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Hypertensive Disorders With Pregnancy. Amr Nadim, MD Professor of Obstetrics & Gynecology Ain Shams Maternity and Women’s Hospital [prof.amrnadim@gmail.com].

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Hypertensive disorders with pregnancy

Hypertensive Disorders With Pregnancy

Amr Nadim, MD

Professor of Obstetrics & Gynecology

Ain Shams Maternity and Women’s Hospital

[prof.amrnadim@gmail.com]


Hypertensive disorders with pregnancy

  • C.G. is a 39 year old married white female gravida 2, para 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

  • The pregnancy had been unremarkable until approximately one month ago when the patient noted increased swelling of her hands and feet. A 6 Kg. weight gain in two weeks time was noted. Blood pressure at that time was 124/78. There was no urinary protein. On the day prior to admission, at 28 weeks, the patient presented with a blood pressure of 160/98 and had been sent home to bedrest with instructions to take a single baby aspirin daily. On the day following, the patient was noted at home to have a persistent blood pressure of 180/100.


Avant propos
Avant propos… 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

  • Complicates 7-10% of pregnancies

    • 70% Preeclampsia-eclampsia

    • 30% Chronic hypertension

    • Eclampsia 0.05% incidence

  • 20% of Maternal Deaths

  • Cause of 10% of Preterm birth

  • Etiology unknown


Hypertensive disorders with pregnancy

  • Young female 3 fold increased risk 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

  • African American 2 fold increased risk

  • Multifetal pregnancies

    • Twins

    • Triplets

  • Hypertension

  • Diabetes Mellitus

  • Renal Disease

  • Collagen Vascular Disease


Hypertension during pregnancy classification
Hypertension during Pregnancy: Classification 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

  • Pregnancy-induced hypertension

    • Hypertension without proteinuria/edema

    • Preeclampsia

      • mild

      • severe

    • Eclampsia

  • Coincidental HTN: preexisting or persistent

  • Pregnancy-aggravated HTN

    • superimposed preeclampsia

    • superimposed eclampsia

  • Transient HTN: occurs in 3rd trimester, mild


Preeclampsia definition
Preeclampsia: Definition 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

  • Hypertension

    • > 140/90

    • relative  no longer considered diagnostic

  • Proteinuria

    • > 300 mg/24 hours or  1or 2+ on urine dipstick

    • may occur late

  • Edema (non-dependent)

    • so common & difficult to quantify it is rarely evoked to make or refute the diagnosis


Criteria for severe preeclampsia

SBP > 160 mm Hg 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

DBP > 110 mm Hg

Proteinuria > 5 g/24 hr. or 3-4+ on dipstick

Oliguria < 500 cc/24 hr.

 serum creatinine

Pulmonary edema or cyanosis

CNS symptoms (HA, vision changes)

Abdominal (RUQ) pain

Any feature of HELLP

hemolysis

 liver enzymes

thrombocytopenia

IUGR or oligohydramnios

Criteria for Severe Preeclampsia


Preeclampsia risk factors
Preeclampsia: Risk Factors 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

  • Nulliparity (or, more correctly, primipaternity)

  • Chronic renal disease

  • Angiotensinogen gene T235

  • Chronic hypertension

  • Antiphospholipid antibody syndrome

  • Multiple gestation

  • Family or personal history of preeclampsia

  • Age > 40 years

  • African-American race

  • Diabetes mellitus


Etiology and prevention
Etiology and Prevention 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

  • Etiology is unknown.

  • Many theories:

    • genetic

    • immunologic

    • dietary deficiency (calcium, magnesium, zinc)

      • supplementation has not proven effective

    • placental source (ischemia)


Etiology and prevention1
Etiology and Prevention 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

  • A major underlying defect is a relative deficiency of prostacyclin vs. thromboxane

  • Normally (non-preeclamptic) there is an 8-10 fold  in prostacyclin with a smaller  in thromboxane

    • prostacyclin salutatory effects dominate

      • vasodilation,  platelet aggregation,  uterine tone

  • In preeclampsia, thromboxane’s effects dominate

    •  thromboxane (from platelets, placenta)

    •  prostacyclin (from endothelium, placenta)


Preeclampsia prophylaxis aspirin
Preeclampsia Prophylaxis: 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.Aspirin

  • Aspirin has been extensively studied as a targeted therapy to  thromboxane production

  • CLASP study, A multicenter RCT

    [CLASP Collaborative Group, Lancet 1994;343:619-29]

    • 9364 women, risk factors for PIH or IUGR or who had PIH or IUGR

    • 60 mg ASA daily vs. placebo

    • Small reduction (12%) in occurrence of PIH

    • Small reduction in preterm deliveries: 20 vs 22%

    • No difference in neonatal outcome


Preeclampsia prophylaxis aspirin1
Preeclampsia Prophylaxis: 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.Aspirin

  • NIH study of high-risk patients, RCT, 60 mg aspirin daily vs. placebo [Caritis, et al., N Engl J Med 1998;338:701-5]

    • pre-gestational DM (471 patients)

    • chronic hypertension (774 patients)

    • multifetal gestations (688 patients)

    • prior history of preeclampsia (606 patients)

  • No reduction in development of preeclampsia in any subgroup or groups in aggregate

  • No difference in perinatal death, preterm delivery, IUGR, maternal or fetal hemorrhagic complications


Preeclampsia mechanism
Preeclampsia: Mechanism 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

  • At this time the most widely accepted proposed mechanism for preeclampsia is:

    Global Endothelial Cell Dysfunction

  • Endothelial cell dysfunction is just one manifestation of a broader intravascular inflammatory response

    • present in normal pregnancy

    • excessive in preeclampsia

    • Proposed source of inflammatory stimulus: placenta


Pathophysiology
Pathophysiology 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

Of importance, and distinguishing preeclampsia from chronic or gestational hypertension, is that preeclampsia is more than hypertension; it is a systemic syndrome, and several of its “non-hypertensive” complications can be life-threatening when blood pressure elevations are quite mild.


Pathophysiology cardiovascular
Pathophysiology: 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.Cardiovascular

  • In severe preeclampsia, typically hyperdynamic with normal-high CO, normal-mod. high SVR, and normal PCWP and CVP.

  • Despite normal filling pressures, intravascular fluid volume is reduced (30-40% in severe PIH)

  • Variations in presentation depending on prior treatment and severity and duration of disease

  • Total body water is increased (generalized edema)


Pathophysiology cardiovascular1
Pathophysiology: Cardiovascular 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

  • Preeclamptic patients are prone to develop pulmonary edema due to reduced colloid oncotic pressure (COP), which falls further postpartum:

    Colloid oncotic pressure:

    Antepartum Postpartum

    Normal pregnancy: 22 mm Hg 17 mm Hg

    Preeclampsia: 18 mm Hg 14 mm Hg


Pathophysiology1
Pathophysiology 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

  • Respiratory:

    • Airway is edematous; use smaller ET tube (6.5)

    •  risk of pulmonary edema; 70% postpartum

  • Renal:

    • Renal blood flow & GFR are decreased

    • Renal failure due to  plasma volume or renal artery vasospasm

    • Proteinuria due to glomerulopathy

      • glomerular capillary endothelial swelling w/subendothelial protein deposits

    • Renal function recovers quickly postpartum


Pathophysiology hepatic
Pathophysiology: 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.Hepatic

  • RUQ pain is a serious complaint

    • warrants imaging, especially when accompanied by  liver enzymes

    • caused by liver swelling, periportal hemorrhage, subcapsular hematoma, hepatic rupture (30% mortality)

  • HELLP syndrome occurs in ~ 20% of severe preeclamptics.


Pathophysiology2
Pathophysiology 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

  • Coagulation:

    • Generally hypercoagulable with evidence of platelet activation and increased fibrinolysis

    • Thrombocytopenia is common, but fewer than 10% have platelet count < 100,000

    • DIC may occur,

      • Acutely esp. with placental abruption

  • Neurologic:

    • Symptoms: headache, visual changes, seizures

    • Hyperreflexia is usually present

    • Eclamptic seizures may occur even w/out BP

      • Possible causes: hypertensive encephalopathy, cerebral edema, thrombosis, hemorrhage, vasospasm


Hypertension during pregnancy classification1
Hypertension during Pregnancy: Classification 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

  • Pregnancy-induced hypertension

    • Hypertension without proteinuria/edema

    • Preeclampsia

      • mild

      • severe

    • Eclampsia

  • Coincidental HTN: preexisting or persistent

  • Pregnancy-aggravated HTN

    • superimposed preeclampsia

    • superimposed eclampsia

  • Transient HTN: occurs in 3rd trimester, mild


Classification
Classification 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

  • Chronic hypertension

  • Preeclampsia-eclampsia

  • Preeclampsia Superimposed upon chronic hypertension or Renal Disease

  • Gestational hypertension (only during pregnancy)

  • Transient hypertension (only after pregnancy)


Chronic hypertension
Chronic Hypertension 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

Defined as hypertension diagnosed

  • Before pregnancy

  • Before the 20th week of gestation

  • During pregnancy and not resolved postpartum


Gestational hypertension
Gestational Hypertension 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

  • Gestational Hypertension:

    • Systolic >140

    • Diastolic>90

    • No Proteinurea

    • 25% Develop Pre-eclampsia


Gestational hypertension1
Gestational Hypertension 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

Diagnosis of gestational hypertension:

  • Detected for first time after midpregnancy

  • No proteinuria

  • Only until a more specific diagnosis can be assigned postpartum

    If:

  • BP returns to normal by 12 weeks postpartum, diagnosis is transient hypertension.

  • BP remains high postpartum, diagnosis is chronic hypertension.

  • Proteinurea develops Superimposed Preeclampsia is diagnosed (25% incidence)


Preeclampsia eclampsia
Preeclampsia-Eclampsia 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

  • Occurs after 20th week (earlier with trophoblastic disease)

  • Increased BP (gestational BP elevation) with proteinuria

  • ‘LL’ Edema is NOT part of this definition


Diagnosis of preeclampsia eclampsia
Diagnosis of Preeclampsia-Eclampsia 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

  • Gestational Hypertension:

    • Systolic >140

    • Diastolic>90

  • Proteinuria is defined as urinary excretion

    • 0.3 g protein or greater in a 24-hour

    • +2 or greater on urine dip specimen


Blood pressure measurement
Blood Pressure Measurement 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

How would you measure the Blood Pressure for a pregnant lady?


Preeclampsia eclampsia1
Preeclampsia-Eclampsia 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

  • Blood pressure

  • Measure blood pressure

    • in the sitting position,

    • with the cuff at the level of the heart.

    • Inferior vena caval compression by the gravid uterus while the patient is supine can alter readings substantially, leading to an underestimation of the blood pressure.

    • Blood pressures measured in the left lateral position similarly may yield falsely low values if the blood pressure is measured in the higher arm and the cuff is not maintained at heart level.

  • Allow women to sit quietly for 5-10 minutes before measuring the blood pressure.


Blood pressure assessment patient preparation and posture
Blood Pressure Assessment: 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.Patient preparation and posture

Standardized technique:

Patient

1. No caffeine in the preceding hour.

2. No smoking or nicotine in the preceding 15-30 minutes.

3. No use of substances containing adrenergic stimulants such as phenylephrine or pseudoephedrine (may be present in nasal decongestants or ophthalmic drops).

4. Bladder and bowel comfortable.

5. Quiet environment. Comfortable room temperature.

6. No tight clothing on arm or forearm.

7. No acute anxiety, stress or pain.

8. Patient should stay silent prior and during the procedure.


Blood pressure assessment patient preparation and posture1
Blood Pressure Assessment: 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.Patient preparation and posture

Standardized technique:

Posture

  • The patient should be calmly seated for at least 5 minutes, with his or her back well supported and arm supported at the level of the heart. His or her feet should touch the floor and legs should not be crossed.

  • The patient should be instructed not to talk prior and during the procedure.


Recommended technique for measuring blood pressure

Standardized technique: 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

Use a mercury manometer or a recently calibrated aneroid or a validated electronic device.

Aneroid devices should only be used if there is an established calibration check every 6-12 months.

Recommended Technique for Measuring Blood Pressure


Recommended technique for measuring blood pressure1

Electronic oscillometric devices: 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

Use a validated electronic device according to BHS, AAMI or IP standards.

For self blood pressure measurement devices, a logo on the packaging ensures that this type of device and model meets the international standards for accurate blood pressure measurement.

Office

Home / Self

Recommended Technique for Measuring Blood Pressure

AAMI=Association for the Advancement of Medical Instrumentation;

BHS=British Hypertension Society; IP: International Protocol.


Recommended technique for measuring blood pressure cont
Recommended Technique 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.for Measuring Blood Pressure (cont.)

  • Select a

  • cuff with the appropriate size


Cuff size
Cuff size 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.


Recommended technique for measuring blood pressure cont1

Locate brachial and radial pulse 0, with one spontaneous abortion who presented for prenatal care at 14 weeks gestation. Blood pressure at that time was 130/80. The patient had no significant medical history and her gynecologic history was significant only for oral contraceptive use several years ago. The patient noted that her physician stopped the birth control pills after only two cycles, but the patient was not told why.

Position cuff at the heart level

Arm should be supported

Recommended Technique for Measuring Blood Pressure (cont.)


Recommended technique for measuring blood pressure cont2

To exclude possibility of auscultatory gap, increase cuff pressure rapidly to 20-30 mmHg above level of disappearance of radial pulse

Place stethoscope over the brachial artery

Recommended Technique for Measuring Blood Pressure (cont.)


Recommended technique for measuring blood pressure cont3

Drop pressure by 2 mmHg / sec pressure rapidly to 20-30 mmHg above level of disappearance of radial pulse

Appearance of sound (phase I Korotkoff) = systolic pressure

Record measurement

Drop pressure by 2 mmHg / beat

Disappearance of sound (phase V Korotkoff) = diastolic pressure

Record measurement

Take 2 blood pressure measurements, 1 minute apart

Recommended Technique for Measuring Blood Pressure (cont.)


Recommended technique for measuring blood pressure cont4

Korotkoff sounds pressure rapidly to 20-30 mmHg above level of disappearance of radial pulse

200

No sound

180

Clear sound

Phase 1

160

Muffling

Phase 2

Auscultatory gap

No sound

140

120

Muffled sound

Phase 3

100

Muffled sound

Phase 4

80

60

Possible readings:

No sound

Phase 5

40

184 / 100

136 / 100

20

184 / 86 = correct

136 / 86

0

mm Hg

Recommended Technique for Measuring Blood Pressure (cont.)

Systolic BP

Diastolic BP


Preeclampsia eclampsia2
Preeclampsia-Eclampsia pressure rapidly to 20-30 mmHg above level of disappearance of radial pulse

  • Blood pressure

    • Record Korotkoff sounds I (the first sound) and V (the disappearance of sound) to denote the systolic blood pressure (SPB) and DPB, respectively.

    • In about 5% of women, an exaggerated gap exists between the fourth (muffling) and fifth (disappearance) Korotkoff sounds, with the fifth sound approaching zero. In this setting, record both the fourth and fifth sounds (eg, 120/80/40 with sound I = 120, sound IV = 80, sound V = 40).


Recommended technique for measuring blood pressure2
Recommended Technique pressure rapidly to 20-30 mmHg above level of disappearance of radial pulsefor Measuring Blood Pressure

  • Standardized technique:

  • For initial readings, take the blood pressure in both arms and subsequently measure it in the arm with the highest reading.

  • Thereafter, take two measurements on the side where BP is highest.


Recommended technique for measuring blood pressure cont5
Recommended Technique pressure rapidly to 20-30 mmHg above level of disappearance of radial pulsefor Measuring Blood Pressure (cont.)

Record the blood pressure to the closest 2 mmHg on the manometer

as well as the arm used

and whether the patient was supine, sitting or standing.


Recommended technique for measuring blood pressure cont6
Recommended Technique pressure rapidly to 20-30 mmHg above level of disappearance of radial pulsefor Measuring Blood Pressure (cont.)

  • Avoid digit preference for five (5) or zeros (0) by not rounding up or down.

  • Record the heart rate.


Recommended technique for measuring blood pressure cont7
Recommended Technique pressure rapidly to 20-30 mmHg above level of disappearance of radial pulsefor Measuring Blood Pressure (cont.)

  • The seated blood pressure is used to determine and monitor treatment decisions.

  • The standing blood pressure is used to test for postural hypotension, if present, which may modify the treatment.


Blood pressure assessment patient preparation and posture2
Blood Pressure Assessment: pressure rapidly to 20-30 mmHg above level of disappearance of radial pulsePatient preparation and posture

Standing position

For patients over age 65, diabetics and patients being treated with antihypertensives, check if there are postural changes while taking blood pressure reading, i.e. after one to five minutes in the standing position and under circumstances when the patients complains of symptoms suggestive of hypotension.


Classification of preeclampsia eclampsia
Classification of Preeclampsia-Eclampsia pressure rapidly to 20-30 mmHg above level of disappearance of radial pulse

  • Mild Pre-eclampsia

  • Severe Pre-eclampsia


Classification of preeclampsia eclampsia1
Classification of Preeclampsia-Eclampsia pressure rapidly to 20-30 mmHg above level of disappearance of radial pulse

  • Criteria for Severe Preeclampsia (one or more)

    • Blood Pressure: >160 systolic, >110 diastolic

    • Proteinurea: >5gm in 24 hours, over 3+ urine dip

    • Oligurea: less than 400ml in 24 hours

    • CNS: Visual changes, headache, scotomata, mental status change

    • Pulmonary Edema

    • Epigastric or RUQ Pain: Usually indicates liver involvement


Classification of preeclampsia eclampsia2
Classification of Preeclampsia-Eclampsia pressure rapidly to 20-30 mmHg above level of disappearance of radial pulse

  • Criteria for Severe Preeclampsia (one or more)

    • Impaired Liver Function tests

    • Thrombocytopenia: <100,000

    • Intrauterine Growth Restriction: With or without abnormal doppler assessment

    • Oligohydramnios


Classification of preeclampsia superimposed upon chronic hypertension
Classification of Preeclampsia Superimposed Upon Chronic Hypertension

  • Hypertension and no proteinuria < 20 weeks:

    New-onset proteinuria after 20 weeks

  • Hypertension and proteinuria < 20 weeks:

    • Sudden increase in proteinuria

    • Sudden increase in BP in women whose hypertension was well controlled

    • Thrombocytopenia (platelet count <100,000 cells/mm3)

    • Increase in ALT or AST to abnormal levels


Clinical implications of preeclampsia
Clinical Implications of Preeclampsia Hypertension

  • Preeclampsia ranges from mild to severe.

  • Progression may be slow or rapid – hours to days to weeks.

    For clinical management, preeclampsia should be over diagnosed to prevent maternal and perinatal morbidity and mortality – primarily through timing of delivery.


Symptoms of preeclampsia
Symptoms of Preeclampsia Hypertension

  • Visual disturbances typical of preeclampsia are scintillations and scotomata. These disturbances are presumed to be due to cerebral vasospasm.

  • Headache is of new onset and may be described as frontal, throbbing, or similar to a migraine headache. However, no classic headache of preeclampsia exists.

  • Epigastric pain is due to hepatic swelling and inflammation, with stretch of the liver capsule. Pain may be of sudden onset, it may be constant, and it may be moderate-to-severe in intensity.


Symptoms of preeclampsia1
Symptoms of preeclampsia Hypertension

  • While mild lower extremity edema is common in normal pregnancy, rapidly increasing or nondependent edema may be a signal of developing preeclampsia. However, this signal theory remains controversial and recently has been removed from most criteria for the diagnosis of preeclampsia.

  • Rapid weight gain is a result of edema due to capillary leak as well as renal sodium and fluid retention.


Physical findings in preeclampsia
Physical Findings in Preeclampsia Hypertension

  • Blood Pressure

  • Proteinurea

  • Retinal vasospasm or Retinal edema

  • Right upper quadrant (RUQ) abdominal tenderness stems from liver swelling and capsular stretch


Physical findings in preeclampsia1
Physical findings in Preeclampsia Hypertension

  • Brisk, or hyperactive, reflexes are common during pregnancy, but clonus is a sign of neuromuscular irritability that raises concern.

  • Among pregnant women, 30% have some lower extremity edema as part of their normal pregnancy. However, a sudden change in dependent edema, edema in nondependent areas such as the face and hands, or rapid weight gain suggests a pathologic process and warrants further evaluation


Differential diagnosis
Differential Diagnosis Hypertension

  • Documentation of HBP before conception or before gestational week 20 favors a diagnosis of chronic hypertension (essential or secondary).

  • HBP presenting at midpregnancy (weeks 20 to 28) may be due to early preeclampsia, transient hypertension, or unrecognized chronic hypertension.


Laboratory tests
Laboratory Tests Hypertension

High-risk patients presenting with normal BP:

  • Hematocrit

  • Hemoglobin

  • Serum uric acid

  • If 1+ protein by routine urinalysis (clean catch) present obtain a timed collection for protein and creatinine

  • Accurate dating and assessment of fetal growth

  • Baseline sonogram at 25 to 28 weeks


Laboratory tests1
Laboratory Tests Hypertension

Patients presenting with hypertension before gestation week 20:

  • Same tests as described for high-risk patients presenting with normal BP

  • Early baseline sonography for dating and fetal size


Laboratory tests2
Laboratory Tests Hypertension

Patients presenting with hypertension after midpregnancy:

  • Quantification of protein excretion

  • Hemoglobin and hematocrit and platelet count

  • Serum creatinine, uric acid, and transaminase level

  • Serum albumin, LDH, blood smear, and coagulation profile


Preeclampsia treatment
Preeclampsia: Treatment Hypertension

  • Goal is to prevent eclampsia and other severe complications.

  • Attempts to treat preeclampsia by natriuresis or by lowering BP may exacerbate pathologic changes.

  • Palliate maternal condition to allow fetal maturation and cervical ripening.


Preeclampsia treatment1
Preeclampsia: Treatment Hypertension

Maternal Evaluation

  • Goals:

    • Early recognition of preeclampsia

    • Observe progression, both to prevent maternal complications and protect well-being of fetus.

      • Early signs:

        • BP rises in late second and early third trimesters.

        • Initial appearance of proteinuria is important.


Fetal monitoring
Fetal Monitoring Hypertension


Preeclampsia treatment2
Preeclampsia: Treatment Hypertension

  • Maternal Evaluation…When To Hospitalize?

    • Often, hospitalization recommended with new-onset preeclampsia to assess maternal and fetal conditions.

    • Hospitalization for duration of pregnancy indicated for preterm onset of severe gestational hypertension or preeclampsia.

    • Ambulatory management at home or at day-care unit may be considered with mild gestational hypertension or preeclampsia remote from term


Preeclampsia
Preeclampsia Hypertension



Preeclampsia1
Preeclampsia Hypertension

  • Antepartum Management of Preeclampsia

    • Little to suggest therapy alters the underlying pathophysiology of preeclampsia.

    • Restricted activity may be reasonable.

    • Sodium restriction and diuretic therapy appear to have no positive effect.


Obstetric management
Obstetric Management Hypertension

  • Classically “stabilize and deliver”


Obstetric management1
Obstetric Management Hypertension

  • Medical management while awaiting delivery:

    • use of steroids X 48 hours if fetus < 34 wks

    • antihypertensives to maintain DBP < 105-110

    • magnesium sulfate for seizure prophylaxis

    • monitor fluid balance, I/O, daily weights, symptoms, reflexes, HCT, plts, LFT’s, proteinuria


Obstetric management2
Obstetric Management Hypertension

  • Indications for expedited delivery:

    • fetal distress

    •  BP despite aggressive Rx

    • worsening end-organ function

    • development or worsening of HELLP syndrome

    • development of eclampsia


Antihypertensive therapy
Antihypertensive Therapy Hypertension

  • Most commonly, for acute control: hydralazine, labetolol

  • Nifedipine may be used, but unexpected hypotension may occur when given with MgSO4

  • For refractory hypertension: nitroglycerin or nitroprusside may be used

    • Nitroprusside dose and duration should be limited to avoid fetal cyanide toxicity

    • Usually require invasive arterial pressure mon

  • Angiotensin-converting enzyme (ACE) inhibitors contraindicated due to severe adverse fetal effects


Seizure prophylaxis treatment
Seizure Prophylaxis & Treatment Hypertension

  • Magnesium sulfate vs. phenytoin for seizure prophylaxis in preeclampsia

    Lucas, et al., N Engl J Med 1995;333:201-5.

    • 2138 patients (75% had mild PIH)

    • Maternal & fetal outcomes similar except 10 seizures in the phenytoin group (0 in MgSO4)

  • Mg vs. diazepam & Mg vs. phenytoin for preventing recurrent seizures in eclamptics

    Eclampsia Trial Collaborative Group, Lancet 1995;345:1455

    • Mg pts were 52% or 67% less likely to have a recurrent seizure than diazepam or phenytoin pts


Seizure prophylaxis
Seizure Prophylaxis Hypertension

  • Evidence is strong that magnesium sulfate is indicated for

    • seizure treatment in eclamptics

    • seizure prophylaxis in severe preeclamptics

  • Role of magnesium prophylaxis in mild preeclamptics is less clear

    • awaits large, prospective, randomized, placebo-controlled trial


Magnesium sulfate
Magnesium Sulfate Hypertension

  • Magnesium sulfate has many effects; its mechanism in seizure control is not clear.

    • NMDA (N-methyl-D-aspartate) antagonist

    • vasodilator

      • Brain parenchymal vasodilation demonstrated in preeclamptics by Doppler ultrasonography

    • increases release of prostacyclin

  • Potential adverse effects:

    • toxicity from overdose (respiratory, cardiac)

    •  bleeding

    •  hypotension with hemorrhage

    •  uterine contractility


Magnesium sulfate1
Magnesium Sulfate Hypertension

  • Renally excreted

  • Preeclamptics prone to renal failure

  • Magnesium levels must be monitored frequently either clinically (patellar reflexes, urinary output) or by checking serum levels q 6-8 hours

    • Therapeutic level: 4-7 meq/L

    • Patellar reflexes lost: 8-10 meq/L

    • Respiratory depression: 10-15 meq/L

    • Respiratory paralysis: 12-15 meq/L

    • Cardiac arrest: 25-30 meq/L

  • Treatment of magnesium toxicity:

    • stop MgSO4, IV calcium, manage airway


  • Treatment of eclampsia
    Treatment of Eclampsia Hypertension

    • Seizures are usually short-lived.

    • If necessary, small doses of barbiturate or benzodiazepine (STP, 50 mg, or midazolam, 1-2 mg) and supplemental oxygen by mask.

    • If seizure persists or patient is not breathing, rapid sequence induction with cricoid pressure and intubation should be performed.

    • Patient may be extubated once she is completely awake, recovered from neuromuscular blockade, and magnesium sulfate has been administered.


    Anesthetic goals of labor analgesia in preeclampsia
    Anesthetic Goals of Labor Analgesia in Preeclampsia Hypertension

    • To establish & maintain hemodynamic stability (control hypertension & avoid hypotension)

    • To provide excellent labor analgesia

    • To prevent complications of preeclampsia

      • intracerebral hemorrhage

      • renal failure

      • pulmonary edema

      • eclampsia

    • To be able to rapidly provide anesthesia for C/S


    Regional vs general anesthesia in preeclampsia
    Regional vs. General Anesthesia in Preeclampsia Hypertension

    • Epidural anesthesia would probably be preferred by many anesthesiologists in a severely preeclamptic pt in a non-urgent setting

    • For urgent cases it is reassuring to know that spinal is also safe

    • This allows us to avoid general anesthesia with the potential for encountering a swollen, difficult airway and/or labile hypertension


    Regional vs general anesthesia in preeclampsia1
    Regional vs. General Anesthesia in Preeclampsia Hypertension

    • General anesthesia is a well-known hazard in obstetric anesthesia:

      • 16X more likely to result in anesthetic-related maternal mortality

      • Mostly due to airway/respiratory complications, which would only be exaggerated in preeclampsia

        Hawkins, Anesthesiology 1997;86:273


    Platelets regional anesthesia in preeclampsia
    Platelets & Regional Anesthesia in Preeclampsia Hypertension

    • Prior to placing regional block in a preeclamptic it is recommended to check the platelet count.

    • No concrete evidence at to the lowest safe platelet count for regional anesthesia in preeclampsia

    • Any clinical evidence of DIC would contraindicate regional anesthesia.


    Hazards of general anesthesia in preeclampsia
    Hazards of General Anesthesia Hypertensionin Preeclampsia

    • Airway edema is common

      • Mandatory to reexamine the airway soon before induction

      • Edema may appear or worsen at any time during the course of disease

        • tongue & facial, as well as laryngeal

    • Laryngoscopy and intubation may  severe BP

      • Labetolol & NTG are commonly used acutely

      • Fentanyl (2.5 mcg/kg), alfentanil (10 mcg/kg), lidocaine may be given to blunt response


    Hazards of general anesthesia in preeclampsia1
    Hazards of General Anesthesia Hypertensionin Preeclampsia

    • Magnesium sulfate potentiates depolarizing & non-depolarizing muscle relaxants

      • Pre-curarization is not indicated.

      • Initial dose of succinylcholine is not reduced.

      • Neuromuscular blockade should be monitored & reversal confirmed.


    Invasive central hemodynamic monitoring in preeclampsia
    Invasive Central Hemodynamic Monitoring in Preeclampsia Hypertension

    • Usually reserved for patients with complications

      • oliguria unresponsive to modest fluid challenge (500 cc LR X 2)

      • pulmonary edema

      • refractory hypertension

        • may have increased CO or increased SVR

    • Poor correlation between CVP and PCWP in PIH

      • However, at most centers anesthesiologists would begin with CVP & follow trend

        • not arbitrarily hydrate to a certain number

      • If poor response, change to PA catheter


    Conclusions
    Conclusions Hypertension

    • Preeclampsia is a serious multi-organ system disorder of pregnancy that continues to defy our complete understanding.

    • It is characterized by global endothelial cell dysfunction.

    • The cause remains unknown.

    • There is no effective prophylaxis.


    Conclusions1
    Conclusions Hypertension

    • Delivery is the only effective cure.

    • Magnesium sulfate is now proven as the best medication to prevent and treat eclampsia.

    • Epidural analgesia for labor pain management & regional anesthesia for C/S have many beneficial effects & are preferred.


    Antihypertensive therapy1
    Antihypertensive Therapy Hypertension

    • Patients with chronic hypertension should continue on their pre-pregnancy medication if NOT contraindicated with pregnancy.

    • The usual cut off to prescribe Antihypertensives with pregnancy is 150/100.

    • Care should be taken NOT to compromise the fetal circulation by bringing the blood pression down to normal.


    Alpha methyl dopa
    Alpha-methyl Dopa Hypertension

    • The most commonly used and presumably the safest with pregnancy.

    • The usual dose starts with 250mg tds to be increased up to 2 grams per day.

    • It blocks the adrenaline release at post synaptic sites.


    Hydralazine
    Hydralazine Hypertension

    • Dose: 5-10 mg every 20 minutes

    • Onset: 10-20 minutes

    • Duration: 3-8 hours

    • Side effects: headache, flushing, tachycardia, lupus like symptoms

    • Mechanism: peripheral vasodilator


    Labetalol
    Labetalol Hypertension

    • Dose:

      • IV:20mg, then 40, then 80 every 20 minutes, for a total of 220mg

      • Oral 100 mg bid to be increased up to 200 mg qid. ( maximum 2400mg daily)

    • Onset: 1-2 minutes

    • Duration: 6-16 hours

    • Side effects: hypotension

    • Mechanism: Alpha and Beta block


    Nifedipine
    Nifedipine Hypertension

    • Dose: 10 mg po, not sublingual

    • Onset: 5-10 minutes

    • Duration: 4-8 hours

    • Side effects: chest pain, headache, tachycardia

    • Mechanism: CA channel block


    Clonidine
    Clonidine Hypertension

    • Dose: 1 mg po

    • Onset: 10-20 minutes

    • Duration: 4-6 hours

    • Side effects: unpredictable, avoid rapid withdrawal

    • Mechanism: Alpha agonist, works centrally


    Nitroprusside
    Nitroprusside Hypertension

    • Dose: 0.2 – 0.8 mg/min IV

    • Onset: 1-2 minutes

    • Duration: 3-5 minutes

    • Side effects: cyanide accumulation, hypotension

    • Mechanism: direct vasodilator


    Preeclampsia2
    Preeclampsia Hypertension

    • Indications for Delivery in Preeclampsia

    • Maternal

      • Gestational age 38 weeks

      • Platelet count < 100,000 cells/mm3

      • Progressive deterioration in liver and renal function

      • Suspected abruptio placentae

      • Persistent severe headaches, visual changes, nausea, epigastric pain, or vomiting

    • Delivery should be based on maternal and fetal conditions as well as gestational age.


    Preeclampsia3
    Preeclampsia Hypertension

    • Indications for Delivery in Preeclampsia

    • Fetal

      • Severe fetal growth restriction

      • Nonreassuring fetal testing results

      • Oligohydramnios


    Preeclampsia4
    Preeclampsia Hypertension

    • The “cure” for preeclampsia is delivery

      • The “cure” is always beneficial for the mother, although c-section might be needed

      • The “cure” may be deleterious for the fetus


    Preeclampsia5
    Preeclampsia Hypertension

    • Route of Delivery

      • Vaginal delivery is preferable.

      • Aggressive labor induction (within 24 hours).

      • Neuraxial (epidural, spinal, and combined spinal-epidural) techniques offer advantages.

      • Hydralazine, nitroglycerin, or labetalol may be used as pretreatment to reduce significant hypertension during delivery.


    Preeclampsia6
    Preeclampsia Hypertension

    • Anticonvulsive Therapy

      • Indicated to prevent recurrent convulsions in women with eclampsia or to prevent convulsions in women with preeclampsia.

      • Parenteral magnesium sulfate reduces the frequency of eclampsia and maternal death. (Caution in renal failure.)


    Treatment of acute severe hypertension in pregnancy
    Treatment of Acute Severe Hypertension in Pregnancy Hypertension

    • SBP > 160 mm Hg and/or DBP > 105 mm Hg

      • Parenteral hydralazine is most commonly used.

      • Parenteral labetalol is second-line drug (avoid in women with asthma and CHF.)

      • Oral nifedipine used with caution. (Short-acting nifedipine is not approved by FDA for managing hypertension.)

      • Sodium nitroprusside may be used in rare cases.


    Postpartum counseling and followup
    Postpartum Counseling and Followup Hypertension

    • Counseling for Future Pregnancies

    • Risk of recurrent preeclampsia increases with

      • Preeclampsia before 30 weeks (40%)

      • Multiparas as compared with nulliparas or new father

      • Risk of recurrent preeclampsia may be substantially greater in African Americans.


    Remote prognosis
    Remote Prognosis Hypertension

    • Preeclampsia-Eclampsia

      • The more certain the diagnosis of preeclampsia, the lower the prevalence of remote cardiovascular disorders.

      • Preeclampsia-eclampsia in subsequent pregnancies helps define future risk.

      • Gestational hypertension in any pregnancy increases remote cardiovascular risk.


    Eclampsia
    Eclampsia Hypertension

    • Women older than 40 years with preeclampsia have 4 times the incidence of seizures compared to women in their third decade of life.

      • Twenty-five percent of eclampsia cases occur before labor (ie, antepartum).

      • Fifty percent of eclampsia cases occur during labor (ie, intrapartum).

      • Twenty-five percent of eclampsia cases occur after delivery (ie, postpartum).

      • Patients with severe preeclampsia are at greater risk to develop seizures.

      • Twenty-five percent of patients with eclampsia have only mild preeclampsia prior to the seizures


    Causes
    Causes: Hypertension

    The cause of the seizures is not clear, although several processes have been implicated in their development.

    • Areas of cerebral vasospasm may be severe enough to cause focal ischemia, which may in turn lead to seizures.

    • Pathologic alterations in cerebral blood flow and tissue edema induced by vasospasm may result in headaches, visual disturbances, and hypertensive encephalopathy, resulting in a seizure.


    Hypertensive disorders with pregnancy

    Prior to the seizures, Symptoms include the following: Hypertension

    Headache (82.5%)

    Hyperactive reflexes (80%)

    Marked proteinuria (52%)

    Generalized edema (49%)

    Visual disturbances (44.4%)

    Right upper quadrant pain or epigastric pain (19%)

    Sometimes, there is:

    Lack of edema (39%)

    Absence of proteinuria (21%)

    Normal reflexes (20%)


    Eclamptic seizure
    Eclamptic seizure Hypertension

    • The patient may have 1 or more seizures.

    • Seizures generally last 60-75 seconds.

    • The patient's face initially may become distorted, with protrusion of the eyes.

    • The patient may begin foaming at the mouth.

    • Respiration ceases for the duration of the seizure.


    Hypertensive disorders with pregnancy

    • The seizure may be divided into 2 phases: Hypertension

      • Phase 1 lasts 15-20 seconds and begins with facial twitching. The body becomes rigid, leading to generalized muscular contractions.

      • Phase 2 lasts approximately 60 seconds. It starts in the jaw, moves to the muscles of the face and eyelids, and then spreads throughout the body. The muscles begin alternating between contracting and relaxing in rapid sequence.

    • A coma or a period of unconsciousness follows phase 2.

      • Unconsciousness lasts for a variable period.

      • Following the coma phase, the patient may regain some consciousness.

      • The patient may become combative and very agitated.

      • The patient has no recollection of the seizure.

    • A period of hyperventilation occurs after the tonic-clonic seizure. This compensates for the respiratory and lactic acidosis that develops during the apneic phase.

    • Seizure-induced complications may include tongue biting, head trauma, broken bones, or aspiration.