【高血压精品英文课件】妊娠高血压 hypertensive disorders in pregnancy

HYPERTENSIVEDISORDERSINPREGNANCY ProfofGyn Obst MansouraFacultyofMedicineEgypt2009 Prof MohammadEmam Introduction Hypertensivedisordersofpregnancyareleadingcausesofmaternalmortality Worldwide 50 000womendieeachyear Egypt 18 ofmaternalmortality Introduction Homeostasisduringnormalpregnancy isanexampleoftheprincipleofpriorities wherethepregnantwomenmustalterherentirephysiologicalandbiochemicalenvironmenttoprovideconditionsbestsuitedforthefetustowhomsheishostess thatisthepriceofviviparity Introduction Inhypertension manycomplexhomeostaticmodificationsoccur someareharmfultothemotherandfetus whileothersarebeneficial Definitions Hypertensioninpregnancy Bl Pof140 90ormoreisabnormal Ifthereisariseof30mmHgormoreinthesystolicbloodpressureor15mmHgormoreinthediastolicbloodpressureIn2occasions6hoursapart MeanarterialBP 105mmHg Systolic 2DiastolicMeanarterialBP 3 Classifications NationalHighBloodPressureEducationProgramClassification NHEP 2000 Gestationalhypertension Preeclampsia mild severe Eclampsia Superimposedpreeclampsiauponchronichypertension Chronichypertensionwithpregnancy Definitions Gestationalhypertension Hypertensionforfirsttimeafter20w withoutProteinuria BPreturnstonormalbefore12weekspostpartum Chronichypertensionwithpregnancy Hypertensionantedatespregnancyanddetectedbefore20w lastsmorethan12weekspostpartum Definitions Preeclampsia ThedevelopmentofhypertensionandProteinuriaafter20wMayoccurearlierinvesicularmoleortwins Eclampsia inGreek Flashoflight Theoccurrenceoftonic clonicconvulsions withoutanyneurologicaldisease inawomanwithpre eclampsia Definitions Superimposedpre eclampsia ItisthenewdevelopmentofProteinuriaafter20weeksgestationinapatientwithchronichypertension Definitions Proteinuria 300mg 24hoursurine 1dipstick HeavyProteinuria 2gm 24hoursor 2indipstick Preeclampsia Epidemiologyofpreeclampsia Incidence Isadiseaseofhumansonly Isthemostcommonmedicaldisordercomplicatingpregnancy5 15 Isthemostcommonhypertensivedisorderinpregnancy Morecommoninprimigravidasandelderlymultipara Morecommoninwinter Moreinblackraces Epidemiology Riskfactors Chronichypertension Chronicnephritis Pasthistory Familyhistory Obesity Multiplepregnancy Epidemiology risks Polyhydramnios Vesicularmole Diabetesmellitus Nulliparity TeenagePregnancy Smoking Stress Etiology theories GeneticPredisposition FreeRadicalsTheoryInpre eclampsiathelevelsoffreeradicalsarehigherthannormotensivewomenleadingtoendothelialdamage Oxidativestress Antioxidantcapacity ROSsynthesis O2 H2O2ONOO VitaminCSOD Etiology theories Endothelialinjury Endothelin1 potentvasoconstrictors NitricOxide vasodilatoraction VascularEndothelialGrowthFactor VEGF Etiology theories Prostaglandins Thereisdecreaseinprostacyclin TXA2ratioleadingto vasoconstrictionandtendencytothrombosis Etiology theories InflammatoryFactors Pre eclampsiaisconsideredaninflammatorydiseaseduetoincreasednumberofactivatedleukocytesinthematernalcirculation ImmunologicalFactor primigravidasMultiparawith1stpregnancyfromanewhusband Abundanttrophoblast vesicularmoleandmultiplepregnancy TheCentralPlayers Hemostats inPET TheEndotheliumNeutrophils3 Platelets4 Coagulationsystem OnceoneistriggeredCo Workersarereleased NO PGs ROS Homosystein etc TriggersforPET GeneticModulatorsPre existingVascularPathology Centralplayers CytokinesRos TheConstantPathophysiologicalChanges IsVascularendothelial Damage Dysfunction Spasm Pathology PETistheclinicalice bergtipmanifestationofthedisturbancesinthematernalhomeostasis involvingmanysystemsandorgans MultisystemFeaturesOfPreeclampsia Diagnosis 1 Prediction 2 CL P Severity3 Eclampsia Diagnosis I Prediction Highriskfactors Rapidweightgainduringthe2ndhalfofpregnancy duetooccultedema Anyincreaseabove3 4kg weekinlatepregnancyisabnormal TestsforPrediction Rollovertestispositive riseofdiastolicbloodpressure20mmHgormoreafterturningfromleftlateraltodorsalposition Increasedpressorresponse Uricacid iselevated Hypercalciuria DopplervelocimetrytodetectUteroplacentalhypoperfusion DiagnosisOfPET Hypertension Proteinuria Twofacetsofacomplexpathophysiologicalprocess A Signs itisadiseaseofsigns 2cardinalsigns or Edema Hypertension usuallyprecedesProteinuria Proteinuria detectedbyBoilingtest Quantitativeassay Dipsticktest or Edema occultormanifest Thelowerextremities Abdominalwall vulvaormaybegeneralizedanasarca usuallyafterhypertension Peripheraledemaisnotausefuldiagnosticcriterion 1 itiscommoninnormalpregnancy 2 PETcanoccurwithoutedema drytype soitspresencedoesnotensureapoorprognosisanditsabsencenotensureafavorableoutcome B Symptoms nonspecific Headache Blurringofvision Nauseaandvomiting Epigastricpain distensionofthelivercapsule Oliguriaoranuria SeverityOfPre eclampsia Theseverityofpre eclampsiaisassessedby Thefrequencyandintensityofthesignsandsymptoms ThemoretheseverityofPET themorelikelyistheneedtoterminatepregnancy DD mild severePET 4 DiagnosisOfEclampsia Eclampticfitstages 4stages Premonitorystage 1 2minute Eyerolledup Twitchesofthefaceandhands Tonicstage 1 2minute Generalizedtonicspasmwithepisthotonus Cyanosis Tonguemaybebittenbetweentheclenchedteeth 4 DiagnosisOfEclampsia Clonicstage 1 2minutes Convulsions Tonguemaybebitten faceiscongestedandcyanosed conjunctivalcongestion bloodstainedfrothfromthemouth Stertorousbreathing temperaturemayrise involuntarypassageofurineorstool Graduallyconvulsionsstop 4 DiagnosisOfEclampsia Coma Variabledurationduetorespiratoryandmetabolicacidosis Deepcomamayoccurs cerebralhemorrhage Laborusuallystartsshortlyafterthefit Sometimeslabordoesnotstartandconvulsionsrecuragainthesocalled intercurrenteclampsia andcarriesabadprognosis ClassificationsofEclampsia IntercurrentEclampsia eclampsiainwhichtheeclampticfitsrecurinthesamepregnancy RecurrentEclampsia eclampsiathatrecursinsubsequentpregnancy ClassificationsofEclampsia Antepartum 65 withthebestprognosis Intrapartum 20 Postpartum 15 withtheworstprognosisasitindicatesextensivepathologyandmultisystemdamage ClassificationsofEclampsia 1 Mild2 Severe Eden scriteria Coma 6hours Temperature 39 pneumoniaorpontinehge SystolicBp 200 riskofcerebralhge Pulse 120 min acuteheartfailure AnuriaorOliguria renalfailure Respiratoryrate 40 min pneumonia Morethan10fits statuseclampticus Investigations A Laboratory Urine 24hoururine Proteinuria Kidneyfunctions serumcreatinine urea creatinineclearanceanduricacid Liverfunctions bilirubin Enzymes SGPTandSGOT Blood CBC HCt HemolysisandPlateletcount Thrombocytopenia CoagulationProfile Bleedingandclottingtime Investigations B InstrumentalFundusExamination C Imagingtechniques CTscanforthebrain Ultrasonograghy E DopplerVelocimetry VI DifferentialDiagnosis A HypertensionWithPregnancy B ProteinuriaWithPregnancy C EdemaWithPregnancy VI DifferentialDiagnosis D ConvulsionsWithPregnancy Eclampsia Epilepsy Hysteria MeningitisandEncephalitis Tetanus Tetany Strychninepoisoning Braintumors Uremicconvulsions VI DifferentialDiagnosis E ComaWithPregnancy Hypoglycemic HyperglycemiccomaUremiccoma Hepaticcoma Alcoholiccoma Cerebralcoma VI DifferentialDiagnosis F HELLPSyndrome Acutefattyliverinpregnancy Hepatitis Thrombocytopeniapurpura HemolyticUremicsyndrome Treatment PREVENTION Antepartumttt ProperantenatalcareExpectanttreatment Controlhypertension Treatmentofeclampsia Preventionandcontrolofconvulsions Terminationofpregnancy Intrapartumcare Postpartumcare Prevention Lowdoseaspirin 75mg day DecreaseTxA2 fromPlatelets Notaffectendothelialprostacyclin PGI2 Calciumsupplementation Ca supplementationmayincreasetheproductionofprostacyclin PGI2 fromendothelialcells ThemosteffectivepreventivemeasuresforOCCURANCEofpre eclampsiaISPREVENTIONOFPREGNANCY contraception Prevention TTTofpreeclampsia ExpectantTreatment ControlofHypertension Preventionofconvulsions Terminationofpregnancy 1 ExpectantTreatment Rest CompletePhysicalandmentalrest Diet IncreaseproteinandcarbohydratewithlowNadiet SedationANDTRANQULIZER Phenobarbitone DIAZEPAAM Observation MATERNAL FETAL 1 ExpectantTreatment Observation Maternal Bloodpressure PulseandRespiratoryrate Urineoutput Proteinuria Anynewsymptoms Investigations creatinine creatinineclearance bloodpicture coagulationprofile Fetal fetalwell being 2 ControlofHypertension A Parentraldrugs 1 Hydralazine ItisaperipheralVD ThebestAntihypertensivedrugusedduringPre eclampsiaandEclampsia Dose 5 10mgIVorIMasinitialdose Repeatedevery20 30minutesuntilbloodpressureiscontrolled 2 ControlofHypertension 2 Labetalol Trandate andnonselective adrenergicblockerresultinginVD Dose 10 20mgIV Thedosecanbedoubledevery10minutesifproperresponseisnotachieved 3 Diazoxide Hyperstat Usedinseveredangerousresistanthypertensionasalastresort Dose 50 150mgIVbolusdose Repeatedevery1 2minutesuntilBPdecreases 2 ControlofHypertension A Oraldrugs 1 methylDOPA aldomet Itisthemostcommonlyused Itis adrenergicagonistcausingdepletionofcatecholaminestores Dose 500mg3 4times dayorally 2 Monohydralazine Aprisoline ItisaweakAntihypertensivewhengivenalone Itusedincombinationwith blockerstoincreaseitsefficacyanddecreaseitssideeffects 2 ControlofHypertension 3 adrenergicblockers Atenolol tenormin 50 100mg4timesdaily Labetalol Trandate 10 20mg3timesdaily 4 Prazocin minipres Itispostsynaptic adrenergicreceptorblockerresultinginVDandreflextachycardia ItisaweakAntihypertensivedrugsousedincombinationwithotherdrugs 5 CalciumChannelBlocker Nifedipine adalatorEpilat TTTofPreeclampsia 3 Preventionofconvulsions videinfra 4 Terminationofpregnancy videinfra TreatmentofEclampsia 1 Generalandfirstaidmeasures Isolationinasingle quite semidarkroom eclampsiaroom Anefficientnurseshouldbepresent ThefollowingequipmentsmustbepresentOxygensource Airway Suctionapparatus Bedwithmovableheadandlegswithlimbties TreatmentofEclampsia 1 Generalandfirstaidmeasures A B C D cont Ensurepatentairwaywithtrachealandbronchialsuction PutthepatientsinTrendlenburgposition toavoidaspirationofsecretions Insertacatheter Nasogastrictubemaybeinserted Nothingbymouthandfluidchart Fulllaboratoryinvestigation TreatmentofEclampsia 2 Observation Pulse temperature BPandRR Levelofconsciousness Durationofcoma Fetalheartsounds Urineoutputandalbuminuria Numberofconvulsions TreatmentofEclampsia 3 Sedation Morphine10 20mgIMthenmaintainbydiazepam10mgIVorIM 8hours Lyticcocktail25mgchlorpromazine 50mgphenergan 100mgpethidine Givenin500CCfluidover4hours Canberepeatedafter6hours Nevergive3rddose 4 ControlofConvulsions A MagnesiumSulfate MgSO4 Itisthedrugofchoice Mechanism CNSdepression MildVD Milddiuresis Inhibitsplateletaggregation IncreasePGI2synthesis MagnesiumSulfate MgSO4 ItcanbegivenIV 20 orIM 50 orSC 15 Thetherapeuticlevelis4 7mEq L ThetotaldoseofMgSO4shouldnotexceed24gmsin24hours ThedoseofMgSO4ismonitoredby Preservedpatellarreflex Respiratoryrate 16 min Urineoutput 100ml 4hours SerumMg level Isstopped24hoursafterdelivery N BAntidoteiscagluconate MagnesiumSulfate MgSO4 IVregimen initially4 6gm 20 in100mlsolution Givenover15 20minutes Then 2gm hourbyIVdrip IMregimen 10gmsof50 solutionaregivendeeplyIM 5gmsineachbuttock Maintainwith5gm 6hoursof50 solution SideeffectsofMgSO4 smallsafetymargin Atalevelof8 10mEq Lpatellarreflexislostandstartsmyometrialinhibition 10 15mEq Lrespiratorydepression 15mEq Lcardiacdepression Curarelikeaction SynergisticeffectwithCa channelblockers Uterineinertia Neonatalhypermagnesemia DecreasedbeattobeatvariabilityinFHS Antidote 10mlof10percentcalciumgluconate 4 ControlofConvulsions B Phyntoin Epanutin Inseverepre eclampsiaInimminenteclampsia Thedoseis15mg kg 4 ControlofConvulsions C Diazepam Valium Thisregimenismainlyforeclampticpatients Initially20 40mgIVslowlyover5minutes then10 20mg 6hours thenthedoseisadjustedat10mg hourtomaintaindrowsiness Sideeffects NeonatallowAPGARscore Neonatalhyperbilirubinemia ModifiedStroganoffmethod TheoriginalStroganoffmethodisMgSO46gminitiallythen4gm 4hours 20mgmorphineIM 4 ControlofConvulsions TreatmentofEclampsia 5 Controlofhypertension VIDESUPRA 6 Otherdrugs ProphylacticdigitalistoguardagainstHFAntibioticforinfection IVglucose25 asaliversupport increasestheurineoutputandimprovesHemoconcentration TreatmentofEclampsia 7 TerminationofPregnancyIndications Eclampsia Retinalhemorrhage byCStoavoidbearingdown Deterioratedcardiac renalorliverfunctions SeverePETnotcontrolledafter24hours MildPETreaching38weeksandnotcontrolled Expectanttreatmentreachingmatur