Complications Of HDP Dr. Shashwat Jani . M. S. ( Obs – Gyn ) Diploma in Advance Laparoscopy. Consultant Assistant Professor , Smt. N.H.L. Municipal Medical College. Sheth V. S. General Hospital , Ahmedabad. Mobile : 99099 44160. E-mail : [email protected]
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COMPLICATIONS OF HYPERTENSIVE DISORDERS OF PREGNANCY BY DR SHASHWAT JANI
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Complications Of HDP
Dr. Shashwat Jani.M. S. ( Obs – Gyn )
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,Smt. N.H.L. Municipal Medical College.
Dynamics and incidence patterns of maternal complications in early-onset hypertension of pregnancy Ganzevoort W et al PETRA investigators. Obstet Gynecol. 2000 Jun;95(6 Pt 2):1017-9
• A clinical neuroradiologic syndrome of heterogenous etiologies , that are grouped together because of similar findings on neuroimaging studies.
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Pathophysiology
• Likely due to vasogenic edema secondary to an acute increase in arterial blood pressure, which overwhelms the autoregulatory capacity of the cerebral vasculature, causing arteriolar vasodilation and endothelial dysfunction, leading to extravasation of fluid (i.e preeclampsia) .
(Thackeray and Tielborg, 2007)
• OR an acute and significant episode of hypertension that causes cerebral vasoconstriction with subsequent ischemia and edema .
(Thackeray and Tielborg, 2007)
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Autoregulatory failure
Normal autoregulation maintains constant cerebral blood flow over a range of systemic blood pressures .
When the upper limit is exceeded, the arterioles dilate, allowing breakdown of the blood-brain barrier, thus allowing extravasation of fluid and blood into the brain parenchyma.
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PRES : Clinical manifestation and Etiopathogenesis• Postulations • Vasogenic cerebral oedema• ischaemia of brain tissue
• Posterior circulation – more susceptible – less sympathetic innervation
of the vertebro-basilar vasculature to protect the parenchyma from rapid increases in arterial blood pressure
Headache, nausea, vomiting Confusion, behavioral changes Changes of consciousness (from
somnolence to stupor) Vision disturbances (blurred vision,
to an excessive accumulation of fluid in the pulmonary interstitial and alveolar spaces.
It complicates around 0.05% of low-risk pregnancies but may develop in up to 2.9% of pregnancies complicated by preeclampsia.
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Only 30 % Antepartum
•Mainly,
- Post Partum,- Mulatiparity- Advance Maternal Age - Associated Medical Disorders
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DiagnosisDyspneaOrthopneaTachypneaAuditory crackles and ralesHypoxemia
ABGA, CHEST X RAY , ECG , CT SCAN , VQ SCAN May 1, 2023 Dr Shashwat Jani.
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Pulmonary Edema ARDS Pleural Effusion
B/L Air bronchogramCentral bat wing patternRight side pleural effusion
Diffuse B/L Coalescent opacities
Left hemithoraxObliteration of right costophrenic angle.Mediastinal shift to right
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TreatmentOxygenPropped up positionI v lasixFluid restrictionInput – output chartingI v antibioticsIn refractory cases,Pulmonary artery catherisation and ventilation .May 1, 2023 Dr Shashwat Jani.
Management Stabilization of pt. Rx of HTN Termination of pregnancy ( Depends on
Gest. Age & maternal condition ) Role of steroids ?????
With or without corticosteroids, the vast majority of women with HELLP syndrome will
recover within 96 hours of delivery. May 1, 2023 Dr Shashwat Jani.
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FUTURE PREGNANCIES The reported risk of Recurrent HELLP
syndrome in a subsequent pregnancy ranges from 3% to 27%.
Future pregnancies are also at increased risk of other adverse events, including other manifestations of preeclampsia, preterm delivery, fetal growth restriction, placental abruption, and cesarean delivery.
The overall risk of such complications is 19–43%.
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Acute Kidney Injury AKI may occur in the context of severe
preeclampsia. In preeclampsia , due to the underlying
endothelial dysfunction the predominant abnormalities seen on renal histology are to the endothelium and glomeruli.
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Diagnostic Criteria : Creatinine clearance by measuring 24 hr urine creatinine remains the gold standard of GFR estimation in pregnancy.
Any Sustained Fall In Output < 0.5ml/Kg/Hr OR Rising Serum Creatinine Should Alert The Clinician Of Likelihood Of AKI.
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Management Supportive therapy includes blood
pressure control, positioning patients so as to improve renal blood flow, correcting fluid and electrolyte imbalance, and maintaining adequate nutrition.
If dialysis is required in pregnancy, hemodialysis is preferred over peritoneal dialysis.
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CVS COMPLICATIONSLow filling pressures and a hyperdynamic circulation• Cardiomyopathy Rare complication Treatment similar to other types of CCF HDP patient with pulmonary may wrongly labeled as a case of
peripartum cardiomyopathy. HTN CMP shows good recovery and regain cardiac function on follow up.
Acute MI Enhanced vascular reactivity to angiotensin II & norepinephrine
Endothelial dysfunction Decreased uterine perfusion leading to renin release Use of ergot alkaloids – Acute MI• Malignant Ventricular Arrhythmias 38
HEPATIC COMPLICATIONS Transaminases frequently elevated Epigastric/Subcostal pain (distension of liver
capsule by edema or subcapsular bleeding) Coagulopathy (high INR) Acute fatty liver Deficiency of the long chain 3-hydroxyacyl
coenzyme A dehydrogenase
Serum bilirubin - Important factor in predicting Maternal mortalityMay 1, 2023 Dr Shashwat Jani.
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Jaundice High colored Urine
Liver Hematoma
Hepatic complications
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Liver Rupture / Hematoma• Mortality Is high.• First stabilize hemodynamically.• Then Exploratory Laparotomy with C.S.• Simple suturing is rarely effective because the entire
liver is edematous and friable and the hepatic parenchyma does not have the tensile strength to retain the sutures.
• Other surgical options include packing with gauze, topical coagulant agents or collagen fleeces coated with fibrin glue, incorporation of omental pedicles or surgical mesh into the liver, ligation of the hepatic artery, radiologic embolization of the hepatic artery, or hepatic lobectomy.
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Hematological Complications :
Hemolysis / Anemia
Bleeding as the incision is being closed & Incision site bleeding
Target cells, schistocytes & paucity of platelets
Associated with increased LDH
DIC
(In preeclampsia there is vasoconstriction which affects blood flow to the liver. Liver releases coagulation factors.)
by a generalized increase in both fibrin formation and fibrinolysis, leading to excessive consumption of clotting factors, which presents clinically as a bleeding diathesis.
• The most common causes of DIC in pregnancy : are excessive blood loss with inadequate blood component replacement, placental abruption, amniotic fluid embolism, and severe preeclampsia / HELLP syndrome.
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Management Evidence of DIC in the setting of severe
preeclampsia / HELLP syndrome should prompt immediate delivery.
The decision of whether to proceed with induction of labor or cesarean delivery depends on such factors as gestational age, parity, cervical Bishop score, motivation of the patient, and the severity of DIC .
A rapidly falling platelet count may make cesarean delivery a more appropriate choice.
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Maintenance of intravascular volume and replacement of blood components and/or coagulation factors, as indicated by laboratory parameters.