a generalized muscular contraction • This phase may persist for 15 to 20 seconds • Suddenly the jaws begin to open and close violently, and soon after, the eyelids as well

33. The other facial muscles and then all muscles alternately contract and relax in rapid succession • The muscles alternately contract and relax, may last about a minute • Gradually, the muscular movements become smaller and less frequent, and finally the woman lies motionless • Status epilepticus • Continuous convulsion in untreated severe cases • Unless treated, the first convulsion is usually the forerunner of others

34. After a seizure, coma then ensues • The duration of coma after a convulsion is variable • When the convulsions are infrequent, the woman usually recovers some degree of consciousness after each attack • As the woman arouses, a semiconscious combative state may ensue • In very severe cases, the coma persists from one convulsion to another, and death may result before she awakens

35. Respirations • Throughout the seizure the diaphragm has been fixed, with respiration halted • For a few seconds the woman appears to be dying from respiratory arrest • But the she takes a long, deep, stertorous inhalation, and breathing is resumed

36. After an eclamptic convulsion, respirations are usually increased in rate and may reach 50 or more per minute • Hypercarbia from lactic acidemia, hypoxia • Cyanosis in severe cases

37. Other sign • High fever : a very grave sign : the consequence of a central nervous system hemorrhage • Proteinuria : almost always present and frequently pronounced • Urine output : diminished appreciably, occasionally anuria

38. Hemoglobinuria : common • Hemoglobinemia : only rarely • The edema : pronounced : at times massive, but also be absent

39. Recovery after delivery • An increase in urinary output : an early sign of improvement • Proteinuria, edema : ordinarily disappear with a week • Blood pressure : return to normal within a few days to 2 weeks : the longer hypertension -> the consequence of chronic vascular disease

40. Eclampsia and delivery • Antepartum eclampsia : Labor may begin spontaneously shortly after convulsion and progress rapidly • Intrapartum eclampsia : Contractions may increase in frequency and intensity : The duration of labor may be shortened

41. Fetal bradycardia • Because of maternal hypoxemia and lactic acidemia caused by convulsions • Usually recovers within 3 to 5 minutes • If it persists more than about 10 minutes, another cause, such as placental abruption or imminent delivery must be considered

42. Complication of eclampsia • Pulmonary edema • Aspiration pneumonitis from inhalation of gastric contents • Cardiac failure as the result of a combination of severe hypertension and vigorous intravenous fluid administration • Cerebral hemorrhage • Sudden death due to massive hemorrhage • Hemiplegia due to sublethal hemorrhage • More likely in older women with underlying chronic hypertension

43. Blindness • In about 10% • Retinal detachment or occipital lobe ischemia and edema • The prognosis for return to normal is good and is usually complete within a week • Altered consciousness, persistent coma • In about 5% • Due to extensive cerebral edema • Transtentorial uncal herniation may cause death

44. Psychosis, violent tendency • Lasts for several days to 2 weeks • Antipsychotic medications have proved effective • The prognosis for return to normal is good, provided there was no preexisting mental illness

45. Differential diagnosis • Epilepsy • Encephalitis • Meningitis • Cerebral tumor • Cysticercosis • Ruptured cerebral aneurysm -> Until other such causes are excluded, all pregnant women with convulsions should be considered to have eclampsia

46. Prognosis • The prognosis for eclampsia is always serious • It is one of the most dangerous conditions in pregnancy • Fortunately, maternal mortality due to eclampsia has decreased • Four decades ago : 10-15 % of maternal death • Between 1991 and 1997 : 6% of maternal death

47. Treatment of eclampsia 1. Control of convulsion • ① Intravenously administered loading dose of magnesium sulfate ② Followed by a continuous infusion of magnesium sulfate • ① Intramuscular loading dose of magnesium sulfate ② Periodic intramuscular injections

48. 2. To lower blood pressure • Intermittent intravenous or oral administration of antihypertensive medication • Whenever the diastolic pressure is considered dangerously high • Some clinicians treat at 100 mmHg • Some at 105 mmHg • Some at 110 mmHg

49. 3. Fluid therapy • Avoidance of diuretics • Limitation of intravenous fluid administration unless fluid loss is excessive • Avoidance of hyperosmotic agent 4. Delivery

50. Magnesium sulfate to control convulsions • Magnesium sulfate • An effective anticonvulsant agent in severe preeclampsia, eclampsia • Without producing central nervous system depression in either the mother or the infant • Usually given during labor and for 24 hours postpartum • Because labor and delivery is more likely time for convulsion to develop • Magnesium sulfate is not given to treat hypertension