hypertensive disorders of pregnancy

Ri 簡睦旼2012/5/3

Classification

Pregnancy-induced hypertension (Gestational hypertension)5-10%

Preeclampsia3.9% Eclampsia Preeclampsia superimposed on chronic

hypertension Chronic hypertension

William’s Obstertrics, 23ed

SBP≥140or

DBP ≥ 90

> GA 20th wk< PP 12th wk

Gestational HTN

Pre-Eclampsia

Proteinuria Generalized seizures

≥ 0.3 g/ 24hr >30 mg/dL

(1+ on dipstick)

before , during or after labor

Eclampsia

Superimposed Preeclampsia

Severe Preeclampsia

HELLP syndrome

Preeclampsia

2~7% of healthy nulliparous; 0.8~5% of multiparous women

The third leading cause of maternal mortality (17%)

A major cause of neonatal morbidity and mortality (intrauterine growth restriction, abruptio placentae and the need for preterm delivery)

DeadlyTriad

Hemorrhage Infection

Preeclampsia

Severe preeclampsia

BP 160/110 mm Hg Proteinuria 2.0 g/24 hours or 2+ dipstick Increase severity /certainty

Serum creatinine >1.2 mg/dL unless known to be previously elevated

Platelets < 100,000/L Microangiopathic hemolysis—increased LDH Elevated serum transaminase levels—ALT or AST Persistent headache or other cerebral or visual

disturbance Persistent epigastric pain

ProteinuriaSBP≥140

orDBP ≥ 90

< GA 20th wk> PP 12th wk

Chronic HTN

Superimposed Preeclampsia

> 20th GA wk

HTN + PTuria b4 20wk↑proteinuria or↑BP orPLT < 100,000/L

Risk factors

Nulliparity Age >35 years (superimposed) or teenager Obesity Multifetal gestation Medical illness: Chronic hypertension, lupus

erythematosus, IDDM, APS, PT C/S deficiency, renal disease

Genetic: Hx / FH of previous preeclampsia or eclampsia

Hydatidiform moles Smoking, placenta previa

Stage 1Poor

Placentation

Stage 2Placental oxidative

stress

Cytokines

Antiangiogenic peptides

sFlt-1,sEng

Vasoconstriction

Endothelial damage

↓NO, PGE2, PGI2, PlGF, VEGF ↑TXA2, Endothelin

Endothelial integrity ↓

HELLP

MAHA

Vasoconstriction Endothelial damage

Endothelial integrity ↓

Principle of management

Difinitive treatment is delivery BP control Seizure prophylaxis

Evaluation of a new-onset HTN Clinical findings:

headache, visual disturbance, epigastric pain, rapid weight gain…

Measure BW QD Analysis for proteinuria on admission

and QOD BP measurement Q4H CRE, AST/ALT, CBC (for PLT). UA? LDH?

Coagulation profile? Sonography: fetal size, amnionic fluid


Management of HTN disorder Dietary Lifestyle Place of care Antihypertensive therapy Corticosteroids Mode of delivery

Management of HTN disorder Dietary

Salt restriction is not recommended Insufficient evidence to make

recommendation Lifestyle

Avoid vigorous exercise Bed rest?

Place of care Severe hypertension or preeclampsia

(BP>160/110)should be hospitalizedLaura Magee et al, 2008, JOGC

Management of HTN disorder Antihypertensive therapy

For severe hypertension (BP>160/110) BP goal: <160/110 Initial antihypertensive: labetalol,

nifedipine hydralazine. MgSO 4 is not recommended as

antihypertensive(only transient decrease in 30 mins)

Continuous FHR monitoring is advised until BP is stable.

Laura Magee et al, 2008, JOGC

Management of HTN disorder Antihypertensive therapy

Non-severe hypertension (BP:140-159/90-109 mmHg) BP goal: w/o cormorbid - 130-155/80-105

w/ cormorbid – 130-139/80-89 Drug of choice: methyldopa, labetalol,

other beta-blockers, CCB (nifedipine). (I-A) ACEi and ARBs should not beused. (II-2E) Atenolol and prazosin are not recommended.


Management of HTN disorder Mode of delivery

Induction of labour Vaginal delivery, unless C/S is indicated Oxytocin at 3rd stage of labor, esp.

thrombocytopenia or coagulopathy Ergometrine should not be given


Management of HTN disorder Corticosteroids

To accelerate fetal pulmonary maturity Pre-eclampsia & GA < 34 wks Gestational HTN & GA < 34 wks, about

to deliver within next 7 days


Management of Pre-eclampsia Delivery is the only cure Timing of delivery MgSO4 Plasma volume expansion


Management of Pre-eclampsia Timing of delivery

GA < 34 wks: expectant management GA: 34-36 wks, non-severe pre-

eclampsia: debated GA > 37 wks: immediate delivery


Management of Pre-eclampsia MgSO4

First-line Tx for eclampsia Prophylaxis against eclampsia in severe-

preeclampsia Phenytoin and BZD should not be used

for eclampsia prophylaxis, unless MgSO4 is contraindicated or ineffective

Plasma volume expansion Not recommended


Management for HELLP syndrome PLT count > 50x109 /L

Prophylactic transfusion of platelets is not recommended

Consider ordering blood when PLT drop rapidly

PLT count < 20 x 109 /L. Platelet transfusion prior to vaginal delivery or

C/S) Corticosteriods may be considered for

PLT count < 50x109 /L Plasma exchange or plasmapheresis?


Postpartum treatment

BP follow-up Peak postpartum, D3, D6

Antihypertensive therapy may be restart, BP goal <160/110 mmHg Acceptable in breastfeeding: Nifedipine,

labetalol, methyldopa, captopril, enalapril NSAID should be avoid if hypertension is

difficult to control, or oliguria, CRE ↑, PLT↓

Thromboporphylaxis may be consideredLaura Magee et al, 2008, JOGC

hypertensive disorders of pregnancy

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