pregnancy induced hypertension - معاونت درمانta.mui.ac.ir/sites/ta.mui.ac.ir/files/pih...
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HypertensionHypertension•• Most common medical problem encountered Most common medical problem encountered
during pregnancyduring pregnancy•• 88% of pregnancies% of pregnancies
•• 4 4 categories:categories: Chronic HypertensionChronic Hypertension Pregnancy Induced hypertensionPregnancy Induced hypertension PreeclampsiaPreeclampsia--eclampsiaeclampsia Preeclampsia superimposed on chronic HTNPreeclampsia superimposed on chronic HTN
*Hypertensive disorder in pregnancy may cause an increase in *Hypertensive disorder in pregnancy may cause an increase in maternal and fetal morbidity and remains a leading source of maternal and fetal morbidity and remains a leading source of maternal mortality*maternal mortality*
HypertensionHypertension
•• ThirdThird leading cause of maternal mortality, after leading cause of maternal mortality, after thromboembolism and nonthromboembolism and non--obstetric injuriesobstetric injuries
•• Maternal DBP > Maternal DBP > 110 110 is associated with ↑ risk of placental is associated with ↑ risk of placental abruption and fetal growth restrictionabruption and fetal growth restriction
•• Superimposed preeclampsia cause most of the morbiditySuperimposed preeclampsia cause most of the morbidity
Pregnancy Induced HypertensionPregnancy Induced Hypertension
•• HTN HTN •• Usually mild and later in pregnancyUsually mild and later in pregnancy•• No renal or other systemic involvement No renal or other systemic involvement •• Resolves Resolves 12 12 wks postpartumwks postpartum•• May become preeclampsiaMay become preeclampsia
PreeclampsiaPreeclampsia•• New onset HTN New onset HTN •• After After 20 20 weeks of gestation, or weeks of gestation, or •• Early postEarly post--partum, previously normotensivepartum, previously normotensive•• Resolves within Resolves within 48 48 hrs postpartumhrs postpartum
•• With the following (Renal or other systemic)With the following (Renal or other systemic)•• Proteinuria > Proteinuria > 300 300 mg/mg/2424hrhr•• Oliguria or SerumOliguria or Serum--plasma creatinine ratio > plasma creatinine ratio > 00..09 09 mmol/Lmmol/L•• Headaches with hyperreflexia, eclampsia, clonus or visual disturbancesHeadaches with hyperreflexia, eclampsia, clonus or visual disturbances•• ↑ LFTs, glutathione↑ LFTs, glutathione--SS--Transferase alpha Transferase alpha 11--11, alanine aminotransferase or right , alanine aminotransferase or right
abdominal painabdominal pain•• Thrombocytopenia, ↑ LDH, hemolysis, DICThrombocytopenia, ↑ LDH, hemolysis, DIC
•• 1010% in primigravid% in primigravid•• 2020--2525% with history of chronic HTN% with history of chronic HTN
Maternal Risk FactorsMaternal Risk Factors
•• First pregnancyFirst pregnancy•• Age younger than Age younger than 18 18 or older than or older than 3535•• Prior h/o preeclampsiaPrior h/o preeclampsia•• Black raceBlack race•• Medical risk factors for preeclampsia Medical risk factors for preeclampsia -- chronic HTN, chronic HTN,
renal disease, diabetes, antirenal disease, diabetes, anti--phospholipid syndromephospholipid syndrome•• TwinsTwins•• Family historyFamily history
Mild vs. Severe PreeclampsiaMild vs. Severe Preeclampsia
MildMild SevereSevere
Systolic arterial pressure Systolic arterial pressure 140 mm Hg 140 mm Hg –– 160 mm Hg160 mm Hg ≥160 mm Hg ≥160 mm Hg
Diastolic arterial pressure Diastolic arterial pressure 90 mm Hg 90 mm Hg –– 110 mm Hg 110 mm Hg ≥110 mm Hg ≥110 mm Hg
Urinary protein Urinary protein <5 g/24 hr<5 g/24 hrDipstick +or 2 + Dipstick +or 2 +
≥5 g/24 hr≥5 g/24 hrDipstick 3+or 4+ Dipstick 3+or 4+
Urine output Urine output >500 mL/24 hr >500 mL/24 hr ≤500 mL/24 hr ≤500 mL/24 hr
Headache Headache No No Yes Yes
Visual disturbances Visual disturbances No No Yes Yes
Epigastric pain Epigastric pain No No Yes Yes
EtiologyEtiology
Exact mechanism not knownExact mechanism not known
•• ImmunologicImmunologic•• GeneticGenetic•• Placental ischemiaPlacental ischemia
•• Endothelial cell dysfunctionEndothelial cell dysfunction•• VasospasmVasospasm•• HyperHyper--responsive response to vasoactive hormones (e.g. responsive response to vasoactive hormones (e.g.
angiotensin II & epinephrine)angiotensin II & epinephrine)
Symptoms of preeclampsiaSymptoms of preeclampsia
•• Visual disturbancesVisual disturbances•• HeadacheHeadache•• Epigastric painEpigastric pain•• Rapidly increasing or nondependent edema Rapidly increasing or nondependent edema -- may be a may be a
signal of developing preeclampsiasignal of developing preeclampsia•• Rapid weight gain Rapid weight gain -- result of edema due to capillary leak result of edema due to capillary leak
as well as renal Na and fluid retentionas well as renal Na and fluid retention
PathophysiologyPathophysiology
•• hematologichematologic•• CardiacCardiac•• RenalRenal•• Hepatic Hepatic •• Fetal and placentaFetal and placenta•• cnscns
Upper airway edemaUpper airway edema
•• Upper airway edemaUpper airway edema•• Laryngeal edemaLaryngeal edema•• Airway obstructionAirway obstruction
•• Potential for Potential for airway compromiseairway compromise or or difficulty in intubationdifficulty in intubation
Cardiac/PulmonaryCardiac/Pulmonary
•• Increased CO & SVRIncreased CO & SVR•• CVP normal or slightly increasedCVP normal or slightly increased•• Plasma volume reducedPlasma volume reduced
•• Pulmonary edemaPulmonary edema•• Decrease oncotic/Decrease oncotic/collidcollid pressurepressure•• Capillary/endothelial damage Capillary/endothelial damage leakleak•• VasoconstrictionVasoconstriction•• Occurs Occurs 3 3 % of % of preeclampticpreeclamptic patientspatients
HepaticHepatic
•• Usually mildUsually mild•• Severe PIH or preeclampsia complicated by HELLPSevere PIH or preeclampsia complicated by HELLP periportal hemorrhagesperiportal hemorrhagesischemic lesionischemic lesiongeneralized swellinggeneralized swellinghepatic swelling hepatic swelling epigastric painepigastric pain
RenalRenal
•• Adversely affected Adversely affected proteinuriaproteinuria•• GFR and CrCl GFR and CrCl decreasedecrease•• BUN increase, may correlate w/ severityBUN increase, may correlate w/ severity•• RBF compromisedRBF compromised•• ARF w/ oliguria ARF w/ oliguria –– PIH, esp. w/ abruption, DIC, HELLPPIH, esp. w/ abruption, DIC, HELLP
**OliguriaOliguria + + renal failurerenal failure may occur in the may occur in the absence of hypovolemiaabsence of hypovolemia. Be . Be careful w/ hydration careful w/ hydration pulmonary edemapulmonary edema**
UterineUterine
•• Activity increasedActivity increased•• Hyperactive/hypersensitive to oxytocinHyperactive/hypersensitive to oxytocin•• Preterm labor Preterm labor –– frequentfrequent•• Uterine/placental blood flow Uterine/placental blood flow –– decreased by decreased by 5050--7070%%•• Abruption Abruption –– incidence increasedincidence increased
Morbidity / MortalityMorbidity / Mortality
Maternal complications:Maternal complications:
•• Leading cause of maternal death in PIH is Leading cause of maternal death in PIH is intracranial hemorrhageintracranial hemorrhage•• SeizuresSeizures•• Pulmonary edema Pulmonary edema •• ARFARF•• ProteinuriaProteinuria•• Hepatic swelling with or without liver dysfunctionHepatic swelling with or without liver dysfunction•• DIC DIC (usually associated with placental abruption and is uncommon (usually associated with placental abruption and is uncommon
as a primary manifestation of preeclampsia)as a primary manifestation of preeclampsia)
Morbidity / MortalityMorbidity / Mortality
Fetal complications:Fetal complications:
•• Abruptio placentaeAbruptio placentae•• IUGRIUGR•• Premature delivery Premature delivery •• Intrauterine fetal deathIntrauterine fetal death
HELLP SyndromeHELLP Syndrome
•• HHemolysisemolysis•• EElevated levated LLiver enzymesiver enzymes•• LLow ow PPlateletslatelets
•• < < 35 35 wkswks•• MalaiseMalaise ((9090%), %), epigastricepigastric painpain ((9090%), Self%), Self--limiting limiting •• MultiMulti--system failuresystem failure
HELLP SyndromeHELLP Syndrome
•• Hemostasis is Hemostasis is not problematicnot problematic unless unless PLT < PLT < 4040,,000000
•• Rate of fallRate of fall in PLT count is important in PLT count is important •• Regional anesthesia Regional anesthesia -- contraindicated contraindicated fall is fall is suddensudden•• PLT count PLT count normal within normal within 72 72 hrs of deliveryhrs of delivery•• Thrombocytopenia may persist for longer periods.Thrombocytopenia may persist for longer periods.•• Definitive cureDefinitive cure is is deliverydelivery
TreatmentTreatment
•• ManagementManagement of maternal hemodynamics & prevention of of maternal hemodynamics & prevention of eclampsia are eclampsia are keykey to a favorable outcome to a favorable outcome
•• MgSOMgSO44 -- Rx of choice for preeclampsia. Rx of choice for preeclampsia.
•• Does not significantly reduce systemic BP at the serum Does not significantly reduce systemic BP at the serum concentration that are efficacious in treating concentration that are efficacious in treating preeclampsiapreeclampsia
•• GoalsGoals•• Control BPControl BP•• Prevent seizuresPrevent seizures•• Deliver the fetusDeliver the fetus
Controlling the HTNControlling the HTN
•• HydralazineHydralazine•• LabetalolLabetalol•• NitroglycerinNitroglycerin•• NifedipineNifedipine•• EsmololEsmolol•• Na Nitroprusside Na Nitroprusside –– risk of cyanide toxicity in the fetusrisk of cyanide toxicity in the fetus
Preventing SeizuresPreventing Seizures
•• MgSOMgSO44 -- Drug of choice. Narrow therapeutic indexDrug of choice. Narrow therapeutic index
•• Reduce > Reduce > 5050% w/o any serious maternal morbidity% w/o any serious maternal morbidity•• 44g IV Bolus over g IV Bolus over 10 10 minutes, then infusion @ minutes, then infusion @ 11g/hrg/hr•• Renal failure Renal failure -- rate of infusion rate of infusion by serum Mg levelsby serum Mg levels•• Plasma Level should be between Plasma Level should be between 44--6 6 mmol/Lmmol/L•• Monitor clinical signs for toxicity Monitor clinical signs for toxicity
•• Toxic:Toxic: 10 10 ml of ml of 1010% Ca Gluconate IV slowly% Ca Gluconate IV slowly
MgSOMgSO4 4 ToxicityToxicity
•• 55--10 10 mEqmEq/L/L –– Prolonged PR, widened QRSProlonged PR, widened QRS•• 1111--14 14 mEqmEq/L/L –– Depressed tendon reflexesDepressed tendon reflexes•• 1515--24 24 mEqmEq/L /L ––AV node block, respiratory paralysisAV node block, respiratory paralysis•• >>25 25 mEqmEq/L /L -- Cardiac arrestCardiac arrest
Anesthetic ConsiderationsAnesthetic Considerations
•• Detailed preanesthetic assessment Detailed preanesthetic assessment •• Focuses on Focuses on airway, fluid status, and BP controlairway, fluid status, and BP control•• Lab: CBC, BUN/Cr, LFTs Lab: CBC, BUN/Cr, LFTs •• Routine coagulation is NOT recommended unless there Routine coagulation is NOT recommended unless there
is clinical suspicionis clinical suspicion•• PLT count PLT count -- if neuraxial techniques are consideredif neuraxial techniques are considered
Regional AnesthesiaRegional Anesthesia
•• Labor epidural Labor epidural -- advantage of a gradual onset of advantage of a gradual onset of sympathetic blockade sympathetic blockade provides cardiovascular provides cardiovascular stability & avoids neonatal depression.stability & avoids neonatal depression.
•• Epidurals may reduce vasospasm and HTN Epidurals may reduce vasospasm and HTN –– may may improve uteroplacental blood flowimprove uteroplacental blood flow
•• Reduce risk of airway complications and avoid Reduce risk of airway complications and avoid hemodynamic alterations associated with intubationhemodynamic alterations associated with intubation
Regional (part Regional (part 22))•• Neuraxial anesthesia in preeclamptic pt Neuraxial anesthesia in preeclamptic pt -- still still
controversial controversial •• Many studies Many studies this is the this is the bestbest optionoption•• National High blood Pressure Education Program National High blood Pressure Education Program
Working GroupWorking Group “Neuraxial, epidural, spinal and combined spinal“Neuraxial, epidural, spinal and combined spinal--epidural (CSE), epidural (CSE),
techniques offer many advantages for labor analgesia and can techniques offer many advantages for labor analgesia and can be safely administered to the parturient with preeclampsia. Dilute be safely administered to the parturient with preeclampsia. Dilute epidural infusions of local anesthetic plus opioid produce epidural infusions of local anesthetic plus opioid produce adequate sensory block without motor block or clinically adequate sensory block without motor block or clinically significant sympathectomy. “significant sympathectomy. “
Regional (part 3)Regional (part 3)
•• Possibility of extensive sympatholysis with profound Possibility of extensive sympatholysis with profound hypotension hypotension
•• decrease CO & uteroplacental perfusiondecrease CO & uteroplacental perfusion
•• Single shot spinal technique Single shot spinal technique controversialcontroversial Recent analysis suggest that it can be used Recent analysis suggest that it can be used safetysafety in pt with in pt with
severe preeclampsiasevere preeclampsia undergoing Cundergoing C--section. BP decline similar section. BP decline similar to epidural. Hypotension can be avoided by meticulous attention to epidural. Hypotension can be avoided by meticulous attention to anesthetic technique and careful volume expansionto anesthetic technique and careful volume expansion
General Anesthetic TechniquesGeneral Anesthetic Techniques
•• Laryngeal response Laryngeal response blunted by preblunted by pre--treatment with treatment with hydralazine, nitroglycerin or labetalolhydralazine, nitroglycerin or labetalol
•• Airway edema Airway edema increased risk of difficult airway increased risk of difficult airway situationsituation
•• Neuraxial techniques Neuraxial techniques preferred method, preferred method, contraindicated in the presence of coaguloapthycontraindicated in the presence of coaguloapthy
•• In pt receiving MgSOIn pt receiving MgSO44, SUX activity , SUX activity potentiatedpotentiated•• EnhancedEnhanced sensitivitysensitivity to nonto non--depolarizing muscle depolarizing muscle
relaxantsrelaxants•• MgSOMgSO44 blunts response to vasconstrictors and inhibits blunts response to vasconstrictors and inhibits
catecholamine release after sympathetic stimulationcatecholamine release after sympathetic stimulation