【高血壓英文ppt精品課件】 hypertensive disorders in pregnancy

HypertensiveDisordersinPregnancy AzzaAlyamaniProf ofObstetrics Gynecology ClassificationWomenwhoarepregnantandhypertensivemustbedividedinto chronichypertension pregnancyinducedhypertension PIH orgestationalhypertension thosewithPIHfurthersubdivided proteinuricPIH preeclampsia minority non proteinuricPIHmajority Therefore womenwithhypertensioninpregnancyareclassifiedashaving 1 preeclampsia proteinurichypertension 2 non proteinurichypertension 3 chronichypertension primary essential hypertension 95 secondaryhypertension 5 renaldis adrenaldis hyperthyroidism Theaetiologyandmanagementofthethreeconditionsaredifferent Incidence Worldwide maternalmortalityfromhypertensivediseaseaccountsfor 100 000deathsperyear preeclampsiaoccursin5 non proteinuricPIH15 itaccountsto15 20 ofmaternalmortalityinthedevelopedcuonteris Definition pregnancyinducedhypertension PIH is Hypertensionthatoccursafter20weeksgestationandunrelatedtootherpathology protienuriaistheexcretionof300mgormoreofproteinin24hoursurine hypertensionandprotienuriadefinepreeclampsia Preeclampsia isamultisystemdisorderinvolvingtheplacenta liver kidneys blood neurologicalandcardiovascularsystems bothmaternalandfetalmorbidity mortalityaremorelikelytooccurwithearly onsetdiseaseas placentalabruption acuterenalfailure cerebralHge DICandIUGR prematurityasdeliveryistheonlycure therefore ANCisdirectedtowardsidentifyingwomenwithhypertensionandprotienuria severityrangesfrom amilddisorder transienthypertensioninthelaterpartofthepregnancy toalife threateningdisorderwithseizureHELLPsyndrome fetalhypoxia andgrowthretardation moreseveredisease 0 5per1000deliveries ChronicHypertension isthepresenceofpersistenthypertensionofwhatevercause before20weeksgestationorpersistenthypertensionbeyond6weekspostpartum sustainedbl pof140 90mmHgor ontwooccasions6hoursapartisconsideredhypertensive AetiologyPregnancyinducedhypertension PIH Preeclampsia isunknown believedtobeinvolved immunemaladaptation placentalischemia oxidativestress geneticpredisposition GeneticPredisposition Faultyinterplaybet invadingtrophoblastanddecidua Decreasedbl supplytofeto placentalunit Releaseofcirculatingfactors Endothelialcellalteration Hypertension Proteinuria IUGR ManagementScreeningforpreeclampsia RiskFactors1 vefamilyhistoryinthefirst degreerelativeincreasetheriskofPET4 8fold 2 primiparety3 medicaldisordersas historyofPET chronichypertension diabetes obesity antiphospholipidsyndrome molarpregnancy multiplepregnancy hydropsfetalis Screeningandassessmentforchronichypertension Womenwhoisfoundtobehypertensivebeforepregnancycanbeadvisedabout 1 weightloss 2 restrictsaltandalcoholintake 3 changeherantihypertensiveagents diuretics angiotensin convertingenzyme ACE inhibitorsand blockerstootheralternatives DiagnosisScreeningtests topredictPETandsuperimposedpreeclampsiaonchronichypertension 1 USitisquick non invasiveandinexpensive UterinearteryDoppler analysisofitswaveformisanearlypredictorofpoorplacentalperfusionanddevelopmentofPET thereisresistancecirculationwithnotch Itspredictivevalueisgreaterat24weeksormore Uterineart DopplerinPET diastolicnotch 2 Biochemicaltestsinpreeclampsia HB andHematocritconcentrations CBCwithplateletscount serumuricacid endothelialactivationmarkersareincreased urinaryexcretionofCaandmicroalbuminuria inseverechronichypertension urineanalysis 24hurineforprotein creatinineclearance catecholaminemetabolitesandfreecortisol bl UreaandelectrolytesasNa k LupusanticoagulantandanticardiolipininAPS serumlipids inaddition 3 fundoscopy 4 ECG ECHO 5 Xraychest Symptoms Signs Criteriaofseverepreeclampsia bloodpressure 160mmHgsystolicor 110mmHgdiastolic Proteinuria 3gin24hours Persistentandseverecerebralorvisualdisturbances headache blurredvision Persistentandsevereepigastricpainorrightupperquadrantpain Pulmonaryedemaorcyanosis Oliguria 500mlurine 24hour Eclampsia grandmalseizures HELLPsyndrome Maternalandfetalassessment theGAatwhichwomanpresentwithhypertensionisanimportantfactorinestablishingrisk Lateonsethypertensionafter37weeksrarelyresultinseriousmaternalorfetalcomplications Superimposedpreeclampsiaonchronichypertensionisdiagnosedbyidentifyingproteinuria raiseduricacidlevelsorfailingplateletscount chronichypertensionisassociatedwithpreeclampsiain20 andabruptioplacentain2 UterinearteryDopplervelocitywaveformsisusedtoassessrisk bl pressureandurineanalysisarecheckedevery2weeks suddenandprofoundriseshouldalertthecliniciantothepossibilityofPET highuricacidandlowplateletcountmaypre dateproteinuriabysomeweeks ManagementPreeclampticToxaemiaA PETremotefromtermEarlyonsetPETisassociatedwith a placentalinsufficiencyresultinginIUGRandfetaldeath Therefore FetalWellbeingmustbecarefullyconsidered 1 monitoringoffetalmovements 2 serialsymphesis fundalheight 3 serialUStoconfirmfetalgrowth AFvolumeandUmbilicalA Dopplerwaveform b involvementofotherorgansystemsresultinginincreasedmaternalmorbidityandmortality 1 serialplateletscountasplateletsareconsumedduetoendothelialactivation Thrompocytopenia 100 000 ml deliveryshouldbeconsidered 2 increasedHBandhaematocritvaluesindicatehypovolaemia 3 clottingabnormalitiesindicateDIC 4 raiseduricacidameasureoffinerenaltubularfunctionisusedtoassessseverityofthedisease raisedureaandcreatinineindicatelaterenalinvolvement 5 severeproteinuria 3g 24hoursurineresultinginfallofcirculatingalbuminandincreasingtheriskofpulmonaryedema 5 HELLPsyndromeitisseverevariantofPET Haemolysis ElevatedLiverenzymesandLowPlatelets PETcancausesubcapsularhematoma liverruptureandhepaticinfarctionwhichresultinraisedlivertransaminasesasASTindicatinghepatocellulardamageandliverinvolvementandtheneedtoconsiderdelivery Delivery shouldbeconsideredoncefetallungmaturityislikely at32weeksgestation especiallyifeithermulti organinvolvementorfetalcompromiseisproved Corticosteroidsaregiventoenhancefetallungmaturity SteroidtherapymayenhancerecoveryfromHEELPsyndrome DeliverybeforetermisusuallybyCS suchpatientsareriskofthromboembolismandshouldbegivenprophylacticSCheparinandstockings IndicationsofterminationofpregnancyinPET 1 uncontrollablehypertension 2 deterioratingliverorrenalfunction 3 progressivefallinplatelets 4 neurologicalcomplicationsascerebralHge 5 deterioratingfetalconditionasnon reactiveCTG B PETneartermLatonsetpreeclampsiararelyresultsinseriousmorbiditytomotherorfetus Drugtherapyshouldbeconsidered a antihypertensivetheaimistolowerthebl pressureandlowertheriskofmaternalcerebrovacularaccidentwithoututerinebl flowandcompromisingthefetus 1 Labetolol blockers canbegivenIVandorally safeduringpregnancy 2 Methyldopacentrallyactingagent verysafeduringpregnancy onlygivenorally takes24hforitseffect 3 NifedipineisCachannelblocker withrapidonsetofaction causesevereheadache NB Diuretics Angiotensin convertingenzyme ACE inhibitorsand blockersarecontraindicated b Lowdoseaspirinresultsinsignificantreductioninpreeclampsiaassociatedfetaldeathandpretermdelivery c forprophylaxisCa fishoil antioxidants vit C vit E Managementofseverefulminatingpreeclampsiaandimpendingeclampsia 1 IVantihypertensiveHydralazine labetololIVinfusiontitrationrapidlyagainstchangesinthebloodpressure 2 AnticonvulsanttherapyMagnesiumSulfate itistheanticonvulsantofchoiceasttt ofeclampsiaandalsoasprophylaxiswhichreducetheriskoffitstohalf Diazepamandphenytoincanbeusedbutlesseffective modeofaction anticonvulsant musclerelaxant vasodilator reducetheintracerebralischaemia dose2gIVasaloadingdosethen1 2g hasmaintenanceinfusion toxicityisdetectedby absenceofthepatellarreflexes respiratoryarrest maybecardiacarrest antidoteis 10mlof10 Cagluconate 3 FluidmanagementaFol