PREGNANCY

INDUCED
HYPERTENSION
PIH
 Gestational Hypertension
or
pregnancy-induced hypertension

 Defined as the
Development of new arterial hypertension in a
pregnant woman after 20 weeks gestation
 INCIDENCE
 5 percent to 8 percent of all pregnancies.
 Young women
 First pregnancy
 Twin pregnancies
 Previous pre-eclmaptic pregnancy
 Diabetese Mallitus
 Chronic hypertension
 Types
 PIH
 Pre-eclampsia (Toxemia of pregnancy)
 Mild
 Severe
 Eclampsia
 HELLP syndrome
 PIH

 MILD
BP 140/90
 SEVERE
BP 160/110 or more
Characteristics
of
Pre-Eclampsia

 Hypertension
 Protienuria
 Edema
 PRIMARY CHARACTERISTICS

 High blood pressure

140/90 mm Hg
or a significant increase in
one or both pressures
 Proteinuria (300 mg or >/24 hours urine)
• Or Urinolysis +++ or ++++

 Edema or recent rapid weight gain

 ECLAMPSIA

 Severe form of PIH

 Women with eclampsia have seizures
 Occurance one in 1,600 pregnancies
 Develops near the end of pregnancy, in
most cases.
 HELLP syndrome
 Complication of severe pre-eclampsia or
eclampsia.
 group of physical changes:
Breakdown of RBCs,
Changes in the liver
Low platelets
 HELLP

 H: Haemolysis
 EL: Elevated Liver Enzymes
 LP: Low Platelets
 HELLP
Diagnosis
 Hemolysis
Blood smear
Bilirubin 1.2 mg/dl or more
 Elevated liver enzymes
SGOT (asperate aminotransferase) > 70 U/L
Lactate dehydrogenase > 600 U/L
 Low Platelets
<100,000 per mm3
cause of PIH

unknown

???
 Pathophysiology
 Immunologic response
 Endothelial Dysfunction
 Abnormal Prostaglandin Metabolism
 Platelet Dysfunction
 Calcium
 Coagulation factors
 Fatty metabolism
 Markers of angiogenesis
 1-Immunologic response

Abnormal
fetal-maternal antigen-antibody response
 Spermatozoa cause formation antibody or

prostaglandins which cause VC

 Normally at 20 weeks, Maternal spiral arteries are

invaded by trophoblast causing release of PGI and

NO,
this mechanism lacks in pre eclampsia
>>>>high
>>>> resistance low flow uteroplacental circulation
 2 Endothelial cell dysfunction
in response to unknown factors
 Resulting in imbalance in the production of :PGI2
and EDRF(NO) >> Vasodialator
&
:TXA2 derived from platelets & endothelaium
>>Vasoconstrictor
 ET-1: chorionic plate arteries constrictor,
elevated in pre-eclampsia
&
pre term rupture of membrane
 3 Platelet factor
Normally aggregating platelet release (serotonin)
5HT + 5HT receptors >> release of NO &
Prostacyclin >> Angiotensin II >> improve
uteroplacental blood flow

 Loss of 5-HT receptor prevents stimulation

of angiotensin II release in pre eclampsia
 4 CALCIUM
 Instead of normal slow rise of intracellular Calcium
concentration
 In Pre eclampsia Ca++ increases rapidly
also enhanced by angiotensin II
(Sensitive indicator of subsequent
development)
 4 Other Factors
 Coagulation factors
disturbance between plasma ratio of von
Willebrand factor and factor VIII
 Fatty metabolism
increased free fatty uptake by liver
hypertriglyceridemia
 Markers of angiogenesis
FLT-I, VEGF (vascular endothelial growth
factor)
 RISK FACTORS
for PIH
 pre-existing hypertension
 kidney disease
 Diabetes Mallitus
 PIH with a previous pregnancy
 Mother's age
younger than 20 or older than 40
 multiple fetuses (twins, triplets)
 Vascular Diseases
 Why is pregnancy-induced
hypertension a concern?

 With high blood pressure there is an increase in

the resistance of blood vessels.
 This may hinder blood flow in many different
organ systems in the expectant mother including
the liver, kidneys, brain, uterus, and
placenta.
 Baby required to be delivered early, before 37
weeks gestation.
 Complications
Maternal Fetal
DIC Pre-maturity
CCF with pulmonary edema Respiratory Distress
Placental Abruption IUG retardation
PPH Oligohydromnios
ARF Intracranial Hemorrhage
Rupture of Liver Small for age
CVA, Seizures Meconium aspiration
Septic shock More Morbidity/Mortality
 Symptoms of PIH
Headach, Visual distubances
Neurological
Hyperexcitability, Seizers
Intracranail hemorrhages, Cerebral edema
Upper airway edema
Pulmonary
Pulmonary edema
Decreased intravascular volume
Cardiovascular
Increased arteriolar resistance
Hypertension, Heart failure
Impaired function, Elevated enzymes
Hepatic
Hematoma, Rupture
Protienuruia, Sodium retention
Renal
Decreased GFR Renal Failure
Coagulopathy
Hematological
Thrombocytopnia
Platelet dysfunction
Microangiopathic hemolysis
 How is pregnancy-induced
hypertension diagnosed
 Increase in blood pressure levels
but other symptoms help
Tests for pregnancy-induced hypertension may include
the following:
 blood pressure measurement
 urine testing
 assessment of edema
 frequent weight measurements
 eye examination (retinal changes )
 Liver and Renal function tests
 Blood clotting tests
 goal of treatment
To prevent the:

Condition from becoming bad to worse

Complications.
 Treatment
for pregnancy-induced
Specific treatment will be determined by the
physician based on:
 pregnancy, overall health, and medical
history
 extent of the disease
 Tolerance for specific medications,
procedures, or therapies
 expectations for the course of the disease
 Patient’s opinion or preference
 Obstetric Management
 Bedrest (either at home or in the hospital)
 Hospitalization (specialized personnel and equipment)
 Magnesium sulfate (or other antihypertensives for PIH)
 Fetal monitoring may include:
 fetal movement counting - fetal kicks and movements
 change in the number/frequency: means fetus under stress.
 nonstress testing - measures the fetal heart rate in response to
the fetus' movements.
 biophysical profile - combines nonstress test with ultrasound
 Doppler flow studies
 Continued laboratory testing of urine and blood (for changes that
may signal worsening of PIH)
 Corticosteroids (help mature the lungs of the fetus)
 Delivery of the baby (if treatments do not control PIH or if the fetus
or mother is in danger)
What antihypertensive medication is
used in PIH ?
 ANTIHYPERTENSIVES

Diuretic Beta ACE inhibitors Calcium Alpha

Blocker /Angiotensin II receptor Channel Blockers
antagonist Blocker

Caution Not No No caution

in Adversely effect fetal Myocardial
late and neonatal blood depressants
pregnancy pressure control,
skull defects,
oligohydromnios,
toxicity
Labetalol Arteriolar dilator
I/V Max 200 mg
2mg/min until satisfactory response
Oral 200 mg BID upto 1200mg
Hydralazine Vasodilator
(Apresoline) Causes tachycardia fluid retention
Oral 25 mg BD
IV 10mg in 10 ml saline in 20 minutes
Nitrates Isorbid dinitrate, Glyceryl trinitrate, isorbid mono
nitrate
Methyldopa 250 – 500 mg 2-3 times/day
(Aldomet) Centrally acting Alph 2 receptor agonist

Sodium 0.5-1.5µgm/kgmin
Cyanide toxocity if treatment exceeds 3 days
Nitropruside
Nifedipine Vasodilator
no myocardial depression
(ADALET)
10-20mg BD
 Alpha methyldopa 500 mg PO bid (up to 2 grams bid)
 Labetolol 200 mg PO bid (up to 1200 mg bid)
 Felodipine 5 mg PO daily (up to 20 mg daily)
 Hydrochlorothiazide
 Not usually initiated in pregnancy due to volume depletion
 May be continued if on pre-pregnancy - consult with local expert
opinion
 Nifedipine XL 30 mg PO bid (up to 120 mg daily)
 Hydralazine 10 mg PO tid (up to 25 mg tid
 GOAL
of

Antihypertensives
 Blood Pressure < 150/100
(much higher than non-pregnant goal)

Anti-hypertensives are not indicated for mild to

moderate chronic Hypertension in pregnancy
 BP <150/100 does not reduce risk to fetus
or prevent Preeclampsia
 Antihypertensives benefit mother only
 do not reduce pregnancy complications
Pre-Operative Evaluation
 Investigations ?
 Blood complete picture
 Platelet count
 Coagulation assay, PT, APTT, Fibrinogen, D - dimer
 Serum Urea/creatinine Electrolytes Uric Acid
 LFTs
 Urinolysis, Microscopy, 24 Hours specimen for protien
and creatinine clearence
 Type and screen Blood
 Monitors
 NIBP
 SaO2
 Hourly deep tendon reflex
 Muscle strength
 Serial Magnesium Sulphate levels
 Foleys Catheter for urine volume
 Urine concentration
 Fetal heart Rate
 IBP
 CVP Persistent oligouria, difficulty in fluid management
therapy in ante/post partum period, Pulmonary edema
 PA
Severe eclampsia Left ventricular systolic function is markedly
reduced
CVP 92% versus PA 8%
What condition mandate immediate
Delivery
 Immediate Delivery
 Severe Hypertension
 Progressive thrombocytopenia
 Liver dysfunction
 Progressive Renal dysfunction
 Persistent headache
 Evidence of fetal jeopardy
 Premonitory signs of ECLAMPSIA
What drug therapy is the treatment
of choice for Seizure prophylaxis

 Diazepam
 Phenytoin
 Magnesium Sulphate
How to use Magnesium Sulphate
 4 - 6 Grams in 20 minutes
followed by 1-2 gram per hour
Monitor
Urine output
Respiratory rate
Patellar reflexes
Serum levels 4 hourly
 Serum levels of
Magnesium Sulphate
5 mEq/L Therapeutic range

10 mEq/L Loss of deep tendon reflexes

Prolonged P-Q interval
Widening QRS complexes
15 mEq/L Respiratory Arrest

20 mEq/L Asystole
 Role of Magnesium Sulphate
 CNS depressant & Anticonvulsant
 CVS Mild Anti-hypertensive effect
 Neuromuscular Junction
Inhibits Ach release
decrease membrane excitability
augment Non and depolarizing muscle relaxant
 Uterus
Mild relaxant effect on vascular & uterine smooth
muscle
Improve uterine blood flow
What are fetal effects of MgSO4
 MgSO4 crosses the placenta

• Neonatal depression
• Respiratory
• Hyporeflexia
• Decreased beat to beat variability in heart rate
 Treatment of Eclampsia

 Stop convulsion (Thiopentone 50-100 mg)

 ABC
 Apply monitors (Pulse Oximeter, NIBP, ECG)
 I/V line
 Check BP repeatedly
 Administer MgSO4
 Treat hypertension
 Deliver baby
Intraoperative Management
 What type?
Analgesia/Anesthesia
for patient with pre-eclampsia
in labour
 EPIDURAL
 Superior pain relief
 Attenuate the hypertensive response to pain
 Reduce circulating level of catecholamines/hormones
 Improve intervillous blood flow
 Stable Cardiac output
 Increased Risk for C-section
 Any Role of Prehydration

 Prehydration with crystalloid

 compensate for decreased prelaod and after
laod >>> ANP >> VD >>renal elimination of
excess ECF
 AVOID if there is recent excessive weight gain
(overhydration)
 Monitor for pulmonary oedema
 Role of Bleeding time or Platelet
count for EPIDURAL

 BT not useful
 Skin bleeding time is not predictor for pre-
eclamptic epidural vein bleeding
 Platelet count reliable
• 50-80,000
 Commonly used Local Anaesthetics
 Bupivacain
• 4 times potent then lignocain
• Onset 5 times longer then lignocain
• Fast in, slow out
 Ropivacain
• Single levorotatory isomer rather then racemic solution
• Less cardiotoxic
 Levobupivacain
• Single levorotatory isomer
• Less cardiotoxic
 Lignocain
• More Motor block
• More hypotension
• instant onset
• Note: with adrenaline should not be used in severe pre-
eclampsia
What type of anaesthesia
for C Section

 Spinal
 General
 Spinal Anaesthesia
 Best even in severe pre-eclampsia
 GA
Severe hypertensive response to intubation
Risk of difficult intubation due to airway edema
 Epidural
Less reliable anaesthesia than spinal
Risk of trauma to epidural vein
 Risk of hypotension 6 times less in pre eclamptic
pregnant woman
 .75% hyperbaric Bupivacain 11-12 mg with or without 15-
20 µg Fentanyl or morphine 100-200 µg
 General Anesthesia
 Aspiration prophylaxis
 Thiopentone sodium induction
 Suxamethonium with cricoid pressure
 Attenute intubation response by deep anaesthesia & lignocain
 Smaller ETT 6-6.5 mm (airway edema)
 Nondepolarizing agent after recovery from suxamethonium
Remember MgSO4
 2/3 rd MAC for adequate depth of anaesthesia
 MgSO4 intra and Post op period
 IBP line for continuous blood pressure monitoring
 Anti HTN drugs
The End
 Pathology of pregnancy, childbirth and the perpurium
Pregnancy ē abortive
outcome
Oedema, proteinuria and
hypertensive disorders
Other, predominantly
related to pregnancy
Maternal care related to the
Fetus and amniotic cavity &
possible delivery problems
Complications of
labour and delivery
Maternal complications
in the weeks after childbirth
Ectopic pregnancy - Hydatidiform mole - Miscarriage
Pregnancy-induced hypertension - Pre-eclampsia
- Eclampsia - Gestational diabetes
Hyperemesis gravidarum - Gestational pemphigoid -
Intrahepatic cholestasis of pregnancy
Polyhydramnios - Oligohydramnios - Chorioamnionitis
- Premature rupture of membranes -
Amniotic band syndrome - Placenta praevia -
Braxton Hicks contractions - Antepartum
haemorrhage –abruption
Premature birth - Postmature birth - Cephalopelvic
disproportion - Dystocia (Shoulder dystocia) -
Fetal distress - Vasa praevia - Uterine rupture -
hemorrhage - Placenta accreta - Umbilical cord
prolapse - Amniotic fluid embolism
Puerperal fever - Peripartum cardiomyopathy -
Postpartum thyroiditis - Galactorrhea -
Postpartum depression