� Multisystem disorder with varied and still unknown etiology with unpredictable outcome, with increase in maternal & fetal morbidity and mortality.

Intro conti…

� Also known as “Toxaemia of pregnancy”

� Major cause of maternal mortality in India.

� Asso with poor outcome of pregnancy if uncared .

� It affects 7 – 15 % of all pregnancies.

� Definition (ACOG) : Diastolic BP of 90mm Hg or higher / systolic BP of

140mm Hg or higher after 20wks of gestation in a woman with previously normal BP.

It should be documented on atleast 2 occasions measured 6hrs apart.

� Proteinuria : It is defined as the urinary excretion of 300mg/L or more of protein in a 24hr urine collection. (correlates with reagent strip >1+ i.e. >30mg/dl)

1)1)1)1) Chronic HTN Chronic HTN Chronic HTN Chronic HTN : HTN present before the 20th week of pregnancy or that present before pregnancy.

2)2)2)2) Chronic HTN with superimposed Preeclampsia Chronic HTN with superimposed Preeclampsia Chronic HTN with superimposed Preeclampsia Chronic HTN with superimposed Preeclampsia : defined as proteinuria developing for first time during pregnancy in a woman with known chronic HTN.

3)3)3)3) Gestational HTN Gestational HTN Gestational HTN Gestational HTN : HTN without proteinuria developing after 20wks of gestation or during labor or the peurperium in previously normotensive non proteinuric woman.

4) PreeclampsiaPreeclampsiaPreeclampsiaPreeclampsia : Gestational HTN associated with proteinuria .

5) EclampsiaEclampsiaEclampsiaEclampsia : Convulsions occuring in a pt with preeclampsia.

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Normal PregnancyBlood Pressure

� Etiology :1. Most common : Essential HTN 2. Secondary HTN : 1. Renal : parenchymal or renovascular 2. Endocrine : pheochromocytoma, primary

aldosteronism, cushings syndrome.3. Neurogenic : increased ICT4. Vascular : Aortic coarctation 3. Systolic HTN : Thyrotoxicosis, hyperkinetic circulation.

RISK FACTORS

� Severe HTN (HTN crisis, risk of stroke and abruption), superimposed PIH, IUGR, abruptio placenta.

CHRONIC HYPERTENSION CONT.

� Difficult to differentiate from PIH as Pts came for ANC mainly after 20th week & very few pts diagnosed in pre-pregnant state.

� Pre-conceptional counseling : for determination of cause, organ functions, exercise & weight loss, salt restriction

� Change of medications : eg omit ACE inhibitors & ARBs

� Daily self monitoring of BP at home� Don’t lower BP rapidly: harm to fetus

1. Vasodilators : Labetalol, Nifedipine, Prazosin, Hydralazine.2. Centrally acting : Methyldopa

� 30% pts have chance to develop super-imposed preeclampsia.

� If this happens, PIH is very severe, occurs early in pregnancy, responds poorly to bed rest.

� How to differentiate aggravated HTN from superimposed PIH ?

� Proteinuria, Urinary Ca excretion,

� Diastolic BP 85 or greater, MAP 95 or greater, in repeated observations 6hrs apart after 14weeks of GA.

� H/O severe HTN in previous pregnancies.� h/o abruption � h/o stillbirth or unexplained neonatal death.� h/o IUGR� AGE > 35yrs or chronic HTN of >15yrs

duration� Marked obesity� Secondary HTN

� ANC visits every 2 weekly until 32 wks & then every weekly.

� Variables to monitor : BP, uterine growth, , DFMC, maternal weight

� Pts with other high risk factor develop complication resulting in preterm delivery.

� Prevalence 6-15% in nulliparas & 2-4% in multiparas.

� Early Early Early Early : before 30wks, frequently severe, advances to preeclampsia and has a guarded perinatal prognosis.

� LateLateLateLate : after 30wks, frequently in obese women and multiple pregnancies, due to poor maternal adaptation to physiological changes in pregnancy.

Conti..� Criteria to identify high risk women with Criteria to identify high risk women with Criteria to identify high risk women with Criteria to identify high risk women with

gestational HTN gestational HTN gestational HTN gestational HTN :

1. BP > 150/100 mm Hg.2. GA < 30wks3. Evidence of end organ damage4. Oligohydramnios5. Fetal growth restriction6. Abnormal Colour Doppler.7. Nullipara, Age > 35yrs, BMI > 35 kg/m2

Incidence : 5-15%

In primigravida: 10%

In Multigravida 5%

� Primi : younger or elderly� Family history of PIH, HTN, DM� H/O PIH in previous pregnancy� Hyperplacentosis as in molar pregnancy, twins,

DM� Obesity, Chronic HTN, pre-existing vascular

or Renal disease, DM� New paternity� Thrombophilias : APLA, deficiency of protein

C/S, factor 5 leiden,

� Abnormal Abnormal Abnormal Abnormal placentationplacentationplacentationplacentation : failure of trophoblast invasion

� Endothelial Dysfunction Endothelial Dysfunction Endothelial Dysfunction Endothelial Dysfunction due to oxidative stress and inflammatory mediators,

� VasospasmVasospasmVasospasmVasospasm due to imbalance b/w vasodilators(PGI2, NO) & vasoconstrictors (TxA2, angiotensin 2, endothelin).

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TROPHOBLASTIC INVASION

Before invasion

After invasion

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Conti..� All of above result in :� Increased vasoconstriction� Decreased organ perfusion : utero-placental –

IUGR, Kidneys- glomerular endotheliosis,oliguria, liver ischaemia, HELLP, CNS seizures.

� Increased endothelial dysfunction – capillary leak, oedema, Pulmonary oedema, proteinuria.

� Activation of coagulation: DIC, low platelets� Haemoconcentration

� BP > 140/90 mmHg (NICE guidelines mild 140/90 to 149/99,

Moderate150/100 to 159/109 & severe 160/110)

� Proteinuria : 24hr urinary protein >300mg, (>5gm severe

PIH) dipstick method > 1+ (30mg/dl)� Urinary Protein/creatinine ratio >

30mg/mmol

Other :� Pathological oedema� Excessive weight gain : is > 0.5kg in one

week or >2kg in one month in later months of pregnancy.

� Clinical e/o vasoconstriction by fundoscopy

Mild vs. Severe Preeclampsia

Mild Severe

Systolic arterial pressure 140 mm Hg – 160 mm Hg ≥160 mm Hg

Diastolic arterial pressure 90 mm Hg – 110 mm Hg ≥110 mm Hg

Urinary protein <5 g/24 hrDipstick +or 2 +

≥5 g/24 hrDipstick 3+or 4+

Urine output >500 mL/24 hr ≤500 mL/24 hr

Headache No Yes

Visual disturbances No Yes

Epigastric pain No Yes

� Headache� Epigastric or rt upper quadrant pain :

particularly in HELLP S due to liver dysfunction.

� Visual symptoms : scotomas progressing to blurred vision, even blindness. (abnormality lies in occipital cortex, not in retina.) recovers faster post natally.

� Brisk DTRs : CNS irritabilty.

� “Never neglect these alarming signs….and u will save a life or two…”

� Haemoconcentration leads to false rise in Hb.

� Thrombocytopenia� RFTs: Serum Uric Acid >4.5mg/dl, serum

creatinine >1.2mg/dl.� LFTs : raised liver enzymes in severe

cases� Increased fibrinogen, it is decreased in

abruption.

� IUGR of 2-4 wks in PIH commonly seen.� Demands uterine, umbilical & MCA

doppler.� Doppler weekly in moderate to severe

PIH.� NST & Modified Biophysical Profile: twice

weekly to assess fetal well-being.

Delivery is the only cure� If only pt. is stable : continue pregnancy.

� If unstable : may require early delivery.� Indication for delivery in k/c/o mild PIH:

BP>160/110, proteinuria > 5gm in 24hrs urine.

� Trying to conserve pregnancy in severe PIH by giving antihypertensive : invitation for disaster.

� Drug of choice: Labetalol orally in dose of 100-400 mg every 8-12hrly.

� Others : � Methyl dopa 250mg-500mg 6-8 hrly.� Nifedipine 10-20mg bd - tds.� Hydralazine : 10-25mg 12hrly.� Iv or oral furosemide, oral thiazide: only

after delivery.� If s/o severity : MgSO4.

Criteria for diagnosis of severe Criteria for diagnosis of severe Criteria for diagnosis of severe Criteria for diagnosis of severe preeclampsia preeclampsia preeclampsia preeclampsia :

� Systolic BP > 160 / Diastolic > 110 on 2 occasions 6hrs apart while pt is in bed rest.

� Proteinuria of 5 g or higher in 24hr urine or 3+ or greater in 2 samples 4hrs apart.

� Oliguria of less than 5oo ml urine in 24 hrs.

� IUGR� Cerebral or visual disturbances

Conti..� Pulmonary oedema or cyanosis� Epigastric or right upper quadrant pain� Impaired liver function� Thrombocytopenia � Very imp : s/o impending eclampsia

� GA > 34 wks :� MgSO4 to prevent seizures� Antihypertensive to control BP� Delivery : if Cx ripe Induction or

Caesarean section.� Don’t try to lower BP suddenly, it will

impair organ perfusion and result in maternal & fetal morbidity

� Labetalol 10-20mg iv every 10min, max upto 300mg iv, maintenance dose 40mg/hr

� Hydralazine : 5mg iv every 30min, max 30mg iv, maint dose 10mg/hr

� Nifedipine : 10-20mg oral, max up to 240mg in 24hrs, for maint 4-6 hrly

� Nitroglycerine : 5microgm/min iv or� Sod nitroprusside 0.25-5 microgm/kg/min

iv short term therapy only when other drugs failed.

1. Intra-muscular (Pritchard) : 5gm im in each buttock, followed by maintanance dose

2. Intra-venous (zuspan or Sibai) 6 gm(25%) iv over 20min f/b maint dose

of 2 gm(50%) /hr or 100ml/hr iv infusion.

• Therapeutic level 4-7 meq/L.• 4 Actions. Toxicity. Antidote.

MgSO4 Toxicity

• 5-10 mEq/L – Prolonged PR, widened QRS• 11-14 mEq/L – Depressed tendon reflexes• 15-24 mEq/L – SA, AV node block, respiratory paralysis• >25 mEq/L - Cardiac arrest• Antidote : 10ml of 10% calcium gluconate i.v slowly

� Guidelines for expectant management :

Bed restDaily weightDaily input & outputAntihypertensive t/tSteroids Lab on alternate daysDaily NSTDFMCCD twice a weekAFI twice a weekUSG to see for fetal growth every 2 weeks

� It is the extremely severe form of PIH char by sudden onset of generalized tonic clonic convulsions.

� Higher frequency in developing countries.� Occurs antepartum in 35-45%, intrapartum in 15-20%, postpartum in 35-45%.� Preceded by impending signs & aura.� In 15 % of patients, HTN & protenuria are absent.� Preventable in 70% cases. � No any long term neurological deficit.

� In mild HTN or normotension : abnormal autoregulatory response consisting of severe arterial vasospasm with rupture of endothelium & pericapillary haemorhages with development of abnormal electric foci causing convulsion.

� In severe HTN, limit of autoregulation exceeded, vasodialatation occurs with hyperperfusion causing endothelial capillary damage and interstitial vasogenic edema.

� Place pt in lateral decubitus.� Mouth gag� Suction oral secretions� O2 by mask� Elevate bedside rails to avoid injury� Switch off lights, keep quite environment surrounding pt.� Pulse oxymeter, foley’s catheter, iv access� MgSO4� Start IV fluids at low rate 100ml/hr.� Antihypertensive : 1st drug of choice in severe

HTN is iv Labetalol. � Deliver the pt.

Conti..� Continue MgSO4 till 24hrs postpartum to avoid

convulsion.� Nimodepine 60 mg oral 4hrly: drug of choice in

mild elevated BP with impending signs/ eclampsia.

� Postpartum i.v. Furosemide should be given aggresively for early recovery.

� Transient fetal distress during seizure, normalizes as seizure is over.

� Continuous fetal distress during tetanic uterine contraction.

� Abruption & IUD.

Increase in LSCS for eclampsia in modern OBs :

� Due to � Unripe cervix, poor progress in labor� IUGR, preterm baby� Inadequate control of BP� Mainly to avoid adverse maternal & fetal

effects of pregnancy continuation.

� MgSO4 for atleast 24hrs after delivery� Aggressive diuresis & maintained several

days� Antihypertensive until BP normalizes.

� Approximately 35% pts will have PIH in subsequent pregnancy.

� Criteria for diagnosis :

1) Haemolysis (microangiopathic hemolytic anemia) Burr cells, schistocytes on smear bilirubin > 1.2mg/dl absent plasma haptoglobin2) Elevated liver enzymes AST > 72 IU/L LDH > 600 IU/L3)Low platelets < 1 lakh/mm3

Conti..Maternal morbidity :complications� Abruption placenta� DIC� Pulmonary oedema� ARF� ARDS� Hepatic rupture leading to DIC & death� Intracranial hemorrhages cause for death� Visual disorders� Death in 1%

Management

� Immediate delivery is indicated once diagnosis of HELLP established.

� Vaginal or LSCS� Platelets if count < 50000 or if s/o altered

hemostasis.� Plasmapheresis is lifesaving if

deterioration in course of disease.� Better to manage by delivering preterm

fetus than to conserve for further harm.

� Daily BP monitoring till pt is indoor.� Once discharged, BP on alt days till

normal value settles in.� Continue antihypertensive till

normalization of BP postpartum.� Do reagent strip for proteinuria at 6wks

follow up. If abn, repeat at 3months. � Counselling of pt about recurrence of

PIH and risk of chronic HTN.

� Research going on without effective solution

� Low dose aspirin� Ca supplementation: cheap & effective� ? Anti-oxidants, ? Fish oil supplementation� No role of salt restricted diet in PIH� Predictive tests.

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� “Let us understand PIH better ,for managing patients more efficiently.”

�“THANK YOU…”