Based on 2014 SOGC Guidelines

Transcription

1 Based on 2014 SOGC Guidelines 22nd Edition

2 ICH + gestational hypertension by far the biggest cause of direct maternal deaths New stats coming in 2013 OCR 22nd Edition

3 Diastolic 90 mmhg is level associated with increased perinatal morbidity 22nd Edition

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5 Cuff should be 1 ½ x arm circumference Korotkoff sounds I and V (disappearance) use K4 if K5 goes to 0 (small proportion of cases) Since the Canadian Consensus Conference in 1997, two major groups have published guidelines: The National High Blood Pressure Education Program Working Group (USA, 2000) and the Australasian Society for the Study of Hypertension in Pregnancy (Australia, 2000). Both recommend using Korotkoff V, the best explanation is in the Australian document. Explanation summarized is as follows: K5 is more reliably detected than K4 during pregnancy K5 more closely reflected true diastolic pressure in pregnancy than K4 changing from use of K4 to K5 does not increase morbidity for mother or baby in hypertensive pregnant women there can be large differences in bp s using K4 and K5. K5 is close to zero in only a very small proportion of pregnancies (in these use K4) 22nd Edition

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7 UPCR <30 can be used reliably in ruling out significant proteinuria Do not confuse UPCR with ACR (Albumin Creatinine Ratio) It is the presence of proteinuria not the amount that impacts prognosis ln nd Edition

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9 PRES = Posterior Reversible Encephalopathy Syndrome clinical symptoms are often post seizure headache, confusion, seizures and visual loss. Diagnosed with imaging (CT, MRI) RIND = Reversible Ischemic Neurological Deficit (<48 hrs) 22nd Edition

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13 Suggestion: Introduce this slide by saying something to the effect that we have defined the terms and now we are going to take these definitions and place them in a working classification. Good luck! 22nd Edition

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17 The incidence of preeclampsia is 5.9/ deliveries 22nd Edition

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21 See table for less important risk factors 22nd Edition

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26 See table in chapter for explanation of why each lab test is done 22nd Edition

27 BPP no longer recommended for surveillance Doppler flow studies reflect placental perfusion and fetal adaptation 22nd Edition

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29 It should be noted that in women with established eclampsia low dose aspirin, calcium supplementation, anti-hypertensives and MgSO4 failed to show an impact in reducing stillbirth rate. Medical complications include collagen vascular disease, renal disease, DM, periodonitis Ref: reference Jabeen et al, nd Edition

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33 Nifedipine (Adalat ) Calcium channel blocker -Direct relaxation of vascular smooth muscle Nifedipine achieves target BP faster than labetalol with fewer doses Oral agent Dosage: Immediate release nifedipine (Adalat ) 5-10 mg swallowed whole or bitten and swallowed, repeat in 30 minutes if no response Intermediate-acting nifedipine (Adalat PA ) 10 mg po with repeat dose at 45 minutes if no response to max of 80 mg/d onset of action within 90 minutes Side effects: flushing, headache, palpitations, tocolysis Labetalol (Trandate, Normodyne ) Combined alpha-1 and b-blocker with intrinsic sympathetic activity Rapid onset of action with both IV and oral route -IV route particularly useful for hypertensive crisis Dosage: bolus - 20 mg IV over 2 minutes. q10-30 minutes up to 300 mg infusion mg/minute, increase by 1 mg q15 minutes to a maximum of 4 mg/minute (each institution should have an agreed-upon protocol. Protocols may vary across institutions.) Cautions: asthma Side effects: bradycardia, masking of hypoglycemia Direct arteriolar vasodilator Intravenous (IV) route: rapid onset therefore useful for hypertensive crisis Can be used orally Hydralzine hydralazine (Apresoline ) trials suggest that hydralazine should not be the first choice agent due to a higher association with more maternal hypotension, C/S, abruptions, maternal oliguria, adverse fetal heart rate patterns, and low APGAR score at 1 minute.29 22nd Edition

34 Dosage: 5 mg IV test dose, followed by 5-10 mg IV q20 minutes, or infusion of mg/h Cautions: may cause unpredictable hypotension with resulting fetal compromise May be associated with more adverse events = hypotension, CS and abnormal FHR Side effects: flushing, headache and tachycardia 22nd Edition

35 CHIPS trial CHIPS trial examined tight 85 v less tight control 100 and showed that tight control was associated with less severe HTN without increased risk of IUGR, lowering DBP to 85 is safer for mother With co morbid conditions, lowering to these numbers protects from end organ damage Angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) should not be used but if used pre preg may be restarted pp even with Breastfeeding GOALS dbp < 80 may lower placental perfusion Any Anti HTN will drop BP but without perinatal maternal improvements in things like stroke, PTD, perinatal death small pilot RCT and meta regression suggesting anti HTN Rx has a significant relationship with SGA or LBW no long term data available DRUGS α-methyl-dopa (Aldomet ) supported by 7-year follow-up of neurodevelopment data centrally acting alpha2-receptor agonist long history of safe use in pregnancy; drug of choice in essential hypertension not for use in acute settings dosage: bid-qid maximum 2gm/day side effects: minimal 22nd Edition

36 labetalol (Trandate, Normodyne ) mg bid-qid, to a maximum daily dose 1,200 mg/d - may use starting dose of 200 mg bid May be more effective anti HTN than Aldomet but no diff in maternal or perinatal outcomes Nifedipine (Adalat-PA or XL ) optimal dose in pregnancy unknown PA (intermediate-acting): mg bid, maximum daily dose 80 mg XL (extended release): mg/day, maximum daily dose 120 mg/d XL has longer onset of action than PA, less useful in acute setting higher doses may be associated with edema 22nd Edition

37 Fluid bolus may lead to pulmonary edema which is a leading cause of maternal death in preeclampsia Fluid bolus pre-epidural is not necessary 22nd Edition

38 Oliguria (<15mL/hour) - Is common in preeclampsia and post-partum - Can be tolerated for a few hours in absence of renal disease or rising creatinine - Plasma volume expanders not recommended - This definition is different from common medical definition (30mL/hour) 22nd Edition

39 Collaborative Eclampsia Trial used 4 mg and 1 gm per hr recurrent seizure Rx with further 2-4 g bolus 22nd Edition

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41 Note recent studies suggest there are no increase in adverse effects with combination of MgSO 4 22nd Edition

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44 There are issues regarding the administration of magnesium sulfate during transport. Check with Provincial Guidelines. Consider IM MgSO 4 (5 g) with xylocaine in each buttock 22nd Edition

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46 In exceptional circumstances, may consider prolonging pregnancy to achieve fetal viability in case of GH with adverse conditions 22nd Edition

47 In exceptional circumstances, may consider prolonging pregnancy to achieve fetal viability in case of GH with adverse conditions 22nd Edition

48 These recommendations are specifically from the Hypertension CPG. They have not been extrapolated to other clinical situations. Studies were not specific to HTN. National practices are varying. Good luck! 22nd Edition

49 Steroids take several hours to work 22nd Edition

50 Measure BP at day 3-6 pp as is time of peak BP due to mobilization of extracellular fluid New onset of late postpartum preeclampsia has been documented up to 3 weeks after pregnancy in an otherwise normal pregnancy 22nd Edition

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