HYPERTENSIVE DISEASE IN PREGNANCY

Posted: July 15, 2010 by gerardloh in O & G


HYPERTENSIVE DISEASE IN PREGNANCY

Definition:

  • BP of 140/90 mmHg or more taken on 2 occasion at least 4 hour apart; OR
  • An increase in systolic BP of 30 mmHg or/and diastolic BP of 15 mmHg compared to pre-pregnancy level
  • Single reader of Diastolic BP more than 110mmHG.

1) GESTATIONAL HYPERTENSION

  • Is hypertension after 20th week of gestation in a previously normotensive woman
  • x proteinuria
  • Condition return to norm within 6 weeks after labour

2) PRE- ECLAMPSIA


3) CHRONIC HYPERTENSION

  • Presence of hypertension of at least 140/90 mmHg before 20th week of pregnancy or beyond 6 weeks postpartum.
  • Includes essential & secondary hypertension.

4) CHRONIC HYPERTENSION WITH SUPERIMPOSED PRE-ECLAMPSIA

  • Development of pre-eclampsia in patient with pre-existing hypertension
  • Criteria used should include:

–        worsening of hypertension

–        proteinuria

Management:

Antenatal:

1. Identify risk factor and observe BP:

  • -primigravida
  • -40yo
  • -chronic hypertension
  • -chronic renal disease
  • -multiple pregnancy
  • -past history or family history of pre eclampsia or eclampsia
  • -excessive weight gain

2. Physical examination,urinanlysis,BP

3. Confirm Diagnosis:

Mild PIH Outpatient

Severe PIH,PE Admission


Outpatient management:

  • Antenatal clinic visit:

– every 4 weeks        if x on treatment,norm biophysical profile,good fetal growth

– every 2 weeks       if on treatment

  • Tests:

– urinalysis (protein)

– BP

– SFH and liquor vol.

– BUSE,FBC,Serum uric acid

  • Fetal surveillance: US monthly,FKC

Inpatient/Admission:

  • BP every 4 hrs
  • SFH and liquor vol.
  • Daily PE chart,urine protein
  • FBC,BUSE,serum uric acid
  • LFT,Coagulation profile(if suspected HELLP)
  • I/O chart
  • Fetal surveillance: – FKC,CTG,US

v     Antihypertensive agents only used if DBP>100mmHg.(aim: maintain 90-100mmHg)

v     Dexamethasone if early delivery expected (<34weeks)

Intrapartum management:

  • BP/ pulse rate half hourly
  • To continue oral antihypertensive treatment
  • Strict I/O chart
  • Adequate analgesia(preferable epidural analgesia)
  • CTG monitoring
  • Shortened 2nd stage- assisted delivery,episiotomy
  • X syntometrime/ergometrine!
  • Use Syntocinon 10 units

Postpartum management

  • Beware of Sx of IE and pulmonary oedema
  • BP monitoring

–        1/2hourly monitoring for at least 2 – 4hours before sending to postnatal ward

–        4 hourly monitoring in the ward for 24 – 48hours before discharge

  • Antihypertensive should be continued and stopped later on postnatal review. (methydopa discontinueà can cz postpartum depression)
  • I/O chart
  • Daily urine albumin,PE chart

Criteria for discharge:

  • Asymptomatic
  • BP< 140/90mmHg
  • Reflexes not brisk
  • Urine albumin- nil
  • Mono-antihypertensive therapy

v     Review patient in 2 weeks and 6 weeks

ANTI-HYPERTENSIVE MEDICATION

AIM: to keep diastolic BP  between  90-100mmHg!


ECLAMPSIA

  • Pregnancy induced hypertension with generalized tonic clonic fits
  • OBSTETRICAL EMERGENCY!
  • Aim of management:

–        Control convulsion

–        Control blood pressure

–        Stabilize patient

-           Delivery

Management

  • 4 subsections:

1) Resuscitation and general management

2) Anticonvulsive therapy

3) Antihypertensive therapy

4) Delivery

(A) Resuscitation and General

1. Left lateral position,2 IV lines

2. Maintain airway,O2 mask

3. Abort fit by- MgSO4 loading dose= 4g IV bolus over 10-15 min

= 5g IM each buttock(10g)

* (1 amp:5ml – 2.5g MgSO4)

* 8ml- 4g (dilute in 12ml Nacl waterà 20ml)

OR

Diazepam IV 10mg bolus (1-2min)

4. After fit aborted- GXM,Coagualtion profile,renal profile,platlet count.

5. Asses level of consciousness & neurological status

6. Closely monitor V/S- BP,PR,SPO2,RR,I/O chart

(B) Anticonvulsive therapy

  1. MgSO4 à Maintainance dose:

*IV infusion of 1g/hour

* 5ml MgSO4 + 45ml 5%Dextrose sol.

à Infuse at 20ml/hour( syringe pump)

OR

* 10ml MgSO4 in 500ml D5% at 33 dpm (drips)

ü       Duration: – continue for 24hours after last fit or after delivery

ü      Monitoring for MgSO4 therapy:

1.Investigations-

  • BUSE,FBC
  • Serum Ca2+,Mg
  • Renal function test (urea,uric acid,creatinine)
  • Coagulation profile
  • UFEME
  • ECG
  • GXM

2. STOP !!! If present signs of Mg toxicity:

à(a) RR < 16/min

(b) Urine output < 25ml/hr

(c) patellar reflex absent

(d) Serum Mg > 3.5mmol/L (therapeutic range: 1.7-3.5)

(e) BP < 90/60 mmHg

3. Antidote: Ca gluconate 10%-10ml

(C) Antihypertensive therapy

  • initiatiate parenterally if BP> 160/110mmHg

(D) Delivery:

v     Definite treatment

v      within 6hrs after mother is stabilised

à if cervix favourable,cephalic: assisted SVD

à if cervix not favaurable: LSCS

v     Pediatrician informed n present at delivery

v      Syntocinon!!!

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Comments
  1. wengkang says:

    dosage for IV antihypertensives?

  2. Noor says:

    Good notes to be read…

  3. LC says:

    “Beware of Sx of IE and pulmonary oedema”
    what does IE mean here?

  4. Azie says:

    Hi! I thought the proteinuria is >3g?

  5. Azie says:

    Hi! I thought the proteinuria is >3g for mild n severe PE?

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