Download HYPERTENSION IN PREGNANCY

Neil Vanes,
Obstetric and Gynaecology
UHCW
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Pre-eclampsia
Eclampsia
Pregnancy-Induced (Gestational)
Hypertension
Essential Hypertension
Raised BP in pregnancy
> or = 140/90
Pregnancy induced hypertension
(Raised BP after 20 weeks)
No proteinuria PIH
Mild and moderate PET
PET/Eclampsia
Chronic hypertension
(Raised BP before 20 weeks gestation)
Proteinuria and Raised BP
Pre -eclampsia
Severe PET
Eclampsia
HELLP
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Definition and symptoms PET
Prevention of PET
Who is at risk of PET
History, examination and investigation of
patients with suspected PET
Management of PET (mild and severe)
Prevention of fits
When to deliver
Postnatal care
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Hypertension and proteinuria with onset
≥20 weeks
 Oedema from classical definition dropped as not
discriminating clinically
 Onset <20 weeks ONLY seen in hydatidiform mole (triploid
pregnancy) –extremely rare
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Symptoms
– NOT necessary to diagnose PET
– Marker of more severe disease/progression towards
eclampsia
George Eliot Hospital, Nuneaton
PET/Eclampsia
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HYPERTENSION: Diastolic ≥90mmHg on 2
occasions 4-6 hours apart OR ≥110mmHg on
one occasion
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PROTEINURIA :
>300mg/24 hours
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Differentiation from PIH/renal disease
• 24 hour collection or (preferably) PCR (>30)
• Timing
• Other findings eg blood in urine, abnormal U+E
MILD
MODERATE
SEVERE
Systolic
140-149
150-159
 160
Diastolic
90-99
100-109
110
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10% women have hypertension
5% pregnancies have PET
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Rates eclampsia 26.8/100 000 maternities
(UKOSS reporting system 2003-5)
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Worldwide every year 1.5-8 million develop PET
with 150 000 deaths
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UK: 18 deaths (2006-8)
• 1-2% pregnancies have severe PET
• 9 cerebral haemorrhage/infarction
• 5 from hypoxic arrest after fit
• 7 were eclamptic, 8 had HELLP syndrome
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Maternal Risks
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DEATH
Blindness
Neurological sequelae (haemorrhage/infarction)
Fits (Eclampsia)
Renal impairment/failure
Hepatic failure/rupture
Abruption
DIC
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Fetal Risks
 Death
◦ Abruption-> hypoxia
◦ IUGR
◦ (onset PET <28 weeks->50% babies have IUGR)
◦ Hypoxia
◦ Prematurity (PET is cause of >40% iatrogenic preterm
dels)
 respiratory complications (RDS)
 neurodevelopmental complications (inc.learning
difficulty/IQ in up to 60%)
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Primiparous
First pregnancy with
new partner
Family history (1 in 3
risk if mother had
PET)
Twins/multiples
Pregestational
Diabetes
Previous PET (if
severe/ <28 weeks,
50% recurrence)
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Essential
hypertension
Renal disease
SLE
Antiphospholipid
syndrome
Thrombophilias
Age >40
Obesity
George Eliot Hospital, Nuneaton
PET/Eclampsia
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“The disease of theories”
Pregnancy specific syndrome
Placenta has a central role to play
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Reduced placental perfusion
Inadequate vascular remodelling at ~16 wks
Relative hypoperfusion
→Oxidative stress
→Widespread endothelial dysfunction
→Systemic disease
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Spectrum of same underlying placental
pathology
Usually coexist
PET
IUGR
HIGH RISK: women with
ANY of:
• hypertensive disease
during a previous
pregnancy
• chronic kidney disease
• autoimmune disease
such as systemic lupus
erythematosis or
antiphospholipid
syndrome
• type 1 or type 2
diabetes
• chronic hypertension.
MODERATE RISK: women
with >1 of:
• first pregnancy
• age 40 years or older
• pregnancy interval of
more than 10 years
• body mass index (BMI)
of 35 kg/m² or more at
first visit
• family history of preeclampsia
• multiple pregnancy.
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Evidence supports use of aspirin in women at
‘high’ or ‘moderate’ risk of developing PET
Use of 75mg per day aspirin from 12 weeks
to delivery
• No evidence of fetal harm at this dose
• No convincing evidence increased risk APH/PPH
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Clinical diagnosis
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Classic triad
◦ Hypertension 140/90
◦ Proteinuria >300mg in 24 hours (RCOG)
◦ Oedema (least reliable)
◦ BUT....
◦ Proteinuria and raised BP x 2 occasions 6 hrs
apart (or once if DBP ≥110 and heavy proteinuria
>2+ (=1g/24h))
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Mild hypertension
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Mild proteinuria
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>20 weeks pregnant
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Mild pre-eclampsia
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Headache (classically severe)
– Effects hypertension
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Visual disturbances (‘flashing lights’)
– Sign of cerebral vasospasm/impending eclampsia
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Epigastric pain
– Hepatic congestion/liver capsule stretching
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Is baby moving normally?
– Fetal wellbeing
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BLOOD:
FBCplatelet count
– Platelets <100 indicate progressive/worsening disease
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U+E
Urate
signs renal dysfunction (late)
hyperuricaemia
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LFTs
elevated transaminases
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Clotting X (not routinely if plts>100)
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– ( early, doesn’t predict outcomes well )
– Can indicate worsening of disease
URINARY:
MSU
to exclude UTI as cause of protein
PCR
quantify proteinuria
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Fetal assessment
– Clinical
– USS for growth
– CTGs
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?cervical assessment –vaginal examination
• (depending on gestation)
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Classically asymptomatic
BP 140/90 (ish)-mild hypertension
Maybe trace-+ proteinuria
Often incidental finding at CMW clinic
attendance
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Monitor BP
– CMW
– Day assessment or Triage Unit (outpatient Mx)
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Monitor bloods
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Monitor fetus
– Weekly or twice weekly (depends on sitn)
– CTG
– Serial USS
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Deliver when
– BP/protein or clinical condition deteriorates so
become moderate or severe PET
– Reaches 41 weeks and no change in condition
– Fetal condition mandates delivery even if maternal
condition stable
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Classically asymptomatic
◦ May have odd headache or occ visual disturbances
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BP 150/100 (ish)-moderate hypertension
Usually + - ++proteinuria
Often incidental finding at CMW clinic
attendance
◦ May present with headaches
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Monitor BP
– Admit initially-4 hourly BP
– Consider antihypertensives if <36 weeks to prolong
pregnancy
– If 36 weeks or greater ?delivery
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Monitor bloods
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Monitor fetus
– Check on admission
– Check 2-3x weekly (if wish to prolong pregnancy)
– CTG
– Serial USS (with LV/Dopplers)
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Deliver when
– Reaches 36-37 weeks or diagnosis after this
gestation
– Fetal condition mandates delivery even if maternal
condition stable and below this gestation
George Eliot Hospital, Nuneaton
PET/Eclampsia
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SYSTOLIC 160-180+
DIASTOLIC >110
◦ =Severe hypertension
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HEAVY PROTEINURIA
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May present unwell or asymptomatic
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Headache (BP)
Flashing lights (lightning) (cerebral oedema)
Epigastric pain (stretching of liver capsule)
Oedema (albumin/BP)
Less common:
• blindness, scotoma, oliguria, SOB
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Asymptomatic
George Eliot Hospital, Nuneaton
PET/Eclampsia
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CNS
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Disorientation/ irritability
Hyperreflexia
FITS
Clonus
Blindness
Scotoma
Papilloedema
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◦ Elevated creatnine,
urea, urate
◦ Oliguria
◦ Heavy proteinuria >5g
in 24 hrs
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Hepatic
◦ Abnormal LFTs/dysfunction
◦ Epigastric pain/tenderness
Haemtological
◦ Thrombocytopaenia
◦ Haemolysis
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Renal
Pulmonary
◦ Shortness of
breath
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Immediate admission to hospital
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High dependency care/LW-QUIET
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Senior multidisciplinary involvement early-
– Invasive monitoring (arterial line +/- CVP)
– NICU for baby if early gestation
obs and anaesthetics
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Aims
1. Prevent seizures
2. Control hypertension (to prevent cerebral
haemorrhage)
3. Deliver safely (stabilise, +/- IUT, +/- steroids)
George Eliot Hospital, Nuneaton
PET/Eclampsia
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BP- every 15 minutes [MEOWS]
Urine output-hourly
Urinary protein dipstix
Strict fluid balance chart
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Bloods
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• Restrict 60-80ml/hr
– U+E, urea, creatnine, urate
– FBC esp. platelets (G+S)
– LFTs
Deep tendon reflexes and presence of
clonus
CTG
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Antihypertensives – aim for diastolic 80-99,
systolic <150
– IV hydralazine (5mg every 15 minutes to acutely
control BP)
– IV labetolol (Not good if asthmatic or already signs of
pulmonary oedema-first line in many places now)
– Oral nifedipine 10mg NOT SUBLINGUAL
– Methyldopa TOO SLOW ONSET (24-48 hours) for use
in acute situation
– Titrate IV antihypertensive vs. BP then infusion
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Systolic blood pressure of 160 mm/Hg or more
= anti-hypertensive treatment.
(irrespective of diastolic)
Consideration starting treatment at lower pressures
if the overall clinical picture suggests likely rapid
deterioration with anticipation of severe
hypertension.
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Magnesium sulphate
– All severe and moderate PET (MAGPIE)
– 4g IV over 15 minutes
– Then infusion 1g/ hour
– Monitor reflexes (present) urine OP
(>30ml/hr) and respiratory rate (>12/minute)
– Slows neuromuscular conduction and decreases
CNS irritability
– Best anticonvulsant in these circumstances
AND IN ECLAMPSIA
– No effect on BP
– Tell anaesthetist if GA as potentiates effects of
muscle relaxants
George Eliot Hospital, Nuneaton
PET/Eclampsia
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If urine OP OK then
likely not to
accumulate (85%
renal excretion)
If urine output falls,
reduce dose to
0.5g/hour
If signs toxicity, stop
Antidote = Calcium
gluconate 1g IV over
3 minutes
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Magnesium levels
◦ Therapeutic 2-4 mmol/l
◦ Warmth, flushing, slurred
speech 3.8-5mmol/l
◦ Loss of patellar reflexes >5
mmol/l
◦ Respiratory depression >6
mmol/l
◦ Respiratory arrest 6.37mmol/l
◦ Cardiac arrest, asystole >12
mmol/l
George Eliot Hospital, Nuneaton
PET/Eclampsia
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MgSO4 produced 58% reduced risk of eclampsia
(0.8% cf. 1.9%)-across all categories of PET
Maternal mortality lower as well RR 0.55, CI
0.26-1.14
Lancet 2002; 359: 1877-90.
George Eliot Hospital, Nuneaton
PET/Eclampsia
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If severe PET, should NOT transfer
Ensure SCBU aware if baby premature
Give antenatal steroids if time but usually, if
require IV therapy, delivery is indicated
once stabilised
If cervix favourable and patient >36 weeks,
consider short trial IOL
If cervix unfavourable and/or <36 weeks,
deliver by LSCS
Anaesthesia regional vs. general
George Eliot Hospital, Nuneaton
PET/Eclampsia
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◦ Risk of sharp rise of BP on intubation
 This may be obtunded by large dose alfentanyl or
similar
 Need experienced and senior anaesthetist to give GA
in these circumstances
◦ Syntometrine should not be given for the active
management of the third stage if the mother is
hypertensive, or if her blood pressure has not been
checked.
 (ergometrine causes vasospasm and a sharp rise in BP
which may precipitate hypertensive crisis, fits or
cerebral haemorrhage)
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Occurrence of fits
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Due usually to cerebral vasospasm
– 44% postpartum
– 38% antenatal)
– ALWAYS GRAND MAL
George Eliot Hospital, Nuneaton
PET/Eclampsia
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 Occurrence
of fits increases
risks of maternal death x10
 Seizures
may precipitate
hypoxic cardiac arrest and
maternal death
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Beware known epileptics
◦ If BP normal, no protein, typical for their type of
fit-may be epilepsy BUT any fit must be
considered as eclampsia until proven otherwise
especially of BP slightly up etc
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Any FOCAL fit is not eclampsia
◦ Consider SOL eg cerebral bleed/infarction due to
severe PET
◦ Arrange head CT urgently
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Treatment is IV magnesium sulphate-4g
loading
• then continue infusion at 1g/hr
• i.e the same as for severe PET
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If recurrent fits or fit already on MgSO4
• then further 2g IV bolus/increase infusion to 1.5g/hr
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If fits persist
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check magnesium levels,
contact anaesthetists,
consider CT,
consider intubation and ventilation
If antenatal, stabilise and Deliver
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Watch closely on HDU/LW
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Anticipate possible worsening BP or seizures in
first 18-24 hours
◦ ¼ hourly BP, SaO2, pulse, resps
◦ Hourly reflexes, urine output, fluid restriction 6080ml/hr
◦ One to one care
 Hence MgSO4, may need antihypertensives de novo
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Continue MgSO4 for 24 hours and then review
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Do not feed within 12 hours as significant risk
ileus-
 Do not need to taper off MgSO4, just stop
 sips H2O only until next morning then review for bowel
sounds
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Often improve quickly
Some may deteriorate further
immediately after delivery –may continue
to worsen for 24 + hours
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Worsening BP
Worsening bloods
Oliguria/anuria
Increased risk fits
Consult seniors and manage with
multidisciplinary team
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Hypertension may persist for some weeks
Switch to oral treatment when feasible
◦ Atenolol
◦ Nifedipine
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Polypharmacy may be required to control BPconsult with physicians
Ensure regular BP checks arranged on
discharge with review and follow-up by GP
◦ Good communication is the key
◦ Check BP days 1, 2, 3-5 and 7
◦ If still hypertensive at 6 weeks, refer physicians
George Eliot Hospital, Nuneaton
PET/Eclampsia
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Haemolysis
Elevated
Liver Enzymes
Low
Platelets
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1-12% PET (usually
severe end of spectrum)
Commoner in multips
Variable presentation
– RUQ pain, epigastric pain,
nausea + vomiting
– 85% hypertensive at
presentation
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Present: 2/3 antepartum,
1/3 postpartum
– mid 2nd trimester to
several days postnatal
George Eliot Hospital, Nuneaton
PET/Eclampsia
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If ‘straightforward’ PET
– Risk PIH 13-53%
– Risk PET 16%
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If severe PET, eclampsia or HELLP and birth
<34 weeks
– Risk PET 25%
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If severe PET/eclampsia/HELLP and delivery
<28 weeks
– Risk PET is 55%
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Development of hypertension in pregnancy
after 20 weeks
↑Risks of progression to PET if diagnosed
<32 weeks
Assess by:
◦ Clinical assessment
◦ Dipstix for proteinuria (should be negative)
◦ Check fetal wellbeing
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Pre-existing raised blood pressure
May be on treatment or just under
observation
May be known prior to pregnancy or detected
at booking as raised BP
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Worsening of BP
Superimposed preeclampsia
Medical overintervention
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Teratogenesis from
certain drugs (eg
ACEI)
IUGR
Pre-eclampsia
Hypoglycaemia if
on labetolol and
breastfeeding
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If planned, review medications
◦ Take off teratogenic meds e.g. ACEI or similar
◦ Take off diuretics (reduce plasma vol and fetal
perfusion)
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Optimise diet/ weight loss (if raised BMI)
Stop smoking
Start folic acid
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Review meds at booking
Take off any teratogenic meds
Start folic acid
Early booking at hospital for risk review
Dating scan +/- NT (combined) scan
Plan for pregnancy
◦ Including issues re: obesity, screening for GDM
◦ Low dose aspirin from 12 weeks
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Regular BP checks
May need to come
off meds if BP ↓↓
May need to start
or restart meds
later in pregnancy
as BP rises
Growth scans
(screen for IUGR)
Joint care between
MW and hospital
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If BP well controlled and fetal growth normal,
aim to labour spontaneously or induce as
postdates
If BP raised, try control first with medications
If superimposed PET or fetal growth issues,
consider delivering early
NO ERGOMETRINE at delivery-syntocinon only
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Watch BP for at least 24-48 hours
May need oral antihypertensives
Communicate closely with GP to ensure that
BP monitoring is taken over and ongoing care
is handed over to GP
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Know definitions PIH, PET, essential HT
Differentiate between each
What questions to ask
What tests to do
Prevention of PET
Treatment of PET
Treatment of PIH
Treatment of essential HT in pregnancy
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What is the definition of mild hypertension in
pregnancy?
BP 140/90
What three symptoms do you specifically ask
about in pre-eclampsia?
Headaches, visual disturbances, epigastric pain
Which of these is not a moderate risk factor for
pre-eclampsia?
◦ Twins
◦ Diabetes
◦ Maternal age >40
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TRUE or FALSE: Calcium has been shown to
prevent PET in UK populations
FALSE
Name a drug used to treat severe hypertension in
pregnancy/PET
Labetolol, Hydralazine, Nifedipine
What is the anticonvulsant of choice in PET?
Magnesium sulphate
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Which of these is not altered in HELLP syndrome?
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◦ Platelets
◦ ALT
◦ Alkaline phosphatase
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TRUE or FALSE? IUGR is present in >50% women
with PET <28 weeks
TRUE
TRUE OR FALSE? Lisinopril is teratogenic
TRUE
TRUE OR FALSE? Moderate PIH is an indication for
delivery <37 weeks
FALSE
TRUE OR FALSE? Women with severe PET and
early gestation should be transferred out to a
tertiary unit ASAP
FALSE
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Magnesium overdose is not associated with
which of the following?
◦ Vomiting
◦ Cardiac arrest
◦ Muscle weakness
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Which drug is the antidote to magnesium
overdose?
Calcium gluconate
Which blood tests should you do in preeclampsia?