12/12/1431

Clinical Features
Forty

years old female , no past Hx of

HTN BP 160 160/ /110 34 weeks pregnant Twin pregnancy Serum Creatinin 1.9 mg /dl

Case presentation A Hypertensive Pregnant Woman

Dr Hisham AboulAboul-Enein Prof. Of Cardiology Benha Faculty of Medicine

CLASSIFICATION

(A)Pregnancy Induced Hypertension PIH

PERGNANCY HTN Definitions

Hypertension without Proteinuria or pathologic edema (gestational ) Preeclampsia p with Proteinuria or p pathologic g edema

Pregnant women with elevated systolic (>140 (>140 mm Hg) and diastolic (>90 (>90 mm Hg) blood pressure on at least two occasions 6 hrs apart. HYPERTENSION complicates 8-10% 10% of all pregnancies, generally after 20 weeks of gestation .

Mild Severe

Eclampsia HELLP Syndrome (Hemolysis , thromobtic tendency , and hepatic affection )

Question # 1
Which

CLASSIFICATION

Type of hypertension , is most

likely ? 1. Coincidental hypertension. 2. Gestational G i l

3.

(B) Coincidental Hypertension

Chronic Hypertension in Pregnancy Pregnancy Aggravated Chronic Hypertension

Superimposed preeclampsia Superimposed Eclampsia

Preeclampsia or eclampsia ?

12/12/1431

Pathophysiology

Risk Factors for preeclampsia

Decreased Intravascular volume Increased Vascular Resistance Endothelial Cell dysfunction Edema , Proteinuria Coagulation abnormalities Multiple system effects by oxygen free radicals

Perfusion and rere-perfusion injury Lipid peroxidation

Trophoblastic Invasion

Two phases

First :Decidua Second: blood vessels 1212-18 weeks gestation

Effects of PIH are reversed with Trophoblast delivery

Primigravid or new paternity Family History of preeclampsia ( (25 25%) %) Diabetes Mellitus Multiple Gestation Obesity Maternal age > >40 40 years Preexisting Hypertension Angiotensin gene T 235 Antiphospholipid Syndrome Hydatiform mole Fetal hydrops

General Signs

Symptoms
preeclampsia

Excessive weight gain Hyperreflexia and clonus Blood Pressure

Onset after 20 weeks gestation Hand and face edema

Least reliable PIH indicator Absent in 33 33% % of PIH cases Often present in healthy third trimester pregnancies

Assumes normal Blood Pressure before pregnancy Based on two supine Blood Pressures, Pressures, 6 hours apart Mild Preeclampsia

Blood Pressure exceeds 140/ 140/90

Use 140/ 140/90 cutoff for all pregnant patients

Severe Preeclampsia

Blood Pressure exceeds 160/ 160/110

Headache Visual disturbance Epigastric Pain

Question # 1
Which

Signs: Severe Preeclampsia

Type of hypertension , is most

likely ? 1. Coincidental hypertension. 2. Gestational G i l

3.

Blood Pressure exceeds 160/ 160/110 Proteinuria > 5 grams per 24 hours Urine Output decreased

Urine output less than 500 ml in 24 hours

Preeclampsia ?

Increased Serum Creatinine Thrombocytopenia Pulmonary edema

12/12/1431

Question No 2

Answer

Which of these investigations you would like to do to confirm diagnosis and assess severity
1)CBC 3) 24 hrs urine protein 5)Serum creatinine 2 ) Serum ALT and AST 4) Urine analysis

No past Hx of Htn ( not coincidental). Risk factors ( twin pregnancy in 40 years old female). Th presence of The f elevated l d serum creatinine i i Correct answer is : No 3 most likely ( preeclampsia ).

1,3,5 All of the Above

Answer 2

2) ALL OF THE ABOVE

Creatinine > 0.9 mg /dl indicates severe preeclampsia

Question no 3
Should this patient be managed as A ) As an outpatient? B) As an inpatient emergency ?

Lab Findings
Platelet count is 90 000 X 109 109/L /L 24 hours urinary execration is 6 gms ALT and AST are normal Serum uric Acid was elevated. Serum creatinine is 1.9 mg /dl as discussed

This is a case of severe eclampsia

12/12/1431

SEVERE PREECLAMPSIA
Protocol: Initial program (Titrate to Diastolic Blood Pressure <100 mmHg)

Labetolol : Safe and offers benefits over Hydralazine

Lower Incidence of maternal hypotension Lower Incidence of cesarean delivery Start: 20 mg IV bolus every 1010-20 minutes prn Switch to other drug if no effect with 220 mg total Oral dosing is safe and effective

Management

Coincidental HTN Mild Preeclampsia Severe Preeclampsia

(hospitalized)

be dosed up to a very high maximum (2400 (2400 mg/day) Contraindications Avoid in Asthma Avoid in Congestive Heart Failure

May

Management: Maintenance medications (titrate to keep Diastolic BP < <100 100) )

SEVERE PREECLAMPSIA

Nifedipine XL) Procardia XL

Methyldopa 250 250-500 mg PO bid bid-qid Atenolol 50- 100 mg PO qd Metoprolol 25- 100 mg PO bid Labetalol 100 100-400 mg PO bid Hydralazine 50-10 mg PO qid Nif di i Nifedipine 3030 -120 mg /day /d

More rapid control of Hypertension than Labetolol Avoid short short-acting Nifedipine as well as other Calcium Channel Blockers Blockers Start: 10 mg PO every 2020-30 minutes prn

Hydralazine) Was considered drug of choice due to 30 years of PIH use

Now considered third line (after Labetolol and Nifedipine (due to adverse effects Fetal Tachycardia Maternal Headache or Palpitation Palpitations s

Precautions
Avoid contraindicated antihypertensives Avoid ACE Inhibitors Inhibitors and ARBs (due to neonatal Renal Failure , ic ,IUGR Teratogenic Teratogen Avoid Atenolol) due to IUGR Avoid Thiazide Diuretics Diuretics , maternal fluid depletion

Adverse effects

Start: 5 mg IV or 10 mg IM every 20 minutes prn Maintenance: 5 mg IV or 10 mg IM every 3 hours prn Switch to another agent if no success

After 20 mg IV total or After 30 mg IM total

Management: Seizure Anticonvulsant Medications

Indications for premature delivery

Maternal Indications for delivery

Magnesium Sulfate) if not already started

Loading dose: 6 grams IV over 1515-20 minutes Maintenance: 2 grams per hour C id rebolus Consider b l of f 2 grams if Seizure S i recurs Obtain Serum Magnesium level at 4 hours

Platelet Count under 100, 100,000 Progressive liver function deterioration Progressive Renal Function deterioration Suspected Abruptio Placenta Refractory severe Hypertension) >160 / 110 Persistant severe Headache or visual changes Persistant severe Epigastric Pain or Emesis

Fetal Indications for Delivery

Anticonvulsant not recommended routinely in Eclampsia

Magnesium Sulfate best option for Seizure control Consider anticonvulsant if Seizure prolonged

Severe fetal Intrauterine Growth Retardation Low umbilical artery systolic/diastolic ratio by Doppler ultrasound (Uteroplacental insufficiency) NonNon -reassuring fetal testing Oligohydramnios

12/12/1431

Course: Postpartum

Complications
Maternal mortality Mortality in U.S.: 0.4% of Eclampsia cases Mortality in Mexico: 14 14% % of ecamplsia cases

Most PIH cases improve in first 1-2 days after delivery

Blood Pressure decreases Diuresis Consider continuing Magnesium Sulfate for 24 hours Continue to follow Blood Pressure and urine output Observe for signs of HELLP Syndrome

Eclampsia may occur after delivery (usually < <24 24 hours

Hypertension remits by 6-12 weeks postpartum

Abruptio Placenta 5.5 5 5 :to 23 23% % of Eclampsia cases Fetal anoxia with severe neurologic deficits: 7%

Conclusios
HYPERTENSION complicates 8-10% 10% of all pregnancies, generally after 20 weeks of gestation. The condition may be complicated by prepre-eclampsia or HELLP syndrome y , and it accounts for 1010-30% 30% of all maternal deaths yearly . Close monitoring of the mother and fetus is needed and cooperation between Ob Gyn and cardiologist is warranted . Antihypertensive treatment is indicated in severe cases of chronic HTN or pre pre-ecalmpsia and termination of pregnancy may be indicated if there are threats to the mother or fetus .

Prognosis
preeclampsia risks outside of pregnancy
Confers future risk of Hypertension ,vascular disease

Increased risk of preeclampsia in future pregnancies