Transcript Modern problems of pregnancy induced hypertension

MODERN PROBLEMS OF
GESTOSES
Prepared by D.M.S., professor
S.N.Heryak
Ternopol medical state univercity
by I.Y. Gorbachevsky
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Gestoses and hypertensive disorders are
among the most common and yet serious
conditions seen in obstetrics.
These disorders cause substantial
morbidity and mortality for both
mother and fetus, despite improved
prenatal care.
CLASSIFICATION
GESTOSIS OF EARLY TERMS OF PREGNANCY
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ptyalism in pregnancy
vomiting
nausea
RARE FORMS OF GESTOSIS IN PREGNANCY
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hyperemesis gravidarum
acute fatty liver of pregnancy
dermatosis gravidarum
tetania gravidarum
osteomalacia gravidarum
bronchial asthma of pregnancy
PREGNANCY INDUCED HYPERTENSION
HELLP-syndrome
Ptyalism in pregnancy
(or excessive salivation).
Ptyalism in pregnancy is
especially annoying for a small
number of patients,
sometimes approaching 1 liter
production per day.
Treatment of ptyalism:
tincture of belladonna
 atropine
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Medical treatment only slightly so that
reassurance of the time-limited nature of
the problem is a mainstay of
management.
Nausea and emesis.
At least 66 % of women experience
nausea and 50 % emesis in the first trimester,
with the frequency of these symptoms
lessening as the second and third trimesters ensue.
Classically, symptoms are
predominantly
present in the morning
("morning sickness"),
but they may occur throughout
the day and evening.
The genesis of pregnancyinduced nausea and vomiting.
It may be that the hormonal changes
of pregnancy are responsible.
Chorionic gonadotropin, for instance,
has been implicated on the basis that
its levels are rather high at the same
time that nausea and vomiting are
most common.
Degrees of vomiting:
light
 moderate
 severe
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Light degree of vomiting.
It is accompanying with 2 - 4
times per day episodes of
vomiting after taking meals,
general state of the woman is
satisfactory, light tachycardia
may be present.
Moderate degree of vomiting.
It is accompanying with 5-10 times
and more per day episodes of
vomiting which don't from taking
meals.
Weight loss, ketosis,
increased temperature are
present.
Severe degree of vomiting.
It is also called as Hyperemesis
gravidarum (intractable emesis during
pregnancy) is a more severe form of nausea
and vomiting, occurring in approximately 4 out
of 1000 pregnancies.
It is also associated with severe symptoms as well
as weight loss, dehydratation, ketosis, and
electrolyte disturbances.
Hospitalization and treatment:
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balanced crystalloid solutions and electrolytes to
correct metabolic disturbances in a short time.
Diet can then be reinstituted slowly and
progressively. Frequent small feedings and
avoidance of foods that are unpleasant to the
patient usually relieve symptoms to a manageable
level.
Recurrences sometimes necessitate repeat
hospitalizations.
Therapeutic abortion for management of this
problem is rarely required.
A variety of antiemetics can be prescribed if the
above measures fail to provide adequate relief
(Metoclopramide, Meclizine, Promethazine).
Risk Factors for PIH
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primigravid status, new paternity;
family history of preeclampsia or eclampsia;
previous preeclampsia or eclampsia;
extremes of maternal age (younger than 20 y or
older than 35 years of age);
preexisting hypertensive vascular, autoimmune,
or renal disease;
preexisting renal, pulmonary, thyroid dysfunction;
Diabetes mellitus;
Multiple gestation;
Nonimmune or alloimmune fetal hydrops;
Hydatidiform Mole.
Theories of PregnancyInduced Hypertension
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Immunological theory
Genetic predisposition
Dietary deficiency
Vasoactive compounds
Endothelial dysfunction
Aspects in pathogenesis of
hypertensive disorders in pregnancy
1. Generalized vasospasm.
2. Hypovolemia.
3. Hemoconcentration.
4. Disseminated intravascular coagulopathy.
5. Metabolic impairment as result of hypoxia.
6.Organ dysfunction – renal, hepatic, cardiac
and pulmonary, hematological, cerebral
problems.
7. Placental dysfunction because the
vasospastic changes.
Classification of PIH
(PREGNANCY INDUCED HYPERTENSION)
1. Hypertensive disorders during
pregnancy.
2. Edema during pregnancy.
3. Proteinuria during pregnancy.
4. Mild preeclampsia.
5. Moderate preeclampsia.
6. Severe preeclampsia.
7. Eclampsia.
“Isolated” and “superimposed”
hypertensive disorders are distinguished.
“Superimposed” hypertensive disorders develop
on the underlying preexisting diseases, such as
Diabetes Mellitus, Hypertensive disease, kidneys
inflammatory diseases, thyroid and pulmonary
dysfunction. They have such peculiarities as:
 early beginning;
 severe duration;
 isolated symptoms only presenting (isolated
proteinuria, edema, or hypertension);
 presence of atypical clinical findings such as
paresthesia, insomnia, hypersalivation.
Chronic hypertension
Is defined as hypertension present
before the twentieth week of
gestation or beyond 6 weeks'
postpartum.
Gestational hypertension
Occurs after 20 weeks of
pregnancy
and
doesn’t
accompanies with proteinuria.
Preeclampsia
Is defined as the development of
hypertension with proteinuria or
edema (or both), induced by
pregnancy, generally in the second
half of gestation.
1. Hypertension in pregnancy.
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It is generally defined as a diastolic blood
pressure of 90 mm Hg or greater, as a
systolic blood pressure at or above 140 mm
Hg at two estimations with the interval 4
hours
or 160/110 mm Hg at once
or as an increase in the diastolic blood
pressure of at least 15 mm Hg or in the
systolic blood pressure of 30 mm Hg or more
when compared to previous blood pressures.
2. Weight gain.
It is a sudden increase in weight may
precede the development of preeclampsia.
Weight increase of about much more than
400 g per week is abnormal.
3. Edema.
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Peripheral edema is common in pregnancy,
especially in the lower extremities;
however, persistent edema unresponsive
to resting in the supine position is not
normal, especially, when it also involves
the upper extremities and face.
edema
4. Headache.
It is unusual in milder cases but frequent
in more severe disease.
It is often frontal but may be occipital,
and it is resistant to relief from ordinary
analgetics.
5. Abdominal pain.
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Epigactric or right upper quadrant pain.
Often is a symptom of severe
preeclampsia and may be indicated of
imminent convulsions.
It may be the result of stretching of the
Hepatic capsule, possibly by edema and
hemorrhage. Tenderness over the liver
should be presented.
6. Visual disturbances.
A spectrum of visual disturbances,
ranging from slight blurring of vision to
scotomas to partial or complete blindness,
may accompany preeclampsia.
These develop as a result of vasospasm,
ischemia, and petechial hemorrhages
within the occipital cortex.
7. Hyperreflexia.
The patellar and achilles deep
tendom reflexes should be carefully
elicited and noted this symptom.
The demonstration of clonus at the
ankle is especially worrisome.
8. Loss of consciousness or seizures.
Any history of loss of
consciousness or seizures, even
in the patient with a known seizure
disorder may be significant.
Laboratory findings of PIH.
Maternal studies
Test or Procedure
Rationale
Proteinuria
Proteinuria is defined as 300 rng or more
Urinary protein during a 24-hour period or
30-100 mg per dL or more in at least two
random urine specimens collected 6 hours or
more apart
Hematocrit in complete blood count / every 2
days
It increasing may signify worsening
vasocanstriction and decreased intravascuiar
volume.
Platelet count / every 2 days
Thrombocytopenia and coagulopathy are
associated
Coagulation profile (FT, PIT)
Fibrin split products
Liver function studies / weekly
Hepaiocellular dysfunction is associated with
worsening PIH
Serum creatinine / twice weekly
Decreased renal function is associated
24-hour urine for creatinine clearance / twice
weekly
24- hour for total protein / twice
Serum uric acid / twice weekly
Laboratory findings of PIH.
Test or Procedure
Fetal studies
Rationale
Ultrasound for fetal growth / every
2 weeks
To assess for pregnancy-associated
hypertension effects on the fetus,
intrauterine growth restriction.
Amniotic fluid volume
Oligohydramnios
Fetal movement record /daily
Chronic fetal distress.
Biophysical profile / twice weekly
Nonstress test / twice weekly
Placental status
Differential diagnosis of chronic
hypertension and preeclampsia
Signs
Hypertensive disease
Preeclampsia
Onset of
hypertension
Before pregnancy and in the
first 20 weeks of gestation
After 20 weeks of gestation
Duration of
hypertension
Constant, lasts during 3
months after delivery
It disappears after 6 weeks
or 3 months after delivery
Hereditary
anamnesis
Presence of hypertensive
disease in the parents, family
Absent
Age
35-40 years old
20-25 years old
Retina
Spasm of vessels,
hemorrhages
Vasospasm, edema of retina
Proteinuria
Absent
Present
Assessment of different
stages of PIH severity
Mild
Moderate
preeclamp
preecla
sia
mpsia
Severe
preeclam
psia
Systolic blood pressure
130-150
mm Hg
150-170
mm Hg
> 170 mm
Hg
Diastolic blood pressure
90-99 mm 100-110
Hg
mm Hg
> 110 mm
Hg
Symptom of
evaluation
Proteinuria in a 24hours < 0,3 g / L
collection sample
0,3-5 g / L
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5 g/ L
Assessment of different
stages of PIH severity
Diuresis per hour
> 50 ml
> 40 ml
Presence of edema
In lower
extremities
In lower
Generalized
extremities
edema
and
abdominal
wall
Number of
thrombocytes
Hematocrit
> 150.000
150 - 80. 000
< 80.000
36 – 38
39 – 42
> 42
< 75
mkmoll/
L
75 – 120
mkmoll/L
Serum creatinine
< 40 ml
> 120
mkmoll/
L
Clinical signs of severe
preeclampsia
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General edema
weight gain exceeds more than 900 g in a
week
cerebral or visual disturbances such as
headache and scotomata
pulmonary edema or cyanosis
epigastric or right upper quadrant pain,
evidence of hepatic dysfunction
Oligouria (less than 500 ml/ day)
Complications of
preeclapsia
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Maternal – placenta abruption,
cerebral hemorrhage, renal and liver
insufficiency, disseminated intravascular
coagulopathy, adrenal insufficiency,
eclampsia.
Fetal – intrauterine growth retardation,
intranatal fetal death, infant morbodity
and mortality.
ECLAMPSIA
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Is characterized typically by those
same abnormalities as severe
preeclampsia with the addition of
convulsions.
The seizures are grand mal and
may appear during pregnancy,
during labor, or postpartum.
the convulsions of eclampsia
Principles of PIH treatment
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Termination of the pregnancy with the
least possible trauma to the mother
and the fetus.
Birth of the infant.
Complete restoration of the health of
the mother.
The
severity
of
the
preeclampsia and the maturity
of the fetus are the primary
considerations
in
the
management of preeclampsia.
TREATMENT
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1. Bed rest. Preferably with as much of the
time as possible spent in a lateral decubitus
position. In this position, cardiac function and
uterine blood flow are maximized and
maternal blood pressures in most cases are
normalized. This improves uteroplacental
function, allowing normal fetal growth and
metabolism.
Ambulatory treatment has no place in the
management of PIH.
Bed-rest throughout the greater part of the
day is essential.
Mild preeclampsia –
expectant management
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Sedative drugs for normalization of
status of central nervous system:
Droperidol – 2 ml IM,
Seduxen – 2 ml IM.
These drugs should be combined with
Droperidol – 0,25 % - 2ml IM or IV
Antihypertensive therapy eliminates
vasospasm of macro- and microcirculation.
It is started if BP > 150/100 mmHg
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Methyldopa – a2 adrenoagonists, false neurotransmission in the
dose 250-500 mg 3- 4 time a day – FIRST-LINE DRUG
Labetalol – a- and b- adrenergic blockers – in the dose 100-400 mg
2-3 times per day (10-20 mg IV every 10 minutes till 300 mg) –
SECOND-LINE DRUG
Atenolol – b1- adrenergic blockers in the dose 25-100 mg once a day
Metoprolol - b1- adrenergic blockers in the dose 12,5-50 mg 2 times
per day
Nifedipine – calcium-channel blocker – in the dose 10 mg po q 4-8
hours;
Hydralazine – miometrial vasodilator (if diastolic pressure is
repeatedly above 110 mm Hg ) An initial dose of 5 mg given every
10 minutes till 20 mg until suitable blood pressure is achieved.
Spasmolytic agents – No-spani 2 % - 2-4 ml IM, Papaverine
hydrochloride – 2 % - 2-4 ml IM, Plathyphillinum – 0,2 % - 2, 0 –
twice a day, Dibasol – 1 % 2-4 ml IM or IV, Euphyllinum – 2,4 % 10,
0 IV.
Magnesium Sulfate
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It is used when diastolic pressure is >
110 mm Hg
It is used to arrest and prevent the
convulsions of eclampsia
It
has
spasmolytic,
sedative,
antihypertensive
and
anticonvulsant effects.
Schemes of magnesium administration in
the case of severe preeclampsia and
eclampsia
Intravenous administration of
Magnesium Sulfate – 4 gram 16 ml 25
% during 5 minutes very slowly (it is
dissolved in 34 ml isotonic solution).
Maintenance dose is 1g-2g/hour (7, 5 g
– 30 ml 25 % solution is dissolved in
220 ml isotonic solution – 3, 33 %
Magnesial solution)
The maximal dose of
magnesium during a day in the
case of severe preeclampsia is
50-80 ml
(12,5 –24 g).
During prescription of
magnesium sulfate
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a. The patellar reflex is present.
b. Respirations are not depressed (> 14
respiratory act in a minute) .
c. Urine output the previous 4 hours
exceeded 100 mL.
Reversal of the effects of excessive
magnesium
concentrations
is
accomplished
by
the
slow
intravenous administration of 10%
calcium gluconate
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Normalization of blood reology
because of hemoconcentration
Trental
Curantil
Komplamin.
Limitated intravenous fluid therapy
under control of blood volume,
hematocrit, diuresis.
Primarily saline (lactated Ringer’s,
isotonic solution) should be given at a
rate of 60-125 ml per hour
PROTOCOL FOR TREATING
ECLAMPSIA
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Turn patient on the side
Establish airways and administer oxygen
Pulmonary ventilation – elimination of
hypoxia
Magnesial therapy. Immediate delivery
within 3 to 6 hours. Continue to administer
magnesium for at least 24 hours after
delivery or last convulsion.
Hypotensive therapy – if DBP > 110 mm
Hg
PROTOCOL FOR TREATING
ECLAMPSIA
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Attention! In the case if severe
preeclampsia and eclampsia three catheters
should be inserted obligatory:
1 – into central vein - v. subclavia for a
fluid therapy and controlling of central
venous pressure;
2 – into urinary bladder for controlling of
diuresis per hour;
3 – transnasal catheterisation of stomach
for prevention of Mendelson’s syndrome.
Duration of treatment
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Mild preeclampsia – 7-10 days
Moderate preeclampsia – 7-10 days
Severe preeclampsia – 24 hours and
termination of pregnancy
Eclampsia – 5 hours and termination of
pregnancy
HELLP SYNDROME
HELLP is the acronym for a specific set of
hypertensive patients who have:
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Hemolysis - anemia
Elevated Liver enzymes – liver dysfunction,
Low Platelet count – hemorrages.
Treatment:
cardiovascular stabilization,
correction of coagulation abnormalities - Platelet
transfusion
correction of liver dysfunction
immediate delivery.
liver dysfunction
Acute fatty liver of pregnancy.
It is a rare complication of pregnancy, but its
severity and maternal mortality rate of 30 % make
its timely diagnosis and treatment of importance. It
is usually occurs late in pregnancy in primagravidas
and characterized by vague gastrointestinal
symptoms becoming worse over several days' time.
Thereafter headache, mental confusion, and
epigastric pain may ensue, and if untreated, there
may be rapid development of coagulopathy, corna,
multiple organ failute and death. Laboratory
findings include an initial modest elevation in
bilirubin and an elevation of transaminase levels.
Treatment of this serious complication is correction
of coagulopathy and electrolyte imbalances,
cardiorespiratory support, and delivery as feasible
by the vaginal route, if possible.