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Hypertension In Pregnancy (Preeclampsia(PET) (PE RISK FACTORS (PE or…
Hypertension In Pregnancy
8-10% of pregnancies
High perinatal mortality of mothers and neonates
Referral values like in non-pregnant patients: below 140/90 mmHg
Increased blood pressure measured twice at least 6 hours apart
Rise of systolic pressure of 30 mmHg or more and diastolic pressure of 15 mmHg or more
Risk factors
PET/PIH in history, Maternal age (<18, >35)
Primiparas, Family history
Multifetal pregnancy, Hydatiform mole
Kidneys insufficiency
Nonimmunologic hydrops fetalis, Black race
Physical assessment of pregnant women
BLOOD PRESSURE MEASUREMENT AT EVERY VISIT IN ALL PREGNANT WOMEN
50% of preeclampsia and eclampsia develope between 22 and 24 weeks of gestation
In high risk patients – RR measurement weekly, optimally once a day at home
Aetiopathology
unknown
Symptoms persist as long, as a live gestational sac or fetus and active placental tissue remain in the uterine cavity.
Abnormal maternal immunological (cellular an humoral) response for presented by the fetus paternal antigens!!! causes disturbancies in developing trophoblast and its penetration in spiral arteries.
It results in placental ischemia and progressive insufficiency and affects fetus causing: IUGR, progressive materno-fetal circulation insufficiency.
Pregnancy with new partner– risk as in the first pregnancy.
Time of exposure for paternal antigens (semen in vagina) plays role – higher risk in pregnancy conceived at the ocasional sexual activity.
Ischemia of:
kidneys (proteinuria)
liver (liver cells necrosis, interstitial hemorrhages)
Other symptoms:
Subcapsular hematoma with bleeding to the abdominal cavity (changes found in pathology)
microangiopathy (fibrin deposits, AT III)
DIC, Placental abruptio
Proteinuria
Should not exceed 300mg/24h (physiological microalbuminuria caused by dilatation of renal arteries and increased GFR)
Isolated proteinuria is an independent risk factor of intrauterine fetal demise and perinatal mortality
In coexistence with hypertension:
is realted to the severity of the disease, decreased glomerular filtration (creatinine clearence)
increases the risk of complications: intrauterine fetal growth retardation and demise in II and III trimester (app. twice), prematurity and maternal death
Oedema
Physiological increase of vessels permeability in pregnancy
In 60-80% of pregnant women lower legs oedema is observed and is not correlated to the higher risk of PIH ad unfavourable pregnancy outcome
There is no correlation between oedema and risk of maternal and fetal complications
15-40% PET/eclapmsia runs without oedema
App. 80% PIH is connected with pathological oedema (increased permeability of renal glomerules and vessels)
Classification
Chronic hypertension
Preeclampsia – eclampsia
Preeclampsia superimposed on the chronic hypertension
Pregnancy hypertension
If diagnosed during pregnancy for the first time:
Transient hypertension without proteinuria at delivery and disappearing up to 12 weeks after delivery
Chronic hypertension – persists after 12 weeks after delivery
Preeclampsia(PET)
Coexistence of hypertension with DPB>90 mmHg with significant proteinuria in a patient with negative history of hypertension
Renal glomerules damage and hypertrophy
Henle loup damage
Constriction of glomerular arteries
changes are reversible
PE RISK FACTORS
PE or severe fetal hypotrophy in history
Chronic hypertension, Chronic renal disease
PGDM, OBESITY
AUTOIMMUNOLOGICAL DISEASE (LUPUS)
THROMBOPHYLIA, APS
PROPHYLAXIS
LOW DOSE ASPIRIN 75-150 mg
Influences apoptosis and trophoblast proliferation
Inhibits thromboxane A2 production
Pevents ischemia in throphoblast
Biochemical markers
Hiperurycemia
!Early marker of PET
!>350µmol/l signalizes kidney involvement and is related to high fetal mortality
!Levels 2-3x above refferal values correspond with PET rather than PIH and obligates to intensive etal and maternal monitoring
!Increased uric acid prognosis HA in the future
SEVERE VS. MILD
CRITERIA
SBP>160 mmHg, DBP>110 mmHg
Proteinura > 5g/dl
Platelet count <100.000/ml
Increased liver enzymes (AST, ALT)
Neurological symptoms (conciousness disturbancies, photopsiae)
Headache (mainly back of the head)
Abdominal pain in the liver region (subcapsulat hematoma)
Oliguria (below 400 ml/24h)
Lung oedema
Eclampsia
Convulsions and coma not related to CNS disorders occuring during pregnancy or puerperium in patients with preeclampsia
Primiparas and patients with multifetal pregnancy have higher risk
Eclampsia occurs usually in the course of mild preeclampsia
Eclampsia is very rare in severe preeclampsia
Management
ANTICONVULSANTS
20 % MgSO4 solution
Bolus: 6g i.v. during 20 min.
Maintanance dose: 2-3 g/h i.v.
Diazepam 10 mg i.v. in slow infusion, the dose may be repeted every few minutes – max. dose 1 mg/kg, but after MgSO4 breath depression may appear after lower dose!
DELIVERY IRRESPECTIVELY TO THE GESTATIONA AGE: Preferred mode of delivery – vaginal after stabilization of the patient; cesarean section when the general condition of the patient doesn’t improve during treatment
complications
Maternal
Intracranial hemorrhage, Central blindness
Convulsions and unconciousness, Lung oedema
Placental abruptio and hemorrhage (2-3%)
Aspiration pneumonia
HELLP syndrome (hemolysis, elevated liver enzymes, low platalet count)
AFLP (Acute Fatty Liver of Pregnancy)
Damage of the kidneys, Deep vein thrombosis
Fetal
PREMATURITY AND IUGR (low birth weight) are the main reasons of increased neonatal mortality and morbidity:
Psychomotoric developement disturbacies
Mental developement delay
High incidence of EPI
Personality disturbancies
US in hypertension
Confirmation of the fetal life – FHR
Biometry (SGA, IUGR)
Amniotic fluid volume (AFI, MVP)
Biophysical profile – assessment of fetal activity
Doppler
Qualitative assessment of blood flow in maternal and fetal vessels (UtA, MCA, UmA) is performed by the use of:
Systolic/diastolic ratio (S/D)
Resistance index (RI): (S/D)/S
Pulsatility index (PI): (S/D)/average V
DOPPLER IS A GOOD METHOD OF FETAL WELLBEING ASSESSMENT
Doppler in PIH/PET
Physiological low-resistant flow in uterine artery at 29 weeks RUA RI=0.47
High-resistant flow in uterine artery in primipara with PET RI=0.75 (N≤ 0.58) ! notch
Physiological low-resistant flow in umbilical artery
RI=0.52 (N≤ 0.70)
S/D=2,07 (N ≤ 3,0)
Pathological flow in umbilical artery:
high resistence (low velocity in diastole)
absent end diastolic flow (AEDF)
reversed end diastolic flow (REDF)
„Brain sparing effect” consists of cerebral vessels dilatation and blood redistribution; it is an answer for decreased partial oxygen pressure caused by placental insufficiency. It is a mechanism of defence from asphyxia.
Fetal indication for intensive monitoring
IUGR, Oligohydramnios / anhydramnios
Abnormal NST, Biophysical profile <6 pts
Fetal indications for delivery
Fetal lung maturity
steroid administration
lung maturity assessment in amniotic fluid (<34 HBD)
Non-reactive NST with silent oscilation and decelerations (at every gestational age)
No improvement in materno-fetal circulation (AEDF, REDF in umbilical artery) after treatment
Biophysical profile <4 pts
Hypertension treatment in pregnancy
Central action: Methyldopa:
1st choice, Fatigue, mouth dryness, Not good in very high RR
B-blockers (decrease EF)
Atenolol: SE: IUGR , Hipoglicemia in neonate
Metoprolol: Hipoglicemia in neonate
Labetalol: fasciculations
Peripheral action: Hydralazine
Headache, fasciculations, IV when RR>160/110
