hypertension in pregnancy tony nicoll consultant obstetrician ninewells hospital
TRANSCRIPT
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Hypertension in Pregnancy
Tony Nicoll
Consultant Obstetrician
Ninewells Hospital
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Outline
• Objectives• Physiology• Classification• Pre-eclampsia• Pathogenesis • Management• Eclampsia• Conclusions
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Objectives
• Understand the processes involved in antenatal care, surveillance in pregnancy, and the roles of the professionals involved (Outcomes 1-11)
• Demonstrate a knowledge of the common problems encountered in obstetric practice (Outcomes 3,4,5,8)
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Hypertension in Pregnancy• Hypertension affects 10-15% of all pregnancies
• Mild pre-eclampsia affects 10% of primigravid women
• Severe pre-eclampsia affects 1% of primigravid women
• Eclampsia affects 1/2000 pregnancies
• Death from eclampsia = 2%
• Pre-eclampsia is the commonest cause of iatrogenic
prematurity
• Up to 25% of antenatal admissions are due to hypertension
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Blood Pressure in Pregnancy
• Blood pressure (BP) proportional to systemic vascular resistance and cardiac output
• Pregnancy Vasodilatation• BP falls in early pregnancy• Nadir reached at 22-24 weeks• Steady rise until Term• BP falls after delivery but subsequently rises and
peaks at day 3-4 P/N
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Hypertension
• ≥140/90 mmHg on 2 occasions
• DBP >110 mmHg
• ACOG - >30/15 mmHg compared to booking BP
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Hypertension in Pregnancy
• Pre-existing hypertension
• Pregnancy Induced Hypertension (PIH)
• Pre-eclampsia
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Pre-existing Hypertension
• Diagnosis prior to pregnancy• Likely if hypertension in early pregnancy
(PET / PIH diseases of second half of pregnancy)• May be retrospective diagnosis if BP has not
returned to normal within 3 months of delivery• Consider secondary causes - renal / cardiac,
Cushing’s, Conn’s, Phaeochromocytoma• Risks include PET (X2), IUGR and abruption
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PIH
• Second half of pregnancy
• Resolves within 6/52 of delivery
• No proteinuria or other features of pre-eclampsia
• Better outcomes than pre-eclampsia
• 15% progression to pre-eclampsia - depends on
gestation
• Rate of recurrence is high
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Pre-eclampsia
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Pre-eclampsia
• Hypertension
• Proteinuria (≥0.3g/l or ≥0.3g/24h)
• Oedema
• Absence does not exclude the diagnosis
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Pre-eclampsia• A pregnancy-specific multi-system disorder with
unpredictable, variable and widespread
manifestations
• May be asymptomatic at time of first presentation
• Diffuse vascular endothelial dysfunction widespread
circulatory disturbance
• Renal / Hepatic / Cardiovascular / Haematology /
CNS / Placenta
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Pathogenesis
• Genetic predisposition
• Stage 1 - abnormal placental perfusion
• Stage 2 - maternal syndrome
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Pathogenesis• Abnormal placentation and trophoblast invasion failure
of normal vascular remodelling • Spiral arteries fail to adapt to become high capacitance, low
resistance vessels• Placental ischaemia widespread endothelial damage
and dysfunction• Mechanism unclear (??oxidative stress / PGI2 : TXA2
imbalance / NO)• Endothelial Activation
Capillary Permeability Expression of CAM Prothrombotic Factors Platelet aggregration• Vasoconstriction
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Normal Placentation
Pre-eclampsia
Non- Pregnant
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A Multi-system Disorder
• CNS
• Renal
• Hepatic
• Haematological
• Pulmonary
• Cardiovascular
• Placental
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CNS Disease
• Eclampsia
• Hypertensive encephalopathy
• Intracranial haemorrhage
• Cerebral Oedema
• Cortical Blindness
• Cranial Nerve Palsy
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Renal disease
GFR• Proteinuria serum uric acid (also placental ischaemia) creatinine / potassium / urea• Oliguria /anuria• Acute renal failure
• acute tubular necrosis• renal cortical necrosis
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Liver Disease
• Epigastric/ RUQ pain• Abnormal liver enzymes• Hepatic capsule rupture
• HELLP SyndromeHaemolysis, Elevated Liver Enzymes, Low Platelets
• high morbidity/ mortality
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Haematological Disease
Plasma Volume• Haemo-concentration• Thrombocytopenia• Haemolysis• Disseminated Intravascular Coagulation
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Cardiac / Pulmonary Disease
• Pulmonary oedema ARDS• iatrogenic• disorder related
• Pulmonary Embolus
• High mortality
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Placental Disease
• Intrauterine growth restriction (IUGR)
• Placental Abruption
• Intrauterine Death
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Symptoms
• Headache • Visual disturbance• Epigastric / RUQ pain• Nausea / vomiting• Rapidly progressive oedema
• Considerable variation in timing, progression and order of symptoms
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Signs
• Hypertension• Proteinuria• Oedema• Abdominal tenderness• Disorientation• SGA• IUD• Hyper-reflexia / involuntary movements / clonus
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Investigations• Urea & Electrolytes
• Serum Urate
• Liver Function Tests
• Full Blood Count
• Coagulation Screen
• CTG
• Ultrasound - biometry, AFI, Doppler
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Management• Assess risk at booking
• Hypertension < 20 weeks - look for secondary
cause
• Antenatal screening - BP, urine, MUAD
• Treat hypertension
• Maternal & fetal surveillance
• Timing of Delivery
• PIH can be managed as O/P in Day Care Unit
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Risk Factors
• Maternal Age (>40 years 2X)• Maternal BMI (>30 2X) • Family History (20-25% if mother affected, up to
40% if sister)• Parity (first pregnancy 2-3X)• Multiple pregnancy (Twins 2X)• Previous PET (7X)• Molar Pregnancy / Triploidy
• Multiparous women develop more severe disease
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Medical Risk Factors
• Pre-existing renal disease
• Pre-existing hypertension
• Diabetes Mellitus
• Connective Tissue Disease
• Thrombophilias (congenital / acquired)
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Predicting Pre-eclampsia
Normal MUAD
Notch
Maternal Uterine Artery Doppler
20 - 24 weeks
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Antenatal Screening• When to refer to AN DCU?
BP 140/90
(++) proteinuria
oedema
symptoms - esp persistent headache
• For every 1000 “Low-risk” patients:
100 hypertensive
60 normal - 20 will return
20 DCU follow up - 10 admitted
20 admitted
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When to admit?1. BP >170/110 OR >140/90 with (++) proteinuria
2. Significant symptoms - headache / visual disturbance / abdominal pain
3. Abnormal biochemistry
4. Significant proteinuria - >300mg / 24h
5. Need for antihypertensive therapy
6. Signs of fetal compromise
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Inpatient Assessment
• Blood Pressure - 4 hourly
• Urinalysis - daily
• Input / output fluid balance chart
• 24 hour urine collection - if proteinuria on urinalysis
• Bloods - FBC, U&Es, Urate, LFTs. Minimum X2 per week
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Fetal Surveillance
• Fetal Movements
• CTG - daily
• Ultrasound
Biometry
Amniotic Fluid Index
Umbilical Artery Doppler
Normal
AEDF
REDF
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Treatment of Hypertension
• Treat regardless of aetiology
• With MAP ≥150 mmHg there is significant risk of cerebral
haemorrhage
• Most treat if BP ≥150/100 mmHg
• BP ≥ 170/110 mmHg requires immediate Rx
• Aim for 140-150/90-100 mmHg
• Control of blood pressure does not reduce the risk of
developing pre-eclampsia
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Treatment of HypertensionMode of Action
Starting Dose
Maximum Dose
Contra-
indicationsBreast
Feeding
Methyl Dopa
Centrally acting agonist
250mg bd 1 gram tds Depression Yes
Labetolol +
antagonist100mg bd 600mg qid Asthma Yes
Nifedipine SR
Ca channel antagonist
10mg bd 40mg bd Yes
Hydralazine Vasodilator 25mg tds 75mg qid Yes
(Avoid Diuretics / ACE Inhibitors)
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When to Deliver?
• The only cure for pre-eclampsia is delivery
• Mother must be stablised before delivery
• Consider expectant management if pre-term
• Most women delivered within 2 weeks of
diagnosis
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Indications for Delivery
• Term gestation
• Inability to control BP
• Rapidly deteriorating biochemistry / haematology
• Eclampsia
• Other Crisis
• Fetal Compromise - REDF, abnormal CTG
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Crises in Pre-eclampsia
• Eclampsia• HELLP syndrome• Pulmonary Oedema• Placental Abruption• Cerebral Haemorrhage• Cortical Blindness• DIC• Acute Renal Failure• Hepatic Rupture
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Steroids• Promote fetal lung surfactant production• ↓ neonatal respiratory distress syndrome (RDS)
by up to 50% if administered 24-48h before delivery
• Administer up to 36 weeks• Only significant effects up to 34 weeks. Proven
benefit up to 1 week• Betamethasone preferred to Dexamethasone
• 1 course = 12mg Betamethasone IM X2 injections 24 hours apart
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Eclampsia
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Eclampsia
• Tonic-clonic (grand mal) seizure occuring with features of pre-eclampsia
• >1/3 will have seizure before onset of hypertension / proteinuria
• Ante-partum (38%) / Intra-partum (16%) / post-partum (44%)
• More common in teenagers• Associated with ischaemia / vasospasm
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Management of Severe PET / Eclampsia
• Control BP
• Stop / Prevent Seizures
• Fluid Balance
• Delivery
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Antihypertensives
• IV Labetolol
• IV Hydralazine
• Beware hypotension – fetoplacental unit
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Seizure Treatment / ProphylaxisMAGNESIUM SULPHATE
Loading dose: 4g IV over 5 minutes
Maintenance dose: IV infusion 1g/h
If further seizures administer 2g Mg SO4
If persistent seizures consider diazepam 10mg IV
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Fluid Balance
• Main cause of death = pulmonary oedema(Capillary leak / fluid overload / cardiac failure)
• Oliguria in 30%. Does not require intervention
• Any doubts about renal function urine osmolality
• Fluid challenges are potentially dangerous
• Safer to run a patient “dry” - 80 ml/h
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Labour and Delivery
• Aim for vaginal delivery if possible• Control BP• Epidural anaesthesia• Continuous electronic fetal monitoring• Avoid ergometrine• Caution with iv fluids
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Postpartum Management
• Breast feeding• Contraception• BP management• Counselling• Future risk
– Depends on other medical factors– Gestation dependent (28/40 - 40%, 32/40 - 30%)
• Long term CVD risk
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Low Dose Aspirin
• Aspirin - inhibits cyclo-oxygenase prevents TXA2 synthesis
• 75mg Aspirin 15% reduction in PET (NNT=90)• May be more beneficial in preventing severe early onset
pre-eclampsia (MRC CLASP Trial)• Safe• Used for high risk women - Renal, DM, APS, Multiple
risk factors, previous PET• Commence before 12 weeks
NICE Aug 2010
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Calcium, Antioxidants & Folic Acid
• Calcium supplementation (>1gram / day) may reduce risk of hypertension (30%), PET (52%) and maternal death (20%). Did not affect pre-term birth or stillbirth (Hofmeyr et al Cochrane Database 2006)
• Antioxidants not effective (Poston et al. VIP Study, Lancet 2006)
• Mid trimester folic acid also appears to be effective in preventing pre-eclampsia (73% reduction) (Wen et al AJOG 2008)
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Conclusions• Hypertension in pregnancy is common
• Pre-eclampsia is a multi-system disorder with unpredictable and variable manifestations
• Pathogenesis involves abnormal placentation and widespread endothelial dysfunction
• Supportive management requires maternal and fetal surveillance
• No cure other than delivery
• Maternal risks balanced against risks of prematurity