Hypertensive disorders of pregnancy
- 2. DEFINITION OF HYPERTENSION DISORDERS IN PREGNANCY Hypertension disorders of Pregnancy also known as maternal Hypertensive disorders is a group of disease that includes Pre-eclampsia , Eclampsia, Gestational Hypertension and Chronic Hypertension. A.V.Raman
- 3. CLASSIFICATION OF HYPERTENSION IN PREGNANCY 1. Gestational Hypertension 2. Pre-Eclampsia 3. Eclampsia 4. Chronic Hypertension 5. Pre-Eclampsia or Eclampsia super imposed on Chronic Hypertension
- 5. PRE-ECLAMPSIA –PREGNANCY INDUCED HYPERTENSION Definition: A multisystem disorder of unknown aetiology characterized by development of Hypertension to the extent of 140/90 mm hg or more with proteinuria after the 20th week in a previously normotensive and nonproteinuric woman. -D.C.Dutta
- 6. CLASSIFICATION OF PRE-ECLAMPSIA The Pre-Eclampsia is classified as A. Primary -70% • Pre-eclampsia • Eclampsia B . Secondary -30% • Pre-eclampsia-eclampsia superimposed on chronic hypertension (25%) • Pre-Eclampsia-Eclampsia superimposed on Chronic renal disease (5%)
- 7. CLASSIFICATION BASED ON SEVERITY 1. Mild Pre-Eclampsia 2. Moderate Pre-eclampsia 3. Severe Pre-eclampsia
- 8. MILD-MODERATE PRE-ECLAMPSIA • Systolic B.P 140-160 mmhg • Diastolic B.P 90-100 mmhg • Proteinuria upto ++ SEVERE PRE-ECLAMPSIA • Systolic B.P >160 mmhg • Diastolic B.P >110 mmhg • Proteinuria upto +++ or more • Epigastric pain
- 9. RISK FACTORS • Primigravidae(Young or elderly) • Family history of hypertension, pre- eclampsia • Placental abnormalities – Hyperplacentosis: (molar pregnancy twins, diabetes) – Poor placentation – Placental ischemia. – Molar pregnancy • Genetic disorders • Immunological phenomenon • Pre-existing vascular disease • New paternity • Thrombophilias
- 10. ETIOLOGY OF PRE-ECLAMPSIA • Placental implantation with abnormal trophoblastic invasion of uterine vessels • Immunological maladaptive tolerance between maternal, paternal (placental),and fetal tissues • Maternal maladaptation to cardiovascular or inflammatory changes of normal pregnancy • Genetic factors
- 12. CLINICAL FEATURES OF PRE- ECLAMPSIA SIGNS: • Abnormal weight gain- >5lb/month or 1lb/week in later months • Rise in blood pressure • Edema- ankles, then spread all over the body • Pulmonary edema • Abdominal examination- chronic placental insufficiency (scanty liquor or IUGR)
- 13. MILD SYMPTOMS • Slight swelling over the ankles which persists on rising from the bed in the morning or tightness of the ring on the finger is the early manifestation of pre- eclampsia oedema. • Gradually, the swelling may extend to the face, abdominal wall, vulva and even the whole body
- 14. ALARMING SYMPTOMS • Headache —occipital or frontal region • Disturbed sleep • Diminished urinary output—Urinary output of less than 400 ml in 24 hours, • Epigastric pain • Eye symptoms—blurring, dimness of vision or complete blindness.
- 15. INVESTIGATIONS • Urine-proteinuria • Opthalmoscopic examination- retinal edema ,constriction of arterioles • Blood values – BUN – Serum creatinine – Thrombocytopenia – Coagulation profile – Liver function test • Antenatal fetal monitoring – USG – Fetal kick count – Cardio tocography – Umbilical artery flow velocimetry – Biophysical profile
- 16. MATERNAL COMPLICATIONS- IMMEDIATE • Antenatal – Eclampsia(2%) – Accidental haemorrhage – Oliguria and anuria – Dimness of vision and even blindness – Preterm labor – HELLP syndrome
- 17. MATERNAL COMPLICATIONS- IMMEDIATE During labour – Eclampsia – Post partum haemorrhage During Puerperium: – Eclampsia (usually within 48 hrs) – Shock. – Sepsis
- 18. FETAL COMPLICATIONS • Intrauterine deaths • Intrauterine growth restriction • Asphyxia • Prematurity
- 19. REMOTE COMPLICATIONS • Residual hypertension • Recurrent preeclampsia • Chronic renal disease • Risk of placental abruption
- 20. PREVENTIVE MEASURES • Regular antenatal check up • Antithrombotic agents-low dose aspirin 60 mg daily • Calcium supplementation- 2gm/day to reduce risk of pre eclampsia • Anti oxidants-vitamin E & C • Nutritional supplementation with Magnesium,Zinc,Fish oil, high protein and low salt diet.
- 21. MANAGEMENT OF PRE-ECLAMPSIA OBJECTIVES 1. To stabilise hypertension and to prevent its progression to severe preeclampsia. 2. To prevent the complications 3. To prevent eclampsia. 4. Delivery of a healthy baby in optimal time. 5. Restoration of the health of the mother in puerperium
- 22. TREATMENT MODALITIES REST • In left-lateral position as much as possible. • It lessen the effects of vena caval compression. • Increases the renal blood flow → diuresis • Increases the uterine blood flow → improves the placental perfusion • Reduces the blood pressure.
- 23. DIET • Should contain adequate amount of daily protein (about 100 gm). • Total calorie approximate 1600 cal/day. • Usual salt intake is permitted. • Fluids need not be restricted.
- 24. SEDATIVES • To cut down emotional factor, mild sedative may be given orally (phenobarbitone 60mg or diazepam 5mg at bedtime is given)
- 25. DIURETICS • Should not be used injudiciously as they can harm to the baby by diminishing placental perfusion and by electrolyte imbalance. • Indications for diuretics use are: – Cardiac failure – Pulmonary oedema – Along with selective antihypertensive drug therapy – Massive oedema
- 26. ORAL ANTIHYPERTENSIVES DRUGS • Methyl dopa-250-500mg TID/QID-central & peripheral anti-adrenergic action. • Labetalol 250 mg TID/QID- Adrenoceptor antagonist • Nifedipine 10-20mg BID –Calcium channel blockers • Hydralazine 10-25mg BID-vascular smooth muscle relaxant
- 27. PROGRESS CHART • Blood pressure Q6H • State of Edema & daily weight • Fluid intake & output • Urine examination for protein/24 hrs • Blood examination- Hematocrit ,platelet count, uric acid, creatinine , LFT once a week.
- 28. METHODS OF TERMINATION INDUCTION OF LABOUR • Aggravation of the pre- Eclamptic features in spite of medical treatment and/or appearance of newer symptoms • Hypertension persists in spite of medical treatment with pregnancy reaching 37 weeks or more. • Acute fulminating pre- eclampsia irrespective of the period of gestation • Post term pregnancy
- 29. METHODS OF TERMINATION CAESAREAN SECTION • Urgent termination is indicated and the cervix is unfavourable. • Severe pre-eclampsia • Associated complicating factors, such as elderly primigravidae, contracted pelvis, malpresentation, etc
- 30. MANAGEMENT DURING LABOUR • Patient should be on bed • Liberal sedatives • Anti-Hypertensives drugs • Blood pressure & urine output is monitored • Care monitor of fetal well being • Labour-ARM and deliver by forceps/ ventouse • IV Ergometrine is contraindicated • IM Oxytocin is given • Sedation immediately-IM Morphine 15mg to prevent postnatal Eclampsia
- 31. MANAGEMENT OF PUERPERIUM • Close monitoring for at least 48 hours • Tab.Phenbarbitone 60mg is repeated for effective sedation • Anti- Hypertensive drugs is given until diastolic pressure is below 100mmhg • Patient is hospitalized until B.P brought down to safe level and proteinuria disappears
- 33. DEFINITION OF ECLAMPSIA Pre-eclampsia when complicated with generalized tonic clonic seizures &/ or coma is called eclampsia. D.C.DUTTA
- 34. PATHOPHYSIOLOGY OF ECLAMPSIA Since Eclampsia is a severe form of pre-eclampsia the histopathological and biochemical changes are similar although intensified than those of pre eclampsia as already described.
- 35. STAGES OF ECLAMPTIC CONVULSIONS • The Eclamptic fits are epileptiform & consist of four stages , that are : 1).PREMONITORY STAGE : *The patient becomes unconscious. *There is twitching of muscles of face, tongue & limbs. *Eye balls or are turned to one side & become fixed. *This stage lasts for about 30 second.
- 36. 2.TONIC STAGE *The whole body goes into a spam called trunk opisthotonus. *Limbs are flexed & hands clenched. *Respiration ceases & tongue protrudes between the teeth. *Cyanosis appears. *Eyes balls become fixed. *This stage lasts for about 30 seconds.
- 37. 3.CLONIC STAGE *All the voluntary muscles undergo alternate contraction & relaxation. *The twitching starts in face then involve one side of extremities & ultimately the whole body is involved in the convulsion. *Biting of tongue occurs. *Breathing is strenuous & blood stained frothy secretions fill the mouth. *Cyanosis gradually disappears. *This stage lasts for 1-4 minutes.
- 38. 4.STAGE OF COMA *Following the fit , the patient passes on the stage of coma. *It may last for a brief period or in others deep coma persists till another convulsion. *On occasion, the patient appears to be in a confused state following the fit & fails to remember the happenings. *Rarely, the coma occurs without prior convulsion
- 39. MANAGEMENT OF ECLAMPSIA PRINCIPLES • Arrest convulsion. • Maintenance of patent airway , breathing & circulation. • Oxygen administration at the rate 8- 10 L/Min. • Terminate pregnancy. • Ventilatory support. • Prevention of complication. • Hemodynimical stable. • Prevention of life threatening situation. • Postpartum care
- 40. FIRST AID TREATMENT • The patient , either at home or in the health centres should be shifted urgently to the tertiary referral care hospitals , because there is no place of continuing the treatment in such place. • Sedation • Maintain airway
- 41. NURSING MANGEMENT • Aim to prevent serious maternal injury from fall , to prevent aspiration , to maintain airway & to ensure oxygenation. • Patient is kept in railed cot & a tongue depressor is inserted between teeth. • She is kept in the lateral position to avoid aspiration. • Collect detailed history from the relatives, relevant diagnosis of eclampsia, duration of pregnancy, number of fits & nature of medication administered outside.
- 42. Cont.. • Continuous Vital signs monitoring • Hourly urine output monitoring • Fetal heart rate monitoring • Fluid balance • Antibiotic therapy
- 43. SPECIFIC MANAGEMENT ANTIHYPERTENSIVE AND SEDATIVE REGIME 1.Magnesium sulphate therapy- IM/Prictchard Regimen- Loading dose-4gm IV/3-5 min followed by 10gm deep IM (5gm in each buttock) Maintenance dose-5gm IM Q4H in alternate buttock
- 44. CONT.. • IV Zuspan or sibai regimen Loading dose-4-6gm/15-20minutes Maintenance dose -1-2 gm/hr IV • Lytic cocktail regimen • Diazepam • Phenytoin therapy • Antihypertensive and diuretics.