Pregnancy Hypertension: Medications and Care

chronic underlying HTN that precedes preganncy or persists postpartum

No they affect the fetal renal system especially in 2nd and 3rd trimesters

Reduce placental perfusion

no medical ttx
conservative: monitoring of BP and placental insufficiency

High blood pressure caused by pregnancy WITHOUT proteinuria

Mild: >140/90
Severe: >=160/110

Aspirin 75-150mg

Labetalol/nifedipine/methyldopa/doxazosin

IV labetalol or hydralazine

☞Sustained Elevation of the BP to 140/90 mmHg or more on two occasions 4 hours apart

☞Proteinuria: >0.3g in a 24 hour urine collection.
OR
>1= on a dipstick test
OR
Protein/creatinine ratio of >0.3

4 hours
elevation of BP >140/90 on two different occasions 4 hrs apart is required to diagnose pre eclampsia

If new onset hypertension >20 wks of gestation is associated with a recent organ dysfunction manifested by one or more of the following:
-Thrombocytopenia (plts <100,000)
-Elevated AST and ALT twice normal
-Rising serum creatinine
-CNS symptoms
-DIC
-Pulmonary edema

-BP: >=160/110
-Serum creatinine > 1.1 mg/dl or doubling
-Elevated liver AST and ALT increased twice normal values
-Thrombocytopenia: PLT<100,000
-Epigastric pain or RUQ and vomiting
-Visual disturbances
-Pulmonary edema
-cerebral or visual disturbances (papilloedma)
-Oliguria <750ml/24 hours
-IUGR
-HELLP syndrome

-Headache
-Visual disturbances
-swelling
-Shortness of breath
-Epigastric pain
-RUQ pain
-Abdominal pain
-Dark scanty urine
-Bleeding
-decreased fetal movements

Seizure occurring due to uncontrolled cerebral hypertension
• Sustained hypertension ≥ 160/110
• Stroke
• Hepatic failure
• Renal failure
• DIC
• Placental abruption

Magnesium sulfate for fit
Antihypertensives : IV hydralazine or Labetalol
resuscitation and stabilization > fetal delivery

-Multiparous
-Previous pre eclampsia
-Underlying medical condition such as HTN or diabetes

- Monitoring of BP and proteinuria
- Referral to a maternity assessment unit or if severe admission to hospital
- Bloods for FBC, renal, liver functions, clotting
- Antihypertensive treatment and prevention of severe hypertention
- Seizure prevention (MgSO4)
- Fetal assessment and monitoring
- Delivery

managed as pre eclampsia but if case is complicated by renal function or retinal changes > consider abortion!

Preeclampsia developing on top of chronic HTN

Death of a women while pregnant or within 42 days of the end of the pregnancy from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

Resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium), from interventions, omissions, incorrect treatment or from a chain of events- any of the above.

Resulting from previous existing disease, or disease that developed during pregnancy and WHICH WAS NOT THE RESULT OF A DIRECT OBSTETRIC CAUSE, but which was aggravated by the physiological effects of pregnancy.

Indirect or direct maternal deaths occuring between 42 days and 1 year after end of pregnancy

From unrelated causes which happen to occur in pregnancy or the puerperium.:
eg) homicide
suicide
illicit drug toxicity
collision
Cancer

Cardiac disease

Group A streptococcus

-Genital tract sepsis
-Pre eclampsia and eclampsia
-Amniotic fluid embolism
-Early pregnancy deaths
-Haemorrhage
-Anaesthesia

Diastolic pressure + 1/3 pulse pressure

(Pulse pressure is the difference between systolic and diastolic)

Type I or II diabetic woman that becomes pregnant

is defined as any degree of glucose intolerance with onset or first recognition during pregnancy

☞Increased production of insulin antagonists:
-Placental lactogen
-Insulinase
-Cortisol
-Oestrogens
-Progesterone

☞Insulin requirements:
Increases during pregnancy due to increased production of insulin antagonists while it decreases postpartum

2nd trimester

1) BMI > 30 kg/m2
2) Previous Macrosomic baby weighing 4.5 kg or above
3) Previous Gestational diabetes
4) Family history of diabetes (first-degree relative with diabetes)

- 2 hour 75g OGTT at 24-28 weeks

-2 hour 75g OGTT at first visit + HbA1c
-If normal> 2 hour 75g OGTT at 24-28 weeks

1- fpg >= 100mg/dl
OR
2- 2 hr 75 g OGTT >=140 mg/dl

6.5%

Measure HbA1c levels in all women with gestational diabetes at the time of diagnosis to identify those who may have pre-existing type 2 diabetes.

-Pregnancy induced hypertension
-Infections as monilial vulval vaginitis or UTI
-Obstructed labour due to macrosomic baby
-deficient lactation

1) Abortions.
2)Polyhydramnios (30%): due to large placenta and foetal size.
3)Congenital anomalies: This is about 4 times the normal incidence (1.5%)
>Sacral dysgenesis is a specific anomaly related to diabetes.
4)Macrosomia: i.e. foetal weight > 4 kg at term may cause obstructed or traumatic delivery.
5)Preterm labour: due to polyhydramnios.
6)Intrauterine fetal death: especially in the last 4 weeks
7)Neonatal mortality and morbidity

sacral dysgenesis

-Ketosis
-Hypoglycemia
-Pre eclampsia
-Congenital anomalies
-Placental insufficiency

-Hypoglycemia
-ARDS
-Congenital anomalies
-Birth trauma
-Hyperbilirubinema
-decreased parathyroid hormone> hypocalcemia and hypomagnesemia

126 mg/dl

Metoformin

1)If fpg > 126mg/dl at diagnosis
2)If fpg levels are between 110-125mg/dl along with complications as macrosomia or polyhydramnios

Glibenclamide

Rapid-acting insulin analogues (Aspart and Lispro) have

• Advise pregnant women with insulin-treated diabetes to always have available a fast-acting form of glucose (e.g, dextrose tablets or glucose-containing drinks).

• Provide glucagon to pregnant women with type 1 diabetes for use if needed. Instruct the woman and her partner or other family members in its use.

• Offer women with insulin-treated diabetes continuous subcutaneous insulin infusion (CSII; also known as insulin pump therapy) during pregnancy if adequate blood glucose control is not obtained by multiple daily injections of insulin without significant disabling hypoglycemia.

-If pre existing diabetes> retinal assesment at first visit (nless done in past 3 months)
-asses again at 28 weeks

-If retinopathy is present at initial visit> asses again at 16-20 weeks

follow up should be for at least 6 months after birth of baby

arrange in first visit if not done in preceeding 3 months

-Done at 20 weeks for fetal structural abnormalities
-Monitor fetal growth and AF volume every 4 weeks between 28 and 36 weeks
-Overall fetal wellbeing monitoring should be done at 38 weeks

Give additional insulin

betamimetics

Elective birth by induction of labor, or by elective caesarean section if indicated,
at 37+0 - 38+6 weeks of pregnancy.

Elective birth <37+0 weeks

Elective birth before 40+6 weeks

-should reduce their insulin immediately after birth and monitor their blood glucose levels carefully to establish the appropriate dose.

-Explain that they are at increased risk of hypoglycemia in the postnatal period, ❗️especially when breastfeeding, and advise them to have a meal or snack available before or during feeds.

-With pre-existing type 2 diabetes can resume or continue to take metformin and glibenclamide immediately after birth, but should avoid other oral blood glucose-lowering agents while breastfeeding.

Avoid other oral blood glucose-lowering agents while breastfeeding, but its okay to take metoformin and glibenclamide

• Discontinue blood glucose-lowering therapy immediately after birth.
• Blood Glucose Test to exclude persisting hyperglycemia.
• Warn them about symptoms of hyperglycemia and to seek medical help if any symptom is met.
• Lifestyle advice (weight loss and exercise)
• Follow-up by Fasting blood glucose 6 weeks postnatal check and annually thereafter.
• Inform about risks of GDM in subsequent pregnancies.

for 6 weeks postnatally by fpg

☞Feed as soon as possible (within 30 minutes) and then at frequent intervals (every 2-3 hours) until feeding maintains pre-feed blood glucose levels at a minimum of 36 mg/dl

☞Test blood glucose levels at 2-4 hours after birth.

☞If one or more of these criteria are met transfer the neonate to the Special Care Baby Unit (SCBU):
• Blood glucose < 36 mg/dl on 2 consecutive readings.
• Abnormal clinical signs
• If the baby is not feeding orally effectively

Aortic dissection

Occurs during the last trimester of pregnancy or the first 6 months after delivery

(Peripartum cardiomyopathy should be considered in any pregnant or puerperal woman who complains of increasing shortness of breath, especially on lying flat or at night. All such women should have an electrocardiogram, a chest X-ray and an echocardiogram.)

systolic hypertension > important to monitor BP during pregnancy

Measurement of pulse rate and rhythm

second

oxytocic regimes can have major cardiovascular adverse effects; a low-dose syntocinon infusion is probably the safest option

Uterine compression sutures are an effective method for the treatment of PPH,

Use of early slow incremental epidural anaesthesia and assisted vaginal delivery.
Caesarean section is usually necessary only for obstetric indications.

-Fetal weight of at least 5,000 g in women without diabetes
-Fetal weight of at least 4,500 g in women with diabetes

30-32 weeks