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Cardiovascular Management of Hypertension during Pregnancy

Cardiovascular Management of Hypertension during Pregnancy. Ma. Rosario Cruz Sevilla, MD, FPCP, FPCC Asian Hospital and Medical Center UPHDMC Heart and Vascular Institute, Las Pinas. Normal Physiologic Changes. Normal Physiologic Changes. Normal Physiologic Changes. LABOR AND DELIVERY

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Cardiovascular Management of Hypertension during Pregnancy

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  1. Cardiovascular Management of Hypertension during Pregnancy Ma. Rosario Cruz Sevilla, MD, FPCP, FPCC Asian Hospital and Medical Center UPHDMC Heart and Vascular Institute, Las Pinas

  2. Normal Physiologic Changes MRCSevilla MD

  3. Normal Physiologic Changes MRCSevilla MD

  4. Normal Physiologic Changes LABOR AND DELIVERY • Uterine contraction = 500 ml blood released – increased CO & BP • CO - >=50% above baseline at stage 2 labor • Blood loss – 400 cc in NSD; 800 ml in CS POSTPARTUM • Abrupt increase in venous return due to: • Autotransfusion from uterus – 24-72 hours • Loss of fetal compression on IVC MRCSevilla MD

  5. Hypertension in Pregnancy (ESC 2011) • Major cause of maternal, fetal, and neonatal morbidity and mortality in developing and in developed countries • Hypertension is the most common medical problem in pregnancy, complicating up to 15% of pregnancies and accounting for about a quarter of all antenatal admissions MRCSevilla MD

  6. PHILIPPINE HEALTH STATISTICS Total Number of Live Births 2008 : 1,920,098 2007: 1,858,361 2006: 1,770,735 MRCSevilla MD

  7. PHILIPPINE HEALTH STATISTICS 2006 Maternal Mortality Data TOTAL: 1,721 deaths CAUSES 1. Complications related to pregnancy occuring in the course of labor, delivery and puerperium N=732 (0.4/1000 Livebirths; 42.5%) 2.Hypertension complicating pregnancy, childbirth and puerperium N=565 (0.3/1000 Livebirths; 32.8%) N=510 (0.3/1000 livebirths; 29.4%) 2005 3. Postpartum Hemorrhage N=261 (0.2/1000; 15.2%) 4. Pregnancy with abortive outcome N=163 (0.1/1000; 9.5%) 5. Hemorrhage in early pregnancy N=0 MRCSevilla MD

  8. Hypertension in Pregnancy (ESC 2011) • These women are at higher risk for severe Cx such as abruptio placentae, cerebrovascular accident, organ failure, and disseminated intravascular coagulation • The fetus is at risk for intrauterine growth retardation, prematurity, and intrauterine death MRCSevilla MD

  9. Case 1: • 26/Female • Known hypertensive for 6 years • On maintenance calcium channel blockers • usual BP = 130/80 MRCSevilla MD

  10. Case 1: • 26/Female • Known hypertensive for 6 years (diagnosed at age 20 – what was highest BP ever recorded? Was secondary hypertension considered? What were the results of any prior cardiovascular work-ups?) • On maintenance calcium channel blockers (which CCB? What dose?) • usual BP = 130/80 (on meds?) MRCSevilla MD

  11. Case 1: • 26/Female • Known hypertensive for 6 years • G1 21-22 weeks • admitted due to severe HPN • BP- 200/100mmHg • PR-76/min • RR-20/min • T-36.5C. MRCSevilla MD

  12. Case 1: • 26/Female • Known hypertensive for 6 years • G1 21-22 weeks (first consult or with prior prenatal check-up? What was previous BP readings during 1st trime?) • admitted due to severe HPN • BP- 200/100mmHg • PR-76/min • RR-20/min • T-36.5C. MRCSevilla MD

  13. Hypertension in Pregnancy (ESC 2011) • Basic lab exams recommended include: • urinalysis (check for proteinuria) • blood count, haematocrit, • liver enzymes • serum creatinine, • serum uric acid • Adrenal UTZ and urine metanephrine & normetanephrine assays may be considered to exclude pheochromocytoma w/c may be asymptomatic and, if not diagnosed before labour, fatal. MRCSevilla MD

  14. Hypertension in Pregnancy (ESC 2011) • Definition and classification: • based on absolute BP values • (SBP ≥140 mmHg or DBP ≥90 mmHg) • and distinguishes : • Mildly elevated BP (140–159/90–109 mmHg) or • Severely elevated BP (≥160/110 mmHg) • in contrast to the grades used by the ESH/ESC, or others MRCSevilla MD

  15. Hypertension in Pregnancy (ESC 2011) • Hypertension in pregnancy - not a single entity but is composed of: • pre-existing hypertension • gestational hypertension • pre-existing hypertension plus superimposed gestational hypertension with proteinuria • antenatally unclassifiable hypertension MRCSevilla MD

  16. Hypertension in Pregnancy (ESC 2011) • Hypertension in pregnancy - not a single entity but is composed of: • pre-existing hypertension • gestational hypertension • pre-existing hypertension plus superimposed gestational hypertension with proteinuria • antenatally unclassifiable hypertension MRCSevilla MD

  17. Hypertension in Pregnancy (ESC 2011) • Pre-existing Hypertension • 1-5% of pregnancies • BP>=140/90 that precedes or occurs before 20 wks AOG • Usually persists >42 days postpartum • May be associated with Proteinuria MRCSevilla MD

  18. Hypertension in Pregnancy (ESC 2011) • Gestational Hypertension • Complicates 6-7% of pregnancies • Develops after 20 wks AOG and resolves within 42 days • Pregnancy-induced hypertension +/- proteinuria; If with proteinuria (>=0.3g/day in 24H urine collection or >=30mg/mmol urinary creatinine in spot random urine sample), it is known as Preeclampsia MRCSevilla MD

  19. Hypertension in Pregnancy (ESC 2011) • Preeclampsia • De novo onset of HPN w new onset significant proteinuria >0.3gm/24H • Complicates 5-7% of pregnancies but may go up to 25% in women w preexisting HPN • Occurs usually in 1st pregnancy, multiple fetuses, H.mole, Diabetes • Causes placental insufficiency – IUGR, most common cause of prematurity, accounting for 25% of LBW infants MRCSevilla MD

  20. Hypertension in Pregnancy (ESC 2011) • Severe Preeclampsia – Signs & Symptoms • RUQ/epigastric pain due to liver edema+/- hepatic hemorrhage • HA +/- visual disturbance (cerebral edema) • Occipital lobe blindness • Hyperreflexia +/- clonus • Convulsions (cerebral edema) • HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count) MRCSevilla MD

  21. Hypertension in Pregnancy (ESC 2011) • Pre-existing Hypertension plus Superimposed Gestational Hypertension with Proteinuria • Worsening BP & proteinuria after 20 wks AOG • Antenatally Unclassifiable Hypertension • When BP is first recorded after 20 wks AOG & HPN is diagnosed; needs reassessment at or after 42 wks pospartum MRCSevilla MD

  22. Case 1: • 26/Female • Known hypertensive for 6 years (diagnosed at age 20 – was secondary hypertension considered? What were the results of any prior cardiovascular work-ups?) • On maintenance calcium channel blockers • usual BP = 130/80 MRCSevilla MD

  23. Hypertension (ESC/ESH 2007) • Secondary Hypertension • suggested by: • severe blood pressure elevation • sudden onset or worsening of hypertension • blood pressure responding poorly to drug therapy MRCSevilla MD

  24. Hypertension (ESC/ESH 2007) • Secondary Hypertension • Etiologies: • Renal Parenchymal Disease – most common • Renovascular HPN – 2nd most common • Phaeochromocytoma – rare (0.2-0.4%) • Primary Aldosteronism – HPN w hypoK • Cushing’s Syndrome – typical habitus • Obstructive Sleep Apnea - overweight • Coarctation of the Aorta - rare • Drug-Induced HPN - licorice, oral contraceptives, steroids, NSAIDS, cocaine & amphetamines, erythropoietin, cyclosporins, tacrolimus. MRCSevilla MD

  25. Case 1: • 26/Female • Known hypertensive for 6 years – probably • G1 21-22 weeks • admitted due to severe HPN • BP- 200/100mmHg • PR-76/min • RR-20/min • T-36.5C. MRCSevilla MD

  26. Hypertension in Pregnancy (ESC/ESH 2011) • Non-Pharmacological Management: • Most women with pre-existing HPN in pregnancy: • have mild to moderate hypertension (140–160/90–109 mmHg) • are at low risk for cardiovascular complications within the short time frame of pregnancy. MRCSevilla MD

  27. Hypertension in Pregnancy (ESC/ESH 2011) • Non-Pharmacological Management: • Women with essential HPN & normal renal function • good maternal and neonatal outcomes • candidates for non-drug therapy • there is no evidence that pharmacological treatment results in improved neonatal outcome. • Some women with treated pre-existing hypertension are able to stop their medication in the first half of pregnancy because of the physiological fall in BP during this period. MRCSevilla MD

  28. Hypertension in Pregnancy (ESC/ESH 2011) • Pharmacological Management: • Drug treatment of severe HPN in pregnancy is required and beneficial, yet treatment of less severe hypertension is controversial. • Although it might be beneficial for the mother with hypertension to reduce her BP, a lower BP may impair uteroplacental perfusion and thereby jeopardize fetal development. MRCSevilla MD

  29. Hypertension in Pregnancy (ESC/ESH 2011) • Pharmacological Management: • Women with pre-existing HPN • may continue current meds except for ACE inhibitors, ARBs, and direct renin inhibitors, which are strictly contraindicated in pregnancy because of severe fetotoxicity, particularly in the 2nd/3rd trimesters • a-Methyldopa is the drug of choice for long-term treatment of HPN during pregnancy. • The alpha & beta blocker labetalol has efficacy comparable with methyldopa. If w severe HPN, it can be given IV • Metoprolol is also recommended MRCSevilla MD

  30. Hypertension in Pregnancy (ESC/ESH 2011) • Pharmacological Management: • CALCIUM CHANNEL BLOCKERS such as nifedipine (oral) or isradipine (i.v.) are drugs of second choice for HPN treatment • can be given in hypertensive emergencies or in hypertension caused by pre-eclampsia. • Potential synergism with MAGNESIUM SULFATE may induce maternal hypotension and fetal hypoxia. • MAGNESIUM SULFATE IV -drug of choice for treatment of seizures and prevention of eclampsia. • Diuretics should be AVOIDED because they may decrease blood flow in the placenta. MRCSevilla MD

  31. Hypertension in Pregnancy (ESC/ESH 2011) • Pharmacological Management: • In Mild to Moderate HPN • Current ESH/ESC guidelines recommend SBP = 140 mmHg or DBP = 90 mmHg as therapeutic thresholds for treatment in women with: • gestational HPN (+/- proteinuria) • pre-existing HPN with superimposed gestational HPN • HPN with subclinical organ damage or symptoms at anytime during pregnancy. MRCSevilla MD

  32. Hypertension in Pregnancy (ESC/ESH 2011) • Pharmacological Management: • Otherwise, ESH/ESC thresholds are SBP= 150 mmHg & DBP = 95 mmHg. • In Severe hypertension • SBP ≥170 mmHg or DBP≥110 mmHg in a pregnant woman is an EMERGENCY, and hospitalization is indicated. • The selection of the antihypertensive drug and its route of administration depend on the expected time of delivery. MRCSevilla MD

  33. Hypertension in Pregnancy (ESC/ESH 2011) • Pharmacological Management: • Treatment of severe hypertension • IV labetalol, or oral methyldopa, or nifedipine should be initiated. • IV HYDRALAZINE is no longer the drug of choice as its use is associated with more perinatal adverse effects than other drugs. • drug of choice – NA NITROPRUSSIDE - but Prolonged treatment with sodium nitroprusside is associated with an increased risk of fetal cyanide poisoning as nitroprusside is metabolized into thiocyanate and excreted into urine. MRCSevilla MD

  34. Hypertension in Pregnancy (ESC/ESH 2011) • Pharmacological Management: • The drug of choice in PRE-ECLAMPSIA ASSOCIATED WITH PULMONARY OEDEMA - Nitroglycerine (glyceryl trinitrate), given as an IV infusion of 5 mg/min and gradually increased every 3–5 min to a maximum dose of 100 mg/min. MRCSevilla MD

  35. Hypertension in Pregnancy (ESC 2011) Severe Preeclampsia – Management: focuses on RECOGNITION of condition and, ultimately, DELIVERY OF THE PLACENTA, which is curative. As proteinuria may be a late sign of pre-eclampsia, it should be suspected when de novo HPN is accompanied by symptoms (HA, visual disturbances, abdominal pain, or abnormal laboratory tests - low platelet count and abnormal liver enzymes; it is recommended to treat such patients as having pre-eclampsia. 23 May 2012 MRCSevilla MD

  36. Long-Term Prognosis Studies have shown that Women who develop hypertension in pregnancy have increased risk for future Cardiovascular Morbidity and Mortality Women must be informed about appropriate preventive measures and should be followed on the long term 23 May 2012 MRCSevilla MD

  37. DRUG THERAPY FOR HYPERTENSION IN PREGNANCY (ESC2011) MRCSevilla MD

  38. DRUG THERAPY FOR HYPERTENSION IN PREGNANCY (ESC2011) MRCSevilla MD

  39. DRUG THERAPY FOR HYPERTENSION IN PREGNANCY (ESC2011) MRCSevilla MD

  40. DRUG THERAPY FOR HYPERTENSION IN PREGNANCY (ESC2011) MRCSevilla MD

  41. DRUG THERAPY FOR HYPERTENSION IN PREGNANCY (ESC2011) MRCSevilla MD

  42. DRUG THERAPY FOR HYPERTENSION IN PREGNANCY (ESC2011) MRCSevilla MD

  43. DRUG THERAPY FOR HYPERTENSION IN PREGNANCY (ESC2011) MRCSevilla MD

  44. DRUG THERAPY FOR HYPERTENSION IN PREGNANCY 23 May 2012 MRCSevilla MD

  45. DRUG THERAPY FOR HYPERTENSION IN PREGNANCY 23 May 2012 MRCSevilla MD

  46. DRUG THERAPY FOR HYPERTENSION IN PREGNANCY 23 May 2012 MRCSevilla MD

  47. DRUG THERAPY FOR HYPERTENSION IN PREGNANCY 23 May 2012 MRCSevilla MD

  48. DRUG THERAPY FOR HYPERTENSION IN PREGNANCY 23 May 2012 MRCSevilla MD

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