Pregnancy induced hypertension #pre-eclampsia#management##methyldopa#Labetalol Hydrochloride#Magnesium Sulphate 4%

Hypertension in pregnancy

Definition:

 The level of BP at which the benefits of treatment outweigh the costs and hazards

Prevalence: 

in 20-30% of the adult population, much higher in black Africans (40-45% of adults)

Measurements: 

All adults should have blood pressure measured 

routinely at least every 5 years

 until the age of 80 years.

■ In the sitting position with the arm supported at the level of the heart

■ After 5 minutes' resting

■ With appropriate cuff size, must encompass more than two-thirds of the arm.

■ Remove tight clothing from the arm

■ Measurements should be made to the nearest 2 mmHg

■ Take two measurements at each visit

☞Isolated systolic hypertension is associated with a two- to three fold increase in cardiac mortality.

Investigations

For All:

1. Urine routine & microscopy (R.M.E)

 for blood, protein and glucose

2. Blood urea, 

Serum Electrolytes

Serum Electrolytes

 and 

Serum creatinine

3. Blood Glucose

4. Lipid Profiles

5. Thyroid function tests

 (May be Hyperthyroid/hypothyroid)

6. ECG

 (to find out left ventricular hypertrophy, coronary artery disease)

For selected patients

• Chest X-ray: to detect cardiomegaly, heart failure...

• Echocardiogram: to detect or quantify left ventricular hypertrophy

• Renal ultrasound:to detect possible renal disease

• Others

Management

Management of hypertension in pregnancy

There are three types of hypertension seen in pregnant woman

• Chronic or pre-existing hypertension

• Gestational hypertension

• Pre-eclampsia and eclampsia.

 Chronic or pre-existing hypertension

In pregnancy normal physiology is a reduction in sBP but rise of dBP

(due to a fall in systemic vascular resistance which is maximal by weeks 22–24).

Methyldopa

 (Initially 250 mg 2–3 times daily, increased gradually at intervals of at least 2 days, max. 3 g daily) – First Choice

Advantage: 

No adverse effects on fetus.

Caution: Sedation may limit up-titration.

Second-line-

1. Nifedipine

 and

2. Labetalol Hydrochloride

Strongly contraindicated antihypertensives are

• ACE inhibitors

• Angiotensin receptor 

• Diuretics

The target blood pressure should be <150/100 mmHg

.

Gestational hypertension:

A. 

>140/90 mmHg in the 2nd trimester in a previously normotensive woman without proteinuria

• BP should be monitored twice weekly.

• Urine R/M/E for protein as there is an increased risk of developing pre-eclampsia.

B. 

Patients with moderate hypertension (159–150/109–100 mmHg)-

Labetalol Hydrochloride

•Oral 

(initially 100 mg (50 mg in elderly) twice daily with food,

increased at intervals of 14 days to usual dose of 200 mg twice daily;

up to 800 mg daily in 2 divided doses (3–4 divided doses if higher); max. 2.4 g daily

• S. electrolytes, LFT should be measured.

C. If severe hypertension (≥160/110 mmHg)

• hospital admission

Pre-eclampsia

(it is a multi-system disorder that occurs after 20 weeks’ gestation consisting of:

• Hypertension

• Oedema

• Proteinuria (>3 g/24 hours).

Management:

• Hospital admission

• Regular BP measurements (4 times daily) and

• Close fetal monitoring (risks of placental insufficiency and intra uterine growth retardation)

Patients who progress to eclampsia (convulsions) and/or HELLP (haemolysis, elevated liver enzymes,

Low platelet count) syndrome -

• Admission to a critical care unit (ICU/HDU*)

• May require intravenous

            Hydralazine

           (1 amp 20 mg + 10ml D/W i.v., at 2.5-5             ml every 15 min until dBP reduced to           90mmHg) ,

• Labetalol Hydrochloride

 (1amp 50mg/10ml; 20mg or 4ml iv slowly then 40-50mg 8-10 ml every 15min until dBP reduced to 90mmHg; maximum dose 300 mg), and

• Magnesium Sulphate 4%

(for convulsions)

Loading dose:

• (4 gm/ 8 ml + 12 ml D/W) slow iv over 10-15 min 

or

• Total 6 gm /12 ml: 3 gm/ 6ml in each buttock

Maintenance dose:

 2.5 mg /5ml deep i.m. in alternate buttock every 4 hours continued 24 hours after last convulsion or delivery.

>Prompt delivery.

Concern::

Pregnancy always desirable.so everyone should always cautious about any unnatural event related to pregnancy such as hypertension.