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Management of Hypertension During Pregnancy: DR Surendra Nath Panda, M.S

This document discusses the management of hypertension during pregnancy. It notes that hypertension is one of the most common complications of pregnancy, affecting about 10% of pregnancies. There are different types of hypertension that can occur during pregnancy, including pregnancy-induced hypertension, chronic hypertension, and preeclampsia. The document outlines recommendations for monitoring both the mother and fetus, treating hypertension through lifestyle changes and medications, timing delivery based on gestational age and maternal/fetal conditions, and providing postpartum care. The overall goal of management is to prevent complications, lower blood pressure, prolong pregnancy to achieve fetal maturity, and deliver safely.

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238 views18 pages

Management of Hypertension During Pregnancy: DR Surendra Nath Panda, M.S

This document discusses the management of hypertension during pregnancy. It notes that hypertension is one of the most common complications of pregnancy, affecting about 10% of pregnancies. There are different types of hypertension that can occur during pregnancy, including pregnancy-induced hypertension, chronic hypertension, and preeclampsia. The document outlines recommendations for monitoring both the mother and fetus, treating hypertension through lifestyle changes and medications, timing delivery based on gestational age and maternal/fetal conditions, and providing postpartum care. The overall goal of management is to prevent complications, lower blood pressure, prolong pregnancy to achieve fetal maturity, and deliver safely.

Uploaded by

maria erika
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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MANAGEMENT OF HYPERTENSION

DURING PREGNANCY

DR SURENDRA NATH PANDA, M.S.


PROF. OF OBST.GYNAEC.
M.K.C.G.MEDICAL COLLEGE
BERHAMPUR,Orissa, INDIA

Lecture presented at the workshop on “Reproductive & Child Health


Care” Of Burla O&G Society
HYPERTENSION DURING PREGNANCY

NEMESIS OF THE OBSTETRICIAN

 MOST COMMON COMPLICATION AFTER ANAEMIA -


affects about 10% of pregnancies
 CAUSE ?- PREGNANCY - CAN’T AVOID
 WHY & HOW ? - STILL A MYSTERY
 PROGRESSIVE DISORDER WITH UNPREDICTABLE
COURSE
 WIDESPREAD MULTIORGAN INVOLVEMENT
 TREATMENT IS DIFFICULT AND UNSATISFACTORY
 POSSIBILITY OF UNEXPECTED, SUDDEN & SERIOUS
COMMPLICATIONS OF MOTHER & FOETUS
 A MAJOR CAUSE OF M / F / N / morbidity & mortality
 RECURRENCE IN SUBSEQUENT PREGNANCY-
1st- 25%, 2nd- 56%, 3rd- 78%
HYPERTENSION DURING PREGNANCY

MANAGEMENTASPECTS

 PREVENTION -
 IDENTIFICATION
OF HIGH RISK GROUP
 PREVENTIVE MEASURES - SUCCESS ?

 AVOID PREGNANCY ?

 DIAGNOSIS - EARLIER THE BETTER


 PATHOPHYSIOLOGY
 MONITORING / SURVEILLANCE
 TREATMENT
HYPERTENSION DURING PREGNANCY

DIAGNOSIS - BP >140/90
1) PREGNANCY INDUCED
TYPES- HYPERTENSION (PIH)

MOSTLY YOUNG PRIMIS / >35, IN 3RD TRIMESTER


(NOT BEFORE 20 WEEKS)

A) HYPERTENSION OF PREGNACY -
BP >140 / 90 MM OF HG ALONE OR WITH MILD OEDEMA
B) PREECLAMPSIA -
B.I) MILD PREECLAMPSIA -
BP <160/100, MILD OEDEMA, PROTEINURIA Trace / 1+,
MINIMAL, LIV ENZ
HYPERTENSION DURING PREGNANCY

DIAGNOSIS - BP >140/90
1) PREGNANCY INDUCED
TYPES- HYPERTENSION (PIH)

B.II) SEVERE PREECLAMPSIA -


BP >160/110, MARKED OEDEMA, PROTEINURIA 2+ ,
HEADACHE,VISUAL DISTURBANCES, ABDOMINAL PAIN,
OLIGURIA, THROMBOCYTOPENIA,BILIRUBIN, LIVER
ENZYMES, CREATININE, FOETAL GROWTH
RETARDATION, PULMONARY OEDEMA
C) ECLAMPSIA -
WITH CONVULSION
HYPERTENSION DURING PREGNANCY

DIAGNOSIS - BP >140/90
2) CHRONIC HYPERTENSION
TYPES- ESSENTIAL / RENAL / Others
 MOSTLY OBESE, ELDERLY, PAROUS & LIKELY TO BE
ON ANTIHYPERTENSIVE DRUGS
 USUALLY PREEXISTS / APPEARS EARLY (<20WKS) &
PERSISTS POSTPARTUM
 END ORGAN DAMAGE MAYBE PRESENT
A) COINCIDENTAL - sustained high BP throughout
pregnancy & postpartum
B) AGGRAVATED BY PREGNANCY -
I) SUPERIMPOSED PREECLAMPSIA
II) SUPERIMPOSED ECLAMPSIA
HYPERTENSION DURING PREGNANCY
PATHOPHYSIOLOGY OF PIH
 VASOSPASM HAEMORRAGE & NECROSIS
END ORGAN CHANGES
 REDUCED PLACENTAL PERFUSION > IUGR &
FOETAL DEATH
 INCRASED CARDIAC OUTPUT
 INCREASED EXTRA CELLULAR FLUID VOLUME
 HAEMOCONCENTRATION
 HYPERCOAGULABILITY-DIC - REDUCED
CLOTTING FACTORS - BLEEDING
 REDUCED GFR - OLIGURIA - ANURIA
 NO ELECTROLYTIC IMBALANCE
HYPERTENSION DURING PREGNANCY
PATHOPHYSIOLOGY OF PIH

SERIOUS COMPLICATIONS: -
 HELLP SYNDROME
 ABRUPTIO PLACENTAE
 PULMONARY OEDEMA
 ACUTE RENAL FAILURE
 CEREBRAL HAEMORRHAGE
 VISUAL DISTURBANCES & BLINDNESS
 HEPATIC RUPTURE
 ELECTROLYTIC IMBALANCE
 POSTPARTUM COLLAPSE
HYPERTENSION DURING PREGNANCY

OBJECTIVES OF MANAGEMENT

 CURE / PREVENT PROGRESSION -


 CLOSE MONITORING
 REDUCE BLOOD PRESSURE -TATRGET- 140/90
 PROMOTE FOETAL MATURITY
 PROLONG PREGNANCY (34 - 36 WEEKS)
 TO ACHIEVE FOETAL MATURITY TERMINATION
 DELIVERY- BEST DAY, BEST WAY & BEST PLACE
 PREVENT / MANAGE COMPLICATIONS
HYPERTENSION DURING PREGNANCY

MATERNAL MONITORING

 LOOK FOR APPEARANCE OF OMINOUS


FEATURES
 DAILY- RECORD B.P 4 TIMES, MONITOR
URINE OUTPUT & TEST FOR PROTEINURIA
QUALI. / QUANT
 ALT.DAY- BODY WEIGHT

 EVERY 4TH DAY- URIC ACID, PLATELET


COUNT, L.F.T. (LDH)
 WEEKLY- CREATININE
HYPERTENSION DURING PREGNANCY

FOETAL MONITORING

 DAILY - CLINICAL FOETAL MONITORING -


FHS, FUNDAL Ht. ABDOMINAL GIRTH,
LIQUOR, FOETAL MOVEMENT COUNT, C.T.G
 USG - ON ADMISSION & THEN 3 WEEKLY
FOR FOETAL BIOPHYSICAL PARAMETERS,
PLACENTA AND LIQUOR VOLUME
 DOPLLER USG FOR PLACENTAL BLOOD
FLOW VELOCITY EVERY 4TH DAY
 L/S RATIO FOR MATURITY
HYPERTENSION DURING PREGNANCY
TREATMENT GENERAL MEASURES

 HOSPITALISATION - FOR MONITORING


 SEDATIVES -
 DIAZEPAM / PHENOBARBITONE / ALPRAZOLAM ?
 NUTRITIONAL SUPLEMENTS -
 PROTEIN, IRON, CALCIUM (1000 MG), VITAMIN E &
C, MICRONUTRIENTS
 STOP - SMOKING & ALCOHOL
HYPERTENSION DURING PREGNANCY
TREATMENT DRUGS
2 ) MAGNESIUM SULPHATE : -
IN SEVERE PRE ECLAMPSIA
5 GM + 5 GM IM START FOLLWED BY 5 GM IM 4
HOURLY
3 ) ALLYLESTRENOL : -
 TO PROMOTE FOETAL GROWTH
 IN DOSES OF 5-10 Mg. 3 - 4 TIMES / DAY

4 ) DIURETICS ? : - AVOID
ONLYIN PULMONARY OEDEMA, CCF, RENAL
HYPERTENSION, SEVERE OLIGURIA / ANURIA.
CHLOROTHIAZIDE, FUROSEMIDE
SHOULD BE STOPED WELL BEFORE
TERMINATION OF PREGNANCY
HYPERTENSION DURING PREGNANCY
TREATMENT DRUGS

5 ) TOCOLYTICS : - ISOXSUPRINE +
IF IUGR IS DETECTED

6 ) GLUCOCORTICOIDS: - <34 WEEKS


 BETAMETHASONE / DEXAMETHASONE -12 MG, 2

DOSES AT 12 HOURS INTERVAL FOLOWED BY


WEEKLY INJ, TILL DELIVERY / 34 WEEKS.

7 ) THYROTROPIN RELEASING HORMONE : - ?


DOSE- 400 µGm, 8 HOURLY FOR 4 DOSES, TO
PROMOTE FOETAL MATURITY IF DELIVERY <34
WEEKS.
HYPERTENSION DURING PREGNANCY
TREATMENT DELIVERY
BEST DAY - WHEN ?
1 ) AT 36 WEEKS: - IN ALL CONTROLLED CASES
2 ) AFTER 32 WEEKS: - FOR FOETAL SALVAGE
 DECREASED FOETAL MOVEMENT
 SEVERE IUGR WITH OLIGOHYDRAMNIOUS
 LATE DECELERATION WITH POOR VARIABILITY
 REVERSED UMBILICAL DIASTOLIC BLOOD FLOW

3 ) ANY TIME : - IF PROGRESSIVE INSPITE OF


TREATMENT, WHEN -
BP >160 /100 MM OF HG
URINE OUTPUT < 400 ML / 24 HOURS
PLATELET COUNT < 50000 / CMM
SERUM CREATININE INCREASES PROGRESSIVELY
LDH >1000 IU / L
HYPERTENSION DURING PREGNANCY
TREATMENT DELIVERY
BEST WAY - HOW ?
1 ) INDUCTION WITH OXYTOCIN: -After 36 weeks
 IF FOETAL CONDITION IS GOOD
 CERVIX IS FAVOURABLE / Cerviprime
 APPLICATION OF FORCEPS / VENTOUSE

2 ) BY LSCS: -
IF TERMINATION BEFORE 36 WEEKS
IN CASES OF MATERNAL / FOTAL JEOPARDY
ANAESTHESIA - GA / EPIDURAL / SPINAL - BETTER
LEFT TO ANAESTHETIST

BEST PLACE - WHERE ?- HIGH-RISK PREGNANCY


UNIT / TERTIARY HOSPITAL / WELL EQUIPED HOSPITAL
HYPERTENSION DURING PREGNANCY
TREATMENT POSTPARTUM

1 ) PPH: - BE PREPARED TO FACE IT


UTERINE ATONY / DIC - FDP/BLEEDING DISORDER
OXYTOCICS / UTERINE MASSAGE / PACKING /
UTERINE ARTERY LIGATION / INTERNAL ILIAC
ARTERY LIGATION / HYSTERECTOMY

2 ) NEONATAL CARE: -
 PRESENCE OF PAEDITRICIAN IS A MUST
 INCUBATOR IS HELPFUL

3 ) DRUGS: -
JUDICIOUS USE OF ANTIHYPERTENSIVES, IV FLUIDS,
DIURETICS, & DIAZEPAM IN THE FIRST 48 HOURS

4) FOLLOW UP FOR 6 WEEKS


Motherhood … .
.. A dream of every woman

TOGETHER WE CAN MAKE IT A REALITY

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