PREGNANCY INDUCED HYPERTENSION：妊娠高血压综合征.ppt

Hypertension in Pregnancy,Dr.Elwassiela Salih MDObstetrician Gynecologist&Reproductive EndocrinologistChief of the DepartmentCollege of MedicineTaif University,OBJECTIVES,Be able to define hypertension in relationship to pregnancyBe able to classify hypertensive diseases in pregnant womenBe able to list criteria for the diagnosis of preeclampsiaBe able to list criteria for the diagnosis of severe preeclampsia/HELLP syndromeBe able to discuss current management considerationsUnderstand and discuss the effects of hypertension on the mother and fetus,Hypertension,Sustained BP elevation of 140/90 or greaterMeasurement taken while seatedArm at the level of the heart,Hypertensive Disease Associated with Pregnancy,Chronic HypertensionGestational HypertensionPreeclampsiaEclampsiaHEELP Syndrome,Hypertensive Disease Associated with Pregnancy,Chronic HypertensionDiagnosed before the 20th week or present before the pregnancyGestational HypertensionPreeclampsiaEclampsiaHEELP Syndrome,Hypertensive Disease Associated with Pregnancy,Chronic HypertensionGestational HypertensionCriteriaDevelops after 20 weeks of gestationProteinuria is absentBlood pressures return to normal postpartumMorbidity is directly related to the degree of hypertensionPreeclampsiaEclampsiaHEELP Syndrome,Overlap/Disease Progression,25%,Hypertensive Disease Associated with Pregnancy,Chronic HypertensionGestational HypertensionPreeclampsiaCriteriaDevelops after 20 weeksBlood pressure elevated on two occasions at least 6 hours apartAssociated with proteinuria and edemaMay occur less than 20 weeks with gestational trophoblastic neoplasiaEclampsiaHEELP Syndrome,Preeclampsia vs.Severe Preeclampsia,Criteria for Preeclampsia,Criteria for Severe Preclampsia,Previously normotensive woman 140 mmHg systolic 90 mmHg diastolicProteinuria 300 mg in 24 hour collectionNondependent edema,BP 160 systolic or 110 diastolic 5 gr of protein in 24 hour urine or 3+on 2 dipstick urines greater than 4 hours apartOliguria 500 mL in 24 hoursCerebral or visual distrubances(headache,scotomata)Pulmonary edema or cyanosisEpigastric or RUQ painEvidence of hepatic dysfunctionThrombocytopeniaIntrauterine growth restriciton(IUGR),Risk Factors for Preeclampsia,Nulliparity Multifetal gestationsMaternal age over 35Preeclampsia in a previous pregnancyChronic hypertensionPregestational diabetes,Vascular and connective tissue disordersNephropathyAntiphospholipid syndromeObesityAfrican-American race,Risk Factors,Hypertensive Disease Associated with Pregnancy,Chronic HypertensionGestational HypertensionPreeclampsiaEclampsiaDiagnosis of preeclampsiaPresence of convulsions not explained by a neurologic disorderGrand mal seizure activityOccurs in 0.5 to 4%or patients with preeclampsiaHEELP Syndrome,Hypertensive Disease Associated with Pregnancy,Chronic HypertensionGestational HypertensionPreeclampsiaEclampsiaHELLP SyndromeA distinct clinical entity with:Hemolysis,Elevated Liver enzymes,Low PlateletsOccurs in 4 to 12%of patients with severe preeclampsiaMicroangiopathic hemolysisThrombocytopeniaHepatocellular dysfunction,Morbidity and Mortality from Hypertensive Disease,Hypertension affects 12 to 22%of pregnant patients Hypertensive disease is directly responsible for approximately 20%of maternal mortality in the United State,Pathophysiology,VasospasmUterine vesselsHemostasisProstanoid balanceEndothelium-derived factorsLipid peroxide,free radicals and antioxidants,Pathophysiology,VasospasmPredominant finding in gestational hypertension and preeclampsiaUterine vesselsHemostasisProstanoid balanceEndothelium-derived factorsLipid peroxide,free radicals and antioxidants,Pathophysiology,VasospasmUterine vesselsInadequate maternal vascular response to trophoblastic mediated vascular changesEndothelial damageHemostasisProstanoid balanceEndothelium-derived factorsLipid peroxide,free radicals and antioxidants,Pathophysiology,VasospasmUterine vesselsHemostasisIncrease platelet activation resulting in consumptionIncreased endothelial fibronectin levelsDecreased antithrombin III and 2-antiplasmin levelsAllows for microthrombi development with resultant increase in endothelial damageProstanoid balanceEndothelium-derived factorsLipid peroxide,free radicals and antioxidants,Pathophysiology,VasospasmUterine vesselsHemostasisProstanoid balanceProstacyclin(PGI2):Thromboxane(TXA2)balance shifted to favor TXA2 TXA2 promotes:Vasoconstriction Platelet aggregationEndothelium-derived factorsLipid peroxide,free radicals and antioxidants,Pathophysiology,VasospasmUterine vesselsHemostasisProstanoid balanceEndothelium-derived factorsNitric oxide is decreased in patients with preeclampsiaAs this is a vasodilator,this may result in vasoconstrictionLipid peroxide,free radicals and antioxidants,Pathophysiology,VasospasmUterine vesselsHemostasisProstanoid balanceEndothelium-derived factorsLipid peroxide,free radicals and antioxidantsIncreased in preeclampsiaHave been implicated in vascular injury,Pathophysiologic Changes,Cardiovascular effectsHematologic effectsNeurologic effectsPulmonary effectsRenal effectsFetal effects,Pathophysiologic Changes,Cardiovascular effectsHypertensionIncreased cardiac outputIncreased systemic vascular resistanceHematologic effectsNeurologic effectsPulmonary effectsRenal effectsFetal effects,Pathophysiologic Changes,Cardiovascular effectsHematologic effectsVolume contraction/HypovolemiaElevated hematocritThrombocytopenizMicroangiopathic hemolytic anemiaThird spacing of fluidLow oncotic pressureNeurologic effectsPulmonary effectsRenal effectsFetal effects,Pathophysiologic Changes,Cardiovascular effectsHematologic effectsNeurologic effectsHyperreflexiaHeadacheCerebral edemaSeizuresPulmonary effectsRenal effectsFetal effects,Pathophysiologic Changes,Cardiovascular effectsHematologic effectsNeurologic effectsPulmonary effectsCapillary leakReduced colloid osmotic pressurePulmonary edemaRenal effectsFetal effects,Pathophysiologic Changes,Cardiovascular effectsHematologic effectsNeurologic effectsPulmonary effectsRenal effectsDecreased glomerular filtration rateGlomerular endotheliosisProteinuriaOliguriaAcute tubular necrosisFetal effects,Renal Effects,Decreased glomerular filtration rateGlomerular endotheliosisProteinuriaOliguriaAcute tubular necrosis,Pathophysiologic Changes,Cardiovascular effectsHematologic effectsNeurologic effectsPulmonary effectsRenal effectsFetal effectsPlacental abruptionFetal growth restrictionOligohydramniosFetal distressIncreased perinatal morbidity and mortality,Management,The ultimate cure is deliveryAssess gestational ageAssess cervixFetal well-beingLaboratory assessmentRule out severe disease!,Gestational HTN at Term,Delivery is always a reasonable option if termIf cervix is unfavorable and maternal disease is mild,expectant management with close observation is possible,Mild Gestational HTN not at Term,Rule out severe diseaseConservative managementSerial labsTwice weekly visitsAntenatal fetal surveillanceOutpatient versus inpatient,Indications for Delivery,Worsening BPNonreassuring fetal conditionDevelopment of severe PIHFetal lung maturityFavorable cervix,Unfavorable Cervix,No contraindication to prostaglandin agentsIf 32 weeks,consider cesareanWhen favorable,oxytocin,Hypertensive Emergencies,Fetal monitoringIV accessIV hydrationThe reason to treat is maternal,not fetalMay require ICU,Criteria for Treatment,Diastolic BP 105-110Systolic BP 200Avoid rapid reduction in BPDo not attempt to normalize BPGoal is DBP 105 not 90May precipitate fetal distress,Characteristics of Severe HTN,Crises are associated with hypovolemiaClinical assessment of hydration is inaccurateUnprotected vascular beds are at risk,eg,uterine,Acute Medical Therapy,HydralazineLabetalolNifedipineAldomet,Hydralazine,Dose:5-10 mg every 20 minutesOnset:10-20 minutesDuration:3-8 hoursSide effects:headache,flushing,tachycardia,lupus like symptomsMechanism:peripheral vasodilator,Labetalol,Dose:20mg,then 40,then 80 every 20 minutes,for a total of 220mg Onset:1-2 minutesDuration:6-16 hoursSide effects:hypotensionMechanism:Alpha and Beta block,Nifedipine,Dose:10 mg po,not sublingualOnset:5-10 minutesDuration:4-8 hoursSide effects:chest pain,headache,tachycardiaMechanism:CA channel block,Seizure Prophylaxis,Magnesium sulfate4-6 g bolus1-2 g/hourMonitor urine output and DTRsWith renal dysfunction,may require a lower dose,Magnesium Sulfate,Is not a hypotensive agentWorks as a centrally acting anticonvulsantAlso blocks neuromuscular conductionSerum levels:6-8 mg/dL,Toxicity,Respiratory rate 12DTRs not detectableAltered sensoriumUrine output 25-30 cc/hourAntidote:10 ml of 10%solution of calcium gluconate 1 v over 3 minutes,Treatment of Eclampsia,Few people die of seizuresProtect patientAvoid insertion of airways and padded tongue bladesIV accessMGSO4 4-6 bolus,if not effective,give another 2 g,Alternate Anticonvulsants,Have not been shown to be as efficacious as magnesium sulfate and may result in sedation that makes evaluation of the patient more difficultDiazepam 5-10 mg IVSodium Amytal 100 mg IVPentobarbital 125 mg IVDilantin 500-1000 mg IV infusion,After the Seizure,Assess maternal labsFetal well-beingEffect deliveryTransport when indicatedNo need for immediate cesarean delivery,Other Complications,Pulmonary edemaOliguriaPersistent hypertensionDIC,HELLP Syndrome,He-hemolysisEL-elevated liver enzymesLP-low platelets,HELLP Syndrome,Is a variant of severe preeclampsiaPlatelets 100,000LFTs-2 x normalMay occur against a background of what appears to be mild disease,Conservative Management,ControversialSteroidsRequires tertiary careMust have stable labs and reassuring fetal statusMay use antihypertensives,Prevention,Low dose ASA ineffective in patients at low riskCalcium supplementation is ineffective(2.0 g of calcium gluconate per day)No compelling evidence that either are harmfulRecent study done with antioxidant(1,000mg VitC and 400mg VitE).Small study that needs to be confirmed.,SUMMARY,Criteria for diagnosisLaboratory and fetal assessmentMagnesium sulfate seizure prophylaxisTiming and place of delivery,