فشار خون بارداری – اکلامپسی، پره اکلامپسی و سندرم HELLP

فشار خون بارداری – اکلامپسی، پره اکلامپسی و سندرم HELLP

اسلاید 1: In the name of AllahA.M.KarimiMedical studentHigh Blood pressure in pregnancy

اسلاید 2: Epidemiology and classificationThe most common medical complication of pregnancy(Most common complication of pregnancy: Abortion)Classification:1- Gestational hypertension ✔Pre-eclampsia syndrome✔Eclampsia syndrome✔Transient hypertension 2- Chronic hypertension

اسلاید 3: Gestational Hypertension (G. HTN)1. Definition: sustained systolic blood pressure at orabove 140mmHg, or a diastolic blood pressure of 90mmHg or greater(increase in BP must be present on at least two separate occasions;6 hours after the first BP assessment Or within a week.)HTN in late pregnancy (>20 weeks Gestation or the first 24 hours after delivery)in the absence of other findings suggestive of preeclampsiaSever G.HTN Criteria: BP above 160/110mmHg in the absence ofother findings suggestive of preeclampsia4. No need to treat. Consider follow up & weekly visit

اسلاید 4: Etiology of Pre-eclampsiaMechanisms that are currently considered important include:1.Placental implantation with abnormal trophoblastic invasion of uterine vessels2.Immunological maladaptive tolerance between maternal , paternal (placental), and fetal tissues3.Maternal maladaptation to cardiovascular or inflammatory changes of normal pregnancy4.Genetic factors including inherited predisposing genes and epigenetic influences.

اسلاید 5: Risk factors of Pre-eclampsiaObesityMultifetal gestationMaternal ageThrombophilia(⬇Protein C ,⬇Protein S , Factor V Leiden)NulliparityFetal hydropsMolar pregnancyInsulin resistanceNephropathyFetal aneuploidyMaternal infectionsAPS syndromeSperm related factorsART(IVF , etc. )

اسلاید 6: Maternal &Fetal ComplicationsMaternalDICHELLP syndromePlacental abruptionPulmonary edemaAcute renal failureMAHA(⬆LDH, Schistocytes on a PBS)FetalPre-term laborIUGRHypoxic Ischemic EncephalopathyCardiac complicationsDeath during childbirthAcute atherosis of decidual arteries

اسلاید 7: ScreeningThe best and most effective and affordable: History of the patientBlood pressure assessment Uric acid(⬆Creatinine ,⬇GFR)Urine Calcium-Creatinine ratio(Hypercalciuria)Beta-HCG, Maternal serum AFP, Inhibin a🔔Excess weight gain🔔Placental Growth factorsArterial Doppler Ultrasound in HIGH-RISK PATIENTS:bilateral and persistent notching of end diastolic flow In uterine arteries

اسلاید 8: PreventionDaily Calcium intake(1.5 gr daily) ▶▶▶ NO PREVENTIVE EFFECTLow dose Aspirin + LMWHeparin only in High-risk pregnancies▶▶▶IT HAS PREVENTIVE EFFECTTreatment of Chronic HTN▶▶▶Decreases risk of Sever HTN

اسلاید 9: Mild(Non severe) Pre-Eclampsia

اسلاید 10: Approach to Mild Pre-EclampsiaPatient compliancePara-clinical evaluationFetal assessment37th w.

اسلاید 11: MANAGEMENT OF MILD PRE-ECLAMPSIA DURING DELIVERYIV Mg Sulfate administration during and 24 hours after deliveryRegional anesthesiaConsider administration of Hydralazine if BP goes above 160/110 mmHgBP must be maintained between 140/90 to 160/110 But not less than 140/90

اسلاید 12: Severe Pre-EclampsiaSystolic BP > 160mmHgand/ordiastolic > 110mmHgProteinuria: >5g on 24h collection or 3+ on single sample HELLPsyndrome

اسلاید 13: EclampsiaPulmonary edemaARFDICPlacental abruptionPlacenta previaGestational age ⬇ 23wApproach to sever Pre-Eclampsia⬇32 w.32 – 34 w.⬆32 w.Fetal assessment: -Close monitoring for 48 hours-Umbilical artery U/S-Sonographic assessment of Amniotic fluid and fetal GrowthMaternalassessment-BP(tight control)-Urine output monitoring-Mental status-RUQ/Epigastric pain-Daily assessment of PLT, LFT, CrNot stableStableWatchful waiting & Corticosteroid administrationDelivery at34th weekCorticosteroids administrationfor 48 hoursCorticosteroids administrationfor 48 hoursNVDOrC/S

اسلاید 14: MANAGEMENT OF SEVERE PRE-ECLAMPSIA DURING DELIVERYIV Mg Sulfate administration during and 24 hours after deliveryRegional Or Epidural anesthesiaConsider administration of Hydralazine if BP goes above 160/110 mmHgUrine output must be more than 100cc/4hAssessment of the signs of HELLP syndromePostpartum hemorrhage management: Oxytocin (Methylergonovine)BP must be maintained between 140/90 to 160/110 But not less than 140/90

اسلاید 15: EclampsiaDefinition: Generalized Tonic clonic seizure (for at least 1 to 2 minutes) in a patient diagnosed with preeclampsia Management of EclampsiaInvolves 6 stages:1. Making sure the airways are clear and the woman can breathe. Controlling the fits (with Mg sulfate:▶additional 2gr▶ additional 2gr ▶IV Amobarbital Na ▶ Induction & intubation)3. Controlling the blood pressure (with Hydralazine, Labetalol or Nifedipine)4. General care and monitoring5. Delivering the baby6. Care after delivery.

اسلاید 16: Medication:Mg Sulfate is the drug of choice:✔Loading dose IV: 4-6gr of 20%MgSO4 in 200cc 5%DW for 20 minutes. IM: 5gr of 50%MgSO4 in each buttock✔Maintenance dose IV: 2-3gr of 20%MgSO4 in 1000cc 5%DW for 20 hours IM: 5gr 50%MgSO4 every 4 hours for 24 hoursMaximum dose:20gr in 24 hours1- Renal failure(is not an absolute contra- indication)2- Myasthenia gravis

اسلاید 17: HELLP SYNDROME

اسلاید 18: RISK FACTORS & COMPLICATIONSRisk factors: Multiparity, White people,⬇35 years oldComplications:✔Sub-capsular hematoma of liver:-Sings: RUQ/Epigastric pain, Hepatomegaly, referral pain(shoulders, esophagus, pleura, gall bladder) -Best diagnostic modality: CT-Scan-Treatment 1.Stable hemodynamic: F/U 2.Unstable hemodynamic: Laparotomy, Management of Coagulation disturbances

اسلاید 19: Approach to HELLP Syndrome⬇34 w.⬆34 w.Watchful waiting & Corticosteroid administrationNVDOrC/SAdministration of Hydralazine & Mg sulfate during and after 48 hours of deliveryRegional anesthesia(Pudendal nerve block)

اسلاید 20: Chronic hypertension in pregnancyIs defined by the ACOG as blood pressure above 140/90 mmHg before pregnancy Or before 20 weeks of gestation.Complications:Superimposed Pre-eclampsia(Chronic HTN for more than 4 years , Renal failure, positive history of HTN in previous pregnancies)Placental abruptionPre-term laborIUGR

اسلاید 21: ManagementAntihypertensive therapy is recommended for average SBP measurements of ≥160 mm Hg or DBP measurements of ≥110 mm Hg Or in the presence of any end-organ failureMethyldopa (Oral) is the drug of choiceHydralazine (IV) is the drug of choice in hypertensive crisis Side effects and complications: Fluid retention, Tachycardia, Palpitation, Headache, Drug induced SLE, Neonatal thrombocytopeniaLabetalol is safe in pregnancy but can not be used in Asthma and CHFNifedipine (CCB) (sublingual) causes MI and Hypotension and is not recommendedWarning: simultaneous use of nifedipine and Mg sulfate is associated with Maternal hypotensionDiuretics: if the patient is prescribed with diuretics before conception it would be safe for her to take the during pregnancy they should not be prescribed during pregnancy if the patient is diagnosed with preeclampsia Or oligohydramniosACE & ARBAre contraindicated in 2nd and 3rd BUTAre the drug of choice after delivery

اسلاید 22: Approach to Chronic HTN in pregnancyLow risk/Group 1High risk/Group 2NVD Or C/SIn 40th week-Mild HTN-No signs of any end-organ damage-No need treat-Administration of Anti-hypertensive drugs must be stopped-In the first Pre-natal visit Involves:-Patients with BP⬆ 160/105-End-organ damageIf:BP⬆ 160/110End-organ damagePre-eclampsiaAdministration of Anti-hypertensive drugsAdministration of Anti-hypertensive drugsNVD Or C/SIn 41st weekif:Well controlled No signs of preeclampsiaAbsence of IUGR

اسلاید 23: ASSESSMENTS:LOW RISK PATIENTS / GROUP 1-Weekly visit in 2nd & 3rd trimester-24 hours urine collection every week-Weekly NST (since 34 weeks of pregnancy)-Sonographic evaluation every month(since 32 weeks of pregnancy)HIGH RISK PATIENTS / GROUP 2-1st and 2nd trimester: 2 visits every month-3rd trimester: weekly visit-24 hours urine collection for every visit-Weekly NST or BPP (since 28 weeks of pregnancy)-Sonographic evaluation every month(since 26 weeks of pregnancy)