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Hypertensive disease of pregnancy

(PIH)

Prepared by:

Dr. Kasturi Malla

Senior Consultant Gynecologist & Obstetrician:


Visiting Professor: CTGU
February 2009 1
Definition:
(After 20 weeks’ gestation)

• Elevation of BP >140/90mmHg
or
• Elevation of systolic >30mmHg or diastolic >15mmHg
or
• MAP>105mmHg or elevation of MAP>20mmHg

(MAP=Diastolic + 1/3rd of pulse pressure)

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Classification…

1. Gestational hypertension = Sustained hypertension


with proteinuria after 20 weeks.

2. Chronic hypertension = Sustained elevation of


BP>140/90mmHg before the pregnancy or before 20
wks’ gestation.

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…Classification

3. Pre-eclampsia = Sustained elevation of


BP>140/90mmHg with proteinuria after 20 wks’
pregnancy without pre-existing hypertension.

• Mild PET = <160/110mmHg


• Severe PET = >160/110mmHg

4. Eclampsia = PET + Convulsion &/or Coma

5. Fulminant PET/Imminent eclampsia = Transitional


condition from severe PET to Eclampsia.
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Pathogenesis
• Diffuse vasospasm: Uterus, Placenta, Kidney, Brain, Heart
–  Tissue hypoperfusion
–  Ischemia
–  Capillary injury Oedema

• Mediators: TXA2>PGI2
– TXA2=Vasoconstrictor/Platelet aggregator
– PGI2=Vasodilator/Platelet aggregation inhibitor

• Loss of refractoriness to vasoactive Angiotensin

• Decreased trophoblastic vascular invasion

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Proteinuria
• Normal=
<300mg/24hrs

• Dipstick test:
– Trace=100mg/L
– 1+ =300mg/L
– 2+ =1gm/L
– 3+ =3gm/L
– 4+ =10gm/L

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Risk factors
1. Primigravida (young or elderly)

2. Hyperplacentosis
• Multiple gestation
• DM
• Rh-incompatibility
3. Molar pregnancy

4. Chronic HTN

5. F/H of HTN

6. Antiphospholipid syndrome

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Clinical features
• Swelling/Abnormal • Diastolic BP =
wt.gain >110mmHg
• Headache • Oliguria<400ml/24hrs
• Persistent epigastric pain • Proteinuria=>5gm/day
• Cerebral/Visual • Plateletes<100,000/cmm
disturbance • Uric acid>4.5mg/dl
• IUGR • Retinopathy:
• Pulmonary edema – A-V nicking
– Hemorrhage
– Exudate
– Papilledema

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Maternal Complication
1. HELLP Syndrome 7. Hepatic rupture
2. Abruptio placentae 8. Electrolyte imbalance
3. Pulmonary 9. Preterm labor
edema/ARDS/Pneu
10. PPH
monia
11. Shock/ Postpartum
4. ARF
collapse
5. Cerebral bleeding
12. Sepsis
6. Visual disturbance &
blindness

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Maternal mortality
1. Eclampsia

2. Accidental hemorrhage

3. ARF

4. Pulmonary edema

5. DIC

6. HELLP syndrome
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Fetal Complication
1. IUFD

2. IUGR

3. Asphyxia

4. Prematurity

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Tests
1. Urine:- Protein
2. Blood:-
– Grouping, VDRL, Suger, Hb,
– Platelets, Uric acid
– RFT(Urea,Cr,Na+K+), LFT
3. USG:-
– Fetal growth
– Placenta
– Gestational age
4. Ophthalmoscopy
5. Fetal monitoring:-
– BPP
– Daily fetal kick count

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Antenatal management
Preventive measures:

1. Regular check up

2. Ca++ supplement: 1-2gm/day after 4 months

3. Low dose Aspirin 60mg/day from the beginning

4. Multivitamins and protein rich diet

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Antenatal management
Therapeutic measures:
1. Hospitalisation
2. Rest
3. Sedation: Phenobarbitone 60mg OD or BD
4. Antihypertensives: P/O
– Methyl dopa 250-500mg TID
– Nifedipine 10-20mg BD
– Labetalol 250mg TID
– Hydralazine 10-25mg BD

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5. Hypertensive crisis: I/V

– Labetalol: 200mg in 200ml N/S @20mg/hr

– Hydrallazine: 5mg stat + 25mg in 200ml N/S


@2.5mg/hr

– Nitroglycerine: 5microgm/min

– Na+nitropruside: 0.25-5microgm/kg/min

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Management of PET without
complication
1. Frequent check up

2. Do not allow postdated

3. If <34weeks: Consider Dexamethsone

4. If >37weeks: Induction

5. If severe: seizure prophylaxis MgSO4

6. If complication seen: Terminate irrespective of gestational age

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Labor management
C/S:
1. Complication with
1. Sedation unfavourable Cx

2. Antihypertensives 2. Severe PET with prolonged


labor
3. Shorten 2nd stage
3. PET + other surgical
4. Avoid orgometrine indication

5. MgSO4 till 48 hrs 4. Unstable hemodynamics

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Fulminant PET/Imminent eclampsia

Symptoms:
1. Headache
2. Visual disturbance
3. Epigastric pain
4. Nausea and vomiting
5. Restlessness/Tremulousness/Twitching
6. Swelling
7. Low urine output

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Fulminant PET/Imminent eclampsia

Signs:
1. Agitation

2. Hyperreflexia

3. Facial and peripheral edema

4. Right upper quadrant


tenderness

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Management
1. MgSO4 therapy

2. Antihypertensives

3. Assess for fetal maturity

4. Consider for termination of pregnancy

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Eclampsia
• PET + Convulsion or Coma

• Timing: Usually in 3rd trimester


– Antepartum-50%
– Intrapartum-30%
– Postpartum-20%

• Causes
– Anoxia
– Cerebral edema
– Decreased seizure threshold

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C/F:
1. Premonitory stage

2. Tonic stage

3. Clonic stage

4. Stage of coma

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D/D:
1. Epilepsy
2. Cranial pathology:
– Meningitis
– Encephalitis
– Cerebral malaria
– Brain tumor
– Cerebral thrombosis
– Stroke
3. Electrolyte imbalance
– Hyponatremia
– Hypo calcemia
– Hypomagnesemia
4. Poisoning
5. Functional

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Principle of management
1. Resuscitation:
– Airway
– Breathing
– Circulation: I/V line
– Catheter
2. Oxygen
3. Control convulsion
4. Control BP
5. Ventilatory support
6. Appropriate tests
7. Plan for early delivery
8. Antibiotics prophylaxis

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MgSO4 Therapy
4gm I/V in 100 mL of fluid over 3-5min

5gm I/M in each buttock

5gm I/M hrly in alternate buttock

OR

5gm I/V over 15-20min

1gm/hr I/V infusion


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MgSO4 Toxicity
1. >12 mg/dL loss of tendon (patella) reflexes)

2. >14 mg/dL respiratory depression

3. 15-17 mg/dL muscular paralysis and respiratory


arrest

4. 30-35 mg/dL cardiac arrest

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Monitor MgSO4 Therapy

1. Knee jerk

2. Resp. rate >12/min

3. Urine output >100ml in 4hrs

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