1. Copyright © 2005 by Elsevier, Inc. All rights reserved. Hypertension During pregnancy Chapter 25

2. Copyright © 2005 by Elsevier, Inc. All rights reserved. 2 Classification of Hypertension During Pregnancy First four are the maine catogries of Hypertension During Pregnancy 1.Preeclampsia 2.Eclampsia 3.Gestational hypertension 4.Chronic hypertension 5.Preeclampsia superimposed on chronic hypertension See table 25-1 (classification of hypertension in pregnancy), page 591 First four are the maine catogries of Hypertension During Pregnancy 1.Preeclampsia 2.Eclampsia 3.Gestational hypertension 4.Chronic hypertension 5.Preeclampsia superimposed on chronic hypertension See table 25-1 (classification of hypertension in pregnancy), page 591

3. Copyright © 2005 by Elsevier, Inc. All rights reserved. Preeclampsia Systolic blood pressure of 140 mmHg or more and diastolic blood pressure of 90 mmHg or more after 20 weeks of pregnancy that is accompanied by proteinurea more or equal 0.3 g in a 24 hour collection or 1+ or more in urine dipstick

4. Copyright © 2005 by Elsevier, Inc. All rights reserved. Eclampsia Progression of preeclampsia to generalized seizures that cannot be attributed to other causes

5. Copyright © 2005 by Elsevier, Inc. All rights reserved. Preeclampsia superimposed on chronic hypertension Development of new onset proteinurea more or equal 0.3 g in a 24 hour collection or 1+ or more in random urine dipstick in a woman who has chronic hypertension. In a woman who had proteinuria before 20 weeks of gestation, Preeclampsia should be suspected if woman has sudden increase in proteinuria from baseline levels, a sudden increase in blood pressure when it had been previously well controlled. Development of thrombocytopenia (Platelets <100,000/mm³), or abnormal elevations of liver enzymes (Aspartate aminotransferase (AST, (SGOT) ) or Alanine aminotransferase (ALT (SGPT)) Development of new onset proteinurea more or equal 0.3 g in a 24 hour collection or 1+ or more in random urine dipstick in a woman who has chronic hypertension. In a woman who had proteinuria before 20 weeks of gestation, Preeclampsia should be suspected if woman has sudden increase in proteinuria from baseline levels, a sudden increase in blood pressure when it had been previously well controlled. Development of thrombocytopenia (Platelets <100,000/mm³), or abnormal elevations of liver enzymes (Aspartate aminotransferase (AST, (SGOT) ) or Alanine aminotransferase (ALT (SGPT)) 5

6. Copyright © 2005 by Elsevier, Inc. All rights reserved. Chronic hypertension Elevated blood pressure that was known to exist before pregnancy or develops before 20 weeks of pregnancy or hypertension that is not resolved during postpartum period

7. Copyright © 2005 by Elsevier, Inc. All rights reserved. Risk Factors 1.First pregnancy 2.Women older than 35 years. 3.Ethnicity (African- American) 4.Positive family history 5.Women who have chronic hypertension or renal disease. 1.First pregnancy 2.Women older than 35 years. 3.Ethnicity (African- American) 4.Positive family history 5.Women who have chronic hypertension or renal disease.

8. Copyright © 2005 by Elsevier, Inc. All rights reserved. 6. Overweight 7. Women with DM 8. Multifetal gestations 9. Presence of immunologic disorders. 9. Women married from fathers who has previously fathered a pregnancy in another woman that was complicated with preeclampsia. 6. Overweight 7. Women with DM 8. Multifetal gestations 9. Presence of immunologic disorders. 9. Women married from fathers who has previously fathered a pregnancy in another woman that was complicated with preeclampsia.

9. Copyright © 2005 by Elsevier, Inc. All rights reserved. Pathophysiology Preeclampsia is a result of generalized vasospasm Vasoconstriction results in the impeded blood flow and elevated blood pressure. As a result, circulation to all body organs, including the kidneys, liver, brain and placenta is decreased. Preeclampsia is a result of generalized vasospasm Vasoconstriction results in the impeded blood flow and elevated blood pressure. As a result, circulation to all body organs, including the kidneys, liver, brain and placenta is decreased.

10. Copyright © 2005 by Elsevier, Inc. All rights reserved. The most significant changes: Decrease renal perfusion lead to Decreased GFR Increased BUN,Increased Createnine,Increased uric acid Proteinurea Generalized edema Increased blood viscosity (elevated hematocrite) Water and sodium retention,rapid weight gain The most significant changes: Decrease renal perfusion lead to Decreased GFR Increased BUN,Increased Createnine,Increased uric acid Proteinurea Generalized edema Increased blood viscosity (elevated hematocrite) Water and sodium retention,rapid weight gain

11. Copyright © 2005 by Elsevier, Inc. All rights reserved. Decreased liver perfusion lead to Impaired liver function Hepatic edema and subscapular hemorrhage Elevated liver enzymes Epigastric pain Vasoconstriction of cerebral vessels lead to Cerebral hemorrhage Headache and visual disturbances(blurred vision and spot before eyes) and hyperreflexia Decreased liver perfusion lead to Impaired liver function Hepatic edema and subscapular hemorrhage Elevated liver enzymes Epigastric pain Vasoconstriction of cerebral vessels lead to Cerebral hemorrhage Headache and visual disturbances(blurred vision and spot before eyes) and hyperreflexia

12. Copyright © 2005 by Elsevier, Inc. All rights reserved. Decreased placental perfusion Intra uterine growth retardation Persistent fetal hypoxemia Abruptio placenta and HELLP syndrome may results DIC Lung Pulmonary edema a( symptoms include dyspnea) Intra uterine growth retardation Persistent fetal hypoxemia Abruptio placenta and HELLP syndrome may results DIC Lung Pulmonary edema a( symptoms include dyspnea)

13. Copyright © 2005 by Elsevier, Inc. All rights reserved. Preventive measures : 1.Early and regular prenatal care 2.Weight gain watching 3.Monitor blood pressure 4.Monitoring of urinary protein 5.Anti oxidants therapy: Recent researches assessed the benefit of 1000mg of Vit C and 400 IU of Vit E starting at 22 weeks. 7. Attempts of prevention in woman of high risks includes: -low dose aspirin -calcium and magnesium supplement -fish oil supplements Preventive measures : 1.Early and regular prenatal care 2.Weight gain watching 3.Monitor blood pressure 4.Monitoring of urinary protein 5.Anti oxidants therapy: Recent researches assessed the benefit of 1000mg of Vit C and 400 IU of Vit E starting at 22 weeks. 7. Attempts of prevention in woman of high risks includes: -low dose aspirin -calcium and magnesium supplement -fish oil supplements

14. Copyright © 2005 by Elsevier, Inc. All rights reserved. Manifestations: 1.Classic signs hypertension proteinurea 2. Additional signs: retinal vasoconstriction; Hyperreflexia Impaired coagulation (decrease platelets) Lab test indicate liver and renal dysfunction Generalised edema Manifestations: 1.Classic signs hypertension proteinurea 2. Additional signs: retinal vasoconstriction; Hyperreflexia Impaired coagulation (decrease platelets) Lab test indicate liver and renal dysfunction Generalised edema

15. Copyright © 2005 by Elsevier, Inc. All rights reserved. Manifestations:Classic Signs: Hypertension & Proteinurea 15 Systolic BP≥140 but < 160 mm Hg Diastolic BP ≥ 90 but < 110 mm Hg Proteinuria ≥0.3g but <2g in 24hr collection 1+ or higher on random dipstick sample Systolic BP ≥160 mm Hg Diastolic BP ≥110 mm Hg Proteinuria ≥5g in 24hr collection 3+ or higher on random dipstick sample Mild preeclampsia Severe preeclampsia

16. Copyright © 2005 by Elsevier, Inc. All rights reserved. 3. Symptoms: 1.continuous headache 2.drowsiness 3.mental confusion 4.convulsion (eclampsia) 5.visual disturbances 6.epigastric pain 7.decreased urinary output < 500ml/ day or 30 ml/hr.(oligurea) See table 25-3 (mild vs. severe preeclampsia) page 594 3. Symptoms: 1.continuous headache 2.drowsiness 3.mental confusion 4.convulsion (eclampsia) 5.visual disturbances 6.epigastric pain 7.decreased urinary output < 500ml/ day or 30 ml/hr.(oligurea) See table 25-3 (mild vs. severe preeclampsia) page 594

17. Copyright © 2005 by Elsevier, Inc. All rights reserved. Therapeutic management: -Delivery is the only definitive treatment but it may not be practical if preeclampsia is mild the fetus is premature. -If the fetus less than 34 wks, steroids to accelerate fetal lung maturity will be given and delay birth for 48 hrs. -If the maternal or fetal condition deteriorates, the woman will be delivered regardless the fetal age or administration of steroids. -Vaginal birth is preferred because of the multisystem impairments. Therapeutic management: -Delivery is the only definitive treatment but it may not be practical if preeclampsia is mild the fetus is premature. -If the fetus less than 34 wks, steroids to accelerate fetal lung maturity will be given and delay birth for 48 hrs. -If the maternal or fetal condition deteriorates, the woman will be delivered regardless the fetal age or administration of steroids. -Vaginal birth is preferred because of the multisystem impairments.

18. Copyright © 2005 by Elsevier, Inc. All rights reserved. Home care for mild preeclampsia: Home management is possible if preeclampsia is mild, the woman and the fetus in stable condition and if she can adhere to the treatment plan and make a follow up visit every 3-4 days 1.Activity restriction;side lying at least one and half hour a day 2.Fetal activity (kick count) should report if no movement noticed in a 4 hour period 3.Weight daily each morning 4.Urinanalysis for proteinurea daily 5.Diet, regular balance nutrition without salt or fluid restrictions 6.Blood pressure checked 2to4 times daily Home care for mild preeclampsia: Home management is possible if preeclampsia is mild, the woman and the fetus in stable condition and if she can adhere to the treatment plan and make a follow up visit every 3-4 days 1.Activity restriction;side lying at least one and half hour a day 2.Fetal activity (kick count) should report if no movement noticed in a 4 hour period 3.Weight daily each morning 4.Urinanalysis for proteinurea daily 5.Diet, regular balance nutrition without salt or fluid restrictions 6.Blood pressure checked 2to4 times daily

19. Copyright © 2005 by Elsevier, Inc. All rights reserved. Inpatient management for severe preeclampsia: Severe preeclampsia is diagnosed if systolic Bp ≥ 160or diastolic ≥110mmHg or multisystem involvement Delivery is necessary even if GW less than 34 Management Bed rest on quiet environment Reduce external stimuli that precipitate a convulsion( noise, light) - Anticonvulsant medications (MgSO4) - Antihypertensive medications: BP 160/110 ≥ Hydralanazine is given. Inpatient management for severe preeclampsia: Severe preeclampsia is diagnosed if systolic Bp ≥ 160or diastolic ≥110mmHg or multisystem involvement Delivery is necessary even if GW less than 34 Management Bed rest on quiet environment Reduce external stimuli that precipitate a convulsion( noise, light) - Anticonvulsant medications (MgSO4) - Antihypertensive medications: BP 160/110 ≥ Hydralanazine is given.

20. Copyright © 2005 by Elsevier, Inc. All rights reserved. S/S of magnesium sulfate toxicity Respiratory rate< 12 per minute Maternal pulse oximetre <95% Hyporeflexia(absence DTR) Sweating, flushing Altered sensorium(confusion and drowsiness Hypotension Sudden decrease in FHR Serum MgSo4 level >8 mg/dl Urine output<30 ml /hour Respiratory rate< 12 per minute Maternal pulse oximetre <95% Hyporeflexia(absence DTR) Sweating, flushing Altered sensorium(confusion and drowsiness Hypotension Sudden decrease in FHR Serum MgSo4 level >8 mg/dl Urine output<30 ml /hour

21. Copyright © 2005 by Elsevier, Inc. All rights reserved. 2. Intrapartum management: a.During labor: -Monitor the mother to prevent convulsions; -Keep woman on lateral position; -Vaginal births is usually the first choice; -Give oxytocin to stimulate birth; -Continuous fetal monitoring. -Pain control ( narcotic or epidural) -Mgso4 to prevent convulsion 2. Intrapartum management: a.During labor: -Monitor the mother to prevent convulsions; -Keep woman on lateral position; -Vaginal births is usually the first choice; -Give oxytocin to stimulate birth; -Continuous fetal monitoring. -Pain control ( narcotic or epidural) -Mgso4 to prevent convulsion

22. Copyright © 2005 by Elsevier, Inc. All rights reserved. 3. Postpartum management: -Careful assessment of the mother’s blood loss and signs of shock; -Assessment of s/s of preeclampsia is continuous for at least 48 hrs; -Continue giving magnesium to prevent seizures. Signs of recovering: -Urinary output 4-6 l/day -Decrease protein in urine -Return BP to normal within 2 weeks. -Gradual improvement in serum laboratory values 3. Postpartum management: -Careful assessment of the mother’s blood loss and signs of shock; -Assessment of s/s of preeclampsia is continuous for at least 48 hrs; -Continue giving magnesium to prevent seizures. Signs of recovering: -Urinary output 4-6 l/day -Decrease protein in urine -Return BP to normal within 2 weeks. -Gradual improvement in serum laboratory values

23. Copyright © 2005 by Elsevier, Inc. All rights reserved. Nursing care: 1.assessment: -Weight daily -Vital signs every 4 hour -Ascultate the chest for moist breath sounds (pulmonary edema) -Assess edema every 4 hours -Measure urine output hourly -Check urine for protein every 4 hours Nursing care: 1.assessment: -Weight daily -Vital signs every 4 hour -Ascultate the chest for moist breath sounds (pulmonary edema) -Assess edema every 4 hours -Measure urine output hourly -Check urine for protein every 4 hours

24. Copyright © 2005 by Elsevier, Inc. All rights reserved. 24 Assessment of Edema  (+1) Minimal edema of lower extremities  (+2) Marked edema of lower extremities  (+3) Edema of lower extremities,face,hands and sacral area  (+4) Generalized massive edema that include ascites (accumulation of fluid in peritoneal cavity)  (+1) Minimal edema of lower extremities  (+2) Marked edema of lower extremities  (+3) Edema of lower extremities,face,hands and sacral area  (+4) Generalized massive edema that include ascites (accumulation of fluid in peritoneal cavity)

25. Copyright © 2005 by Elsevier, Inc. All rights reserved. 25

26. Copyright © 2005 by Elsevier, Inc. All rights reserved. -Fetal monitoring -Check brachial, radial and patellar reflexes for hyperreflexia, or hyporeflexia which indicate magnesium excess, -Ask woman about symptoms e.g. headache, visual disturbances epigastric pain, nausea vomiting and increased edema. -Fetal monitoring -Check brachial, radial and patellar reflexes for hyperreflexia, or hyporeflexia which indicate magnesium excess, -Ask woman about symptoms e.g. headache, visual disturbances epigastric pain, nausea vomiting and increased edema.

27. Copyright © 2005 by Elsevier, Inc. All rights reserved. Management of eclampsia : -Maintain patent airway -Adequate oxygenation -Put the patient on lateral position to prevent aspiration -After convulsion suction of food and fluids -Administer anticonvulsant -Monitor fetal status -Blood specimen for type and Rh, -Accurate assessment of urine output. Management of eclampsia : -Maintain patent airway -Adequate oxygenation -Put the patient on lateral position to prevent aspiration -After convulsion suction of food and fluids -Administer anticonvulsant -Monitor fetal status -Blood specimen for type and Rh, -Accurate assessment of urine output.

28. Copyright © 2005 by Elsevier, Inc. All rights reserved. HELLP Syndrome H: Hemolysis EL: Elevated liver enzymes (AST and ALT) LP: Low platelets counts, <100,000/mm³ The prominent symptoms: Pain in the right upper quadrant, the lower chest or epigastric area Nausea, vomiting and severe edema Treatment in intensive care unit H: Hemolysis EL: Elevated liver enzymes (AST and ALT) LP: Low platelets counts, <100,000/mm³ The prominent symptoms: Pain in the right upper quadrant, the lower chest or epigastric area Nausea, vomiting and severe edema Treatment in intensive care unit