Hypertension in Pregnancy

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DEPARTMENTAL SCIENTIFIC DISCUSSION:

D EPARTMENTAL SCIENTIFIC DISCUSSION ORGANIZED BY DEPARTMENT OF CARDIOLOGY HOSPITAL NO-01 LUGANSK STATE MEDICAL UNIVERSITY

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BY DR. SUMANTA KUMER SAHA MBBS, FCPS-II (MEDICINE) MD COURSE IN CARDIOLOGY LUGANSK STATE MEDICAL UNIVERSITY GOOD MORNING

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H YPERTENSION IN P REGNANCY

CONTENTS…:

C ONTENTS … DEFINITION INCIDENCE COMPLECATIONS TYPES CHRONIC HYPERTENSION GESTATIONAL HTN: ANTIHYPERTENSIVE DRUGS IN PREGNANCY ACUTE TREATMENT OF SEVERE HYPERTENSION

DEFINITION: HTN IN PREGNACNY:

D EFINITION : HTN IN PREGNACNY IT CAN BE DEFINED AS BP: SBP >140 mm-Hg DBP >90 mm-Hg AT LEAST 2 OCCASIONS 6 HOURS APART

INCIDENCE: :

I NCIDENCE: PRESENT IN 8-10% OF ALL PREGNANCY

COMPLICATIONS::

C OMPLICATIONS: ABRUPTIO PLACENTA PULMONARY EDEMA RESPIRATORY FAILURE DIC CEREBRAL HARMORRHAGE HEPATIC FAILURE ARF FETAL COMPLICATIONS: IUGD STILL BIRTH NEONATAL DEATH

TYPES: 3 BROAD CATEGORIES:

T YPES: 3 BROAD CATEGORIES CHRONIC HYPERTENSION GESTATIONAL HYPERTENSION PRE-ECLAMPSIA-ECLAMPSIA

CHRONIC HYPERTENSION(CHT) :

C HRONIC HYPERTENSION(CHT) DEFINITION : ELEVATED BP DETECTED BEFORE 20 TH GESTATINAL WEEK OR FAILS TO BECOME NORMAL 12 WEEKS AFTER DELIVERY OCCURS IN 1-5% OF PREGNANCIES COMPLICATIONS SAME, MORE COMMON IN PATIENTS OLDER THAN 30 YEARS

CHRONIC HYPERTENSION :

C HRONIC HYPERTENSION PHYSIOLOGICAL DECLINE IN BP IN EARLY PREGNANCY IS EXAGGERATED IN WOMEN WITH CHT – NORMOTENSIVE INITIALLY AND LATER, NORMAL RISE IN BP EXAGGERATED IN WOMEN WITH CHT- HYPERTENSIVE IN 3 RD TRIMESTER REGARDING ANT-HTN: ACE-Is SHOULD BE AVOIDED, AS THIS IS ASSOCIATED WITH FETAL & NEONATAL RENAL FAILURE AND DEATH. WOMEN WITH MILD TO MODERATE HTN SHOULD DISCONTINUE TREATMENT PRIOR TO CONCEPTION BECAUSE THE RISK OF IUGR .

CHRONIC HYPERTENSION :

C HRONIC HYPERTENSION THERE IS NO EVIDENCE THAT TREATING CHT REDUCES THE RISK OF SUPERIMPOSED PRE-ECLAMPSIA, NOR ANY EVIDENCE TO SUPPORT A PARTICULAR FETAL BENEFIT. LONG-TERM USE OF ANTI-HTN HAS BEEN ASSOCIATED WITH IUGR; IT IS UNCERTAIN WHETER THIS IS A SPEICFIC DRUG EFFECT (BETA-BLOCKERS) OR A CONSEQUENCE OF A REDUCTION IN PLACENTAL PERFUSION FOLLOWIN A LOWERING OF BP.

DRUG THERAPY :

D RUG THERAPY RECOMMENDED FOR PATIENTS WITH HIGH RISK CHARACTERSTICS OF PRE-ECLAMPSIA: SEVERE HTN WITH EVIDENCE OF END ORGAN INVOLVEMENT A POOR OBSTETRIC HISTORY RENAL INSUFFICIENCY COLLAGEN VASCULAR DISEASE LOW RISK PATIENTS: SBP: 140-160 mm-Hg, DBP: 90-110 mm-Hg NORAML PHYSICAL EXAMINATION NORMAL ECG & ECHOCARDIOGRAPHY NO PROTEINURIA ANTI-HYPERTENSIVE THERAPY HAS NOT BEEN SHOWN TO PREVENT DEVELOPMENT OF PRE-ECLAMPSIA OR AFFECT FETAL OUTCOME

GESTATIONAL HYPERTENSION :

G ESTATIONAL HYPERTENSION HTN INDUCED BY PREGNANCY BEGINNING AFTER 20 TH GESTATINAL WEEK AND RESOLVED BY 6 TH POST-PARTUM WEEK. TYPES: TRANSIENT HTN: (HTN WITHOUT PROTIENURIA): USUALLY ARISE IN THE LATE 3 RD TRIMESTER WITH RETURN OF BP BY THE 10 TH POST-PARTUM DAY PRE-ECLAMPSIA: HTN WITH PROTEINURIA

GESTATIONAL HYPERTENSION :

G ESTATIONAL HYPERTENSION IN TRANSIENT HTN , ANTI-HTN THERAPY SHOULD BE RESERVED FOR PATIENTS WITH BP> 160/110 mm-Hg IF UNCERTAIN WHETHER TRANSIENT HTN OR PRE-ECLAMPSIA, SEIZURE PROPHYLAXIS SHOULD BE STARTED EMPERICALLY WITH BP> 160/110 mm-Hg

PRE-ECLAMPSIA-ECLAMPSIA:

P RE-ECLAMPSIA-ECLAMPSIA DEFINITION : A PREGNANCY SPECIFIC SYNDROME THAT USUALLY OCCURS 20WEEKS GESTATION AND IS DEFINED BY THE APPEARANCE OF HTN (SBP>160, DBP>110) ACCOMPANIED BY NEW ONSET PROTIENURIA (300 MG OR MORE PER DAY) USUALLY REGRSSES WITHIN 24-48 HOURS AFTER BIRTH

PRE-ECLAMPSIA-ECLAMPSIA:

P RE-ECLAMPSIA-ECLAMPSIA INDICATIONS FOR DRUG THERAPY : SBP>150-160 mm-Hg OR DBP> 100-110 mm-Hg OR THE PRESENCE OF TOD

PRE-ECLAMPSIA-ECLAMPSIA:

P RE-ECLAMPSIA-ECLAMPSIA MANAGEMENT DELIVERY IS THE ONLY DEFINITIVE TREATMENT ***THERE IS NO EVIDENCE THAT ANY OTHER THERAPY ALTERS THE UNDERLYING PATHOLOGY OR IMPROVES THE PERINATAL OUTCOME

PRE-ECLAMPSIA-ECLAMPSIA:

P RE-ECLAMPSIA-ECLAMPSIA TIME OF DELIVERY: AT 40 WEEKS - ON DIAGNOSIS AT 38 WEEKS- MILD DISEASE & FAVOURABLE CERVIX BEYOND 32-34 WEEKS- SEVERE PRE-ECLAMPSIA BETWEEN 23-32 WEEKS- IF THERE ARE WORSONING MATERNAL SYMPTOMS LAB EVIDENCE OF END ORGAN DYSFUNCTION FETAL DETERIORATION

PRE-ECLAMPSIA-ECLAMPSIA:

P RE-ECLAMPSIA-ECLAMPSIA INDICATIONS OF DELIVERY: ECLAMPSIA PERSISTENT SEVERE HTN (REFRACTORY TO MAXIMUM DOSES OF 3 ANTI-HTN DRUGS) COMPLETION OF 34 WEEKS HELLP SYNDROME ABNORMAL FETAL TESTING

RECOMMENDED GOAL OF THERAPY:

RECOMMENDED GOAL OF THERAPY REDUCTION OF MEAN BP BELOW 126 UPTO 105 DBP BETWEEN 90-105 MM OF HG.

ANTI-HTN DRUGS IN PREGNANCY:

A NTI-HTN DRUGS IN PREGNANCY CENTRAL α -2 AGONIST: METHYLDOPA 250 mg: TDS (MAX: 4 mg/day) CLONIDINE 0.1 to 0.3 mg BD (1.2 mg/day) ALPHA-1 BLOCKER: PRAZOSIN 1mg BD (20 mg/day) CCB : NIFEDIPINE 10 mg QDS (120 mg/day) BETA-BLOCKER: ATENOLOL 100 mg qd (100 mg BD) DIURETICS: HTZ 25 mg qd (50 mg/day) ALPHA+BETA BLOCKER: LABETALOL 100 mg TDS (2400 mg/day)

ACUTE TREATMENT OF SEVERE HTN:

A CUTE TREATMENT OF SEVERE HTN ARTERIAL DILATOR: HYDRALAINE: 5-10 mg IV q 15-30 min DIAZOXIDE: 30-60 mg IV q 10-15 min CCB: NIFEDIPINE: 10-20 mg PO q 30 min ALPHA+BETA BLOCKER: LABETALOL 20 to 40 to 80 mg IV q 10-20 min VENOUS DILATOR: SODIAUM-NITROPRUSIDE 50 mg in 250 ml NS 0.5-5 mcg/kg/min HYDRALAZINE >>> LABETALOL>>> NIFEDIPINE>>> GTN/NITROPRUSSIDE

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THANKS A LOT

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ON 21 ST APRIL, 2007

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ON 21 ST APRIL, 2007

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ON 21 ST APRIL, 2007

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