Hypertension in pregnancy Hypertensive disorders complicate 3 7

Hypertension in pregnancy Hypertensive disorders complicate 3. 7% of all pregnancies and is a leading cause of maternal and perinatal mortality and morbidity. Identification of patients at high risk and timely detection with proper management can prevent life threatening complications. Diagnosis-working group report(2000) 1)Gestational hypertension. Bp >/= 140/90 mm of h. G for first time during pregnancy No proteinuria Bp returns to normal within 12 weeks postpartum So final diagnosis-only post partum

2)Pre-eclampsia -minimum criteria bp>/=140/90 mm of hg after 20 weeks gestation. u Proteinuria >/= 300 mg /24 hrs Increased certainity of pre-eclampsia u Bp>/= 160/110 mm of hg u Proteinuria 2 g/24 hrs or >/=2+dipstick u S. creatinine > 1. 2 mg%(unless previously elevated) u Platelets<100, 000/cu. mm u Microangiopathic hemolysis u Elevated ALT/AST u Persistent headache/cerebral/visual disturbances/persistent epigastric pain.

3)eclampsia-seizures that cannot be attributed to other causes in a woman with pre eclampsia 4)Superimposed preeclampsia(on chronic hypertension) New onset proteinuria >/=300 mg/24 hrs but no proteinuria before 20 weeks. Sudden increase in proteinuria/BP/platelet count<100, 000/cumm if hypertension & proteinuria before 20 weeks 5)Chronc hypertension-BP>/=140/90 mm of hg before pregnancy or before 20 weeks gestation (excluding hydatidiform mole/acute polyhydramnios) OR Hypertension first diagnosed after 20 weeks gestation and persistent after 12 weeks post partum.

HISTORY u u u u Age –more common in young primigravidae and elderly primigravidae >35 years(increased incidence of hypertension with superimposed pre-eclampsia) Poor socioeconomic status-poor antenatal care and poor nurtition Residence-high altitude-increased incidence of preeclampsia Race-african american women are more prone Obstetric history-parity-primigravidae, h/o pregnancy complications like h. mole, multiple pregnancy, polyhydramnios, rh-incompatibility, gestational diabetes Marital history-h/o new paternity Past h/o any medical disorders-essential HT, chronic renal disease, diabetes mellitus, endocrine disorders, connective tissue disorders Family h/o of pre-eclampsia/eclampsia in mother/siblings

h/o symptoms of pre-eclampsia(usually after 20 th week) u h/o swelling of ankles which persists on rising from bed in the morning u Tightness of the finger ring u Swelling may extending to face, abdomen, vulva or whole body. Ominous symptoms u Headache-occipital/frontal, disturbed sleep u Dimished output of urine u Epigastric pain/vomiting-due to hepatocellular ischemia/necrosis, edema, with stretching of glissons capsule, subcapsular hge u Blurring/dimness of vision, blindness-spasm of retinal vessels, retinal edema, retinal detachment, occipital lobe lesions(hypodensities on MRI)

SIGNS Abnormal weight gain-greater than 5 pounds/month or 1 pound/week u Edema-common feature in 80% of normotensive pregnancies, so no longer incloded in the definition of pre-eclampsia u Mild edema-ignore u Sudden, severe widespread edemapathological-may indicate imminent eclampsia u

u Blood pressure measurement-ideally woman should be seated for 5 minutes before measuring BP with feet supported on the ground & arm resting on a table at the level of the heart. ( Each cm above/below-0. 8 mm hg change in bp recording) u BP recording in LLP-spuriously reduced by 10 -15 mm of hg. u The same arm should be used on each occasion u Cuff should be of appropriate size (12 cm bladder width for regular patients & 15 cm for more obese women) u Readings should be recorded to the nearest 2 mm of hg. u Use korotkoff phase 5(disappearance of sound)

To diagnose HT in pregnancy BP should be >/= 140/90 mm of hg at 2 separate readings at least 4 hrs apart. MAP=systolic BP+2* diastolic BP 3 MAP>/=105 mm of hg or ^ in MAP from previous is also diagnostic of pregnancy by 20 mmof hg HT in Diastolic BP tends to rise first followed by the systolic

P/A-the fundal height will be less than period of gestation-oligohydramnios, iugr Abdominal wall edema may be present-FHS may be difficult to localise Signs of IUD/abruption/preterm labour Fundoscopic examination-retinal edema, arteriolar constriction, alteration of normal vein to arteriole diameter from 3: 2 to 3: 1, nicking of veins by the arterioles Patient may present with eclampsia in the antenatal period(50%) Eclamptic fit-premomitory stage, tonic stage, clonic stage, stage of coma. Fits usually multiple episodes at varying intervals/status epilepticus

u Premonitory stage-unconscious, twitching of the muscles of face , tongue and limbs, rolling f eyeballs-30 sec u Tonic stage-tonic spasm of all voluntary muscles with opisthotonus, limbs flexed, hands clenched. respiration ceases, tongue protrudes. cyanosis appears , eyeballs are fixed-30 sec u Clonic stage-voluntary muscles undergo alternate contractuion/relaxationbiting of tongue , breathing sterterous, blood stained frothy secretions fill mouth, cyansis disappears gradually-1 to 4 min u Stage of coma-for brief period or lasyts till next convulsion, pt may be in confused state foll seizure, coma may occur without prior convulsion

u r/o other causes of convulsionsepilepsy/, hysteria, encephalitis, meningitis, poisoning, cerebral malaria, neurocysticercosis, intracranial tumours u o/e-temp raised, ^ pulse, resp rate, BP u Disoriention-cerebral haemorrhage u Urine output-markedly decreased, haematuria with jaundice(HELLP syndrome), anuria-b/l renal cortical necrosis u Injuries-tongue bite, due to fall u RS-basal crepitations- pulmonary edema(aspiration), signs of hypostatic/infective pneumonia, pulmonary embolism(cyanosis, resp distress) u Shock-acute LVF-due to anoxia , muscular exhaustion u Generalised bleeding tendency-DIC u Blindness

Tests of prediction u Based on the abnormal vascular responsivity/sympathetic overactivity in women destined to develop HT later in pregnancy. u ROLL OVER TEST-28 -32 weeks u Positive predictive value-33% u Positive roll over test indicates abnormal angiotensin 2 sensitivity u Angiotensin 2 infusion test

Early prenatal detection u u u u Increased prenatal visits during 3 rd trimester If overt hypertension(>140/90 mm 0 f hg)-admit the patient and evaluate the severity of pih Pts with new onset diastolic BP of 80 -90 mm of hg or wt gain>2 pounds/week should come for return visit in 3 -4 days Once admitted-daily scrutiny for symptoms/signs of imminent eclampsia Daily wt chart 4 th hrly BP chart Clinical evaluation of fetal size, amniotic fluid volume