COMPANY NAME Hypertension in Pregnancy นพ. สิทธิพงศ์ ถวิลการ กลุ่มงานสูตินรีเวชกรรม รพ. ขอนแก่น.

COMPANY NAME

Hypertension in Pregnancyนพ.สิ�ทธิ�พงศ์ ถวิ�ลการ

กล��มงานสิ�ติ�นร�เวิชกรรม รพ.ขอนแก�น

Contents

Classification

Management

Diagnosis

Pathogenesis and Risk factorsHT

In

Pregnancy

HT

In

Pregnancy

Prediction and prevention

Hypertensive disorders of pregnancy remain a major health issue for women and their infants worldwide

The ACOG convened a task force of experts in the management of HT in pregnancy to review available data and publish evidence-based recommendations for clinical practice

Preclampsia is a dynamic process, by nature is progressive

Introduction

Classification

Preeclampsia-eclampsia:

Chronic hypertension

BP elevation after 20 weeks of gestation with proteinuria or any of the severe features of preeclampsia

Chronic hypertension with superimposed preeclampsia

Gestational hypertension :evidence for the preeclampsia not develop and HT resolves by 12 weeks postpartum

BP elevation before 20 weeks of gestation or before pregnancy

Previous classification

p

Classification

Avoid use of term mild preeclampsia >> replace with preeclampsia without severe features

Severe preeclampsia >> preeclampsia with severe features

Pathogenesis

Pathogenesis of

Preeclampsia

Geneticfactors

Abnormal trophoblastic

invasion 

Vasospasm

Endothelial cell injury

Pathophysiology

Risk factors

Young and Nulliparous

Previous Preeclampsia

ObesityMultifetal gestation

Incidence 3-10% Older women : Chronic

HT with superimposed precclampsia

4.3% in BMI < 20 13.3 % in BMI > 35 Twins 13% vs

Singleton 5%

Diagnosis : Preeclampsia

Diagnosis : Preeclampsia with severe feature

Diagnosis : Preeclampsia with severe feature The diagnosis of severe preeclampsia is no longer

dependent on the presence of proteinuria

Do not delay management of preeclampsia in the absence of proteinuria

Massive proteinuria (> 2 g) has been eliminated from consideration of preeclampsia as severe

Fetal growth restriction has been removed as a finding indicative of severe preeclampsia

Prediction of preeclampsia

Screening to predict preeclampsia beyond obtaining an appropriate medical history to evaluate for risk factors is not recommended

TVS of a cervix and funneling

Prevention of preeclampsia

Antioxidants: vitamins C and E are not effective.

Calcium: may be useful in populations with low calcium intake (not in the USA).

Low-dose aspirin (60 to 80 mg/day): beginning in the late first trimester may have slight effect to reduce preeclampsia and adverse perinatal outcomes.>> suggest in women with Hx of early onset preeclampsia and preterm delivery less than 34 wks or preeclampsia in more than one prior pregnancy

Bed rest or salt restriction: no evidence of benefit.

TVS of a cervix and funneling

Management

Basic manage

ment objectiv

e

Termination of pregnancy with the least possible trauma to mother and fetus

Birth of infants who subsequently thrives Complete retroration of health to mother

Important

Early diagnosis of preeclampsia Precise gestational age

Current clinical issues

Timing of delivery Antihypertensive drugs Magnesium sulfate

Management

Hospitalization for women with new onset HT Daily assessment of maternal symptoms,

weight gain and fetal movement Analysis for proteinuria BP every 4 hours Measurement of serum Cr, Hepatic

enzymes, CBC (some recommend uric acid, LDH, coagulogram)

Evaluation of fetal size, amniotic volume, well-being

Management

Timing of delivery : Preeclampsia without severe features; 37

weeks Severe preeclampsia ;

• < 34 weeks of gestation with stable maternal and fetal conditions, it is recommended that continued pregnancy be undertaken only at facilities with adequate maternal and neonatal intensive care resources

• ≥ 34 weeks of gestation, and in those with unstable maternal or fetal conditions irrespective of gestational age, delivery soon after maternal stabilization is recommended

Chronic hypertension; 38 weeks

Management

Management

Management

Antihypertensive drugs ; preeclampsia with severe hypertension during

pregnancy (sustained systolic BP of at least 160 or diastolic of at least 110)

persistent chronic hypertension with systolic BP of at least160 or diastolic BP of at least105

Management

Antihypertensive drugs ; IV labetalol• bolus doses 20-40 mg (max 300/hr) • continuous IV infusion (1-2 mg/min) IV bolus doses of hydralazine• 5, 10, 10 mg q 20 min (max 25 mg) Oral nifedipine• 10-20 mg q 20 min (max 60 mg) IV Sodium nitroprusside

Management

Magnesium sulfate prevent seizure;

Preeclampsia without severe feature do not need magnesium sulfate(risk for eclampsia = 1/100)

Management : MgSO4 dosage

Management : MgSO4 dosage

TASK FORCE RECOMMENDATIONS

Close monitoring of women with gestational HT or preeclampsia without severe features with serial assessment of maternal symptoms and fetal

movement (daily by the woman) serial measurements of BP (twice weekly) assessment of platelet counts and liver enzymes

(weekly) is suggested US to assess fetal growth and antenatal testing to

assess fetal status If evidence of fetal growth restriction is found in,

fetoplacental assessment that includes umbilical artery Doppler velocimetry as an adjunct antenatal test is recommended

TASK FORCE RECOMMENDATIONS

For women with preeclampsia, it is suggested that a delivery decision should not be based on the amount of proteinuria or change in the amount of proteinuria

For women with preeclampsia, it is suggested that the mode of delivery need not be cesarean delivery. The mode of delivery should be determined by fetal gestational age, fetal presentation, cervical status, and maternal and fetal conditions

TASK FORCE RECOMMENDATIONS

For women with HELLP syndrome; before the gestational age of fetal viability, it is

recommended that delivery be undertaken shortly after initial maternal stabilization

≥34 weeks of gestation, it is recommended that delivery be undertaken soon after initial maternal stabilization

gestational age of fetal viability to <34 weeks of gestation, it is suggested that delivery be delayed for 24-48 hours if maternal and fetal conditions remain stable to complete a course of corticosteroids for fetal benefit

TASK FORCE RECOMMENDATIONS

Post partum period; BP be monitored in the hospital or that equivalent

outpatient surveillance be performed for at least 72 hours postpartum and again 7-10 days after delivery or earlier in women with symptoms

discharge instructions include information about the signs and symptoms of preeclampsia as well as the importance of prompt reporting of this information to their health care providers

TASK FORCE RECOMMENDATIONS

Post partum period; new-onset hypertension associated with

headaches or blurred vision or preeclampsia with severe hypertension, the parenteral administration of magnesium sulfate is suggested

persistent postpartum hypertension, BP of 150 systolic or 100 diastolic or higher, on at least two occasions that are at least 4-6 hours apart, antihypertensive therapy is suggested

Persistent BP of 160 systolic or 110 diastolic or higher should be treated within 1 hour

References

American College of Obstetricians and Gynecologists: Hypertension in pregnancy Executive summary, November 2013

Williams Obstetrics, 24ed 

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