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HYPERTENSIVE DISEASE OF PREGNANCY

HYPERTENSIVE DISEASE OF PREGNANCY. Prof. Mehdi Hasan Mumtaz. MATERNAL PHYSIOLOGY. Anaemia. Hyperventilation. Hypovolaemia. Hyper-coagubility. HYPERTENSIVE DISEASE OF PREGNANCY. Pre-eclampsia. Eclampsia. HELLP syndrome. PRE-ECLAMPTIC TOXEMIA (PET). TRIAD Hypertension. Proteinurea.

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HYPERTENSIVE DISEASE OF PREGNANCY

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  1. HYPERTENSIVE DISEASE OF PREGNANCY Prof. Mehdi Hasan Mumtaz

  2. MATERNAL PHYSIOLOGY • Anaemia. • Hyperventilation. • Hypovolaemia. • Hyper-coagubility.

  3. HYPERTENSIVE DISEASE OF PREGNANCY • Pre-eclampsia. • Eclampsia. • HELLP syndrome.

  4. PRE-ECLAMPTIC TOXEMIA(PET) TRIAD • Hypertension. • Proteinurea. • Oedema.

  5. SEVERE-PRE-ECLAMPSIADefinitions • BP> 140/90. • Proteinurea >0.5 G/24h or >2+ urine analysis + Epigastric pain. Haedache. Visual disturbances. Clonus> 3beats. Platelet count <100x109. ALT>50IU/L. OR SPB = > 170 DBP = > 110 PROTEINUREA >0.5 G/24h OR > 2+ URINE ANALYSIS.

  6. HAEMODYNAMIC FINDINGSSevere Pre-eclampsia • Low plasma volume. • Low /Normal CO. • Low/ Normal CVP/PCWP. • myocardial contractility. • Low COP.

  7. ECLAMPSIA • Hypertension. • Protein urea. • Oedema. • Convulsion.

  8. HELLP SYNDROME “Mos severe end of pre-eclamptic condition” • H – Haemolysis. • EL -  Liver enzyme. • LP -  Platelet count. “Additional: Haemopoietic system” “Liver involvement”

  9. PATHOLOGICAL FEATURES • Hypertension. • Renal functions. • Hypovolaemia. • Hypoproteinaemia. • Coagulation/fibrinolytic imbalance. • Cerebral irritability. • Placental perfusion.

  10. NORMAL PREGNANCY Vasoconstriction Platelet aggregations Uterine activity Utero-placental blood flow  Thromboxane Vasoconstriction Platelet aggregations Uterine activity Utero-placental blood flow  Prostacyclin

  11. PRE-ECLAMPSIA Vasoconstriction Platelet aggregations Uterine activity Utero-placental blood flow  Prostacyclin Vasoconstriction Platelet aggregations Uterine activity Utero-placental blood flow  Thromboxane

  12. FLUID MANAGEMENT“Important” • Relatively Low PV Low PAWP CO • Endothelial damage. • Low COP • Excessive fluid therapy fetal distress oligurea risk pulmonary oedema

  13. Definitive Delivery of baby Delivery of plaenta MANAGEMENT Symptometic • Control • Blood pressure. • Convulsions. • Fluid balance

  14. MANAGEMENT SYMPTOMATIC HIGH BLOOD PRESSURE • Dangers: Cerebral haemorrhage. Pul oedema • Objective: DBP 90-100mmHg <90 uteroplacentl perfusion

  15. BLOOD PRESSURE • CAUTION. • 4.5% HES 500ml preload. Before IV anti-hypertensive. • EXCEPTION. • Patient post delivery. • Who has 4.5% HES already. • DBP >120.

  16. BLOOD PRESSURE • HYDRALLAZINE • 5mg/5min in 20 min. If BP 90-100 • 40mg/N-saline, 1-5mg/h. • IF AT 20min DBP >100 • 5mg/min in 20 min. If BP 100 • 40mg/N-saline, 1-5mg/h. • IF AT 20min DBP >100 • LABETALOL 10-20mg IV/10min • If DBP 90-100 or • Total 220mg given

  17. BLOOD PRESSURE • Labetalol. • 10-20mg boluses/15min. • If DBP 90-100. • Infusion 5mg/ml (0-160mg/hr). • Ca+ channel blockers. • Nitrates. • Adrenergic neuron blockers.

  18. ECLAMPSIA ROOM • Indications. 1. Eclampsia. 2. Hypertension > 170/110 + Proteinurea > 2+ 3. Hypertension > 140/90 Proteinurea 2+ + One of the symptom/signs

  19. Headaches. Visual disturbances. Hyper-reflexia. Clonus (>3beats). Nausea & vomiting. Epigastric pain. Raised liver enzymes. Thrombocytopenia<100x10/L. SYMPTOM/SIGNS

  20. “MONITORING” Eclampsia Room • ECG. • NIBP. • SPO2. • Fluid balance. • Urine output. • CTG. • CVP.

  21. INTRACELLULAR INTERSTITIAL VASCULAR CAPILLARY EG CELL OSMOLALITY Na+ COP

  22. FLUID BALANCE • Restrict fluids. • (2000ml/24hrs) • Urine output <25ml/hr. • Pass CVP catheter. • CVP • Group A: CVP <4mmHg- underfilled. • Group B: CVP 4-8mmHg- optimialy filled. • Group C: CVP >8mmHg- over filled.

  23. CVP • GROUP - A. • Fluid challenge. • HES 4.5% 100ml. • Bring CVP 4-8. • GROUP - B. • Fluid challenge careful. • CVP 4-8. • Urine O/P <25ml give dopamine.. • GROUP - C. • No pul oedema. • Dopamine 1-3g/kg/min. • Pulmonary oedema present. • Frusemide 20mg. • Refer to ICU.

  24. SEIZURE PROPHYLAXIS “Severe pre-eclampsia” “Controversial” • Magnesium sulphate. • Loading dose 4G. • Infusion 2G/hr. • Optimum level 2-4mmol/L.

  25. Mgnesium (mmol/L) 0.7-1 2-4 >5 >7.5 >10 Effect Normal Therapeutic range. Loss of reflexes. Respiratory depression Cardiac arrest MAGNESIUM SULPHATEBlood Levels

  26. MAGNESIUM SULPHATE • Magnesium level >4 = dose (.5-1G/h) • Magnesium level <1.7=give 2G bolus. dose 2.5G/h. • Magnesium level 1.7-2 continue 2G/h.

  27. MONITORING DURING MAGNESIUM INFUSION • Patellar reflex. • ECG. • SPO2. • Mgnesium level.

  28. MANAGEMENT MAGNESIUM TOXICITY • Loss of patellar reflex. • Stop infusion. • Measure level. • Withold till reflex returns. • Once reflex return – 1G/h. • SPO2 <90%. • Give O2. • Stop maintenance dose. • Measure level. • Inform anaesthetist. • Cardio-respiratory arrest. • Stop infusion. • CPR. • Calcium gluconate. • Intubation/ventilation.

  29. MAGNESIUM THERAPY Considerations • Tocolytic effect. • Interaction – muscle relaxants. • Interaction – calcium antagonists.

  30. “INDICATIONS”ICU – ADMISSION • Severe coagulopathy or DIC. • Recurrent seizures. • Hypertension – poor control. • Persistant oligurea. • Pulmonary oedema + oligurea. • Compromised myocardial function.

  31. Definitive Delivery of baby Delivery of plaenta MANAGEMENT

  32. MANAGEMENTSevere Cases • Arrest & prevention of convulsion. • Barbituates. • Benzodiazepines. • Megnesium SO4. • Paralyse & IPPV. • Blood pressure. • Hypertension – vasodilatation. • Hypotension – inotropics.

  33. MANAGEMENTSevere Cases • Restoration of blood volume. • Low proteins. • Colloids. • Colloid substitutes. • Progressive dehydration. • Replace out put. • Keep BV normal.

  34. ECLAMPSIA“Labour Room” • S.B.P. > 160 Torr. • DBP > 110 Torr. • Protein urea >5G/24h. • Oligurea 500ml or less. • Epigastric pain. • Cyanosis. • Pulmonary oedema. • Convulsions.

  35. IN ICU • B. P. < 80 Torr. • Urine output – nil. • Convulsions. • Pulmonary oedema. • Cyanosis.

  36. CVP Monitoring. Urinary catheter. Nasogastric catheter. Heavy sed with: Valium. Pheno. IPPV. Aemocel 500ml daily Blood 500ml/day. Digitalise. Inotropes if needed. Balance. Negative 7-10day=10-14L Ventilator off 3-4 day. ROUTINE

  37. IDEAL MANAGEMENT • Pass CVP catheter. • Pass urinary catheter. • Pass nasogastric tube. • Replace obvious loss by crystaloids. • Normalise blood volume by colloids. • Remove excess fluids. • From ext vascular comp. • By forced diuresis. • Keep the body in electrolyte balance.

  38. IDEAL MANAGEMENT • Routine investigations. • Hb. • HCT. • Plasma proteins. • Serum Na+ K+. • Monitoring. • Urine output. • ECG. • BP. • Pulse • CVP.

  39. HELLP SYNDROME • H – Haemolysis. • EL – elevated Liver enzyme activity. • LP -  Platelet count. “most sevre end of pre-eclamptic condition”

  40. CLINICAL FEATURES • Epigastric pain. • Upper abdominal tenderness. • Proteinurea. • Hypertension. • Jaundice. • Nausea & vomiting.  • Haematuria. • Oligurea. • A T necrosis. • Cortical necrosis. • Pan-hypopituitarism. • Actue liver rupture • RDS.

  41. MANAGEMENT • Early diagnosis. • Stbilization. • Prompt delivery if. • Pre-eclampsia worsens. • Worsening of hepatic renal functions. • Severe thrombocytopenia. • Gestational age at or beyond 32-34wks. • Evidence of foetal distess. • Evidence of foetal maturity.

  42. MANAGEMENT • Pre-op investigations. • Platelet count. • PCV. • Hb. • PTT. • Fibrinogen concentration. • FDP. • LFTs. • Creatinine. • Urea. • Uric acid. • X-ray chest.

  43. Platelet infusion if. • <50000mm-3 cs. • <20000mm-3 vag.D. • Blood transfusion if. • B <10.0G/dl. • Hb. • PPF. • FFP. • CVP. • Urine output. • Maternal blood glucose control. • IPPV.

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