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ΕΓΚΥΜΟΣΥΝΗ ΚΑΙ ΥΠΕΡΤΑΣΗ Ανδρέας Πιτταράς Καρδιολόγος Hypertension specialist ESH Υπερτασικό Ιατρείου Τζάνειο νοσοκομείο Υπερηχοκαρδιογραφικό εργαστήριο ΝΜΥΑ ΙΚΑ. Hypertensive disorders in pregnancy:. a major cause of. maternal fetal neonatal morbidity and mortality. - PowerPoint PPT Presentation

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  • Hypertension specialist ESH

  • Hypertensive disorders in pregnancy: maternal fetal neonatal morbidity and mortalitya major cause of

  • Pregnant women with hypertensionat higher risk for abruptio placentae cerebrovascular events organ failure DIC

  • Fetus at higher risk for intrauterine growth retardation prematurity intrauterine death

  • WHO definition of hypertensionin pregnancy1. SBP > 140 mmHg or DBP > 90 mmHg

    2. Rise in SBP > 25 mmHg or rise in DBP > 15 mmHg compared to pre-pregnancy values or those in the first trimester

  • Definition of hypertensionin pregnancySBP > 140 mmHg or DBP > 90 mmHg

  • Cardiovascular changes in pregnancySBPDBPMAPHRSVCO 4-6 mmHg 8-15 mmHg 6-10 mmHg 12-18 BPM 10-30% 33-45%All bottom at 20-24 wks, then rise gradually to pre-pregnancy values at term

    Early 2nd trimester, then stableEarly 2nd trimester, then stablePeaks in early 2nd trimester, then until termParameter TimingMain DM, Main EK: Obstetrics and Gynecology, 1984

  • Definition CHS NHBPEPWG WHOHypertension,mmHg

    Severe hypertensionDBP > 90

    DP > 110BP > 140/90

    DP > 110 orSP > 160BP > 140/90or riseSP > 25 and/orDP > 15 mmHg

    DP > 110SP > 160CHS = Canadian Hypertension SocietyNHBEPWG = National High Blood Pressure Education Program Working Group (US)WHO = World Health Organization

  • Definition ISSH ASSH ACOGHypertension,mmHg

    Severe hypertensionDP > 90

    DP > 110DP > 90 and/orSP > 140, or risein SP of > 25 andin DP of > 15

    DP > 110 and/orSP > 170DP > 90or SP > 140

    DP > 110SP > 160-180ISSH = International Society for Study of HypertensionASSH = Australian Society for Study of HypertensionACOG = American College of Obstetricians and Gynecologists

  • Criterion CHS NHBPEPWG WHOKorotkoffsound

    Severe proteinuria(24-h urine collection, g/d)IV

    > 3V

    > 2IV

    -CHS = Canadian Hypertension SocietyNHBEPWG = National High Blood Pressure Education Program Working Group (US)WHO = World Health Organization

  • Criterion ISSH ASSH ACOGIV

    > 3Korotkoffsound

    Severe proteinuria(24-hr urine collection, g/d) IV

    > 0.3 or positivedipstick result of> 2+-

    > 5ISSH = International Society for Study of HypertensionASSH = Australian Society for Study of HypertensionACOG = American College of Obstetricians and Gynecologists

  • Measurement of BP Mercury sphygmomanometer

    Both Phases IV and V to be recorded

    Phase IV should be used for initiating clinical investigation and management

  • Classification of hypertensionin pregnancy pre-existing hypertension gestational hypertension pre-existing hypertension plus superimposed gestational hypertension with proteinuria antenatally unclassifiable hypertension

  • Pre-existing hypertension 1-5% of pregnancies

    BP > 140/90 mmHg predates pregnancy or develops before 20 weeks of gestation

    In most cases, hypertension persists more than 42 days post partum, it may be associated with proteinuria

  • Gestational hypertensionPregnancy-induced hypertension withor without proteinuria

    Hypertension develops after 20 weeksgestation, in most cases, it resolves within42 days post partum

    Poor organ perfusion

  • Pre-existing hypertension plussuperimposed gestational hypertensionwith proteinuriaFurther worsening of BP and proteinexcretion > 3 g/day in 24-hour urine collection after 20 weeks gestation

    Previous terminology chronic hypertension with superimposed pre-eclampsia

  • Antenatally unclassifiable hypertensionHypertension with or without systemicmanifestation

    BP first recorded after 20 weeks gestation,re-assessment necessary at or after 42 dayspost partum

  • Pre-eclampsia

    Gestational hypertension associated with significant proteinuria

    300 mg/l or 500 mg/24 h or dipstick 2+ or more

    Poor organ perfusion

  • Basic laboratory tests for monitoringhypertension in pregnancy Hemoglobin and hematocrit Platelet count Serum AST, ALT, LDH Proteinuria (24-h urine collection) Urinalysis Serum uric acid Serum creatinine

  • Hemoglobinand hematocrit

    Platelet countHemoconcentration supports diagnosis of gestationalhypertension with or without proteinuria. It indicatesseverity. Levels may be low in very severe casesbecause of hemolysis.

    Low levels < 100,000 x 109/L may suggest consumptionin the microvasculature. Levels correspond to severityand are predictive of recovery rate in post-partumperiod, especially for women with HELLP syndrome.* Basic laboratory tests for monitoring hypertension in pregnancy* HELLP Hemolysis, Elevated Liver enzyme levels and Low Platelet count

  • Basic laboratory tests for monitoring hypertension in pregnancySerum uric acid

    SerumcreatinineElevated levels aid in differential diagnosis of gestational hypertension and may reflect severity.

    Levels drop in pregnancy. Elevated levels suggestincreasing severity of hypertension; assessment of 24-h creatinine clearance may be necessary.

  • Basic laboratory tests for monitoring hypertension in pregnancySerum AST,ALT

    Serum LDHElevated levels suggest hepatic involvement. Increasing levels suggest worsening severity.

    Elevated levels are associated with hemolysis and hepatic involvement. May reflect severity and may predict potential for recovery post partum, especially for women with HELLP* syndrome.* HELLP Hemolysis, Elevated Liver enzyme levels and Low Platelet count

  • Basic laboratory tests for monitoring hypertension in pregnancyUrinalysis

    Proteinuria(24-h urinecollection)Dipstick test for proteinuria has significant false-positiveand false-negative rates. If dipstick results are positive(> 1), 24-h urine collection is needed to confirmproteinuria. Negative dipstick results do not rule outproteinuria, especially if DBP > 90 mmHg.

    Standard to quantify proteinuria. If in excess of 2g/day,very close monitoring is warranted. If in excess of 3g/day,delivery should be considered.

  • Management of hypertension in pregnancy

    depends on

    BP levels gestational age associated maternal and fetal risk factors

  • Non-pharmacologic management SBP 140-149 mmHg or DBP 90-99 mmHg

    activity, bed rest (left lateral position)

    AVOID : weight reduction and salt restriction

  • Emergency management of hypertension in pregnancy

    SBP 170 or DBP 110 mmHghydralazine, labetalol, methyldopa or nifedipine

  • Thresholds for drug treatment initiation

    BP > 140/90 mmHg in women with gestational hypertension without proteinuria or pre-existing hypertension before 28 weeks' gestation or gestational hypertension and proteinuria or symptoms at any time or pre-existing hypertension and TOD or pre-existing hypertension and superimposed gestational hypertension

    BP > 150/95 mmHg In all other circumstances methyldopa, labetalol, calcium antagonists, and beta-blockers

    AVOID: ACE inhibitors, AIIA, diuretics

    magnesium sulfate: eclampsia, treatment and prevention of seizures

  • Br J Obstet Gynaecol 1998;105:718-22

  • Antihypertensive drugs used in pregnancyWomen with pre-existing hypertension are advisedto continue their current medication except for ACEinhibitors and AIIA

  • Antihypertensive drugs used in pregnancyCentral alfaagonists

    Beta-blockers

    Alfa-/beta-blockersMethyldopa is the drug of choice.

    Atenolol and metoprolol appear to be safe and effectivein late pregnancy.

    Labetalol has comparable efficacy with methyldopa,in case of severe hypertension, it could be givenintravenously.

  • Antihypertensive drugs used in pregnancyCalcium-channel blockers

    ACE inhibitors,angiotensin IIantagonistsOral nifedipine or i.v. isradipine could be givenin hypertensive emergencies. Potential synergismwith magnesium sulfate may induce hypotension.

    Fetal abnormalities including death can be causedand these drugs should not be used in pregnancy.

  • Antihypertensive drugs used in pregnancyDiuretics

    DirectvasodilatorsDiuretics are recommended for chronic hypertensionif prescribed before gestation or if patients appear tobe salt-sensitive. They are not recommended inpre-eclampsia.

    Hydralazine is no longer the parenteral drug of choice;perinatal adverse effects.

  • Breast-feeding

    Does not increase BP in nursing mothers

    All antihypertensive agents taken by the nursing mother are excreted into breast milk; however, most of them are present at very low concentrations, except for propranolol and nifedipine concentrations, which are similar to maternal plasma

  • Implications of hypertension in pregnancy

  • Pathophysiologic factors involved in preeclampsia

  • Chronic hypertension BP 140/90 mm Hg before the 20th week of gestationPreeclampsia Elevated BP ( 140/90 mm Hg) in a patient who was normotensive before 20 weeks of gestation, accompanied by Urinary excretion of 0.3 g of protein in a 24-h collectionOther features that increase the certainty of the diagnosis of preeclampsia BP 160/110 mm Hg Proteinuria 2.0 g/24 h that appears initially during pregnancy and regresses postpartum Newly-elevated se