hypertensive disorders of pregnancy. clinical classification of hypertensive disorders of pregnancy...
Post on 21-Jan-2016
270 Views
Preview:
TRANSCRIPT
HYPERTENSIVE DISORDERS OF HYPERTENSIVE DISORDERS OF PREGNANCYPREGNANCY
CLINICAL CLASSIFICATION OF HYPERTENSIVECLINICAL CLASSIFICATION OF HYPERTENSIVEDISORDERS OF PREGNANCYDISORDERS OF PREGNANCY
1. Gestational hypertension (without proteinuria)1. Gestational hypertension (without proteinuria)
2. Gestational proteinuria (without hypertension)2. Gestational proteinuria (without hypertension)
3. Gestational proteinuric hypertension (pre-eclampsia)3. Gestational proteinuric hypertension (pre-eclampsia)
B.B. CHRONIC HYPERTENSION AND CHRONIC RENAL DISEASECHRONIC HYPERTENSION AND CHRONIC RENAL DISEASE
1. Chronic hypertension (without proteinuria)1. Chronic hypertension (without proteinuria)
2. Chronic renal disease (proteinuria with or without HTN2. Chronic renal disease (proteinuria with or without HTN
3. Chronic HTN/ CRD with superimposed pre-eclampsia 3. Chronic HTN/ CRD with superimposed pre-eclampsia
C.C. UNCLASSIFIED HYPERTENSION AND/OR PROTEINURIAUNCLASSIFIED HYPERTENSION AND/OR PROTEINURIA
1. Unclassified1. Unclassified hypertension (with out proteinuria)hypertension (with out proteinuria)
2. Unclassified2. Unclassified proteinuria (with out hypertension)proteinuria (with out hypertension)
3. Unclassified3. Unclassified proteinuric hypertensionproteinuric hypertension
A. . GESTATIONAL HYPERTENSION AND /OR PROTEINURIAGESTATIONAL HYPERTENSION AND /OR PROTEINURIA
P.I.H
HTN/ or PTN developing after 20 weeks of pregnancy, during labour or the puerperium in a previously normotensive non-proteinuric woman
(ISSHP)
PRE-ECLAMPSIA
Hypertension and Proteinuria Occurring after the 20th week of gestation in a previous
normotensive, non proteinuric woman
ECLAMPSIA ECLAMPSIA Above signs + fits.
SUPERIMPOSED PRE – ECLAMPSIASUPERIMPOSED PRE – ECLAMPSIARise of 30 mm hg systolic Or 15 mm hg diastolic above previous levels with proteinuria
• One measurement of DBP of 110 mm Hg or more
OR
• Two consecutive measurements of DBP > 90 mm Hg 4 h or more apart.
HYPERTENSION
PROTEINURIA • Protein excretion of 300 mg or more in 24 hours urine
OR• Two random clean catch or catheter urine specimen with 2+ (1 gm albumin/L) or more
PATHOGENESISPATHOGENESIS
1.1. Rejection phenomenonRejection phenomenon2.2. Uteroplacental ischaemiaUteroplacental ischaemia3.3. Imbalance between prostacyclin andImbalance between prostacyclin and ThromboxaneThromboxane4.4. Decreased GFR with salt and water Decreased GFR with salt and water
retention.retention.5.5. Decreased intra vascular volumeDecreased intra vascular volume6.6. Increased central nervous system Increased central nervous system
irritabilityirritability7.7. D.I.CD.I.C8.8. Dietry factorsDietry factors9.9. Uterine muscle stretchUterine muscle stretch10.10. Genetic factorsGenetic factors
Exact cause is unknown some theories areExact cause is unknown some theories are:
DAMAGE TO ENDOTHELIAL CELLS
DEFICIENCY OF (ENDOTHELIAL DERIVED RELAXING FACTOR)
PLATELET AGGREGATION
VASOSPASM
HYPERTENSION
NORMAL PREGNANCYNORMAL PREGNANCY
VasodilatationVasodilatation
Uteroplacental blood flowUteroplacental blood flow
Platelet aggregationPlatelet aggregation
ThromboxaneThromboxane
ThromboxaneThromboxaneProstacylinProstacylin
VasodilatationVasodilatation
Uteroplacental blood flowUteroplacental blood flow
Platelet aggregationPlatelet aggregation
PRE -ECLAMPSIA
Prostacyclin
PLATELET AGGREGATION SENSITIVITY TO PRESSOR AGENTS
UTEROPLACENTAL CIRCULATION
HAEMATOLOGICAL SYSTEM
LIVER KIDNEYS LUNGS BRAIN
IUGR FETAL DISTRESS
IUD
H. ANAEMIA THROMBOCYTOPENIA
HEPATOCELLULAR DAMAGE
PROTEINURIA PERFUSION ABNORMALITIES
FITS I.C.H
BLINDNES
PROSTACYCLIN DEFICIENCY
THROMBOTIC THROMBOCYTOPENIC PURPURA
ACUTE FATTY LIVER LIVER RUPTURE
RENAL FAILURE
PRE DISPOSING FACTORS• Age 20 yrs in primi > 30 yrs in all.• Race• Climate• Diet• Social status• Multiparty• Multiple gestation• Molar pregnancy• Pre existing hypertension• Previous h/o preclampsia, eclampsia• Family history of PIH• Diabetes mellitus • Non immune hydrops• Anti phospholipid antibody syndrome•
Collagen disease
FOETALFOETAL1.1. Intra uterine growth retardationIntra uterine growth retardation2.2. Intra uterine deathIntra uterine death3.3. PrematurityPrematurity4.4. Intrapartum foetal distress or still birthIntrapartum foetal distress or still birth
MATERNALMATERNAL 1.1. EclampsiaEclampsia2.2. Abruptio placentaeAbruptio placentae3.3. D.I.C D.I.C 4.4. Retinal complications Retinal complications 5.5. Renal failureRenal failure6.6. Liver failureLiver failure7.7. Hypertensive encephalopathyHypertensive encephalopathy
FOETALFOETAL1.1. Intra uterine growth retardationIntra uterine growth retardation2.2. Intra uterine deathIntra uterine death3.3. PrematurityPrematurity4.4. Intrapartum foetal distress or still birthIntrapartum foetal distress or still birth
MATERNALMATERNAL 1.1. EclampsiaEclampsia2.2. Abruptio placentaeAbruptio placentae3.3. D.I.C D.I.C 4.4. Retinal complications Retinal complications 5.5. Renal failureRenal failure6.6. Liver failureLiver failure7.7. Hypertensive encephalopathyHypertensive encephalopathy
COMPLICATIONS
MILD DBP OF < 160/110 No Proteinuria MODERATE
BP OF > 160/110 + Proteinuria SEVERE
1. BP OF > 160/110 mm Hg2. Proteinuria - 5 G IN 24 hoursor 3 – 4 + on Dipstick3. Oliguria < 500 mls in 24 hours
4. Cerebral & visual disturbances5. Epigastric pain 6. Thrombocytopenia7. Pulmonary oedema 8. Jaundice
TYPES OF P.I.H
LABORATORY FINDINGS
* Haemoglobin and heamatocrit high
Fibrin split products high
Serum uric acid high
Serum creatinine high
Alkaline phosphatase high
Lactate dehydrogenase high
Platelet count low
HELLP SYNDROME
H - Haemolytic anaemia El - Elevated liver enzymes LP - Low platelets
HELLP SYNDROME
H - Haemolytic anaemia El - Elevated liver enzymes LP - Low platelets
MANAGEMENT
Prevention
1. Low dose aspirin It inhibits platelet cyclooxygenase And blocks synthesis of thromboxane
2. Nutritional supplements
3. Oral calcium
4. Fish oils
5. Dipyridamole
6. Antihypertensive drugs
MANAGEMENT
Prevention
1. Low dose aspirin It inhibits platelet cyclooxygenase And blocks synthesis of thromboxane
2. Nutritional supplements
3. Oral calcium
4. Fish oils
5. Dipyridamole
6. Antihypertensive drugs
MANAGEMENT
Delivery is the only available cure for PIH Aim of management is to determine
the optimum time of delivery
MILD PREECLAMPSIA LESS THAN 37 WKS.
Bed rest in left lateral position
Increases venous return to heart cardiac output uterine and kidney perfusion
B.P. Monitoring
Urine check BD for proteinuria
Daily weight
LFTs, uric acid, electrolytes and Serum albumin weekly
Coagulation profile
Anti hypertensives when DBP-100 mm Hg
After initial hospitalization review in
OPD weekly.
FETAL SURVEILLANCE
1) Detailed USG to rule out multiple pregnancy, hydrops and
H. Mole.
2) Non-stress test (twice weekly)
3) Contraction stress test (weekly)
4) Biophysical profile (weekly)
5) Growth scan (10-14 day)
6) Doppler flow studies
HOSPITALIZATION IF:
(1) Progression of the disease (2) NST is non reactive (3) Oligohydramnios (4) I.U.G.R.
SEVERE PRE ECLAMPSIA
Principle of Treatment
1. Prevent convulsions
2. Control maternal blood pressure
3. Prevent complications
4. Deliver a surviving neonate
to a surviving mother
PREVENTION OF CONVULSIONS
1. Magnesium sulphate
2 – 4 g in 10% d. Solution I.V. Stat followed by 1.5 to 2 g/hour.
10 g in 50% solution – 2 doses of 5 g each injected deep in each
buttock followd by 5 g IM every 4 hours.
2. Diazepam
Respitry depression, hypotonia, hypothermia, hyperbilirubinaemia
3. Lytic cocktail
4. Thiopentone sodium
CONTROL OF HYPERTENSION
1. Hydralazine – direct arterialvasodilator. Increases cardiac output and renal and uterine perfusion
* 20 mgs in 250 ml D/W iv slowly * 5 mgs iv Stat. If no fall in BP the dose is increased in 5 mg
increments (10, 15, 20)
2. Methyldopa – 250mg 2stat. 3. Labetalol – 20 – 80 boluses. 4. Calcium channel blockers 5. Tridil (5, 25 mg), Isokit (10 mg).
INDICATIONS FOR DELIVERY
MATERNAL - HELLP SYNDROME - DIC - ECLAMPSIA - ABRUPTIO PLACENTAE - PROM - WARNING SYMPTOMS
e-g HEADCHE, BLURRING OF VISION, EPIGASTRIC PAIN, HYPERREFLEXIA
FETAL - FETAL DISTRESS
- OLIGOHYDRAMNIOS - IUGR - POSTIVE CST - BPS < 6
MODE OF DELIVERY
ELECTIVE C. SECTION
1. Cervix is not effaced and os is closed 2. CPD 3. Maturity less than 34 weeks 4. Severe placental insufficiency.
LABOUR INDUCED BY
Prostin E2 pessary
Misoprostol
Forewater amniotomy
Syntocinon infusion
Careful intrapartum fetal and maternal monitoring.
Second stage shortened by ventouse or forceps
ECLAMPSIA
FROM GREEK WORD ‘LIKE A FLASH OF LIGHTENING’
20% Without warning symptom 80% Follow severe Pre–eclampsia
Antepartum ______ 50 % Intra partum ______ 30 % Post partum ______ 20 %
Fits 07 days after delivery is not due to
Eclmpsia
THE SEIZURES OCCUR IN FOUR STAGES
STAGE I - PREMONITORY - 20 –30 SECONDS
STAGE II - TONIC - 30 – 60 SECONDS
STAGE III - CLONIC - 60 – 90 SECONDS
STAGE IV - COMA - MIN TO HOURS
D/D OF ECLAMPSIA
Epilepsy
Cerebral Malaria
Meningitis
Tetanus
Septicaemia
Brain Abscess & Tumours
Hypoglycemia
MANAGEMENT
AIM IS TO :
(1) TREAT CONVULSIONS AND PREVENT
FURTHER FITS
(2) CONTROL BLOOD PRESSURE
(3) PREVENT COMPLICATIONS
(4) DELIVERR FETUS
(5)
MANAGEMENT
GENERAL MEDICAL OBSTETRIC STETRIC MANAGEMENT
top related