logging in or signing up acute severe hypertension in pregnancy vkumar Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 1019 Category: Education License: All Rights Reserved Like it (1) Dislike it (0) Added: April 25, 2010 This Presentation is Public Favorites: 2 Presentation Description hyppertensive crises needs to be managed effectively lest maternal morbidity and mortality increases.this original ppt attempts to review the current evidence Comments Posting comment... By: makambata (16 month(s) ago) I LIKE THIS Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript ‘Acute severe hypertension treatment’ review of contemporary evidence : ‘Acute severe hypertension treatment’ review of contemporary evidence Veerendrakumar C.M. MD., DNB. Associate professor VIMS, Bellary. veerendrakumarcm@gmail.com 4/25/2010 1 VIMS : VIMS 4/25/2010 2 Major Killers - A P E S : Major Killers - A P E S Anemia PPH Eclampsia Sepsis 4/25/2010 3 Safe motherhood initiative… 300 to 30 in 3 years : Safe motherhood initiative… 300 to 30 in 3 years Train all medical / Para medical personnel - uniform protocol throughout the district Easily preventable deaths can be prevented ! Now our MMR is 156 / 1 lakh live births 4/25/2010 4 Hypertensive crises deaths difficult to treat : Hypertensive crises deaths difficult to treat 4/25/2010 5 Hypertensive crises : Hypertensive crises “Hypertensive emergencies”Severe Hypertension with end organ damage Malignant hypertension now called “hypertensive emergency” “Hypertensive urgencies.” Severe Hypertension without end organ damage 4/25/2010 6 Causes of maternal mortalityin VIMS study of 513 patients Joshi et al 2003-2007 : Causes of maternal mortalityin VIMS study of 513 patients Joshi et al 2003-2007 4/25/2010 7 VIMS study –Joshi et al : VIMS study –Joshi et al 4 out of 8 died of ICH in a series of 164 cases of eclampsia 1997-1999 4/25/2010 8 Mean MAP 124.2 mm of Hg Joshi et al : Mean MAP 124.2 mm of Hg Joshi et al <100 24 4.7 100-110 68 13.2 >110 421 82.1 4/25/2010 9 VIMS study 164 pts (1997-1999) : VIMS study 164 pts (1997-1999) MAP > 110 maternal mortality was 11.4% MAP < 110 maternal mortality 4.5% 4/25/2010 10 Vicious cycle : Vicious cycle Severe HTN Endothelial injury Fibrinoid necrosis Ischemia Vasoactive amines 4/25/2010 11 RCOG 2006 : RCOG 2006 Antihypertensive treatment started in women with a sBP > 160 mmHg or a dBP > 110 mmHg. other markers of potentially severe disease, treatment considered even at lower degrees of hypertension. 4/25/2010 12 Slide 13: There is concordance that severe hypertension should be treated without delay to reduce maternal risks of acute cerebrovascular complications. Marko Folic et al ,Acta Medica Medianae 2008;47(3):65-72. 4/25/2010 13 Indications for treatment : Indications for treatment Based on practice patterns established over the years rather than Clinical trials with clearly defined outcomes 4/25/2010 14 Anti-HT treatment in mild HTN : Anti-HT treatment in mild HTN 50-66% reduction in severe hypertension, but no difference in perinatal outcomeAbalos E et al , Cochrane Data base Syst Rev. 2007;CD002252. A 10 mm of Hg fall in MAP was associated with 176g decrease in fetal weight J Obstet Gynecol Can 2002:24:92 4/25/2010 15 What precedes Severe HTN ? : What precedes Severe HTN ? Mild to moderate HTN 4/25/2010 16 Different standards for treatment : Different standards for treatment American ≥160/100 Am J Obstet Gynecol 2000;183:S1–S22. 4/25/2010 17 Slide 18: The Canadian HTN Society140- 150 / 90-95 80 to 90 mm Hg Can Med Ass Journal 1997;157:1245-54. Australia 160/90 140/90 Hg Aust NZ J Obstet Gynaecol 2000;40:139– 55. 4/25/2010 18 Finally Sibai …. : Finally Sibai …. …however, guidelines and reviews generally recommend the introduction of antihypertensive treatment with the BP values of 140 – 155 / 90 -105 mmHg Am J Obstet Gynecol. 2007;196:514 e511–e519. 4/25/2010 19 Slide 20: Systolic pressure may be a better predictor of stroke than DBP 4/25/2010 20 Slide 21: Organ dysfunction is uncommon with a DBP 130 mm Hg (except in children and pregnancy). Chest 2000; 118:214–227, Women - encephalopathy may develop with a DBP of only 100 mm Hg. Can Med Assoc J 1997; 157:1245–1254 4/25/2010 21 Auto regulation : Auto regulation In the uninjured, normotensive brain, auto regulation is effective over MAP ranging from about 50 – 150 In the chronic hypertensive, this range is increased (e.g. 80 – 180) 4/25/2010 22 Auto regulation : Auto regulation 4/25/2010 23 Altered auto regulation : Altered auto regulation Rapid and excessive correction of the BP can further reduce perfusion and propagate further injury. Therefore, patients with a hypertensive emergency are best managed with a continuous infusion of a short-acting, titratable antihypertensive agent. 4/25/2010 24 Slide 25: The immediate goal is to reduce DBP by 10 to 15% or to approximately 110 mm Hg over a period of 30 to 60 min Paul E. Marik, Joseph Varon, CHEST 2007; 131:1949 –1962 4/25/2010 25 Placental blood flow is not auto regulated : Placental blood flow is not auto regulated Overzealous blood pressure control Placental hypo perfusion Blood flow not auto regulated Compromised fetus 4/25/2010 26 Bitter reality ! : Bitter reality ! Disciplined use of established protocols is difficult to achieve in resource poor settings 4/25/2010 27 In India : In India Most centers lack ideal set up for management of eclampsia maternal morbidity and mortality Practitioners rely on their clinical experience to treat hypertension 4/25/2010 28 RCOG Guideline No. 10(A)March 2006 : RCOG Guideline No. 10(A)March 2006 The Confidential Enquiries into Maternal Deaths persistently show substandard care in significant deaths 4/25/2010 29 The Confidential Enquiries : The Confidential Enquiries ….Nine women died from cerebral causes, with substandard care in 50% of cases.…….Therefore, there is yet room for improvement. In particular, the control of hypertension and the management of fluid balance were highlighted. RCOG Guidelines 2006 4/25/2010 30 Slide 31: Restoration of intravascular volume with IV saline solution will serve to restore organ perfusion and prevent a precipitous fall in BP when antihypertensive regimens are initiated. 4/25/2010 31 Slide 32: The blood pressure should be checked each 15 minutes until the woman is stabilized and then every 30 minutes in the initial phase of assessment. The blood pressure should be checked 4-hourly if a conservative management plan is in place and the woman is stable and asymptomatic. 4/25/2010 32 Slide 33: Preeclampsia - detection of hypertension Prevention of eclampsia - detect and treat hypertension at the earliest Eclampsia - focus mainly on anticonvulsant regimen, antihypertensive treatment takes a back seat. 4/25/2010 33 Dilemmas… : Dilemmas… experience and evidence In India difficult to cling on to a particular option Complex clinical, social situations 4/25/2010 34 Slide 35: Make the right choice.. 4/25/2010 35 Slide 36: Short acting titratable IV antihypertensives should be used in ICU setting to treat hypertensive emergencyPaul E. Marik, Joseph Varon, CHEST 2007; 131:1949 –1962 4/25/2010 36 Slide 37: Due to unpredictable pharmacodynamics, the sublingual and IM route should be avoided. Paul , Joseph ,CHEST 2007; 131:1949 –1962 4/25/2010 37 Slide 38: Labetalol - intravenously, Nifedipine - orally Hydrallazine - intravenouslyused for the acute management of severe hypertension. Nifedipine should be given orally not sublingually. 4/25/2010 38 Slide 39: Meta-analysis of intravenous hydrallazine usage in severe hypertension in pregnancy concluded that parenteral Labetalol or oral nifedipine were preferable first-line agents Magee LA et al BMJ 2003;327:955–60 4/25/2010 39 Labetalol : Labetalol Little placental transfer occurs mainly due to the negligible lipid solubility of the drug. 4/25/2010 40 Labetalol preferred : Labetalol preferred Lack of reflex tachycardia, hypotension and increased intracranial pressure ….the most common side effect of hydrallazine is unpredictable hypotension AM J Health syst Pharma 2009 Feb 15 ;66(4)337-44 4/25/2010 41 Labetalol : Labetalol Maintains cardiac output. Reduces the SVR without reducing total peripheral blood flow. The cerebral, renal and coronary blood flow are maintained. Br J Anaesth 1995; 75:51–54 4/25/2010 42 Cochrane Data base Syst Rev. 2007 : Cochrane Data base Syst Rev. 2007 Discontinuation of usage because of adverse effects is uncommon Abalos E, Duley L, Steyn D, Henderson-Smart D. 4/25/2010 43 Nifedipine : Nifedipine Capsules associated with maternal hypotension and fetal distress - suggested the usage of a long-acting preparation Br J Obstet Gynaecol. 1993;100:959–61. AmJ Obstet Gynaecol 1989;159:308-9. 4/25/2010 44 Nifedipine : Nifedipine Sublingual nifedipine is not approved by US –FDA JAMA 1996 ;276:1328 4/25/2010 45 Slide 46: Poorly soluble and is not absorbed through the buccal mucosa. It is however rapidly absorbed from the GI tract after the capsule is broken/dissolved. The use of nifedipine capsules for hypertensive emergencies and “pseudo emergencies” should be abandoned. Paul Marik, Joseph Varon,CHEST 2007; 131:1949 4/25/2010 46 Nifedepine & MgSO4 : Nifedepine & MgSO4 Neuromuscular blockade AmJ Obstet Gynaecol 1989;161:35-6. 4/25/2010 47 Nifedipine - a degree of complacency? : Nifedipine - a degree of complacency? A degree ofcomplacency ? 4/25/2010 48 Slide 49: Best suited for use at periphery Midwifery to consultant level 4/25/2010 49 labetalol : labetalol An initial dose of 20 mg is given and is followed by progressively increasing doses (20, 40, 80 mg) every 10 minutes, to a total dose of 300 mg. Naden 1985 - Critical care obstetrics by Clarke 4/25/2010 50 labetalol : labetalol Alternatively, constant IV infusion may be started at 1 to 2 mg /min until therapeutic goals are achieved, then decreased to 0.5 mg/min or completely stopped Naden 1985 - Critical care obstetrics by Clarke 4/25/2010 51 Pharmacology-Labetalol : Pharmacology-Labetalol Onset: 5-10 min Half-life: 5.5 hrs Metabolism: Hepatic Adverse Effects: May exacerbate CHF and induce bronchospasm 4/25/2010 52 hydrallazine : hydrallazine an initial IV dose of 2.5 mg, If appropriate change in BP is not achieved 5-to 10-mg doses may be administered IV at 20-minute intervals to a total of 30 mg 10-30 min onset of action , lasts for 3-6 hrs 4/25/2010 53 Slide 54: Nifedipine 10 mg every 30 min up to a max 80mg Overshoot hypotension 4/25/2010 54 Slide 55: Sodium nitroprusside and nitroglycerine not recommended because of 1.Toxicity 2. Difficulty in invasive hemodynamic monitoring 4/25/2010 55 Critical care Obstetrics : Critical care Obstetrics Labetalol is best suited for management of hypertensive crises Need of the hour is to reduce the maternalmortality by implementing the proper antiHTN treatment in HDU set up Constantly upgrade our knowledge and evidence 4/25/2010 56 www.vimsobg.com : www.vimsobg.com veerendrakumarcm@gmail.com Thank you 4/25/2010 57 You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
acute severe hypertension in pregnancy vkumar Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 1019 Category: Education License: All Rights Reserved Like it (1) Dislike it (0) Added: April 25, 2010 This Presentation is Public Favorites: 2 Presentation Description hyppertensive crises needs to be managed effectively lest maternal morbidity and mortality increases.this original ppt attempts to review the current evidence Comments Posting comment... By: makambata (16 month(s) ago) I LIKE THIS Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript ‘Acute severe hypertension treatment’ review of contemporary evidence : ‘Acute severe hypertension treatment’ review of contemporary evidence Veerendrakumar C.M. MD., DNB. Associate professor VIMS, Bellary. veerendrakumarcm@gmail.com 4/25/2010 1 VIMS : VIMS 4/25/2010 2 Major Killers - A P E S : Major Killers - A P E S Anemia PPH Eclampsia Sepsis 4/25/2010 3 Safe motherhood initiative… 300 to 30 in 3 years : Safe motherhood initiative… 300 to 30 in 3 years Train all medical / Para medical personnel - uniform protocol throughout the district Easily preventable deaths can be prevented ! Now our MMR is 156 / 1 lakh live births 4/25/2010 4 Hypertensive crises deaths difficult to treat : Hypertensive crises deaths difficult to treat 4/25/2010 5 Hypertensive crises : Hypertensive crises “Hypertensive emergencies”Severe Hypertension with end organ damage Malignant hypertension now called “hypertensive emergency” “Hypertensive urgencies.” Severe Hypertension without end organ damage 4/25/2010 6 Causes of maternal mortalityin VIMS study of 513 patients Joshi et al 2003-2007 : Causes of maternal mortalityin VIMS study of 513 patients Joshi et al 2003-2007 4/25/2010 7 VIMS study –Joshi et al : VIMS study –Joshi et al 4 out of 8 died of ICH in a series of 164 cases of eclampsia 1997-1999 4/25/2010 8 Mean MAP 124.2 mm of Hg Joshi et al : Mean MAP 124.2 mm of Hg Joshi et al <100 24 4.7 100-110 68 13.2 >110 421 82.1 4/25/2010 9 VIMS study 164 pts (1997-1999) : VIMS study 164 pts (1997-1999) MAP > 110 maternal mortality was 11.4% MAP < 110 maternal mortality 4.5% 4/25/2010 10 Vicious cycle : Vicious cycle Severe HTN Endothelial injury Fibrinoid necrosis Ischemia Vasoactive amines 4/25/2010 11 RCOG 2006 : RCOG 2006 Antihypertensive treatment started in women with a sBP > 160 mmHg or a dBP > 110 mmHg. other markers of potentially severe disease, treatment considered even at lower degrees of hypertension. 4/25/2010 12 Slide 13: There is concordance that severe hypertension should be treated without delay to reduce maternal risks of acute cerebrovascular complications. Marko Folic et al ,Acta Medica Medianae 2008;47(3):65-72. 4/25/2010 13 Indications for treatment : Indications for treatment Based on practice patterns established over the years rather than Clinical trials with clearly defined outcomes 4/25/2010 14 Anti-HT treatment in mild HTN : Anti-HT treatment in mild HTN 50-66% reduction in severe hypertension, but no difference in perinatal outcomeAbalos E et al , Cochrane Data base Syst Rev. 2007;CD002252. A 10 mm of Hg fall in MAP was associated with 176g decrease in fetal weight J Obstet Gynecol Can 2002:24:92 4/25/2010 15 What precedes Severe HTN ? : What precedes Severe HTN ? Mild to moderate HTN 4/25/2010 16 Different standards for treatment : Different standards for treatment American ≥160/100 Am J Obstet Gynecol 2000;183:S1–S22. 4/25/2010 17 Slide 18: The Canadian HTN Society140- 150 / 90-95 80 to 90 mm Hg Can Med Ass Journal 1997;157:1245-54. Australia 160/90 140/90 Hg Aust NZ J Obstet Gynaecol 2000;40:139– 55. 4/25/2010 18 Finally Sibai …. : Finally Sibai …. …however, guidelines and reviews generally recommend the introduction of antihypertensive treatment with the BP values of 140 – 155 / 90 -105 mmHg Am J Obstet Gynecol. 2007;196:514 e511–e519. 4/25/2010 19 Slide 20: Systolic pressure may be a better predictor of stroke than DBP 4/25/2010 20 Slide 21: Organ dysfunction is uncommon with a DBP 130 mm Hg (except in children and pregnancy). Chest 2000; 118:214–227, Women - encephalopathy may develop with a DBP of only 100 mm Hg. Can Med Assoc J 1997; 157:1245–1254 4/25/2010 21 Auto regulation : Auto regulation In the uninjured, normotensive brain, auto regulation is effective over MAP ranging from about 50 – 150 In the chronic hypertensive, this range is increased (e.g. 80 – 180) 4/25/2010 22 Auto regulation : Auto regulation 4/25/2010 23 Altered auto regulation : Altered auto regulation Rapid and excessive correction of the BP can further reduce perfusion and propagate further injury. Therefore, patients with a hypertensive emergency are best managed with a continuous infusion of a short-acting, titratable antihypertensive agent. 4/25/2010 24 Slide 25: The immediate goal is to reduce DBP by 10 to 15% or to approximately 110 mm Hg over a period of 30 to 60 min Paul E. Marik, Joseph Varon, CHEST 2007; 131:1949 –1962 4/25/2010 25 Placental blood flow is not auto regulated : Placental blood flow is not auto regulated Overzealous blood pressure control Placental hypo perfusion Blood flow not auto regulated Compromised fetus 4/25/2010 26 Bitter reality ! : Bitter reality ! Disciplined use of established protocols is difficult to achieve in resource poor settings 4/25/2010 27 In India : In India Most centers lack ideal set up for management of eclampsia maternal morbidity and mortality Practitioners rely on their clinical experience to treat hypertension 4/25/2010 28 RCOG Guideline No. 10(A)March 2006 : RCOG Guideline No. 10(A)March 2006 The Confidential Enquiries into Maternal Deaths persistently show substandard care in significant deaths 4/25/2010 29 The Confidential Enquiries : The Confidential Enquiries ….Nine women died from cerebral causes, with substandard care in 50% of cases.…….Therefore, there is yet room for improvement. In particular, the control of hypertension and the management of fluid balance were highlighted. RCOG Guidelines 2006 4/25/2010 30 Slide 31: Restoration of intravascular volume with IV saline solution will serve to restore organ perfusion and prevent a precipitous fall in BP when antihypertensive regimens are initiated. 4/25/2010 31 Slide 32: The blood pressure should be checked each 15 minutes until the woman is stabilized and then every 30 minutes in the initial phase of assessment. The blood pressure should be checked 4-hourly if a conservative management plan is in place and the woman is stable and asymptomatic. 4/25/2010 32 Slide 33: Preeclampsia - detection of hypertension Prevention of eclampsia - detect and treat hypertension at the earliest Eclampsia - focus mainly on anticonvulsant regimen, antihypertensive treatment takes a back seat. 4/25/2010 33 Dilemmas… : Dilemmas… experience and evidence In India difficult to cling on to a particular option Complex clinical, social situations 4/25/2010 34 Slide 35: Make the right choice.. 4/25/2010 35 Slide 36: Short acting titratable IV antihypertensives should be used in ICU setting to treat hypertensive emergencyPaul E. Marik, Joseph Varon, CHEST 2007; 131:1949 –1962 4/25/2010 36 Slide 37: Due to unpredictable pharmacodynamics, the sublingual and IM route should be avoided. Paul , Joseph ,CHEST 2007; 131:1949 –1962 4/25/2010 37 Slide 38: Labetalol - intravenously, Nifedipine - orally Hydrallazine - intravenouslyused for the acute management of severe hypertension. Nifedipine should be given orally not sublingually. 4/25/2010 38 Slide 39: Meta-analysis of intravenous hydrallazine usage in severe hypertension in pregnancy concluded that parenteral Labetalol or oral nifedipine were preferable first-line agents Magee LA et al BMJ 2003;327:955–60 4/25/2010 39 Labetalol : Labetalol Little placental transfer occurs mainly due to the negligible lipid solubility of the drug. 4/25/2010 40 Labetalol preferred : Labetalol preferred Lack of reflex tachycardia, hypotension and increased intracranial pressure ….the most common side effect of hydrallazine is unpredictable hypotension AM J Health syst Pharma 2009 Feb 15 ;66(4)337-44 4/25/2010 41 Labetalol : Labetalol Maintains cardiac output. Reduces the SVR without reducing total peripheral blood flow. The cerebral, renal and coronary blood flow are maintained. Br J Anaesth 1995; 75:51–54 4/25/2010 42 Cochrane Data base Syst Rev. 2007 : Cochrane Data base Syst Rev. 2007 Discontinuation of usage because of adverse effects is uncommon Abalos E, Duley L, Steyn D, Henderson-Smart D. 4/25/2010 43 Nifedipine : Nifedipine Capsules associated with maternal hypotension and fetal distress - suggested the usage of a long-acting preparation Br J Obstet Gynaecol. 1993;100:959–61. AmJ Obstet Gynaecol 1989;159:308-9. 4/25/2010 44 Nifedipine : Nifedipine Sublingual nifedipine is not approved by US –FDA JAMA 1996 ;276:1328 4/25/2010 45 Slide 46: Poorly soluble and is not absorbed through the buccal mucosa. It is however rapidly absorbed from the GI tract after the capsule is broken/dissolved. The use of nifedipine capsules for hypertensive emergencies and “pseudo emergencies” should be abandoned. Paul Marik, Joseph Varon,CHEST 2007; 131:1949 4/25/2010 46 Nifedepine & MgSO4 : Nifedepine & MgSO4 Neuromuscular blockade AmJ Obstet Gynaecol 1989;161:35-6. 4/25/2010 47 Nifedipine - a degree of complacency? : Nifedipine - a degree of complacency? A degree ofcomplacency ? 4/25/2010 48 Slide 49: Best suited for use at periphery Midwifery to consultant level 4/25/2010 49 labetalol : labetalol An initial dose of 20 mg is given and is followed by progressively increasing doses (20, 40, 80 mg) every 10 minutes, to a total dose of 300 mg. Naden 1985 - Critical care obstetrics by Clarke 4/25/2010 50 labetalol : labetalol Alternatively, constant IV infusion may be started at 1 to 2 mg /min until therapeutic goals are achieved, then decreased to 0.5 mg/min or completely stopped Naden 1985 - Critical care obstetrics by Clarke 4/25/2010 51 Pharmacology-Labetalol : Pharmacology-Labetalol Onset: 5-10 min Half-life: 5.5 hrs Metabolism: Hepatic Adverse Effects: May exacerbate CHF and induce bronchospasm 4/25/2010 52 hydrallazine : hydrallazine an initial IV dose of 2.5 mg, If appropriate change in BP is not achieved 5-to 10-mg doses may be administered IV at 20-minute intervals to a total of 30 mg 10-30 min onset of action , lasts for 3-6 hrs 4/25/2010 53 Slide 54: Nifedipine 10 mg every 30 min up to a max 80mg Overshoot hypotension 4/25/2010 54 Slide 55: Sodium nitroprusside and nitroglycerine not recommended because of 1.Toxicity 2. Difficulty in invasive hemodynamic monitoring 4/25/2010 55 Critical care Obstetrics : Critical care Obstetrics Labetalol is best suited for management of hypertensive crises Need of the hour is to reduce the maternalmortality by implementing the proper antiHTN treatment in HDU set up Constantly upgrade our knowledge and evidence 4/25/2010 56 www.vimsobg.com : www.vimsobg.com veerendrakumarcm@gmail.com Thank you 4/25/2010 57