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MYNESTRY OF HEALTH OF UZBEKISTAN
TASHKENT MEDICAL ACADEMY
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
GP TRAINING
Lecture on
Hypertensive state DURING PREGNANCY
(For students of medical and preventive
health departments)
TASHKENT – 2012
MYNESTRY OF HEALTH OF UZBEKISTAN
TASHKENT MEDICAL ACADEMY
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
GP TRAINING
APPROVED”
Dean of the Faculty of Medicine
Professor Khalmatova B.T
___________________
____ _____________ 2012 y.
Lecture on
Hypertensive state DURING
PREGNANCY
Speaker: Professor, M.D Najmutdinova D.K
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TECHNOLOGY OF THE TRAINING
Number of students 25-26
Time – 2 hrs
Form of lesson
Lecture - presentation
1. 1. A definition of hypertensive states in
Plan of the lecture
pregnancy, classification
2. 2. Discuss methods of diagnosis and management
of hypertension, pre-eclampsia and eclampsia
3. 3. Describe the tactics of control of hypertension
4. The approaches to the prevention and treatment of
seizures in pre-eclampsia and eclampsia
The purpose of the training session: To introduce students future general practitioners management of
pregnant women with hypertensive conditions, criteria for the diagnosis, management of pregnant
women with complications, modern principles of prevention and treatment of seizures in pre-eclampsia
and eclampsia
Tasks the teacher:
Learning outcomes:
1. Learn to identify women with risk factors for
hypertensive conditions during pregnancy and
childbirth
2. Learn to recognize and be able to use basic
methods of treatment of hypertension in
pregnancy
3. Develop students' skills of independent
informed decisions when interpreting the basic
functional studies in pregnancies with
hypertensive syndrome
4. Familiarize students with the principles of
prevention activities
Methods and techniques of teaching
Learning Tools
Forms of learning
Conditions of Learning
The student should know:
1. classification of hypertensive conditions during
pregnancy and childbirth, factors driving their
development.
2. changes occurring in pregnant women with
hypertensive syndrome
3. diagnostic features.
4. principles of outpatient and inpatient management
of pregnant women with hypertension.
5. carrying out rehabilitation, and prevention.
Lecture - visualization, presentation, technique: a
quiz, focusing questions, the technique of "yes-no"
Laser projector, visual materials, information
technology
collective
Audience, work with TSO
Technology card of LECTURES
3
Stages, Time
stage 1
introduction
(5 min)
stage 2
actualization of
knowledge
(20 min)
stage 3
The Information
(55 min)
stage 4
concluding
(10 min)
activities
students
1. Reported the topic name, purpose,
deliverables lectures and plan for its
performance (lyrics № № 1-3 in English.
Language)
2.1. Displays and offers available for the
purpose of the lecture. Comments on the
content of the slides. Slides № 2-3
2.2. With a view to mainstreaming gives
students a focusing problem: Slide number 4
Pregnant or have recently given birth to a
woman who:
- Has high blood pressure
- Complains of headaches or blurred vision
- Found unconscious or convulsing
Conducts blitz poll.
2.3. Displays the slide number 5
students
1. listen
2.1. Examine the contents of a
slide № 2-8
2.2. Answer questions
2.3. Examine the contents of
the slide number 10
3.1. Consistently presents the material lectures 3.1. Discuss the content of the
on the plan, using visual materials and a system proposed materials, clarify and
of focusing questions:
ask questions.
Plan on one question: Define hypertensive
states in pregnancy
Plan on 2 issue: list methods of diagnosis and
management of hypertension, pre-eclampsia
and eclampsia
3 questions on the plan: describe the tactics of
control of hypertension
Plan on 4 issue: approaches to prevention and
treatment of seizures in pre-eclampsia and
eclampsia
Write down the main
Focuses on key topics, offers them down.
4.1. Asks the question:
4.1. Answer questions
1. What is the distinctive feature between GiP
and CAG?
4.2. Listen and write
2. Initial first aid for eclampsia?
4.2. Gives the task for independent work:
Contraception after birth in women with
hypertensive syndrome
Lecture 1
4
Hypertensive conditions during pregnancy
Plan
- to Discuss modern methods of the diagnostics and conduction hypertension, pre-eclamsia
and eclamsia
- to Describe tactics of the checking of hypertension
- to Describe approaches to prevention and treatment of the cricks on pre-eclamsia and
eclamsia
Two ethiological different conditions are considered to be reason of most hypertension
breaches during pregnancy. One of them appears as a result of pregnancy - " hypertension
induced or caused by pregnancy", if it does not accompany with proteinuria, "pre-eclampsia" if
joins proteinuria and "eclampsia" - if it leads to convulsion and coma. The Second breach chronic hypertension, which often existed before pregnancy, and the most cases conditionning
this disease had been previously known, for example pathology of kidney which had patient.
Besides, there can be combination of both types of hypertension.
In determined cases hypertension breaches can have a tragic consequences, both for mother,
and child. So, among the reasons of maternal death, pre-eclampsia occupies third place (after
bleedings and infectious-inflammatory complications) in the world and forms 12,9%.
Classification of hypertension states during pregnancy childbirth (WCD 10)
*Chronic arterial hypertension (hypertension before 20 weeks)
* Hypertension Induced by pregnancy(HIP)
-HIP without proteinuria
- Mild pre-eclampsia
- Severe pre-eclampsia
- Eclampsia
* Chronic arterial hypertension accompanied with pre-eclamsia or eclampsia
Type of arterial hypertension greatly effects:
> On tactic of conducting pregnancy
> On need and intensity of hypotensive therapy
> On time of childbirth.
Diastolic BP (DBP) is an indicator for the correct conduction of childbirth and pregnancy.
DBP shows the peripheral resistance and does not vary depending on the emotional state of
the women
If DBP at a rate of 90 Hg or increased in two consecutive measurements at interval of 4
hours, then it is hypertension!
If hypertension develops after 20 weeks, during childbirth or within 48 hours after birth–then
it is pregnancy-induced hypertension.
If DBP 90- 100 mm.Hg. before 20 weeks + proteinuria under 2 (1g/l)- chronic hypertension
with mild pre-eclampsia.
Chronic arterial hypertension (ChAH)
Diagnostics of pregnants.
Talking about ChAH we should remember that the diagnosis was set when was NOT
pregnant. Most often chronic arterial hypertension is:
primary(90-95%) or essential
in other cases it is represented by a secondary or symptomatic arterial hypertension.
If it is not enough information to differentiate between ChAH and HIP, then the following
criterias for ChAH:
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Hypertension appears before 20 weeks of pregnancy and lasts more than 6 weeks after
childbirth in the absense treatment.
Reccurent hypertension at each pregnancy, should be considered as a chronic arterial
hypertension.
Diagnostic mistakes.
About at 40 % of pregnant women, suffering from hypertension have significant reduction in
AH in early periods of pregnancy with its increasing in the third trimester so there is a big
possibility to make wrong diagnosis hypertension induced by pregnancy, in the presence of
minimal proteinuria and diagnosis of preeclampsia.
Conducting
o Additional rest
o Decrease in BP leads to a reduction in renal and placental perfusion. BP should be reduced
not lower than the lever she used to have.
^ If woman was taking the hypotensive medications before pregnancy, then she should
continue!
^ If DBP 110 mm.Hg. and more and SBP 160 and more, it is necessary to prescribe
hypotensive drugs.
^ If there is a proteinuria, it is a sign of preeclampsia and it is conducted as mild preeclampsia.
^ Watch for growing and condition of the fetus
^ If there is no complications – childbirth will be upon the terms
^ If the heartbeat of fetus <100 and >180 beats. at minute – it is fetus distress!
^ If severe IUFD then it is shown early labor.
^ Determination of gestational age at late period of pregnancy by ultraound is not exact!
Hypertension induced by pregnancy
Hypertension induced by pregnancy (HIP) – is considered high blood pressure after 20 weeks
(except for hydatidiform mole). Increasing BP during pregnancy is considered as an adaptive
reaction of the body, that occurs in response to inadequate perfusion of different parts of the
bloodstream of pregnant, vital organs.
The Criterion of hypertension during pregnancy.
> Increased diastolic blood pressure above 90 mm.Hg.
> Increased systolic blood pressure above 140 mm.Hg.
> The genuine increase in BP can be seen at the base of at least 2 measurements of BP during
4 hours.
Hypertension without pragnancy – hypertension of pragnancy (gestational
hypertension)
Pathophysiology
Increasing of the arterial pressure, first noted in the second half of pregnancy, is an answer to
increased peripheral resistance of blood vessels. Such reaction, as a rule, is an adaptive reaction
aimed at maintaining adequate blood perfusion of vital organs and parts (the brain, liver, kidneys
and others), as a pregnant so and fetus.
Obviously that reduction of the blood pressure with anihypertensive drugs may lead to
violation of these divisions and perfusion, including the further deterioration of the fetus.
Conduction on an outpatient basis.
-BP, urine on proteinuria, condition of fetus once a week!
- in cases of elevated BP women should be conducted as in the mild pre-eclampsia
- If signs of disturbed growth of the fetus or impairment of its’ condition-urgent
hospitalization for premature delivery
-Mandatory counseling for woman and her families about danger signs severe pre-eclampsia
and eclampsia - If condition of pregnant is stable, then vaginal birth is shown.
Preventive maintenance
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- Restriction of callorage, liquids and salts does not prevent a development of HIP and even is
harm for fetus
- It is Not proved positive influence of the aspirin, calcium and other medications on
prevention HIP
- Early detection and helping woman with risk factors-is critical on treatment HIP.
* Education of family
* Social support
Arterial hypertenion with proteinuria - Preeclampsia
Pathophysiology
Compensatory-adaptive reaction of the body to improve perfusion of the vital important
organs and fetus. This is an adaptation, that leads to AH as a result of:
- Generalized vasospasm, leading to increased peripherial vascular resistance and consequent
reduction in perfusion of vital organs(brain, liver, kidney, placenta), which in turn leads to a
decrease of placental perfusion and may lead to growth disturbances of the fetus is a major cause
of morbidity and mortality. Reduced uteroplacental blood flow by 50-60 % occurs 3-4 weeks
before the hypertension becomes apparent.
Decreasing of renal blood flow and glomerular filtration rate are the reason of:
1. hypoxia of glomerules, as a consequence-proteinuria, water retention and edema
development.
2. Increased concentration of uric acid, creatinine and urea(in severe cases in plasma).
3. Hemoconcentration as a result of increased vascular permeability with a decrease in
intravascular fluid(hypovolemia) and signs of extravascular growth.
Vascular endothelial damage (due to peroxidation products as a result of reaction to a fruit
tissue) is:
- Simulation of the coagulation mechanisms aggregation.
- Violation of production and decay of prostacyclin/thromboxane-prostaglandins having
opposite effects on vascular tone and platelet aggregation.
Diagnostic criterias:
Pre-eclampsiya - arterial hypertension + proteinuria in the second half of pregnancy. By the
recommendations of WHO pre-eclampsia is divided into two forms:
By severity:
-Mild
-Heavy
By gestational age:
mature(> or = 36 weeks gestation)
premature(< 36 weeks gestation
Mild preeclampsia – a doule-marked rise in diastolic blood pressure above 90 mm Hg to 110
mm Hg within 4 hours after 20 weeks of gestation with proteinuria over 0.3 g/l to 1g/l.
Management of mild pre-eclampsia.
If < 37 weeks
Obligatory consultancy of the woman and her family about dangerous signs of severe
preeclampsia and eclampsia.
Conduction DKB
If signs are not modified or normal state, the woman is obsevered twice a week on an
outpatient basis:
- BP, urine on proteinuria, reflex, condition of fetus!
- To study pregnant women and her family about dangerous signs of preeclampsia and
eclampsia
- Encouragement of the additional rest!
- Encouragement of the normal feeding!
- Do Not fix: antyconvulsive, antyhypertensive, sedative and tranquillizers
- If ambulatory monitoring is impossible, send her to the hospital!
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Gestation less 34 weeks and fetal weight less 2000 g to prevent the SDR in the newborn. For
the prevention of the SDR in the newborn are using glucocorticoids (deksazon,dexamethasone)
on one of the schemes:
- At 12 mg in/m or in/ven in 12 hours. The Whole 3 injections.
- At 12 mg in/m or in/ven in 24 hours. The Whole 2 injections.
* The prevention is effective if the period between the first injection and delivery is not less
48 hours .
* The effectiveness of prevention SDR is only 7 days.
If > 37 weeks
Evaluation of cervix maturity and delivery planning.
- Cervix is mature-dissection of membranes in the absence of progression of labor within a
few hours, you can apply the induction of labor by prostaglandins or oxytocin.
- immature cervix-prepare, using prostaglandins or a Foley catheter, if there is no effect labor
induction during several days, as far as the health of woman and the fetus allows, or to schedule
a cesarean section.
Heavy preeclampsia – increasing of DBP over 110 mm.Hg. after 20 weeks of pregnancy +
proteinuria over 3g/l, or mild preeclampsia accompinied any signs of threatening eclampsia(mild
preeclampsia + any signs of threatening eclampsia).
The Signs of threatenning eclampsia:
1 Sudden change of the emotional state.
2 Sudden and very high arterial pressure
3 Hyperreflexia.
4 Acute headache
5 Impairment of the vision
6 Oliguria (separation less 400 ml. urines for 24 hours)
7 Pains in upper part of abdomen.
8 Icterus of the skin.
9 Sudden edemas, particularly in the back and face
10 Increasing of liver enzymes in blood.
11 Decreasing of thrombocytes.
12 Changes in blood coagulating system.
13 Signs of the lung edema.
14 Nausea and vomiting.
Proteinuria.
The Second sign of pre-eclampsia.
Level of proteinuria has practical importance -0,3г/l and more in collected overnight urine (at
exception of the infections of the urinary tract)
Edemas
It has not diagnostic importance, in determination of progressive preeclampsia. The Exception
are suddenly (for not more than 2 days) appeared edemas in face and back, that is a sign of
threatenning eclampsia.
Tactics on severe preeclampsia
*The only specific method of the treatment of severe preeclampsia is an abruption of
pregnancy! Aproximately 15-25% of the women who had diagnosis HIP, develops preeclampsia
* it is Difficult to predict, who will have preeclampsia.
On decision of labor must not effect:
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- A Period of gestation.
- "Maturity" of fetus lungs.
- Readiness of the generic ways
Labor is conducted thinking women, who is in danger. Readiness of the generic ways can
affect only on way of labor (vaginal or ceserian section), but not on periods.
The childbirth must occur within 24 hours after appearance of signs.
On eclampsia childbirth must occur within 12 hours after appearance of the cricks.
- if vaginal birth are not expected in time it is shown caesarean section (eclampsia).
-if the rate of fetus heartbeat is <100 or >180 a minute - a Caesarean section!
-do not use the locally analgesia or cethamyn to women with preeclampsia and eclampsia.
ECLAMPSIA - cricks, appearing after 20 weeks of pregnancy on womans, who didn’t have
cricks before
- Small group of women have normal arteria pressure exists with eclampsia
THE PRIMARY ESTIMATION And CONDUCTION of ECLAMPSIA.
- Call for help, mobilize the personnel.
- Estimate the breathing and condition of the consciousness.
- Check passability of the respiratory ways, measure BP and pulse
- to Put on left side
- Protect from traumas, but do not restrain her actively
- Begin in/ven infusion of liquids by needle of the big size
- Give the oxygen at the speed of 4 litres in 1 minute
- Never leave the woman without care.
THE TREATMENT OF SEVERE ECLAMPSIA AND ECLAMPSIA.
Anticonvulsive drugs:
MgSO4, diasepam, fenotoin.
Use magnesium sulphate:
-On eclampsia
-On severe preeclampsia
-Women with urgent labor due to severe preeclampsia
-Begin using MgSO4 as soon as it will be accepted decision about labor.
-Continue the treatment for 24 hours after labor or after the last crick.
THE MAGNESIUM SULPHATE
Exciting dose:
-15 ml 25% MgSO4 for 5 minutes.( in 2-3 syringes)
-Then immediately 20 ml in each buttock in/m with novocaine
-if cricks were repeated after 15мин. 10 ml in/ven in for 5мин.
Supporting dose MgSO4
-10 ml in/m each 4 hours
-continue the introduction MgSO4 for 24 hours after labor or after the last crick
Before each repeated introduction make sure that:
-The rate of breath is not less 16 in minutes
-that knee reflexes are present
-diuresis is not less 30 ml hour at last 4 hours
Stop introduction MgSO4 if:
-The rate of respiratory rate less 16
-Dieresis is less 30 ml
- knee reflexes are absent at hour last 4 hours
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- enter the antidoth!
Glyukonat calcium in/ven 10 % slowly till recovering the breathing and if required AVL.
MgSO4 DOES NOT INFLUENCE ON result of labor.
The diazepam(valium, dormikum, sibazon, seduksen, relanium):
-only in the event of absence MgSO4!
Exciting dose:
" 10 mg (2ml) diazepam in/ven for 2 minutes
" if cricks were renewed , repeat exciting dose.
The Supporting dose:
" 40 mg diazepam in 500 ml phys. solution in/ven droplet for maintenance of the condition
sedation, but must be in consciousness.
" if dose will be more 30 mg for one hour it can approach the stop of the breathing:
" AVL
" Not to use more than 100 mg diazepam for 24 hours.
" -an rectul introduction: when in/ven impossible, 20 mg in 10 ml syringe рег rectum, in
current 10 min. syringe leave in rectum. If cricks were repeated - else 10 mg an hour in addition.
Chronic arterial hypertension (ChAH)
Diagnostics of pregnants.
Talking about ChAH we should remember that the diagnosis was set when was NOT
pregnant. Most often chronic arterial hypertension is:
primary(90-95%) or essential
in other cases it is represented by a secondary or symptomatic arterial hypertension.
If it is not enough information to differentiate between ChAH and HIP, then the following
criterias for ChAH:
Hypertension appears before 20 weeks of pregnancy and lasts more than 6 weeks after
childbirth in the absense treatment.
Reccurent hypertension at each pregnancy, should be considered as a chronic arterial
hypertension.
Diagnostic mistakes.
About at 40 % of pregnant women, suffering from hypertension have significant reduction in
AH in early periods of pregnancy with its increasing in the third trimester so there is a big
possibility to make wrong diagnosis hypertension induced by pregnancy, in the presence of
minimal proteinuria and diagnosis of preeclampsia.
Antigipertenzivnye drugs are used on DBP more110 mm.Hg:
-gidralazin (apressin)
- labetalol (athenolol) 10 mg in/ven
-nifedipin(corinfar, adolat) 5 mg under tongue, after 10 min one more 5 mg under tongue.
THE PRINCIPLES:
- begin using antihypertensive drugs if DBP is more than 110 mm.rt.st.
- support DBP at 90-100 mm.Hg. to prevent the cerebral hemorrage.
So,
- Time and method of labor depend on state of mother and maturity of fetus
- Estimation of the fetus: signs of the impairment of the condition of fetus
- Checking for crick
- Checking for hypertension
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- Direction on more high quality of medical service if there are breaches in function of other
organs: lungs, kidneys, central nervious system. There are a lot of symptoms of high blood
pressure during pregnancy.
*It is impossible to predicate which patients are in group of the risk on development severe
preeclampsia or eclampsia.
*It is necessary to observe throughly to make a diagnosis.
*After making the diagnosis, right treatment will be able to shorten the morbidity and
mortality.
*We shoud use the anticonvulsive drugs, in the first sulphate magnesium
*Antihypertensive drugs should be used when they are really necessary
*It is necessary to carry out monitoring of adverse effects of drugs.
Rehabilitation after childbirth:
*The dispensary observation by general practitioner with specialists of different profile
for well-timed recovery outside of pregnancy and planning of following pregnancy;
*selecting the methods of contraception with provision for their contraindications.
Literature
1. Manualч efficient help at pregnancy and birth child. 3 publishings.Merrey Enkin and
others translation with angel. A.V. Mihaylova SPB., Petropolis. 2003 -460.
2. American College of Obstetricians an Gynecologists. 1996. Technical Bulletin
Hypertension in Pregnancy #219.
3. Chesley LC and BM Sibai. 1987. Blood pressure in mid-trimester and future eclampsia.
Am J Obstet Gynecol 157(5): 1258-1561.
4. Coetzee E, J Dommisse and J Anthony. 1998. A randomised controlled trial of
intravenous magnesium sulphate versus placebo in the management of women with severe preeclampsia. Br J Obstet Gynaecol 105: 300-303.
5. Duley L and D Henderson-Smart. 2000a. Magnesium sulphate versus diazepam for
eclampsia (Cochrane Review), in The Cochrane Library, Issue 4. Update Software: Oxford.
6. Duley L and D Henderson-Smart. 2000b. Magnesium sulphate versus phenytoin for
eclampsia (Cochrane Review), in The Cochrane Library, Issue 4. Update Software: Oxford.
Leveno KJ et al. 1998. Does magnesium sulfate given for prevention of eclampsia affect the
outcome of labor? Am J Obstet Gynecol 178(4): 707-712.
7. Moutquin J et al. 1985. A prospective study of blood pressure in pregnancy: Prediction of
preeclampsia. Am J Obstet Gynecol 151: 191-196.
8. Saudan P et al. 1998. Does gestational hypertension become pre-eclampsia? Br J Obstet
Gynaecol 105: 1177-1184.
9. Szal SE, MS Croughan-Minihane and SJ Kilpatrick. 1999. Effect of magnesium
prophylaxis and preeclampsia on the duration of labor. Am J Obstet Gynecol 180: 1475-1479.
10. Villar MA and BM Sibai. 1989. Clinical significance of elevated mean arterial blood
pressure in second trimester and threshold increase in systolic and diastolic blood pressure
during third trimester. Am J Obstet Gynecol 160: 419-423.
11. Witlin AG, SA Friedman and BM Sibai. 1997. The effect of magnesium sulfate on the
duration of labor in women with mild preeclampsia at term: a randomized, double-blind,
placebo-controlled trial. Am J ObstetGynecol 176(3): 623-627.
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RESUME
"Gipertenzivnye
conditions during pregnancy"
For the reason reductions maternal and perinatal to death-rate, necessary to reveal
the womans falling into group of the risk on development gipertenenziv syndrome
during pregnancy, know the tactician of conduct pregnant with gipertenenziv by
conditions, including quick reaction. The General practitioner must know how in
good time to diagnose, direct for study and decisions of prolonged pregnancy,
define the periods planned and emergency hospitalization pregnant with
gipertenenziv y conditions.
1.
Teach to recognize and know how to use the main methods of the
treatment gipertenenziv beside pregnant;
2.
Teach to diagnose and know how to use the main methods of the
treatment preeklampsii;
3.
Form the knowledges on plan action in primary section at appearance
sign and simptoms heavy preeklampsii /threatenning eklampsii;
4.
Work out the skills on postnatal rehabilitation of the womans with
gipertenenziv by syndrome, including methods to contraceptions;
5.
Work out the skills on interpreting the main functional methods of the
studies at pregnancy with gipertenenziv y syndrome.
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