MANAGEMENT OF MANAGEMENT OF HYPERTENSIVE CRISISHYPERTENSIVE CRISIS

Dr. Kirtan VyasAssistant Professor

P. D. U. Medical College, Rajkot

Dr. Kirtan VyasDr. Kirtan VyasM.S.(Ob/Gy)M.S.(Ob/Gy)

Gujarat Uni. First-Gold medallistGujarat Public Service Commission(GPSC) firstFellow in Gynec Endoscopy(Mumbai)Fellow in Ultrasonography(FOGSI)Publications in various International Journals Presented Scientific Papers and Chaired Sessions at State and National conferencesFaculty at State and National ConferencesLocal Joint Secretary of SOGOG-Gujarat State Org of Ob Gy 2015 Organizing Secretary for the First Rajkot Obstetrics and Gynec Society Annual Conference 2015 and Committee Member at State and National conferencesOrganizing secretary for the West Zone Yuva Fogsi 2016, RajkotFaculty at FOGSI-JOGI PICSEP Scientific Program 2016 at RajkotPresently an Assistant Professor at P.D. U. Medical College, Rajkot

Nothing baffles the researchers more than hypertensive disorders of pregnancy

It is probably the most studied and least understood problem of obstetrics

OBJECTIVESOBJECTIVES

• Defining HTN crisis Defining HTN crisis

• Diagnostic CriteriaDiagnostic Criteria

• End Organ ConsequencesEnd Organ Consequences

• Medical ManagementMedical Management

INTRODUCTIONINTRODUCTION• Hypertensive disorders of pregnancy are

responsible for significant maternal and maternal and perinatal morbidity perinatal morbidity

• Complicate 10% to 15% 10% to 15% of all pregnancies

• 17% of maternal deaths 17% of maternal deaths in India

HYPERTENSIVE DISORDERS IN PREGNANCY

• Important cause of “BAD OBSTETRIC OUTCOME”“BAD OBSTETRIC OUTCOME”

• MultisystemMultisystem Involvement

• Requiring close monitoringclose monitoring of Mother & Fetus

• Hospital Management Hospital Management preferred in severe cases

• Prognosis has improved with advances improved with advances in management and team approach

Chronic (Preexisting)

HTNGestational

HTN Preeclampsia Severe Preeclampsia Eclampsia

CLASSIFICATIONCLASSIFICATION

•Systolic BP > 160 / Diastolic > 110 on 2 occasions 6hrs apart while pt is in bed rest.•Proteinuria of 5 g or higher in 24hr urine or 3+ or greater in 2 samples 4hrs apart.•Oliguria of less than 5oo ml urine in 24 hrs.•IUGR•Cerebral or visual disturbances

SEVERITY OF PREECLAMPSIASEVERITY OF PREECLAMPSIA

DEFINITION OF HYPERTENSIVE DEFINITION OF HYPERTENSIVE CRISIS IN PREGNANCYCRISIS IN PREGNANCY

It is the acute, severe, persistent acute, severe, persistent (lasting for 15 min or more) hypertension – usually > 160/110 mm Hg, in the setting of preeclampsia or eclampsia, associated with acute and ongoing organ damageongoing organ damage to kidney, brain, heart or vascular system *

A hypertensive emergency requires hospitalization, immediate antihypertensive treatment to reduce maternal blood pressure without substantially decreasing placental perfusion and compromising the fetus, and delivery of the fetus ASAP

*ACOG 2011

• Headache• Epigastric or right upper quadrant pain :

particularly in HELLP due to liver dysfunction.• Visual symptoms : scotomas progressing to

blurred vision, even blindness. (abnormality lies in occipital cortex, not in retina.) recovers faster post natally.

• Brisk DTRs : CNS irritability.

Placenta is the Placenta is the central player central player inducing changes in inducing changes in the fetus and the the fetus and the mother.mother.No fetus is required No fetus is required for the development for the development of pregnancy of pregnancy induced induced hypertension.hypertension.

MORBIDITY AND MORTALITYMORBIDITY AND MORTALITY

HTNHTNCADCADCVACVAESRDESRD

IUGRIUGRSGASGAIUDIUD

MaternalMaternal NeonatalNeonatal

END ORGAN CONSEQUENCEEND ORGAN CONSEQUENCE

BASIC MANAGEMENT BASIC MANAGEMENT OBJECTIVESOBJECTIVES

• Termination of pregnancy with least possible trauma to the mother and the fetus

• Birth of an infant who subsequently thrives

• Complete restoration of health to the mother

GOALS OF TREATMENTGOALS OF TREATMENTWithin 1-2 hours Reduce MAP 20-25% Controlled environment Use IV medications

–This is a special situation when we need to decrease B. P. quickly and effectively

–A single drug is better in small intermittent doses , combinations should be avoided as they may have compound side effects

MAGNESIUM SULPHATEMAGNESIUM SULPHATE

Prevention & Treatment of

Seizures

Fetal neural protection for

preterm delivery

Short-term prolongation of pregnancy

(48 hrs)

MECHANISM OF ACTIONMECHANISM OF ACTION

VasculatureCa2+ Antagonist

Smooth muscle relaxationVasodilation

Relieve vasospamDecreased vascular

resistance

Anticonvulsant NMDA AntagonistDecreases effect of

glutamateLimits neuronal depolarization

Increases seizure threshold

Cerebral EndotheliumCa Antagonist

Decrease stress fiber contraction

Decrease paracellular BBB permeability

Limits cerebral edema

PROFILE OF AN IDEAL PROFILE OF AN IDEAL ANTIHYPERTENSIVEANTIHYPERTENSIVE

• Preserves GFR and renal blood flow

• Few or no drug reactions • Rapid onset and offset of action

• Minimal hypotension “overshoot”

• Minimal need for continuous BP monitoring and frequent dose titration

TREATMENT OF ACUTE SEVERE TREATMENT OF ACUTE SEVERE HYPERTENSION DURING PREGNANCYHYPERTENSION DURING PREGNANCY

• Parenteral hydralazine is most commonly used

• Parenteral labetalol is second-line drug (avoid in women with asthma and CHF)

• Oral nifedipine used with caution. (Short-acting nifedipine is not approved by FDA for managing hypertension)

DRUG OF CHOICE – WHICH ONE IS BESTDRUG OF CHOICE – WHICH ONE IS BEST

AGENT DOSAGE

Hydralazine(preferred)

5 mg iv bolus, then 10 mg every 20 to 30 minutes to a maximum of 30 mg, repeat in several hours as necessary

Labetalol(second line)

20 mg iv bolus, then 40 mg 10 minutes later, 80 mg every 10 minutes for 2 additional doses to a maximum of 220 mg

Nifedipine(controversial)

10 mg po, repeat every 20 minutes to a maximum of 30 mgCautious use with magnesium sulfate, can see precipitous blood pressure dropShort acting nifedipine is not approved by FDA for managing hypertension

Sodium nitroprusside(rarely when others fail)

0.5 ug/kg/min to a maximum of 5 ug/kg/min Fetal cyanide poisoning may occur if used for more than 4 hour

COCHRANE REVIEW 2013COCHRANE REVIEW 2013

35 Randomized Control Trials35 Randomized Control Trials3573 Women included3573 Women included

Not enough evidence to show which drug is most effectiveNot enough evidence to show which drug is most effective

Hydralazine Hydrochloride

Direct vasodilator

Relaxes blood vessels which helps to lower blood pressure

Reduces the amount of work that the heart has to do to pump blood around the body & so it can be used to treat heart failure

Used to treat pregnancy induced hypertension/ pre-eclampsia

Hydralazine

Efflux of K+ and hyperpolarization

Prevents calcium mediated activation

Constriction of Smooth muscle

Vasodilation

Binds and activates gated K+ channels on vascular

smooth muscle

HYDRALAZINE HYDROCHLORIDE - MOA

CLINICAL STUDIES ON HYDRALAZINECLINICAL STUDIES ON HYDRALAZINE• Clinical studies have shown superiority of

Hydralazine over methyl dopa and labetalol in terms of safety and efficacy

• Magee et al in Br J Clin Pharmacol 2011 concludes that parentral hydralazine more effective than labetalol with lesser chances of fetal bradycardia

• Griffis et al in Am J Perinatol. concludes that when hydralazine compared with methyl dopa, it effectively lowered mean arterial pressure in post partum period

• Hydralazine was thought to cause severe hypotension, abruption, stillbirths and low APGAR scores but recent studies rule out all these side effects

* Von Dadelszen et al; Clin Obst Gynecol , Jun 2005

• Criteria for diagnosis :

1) Haemolysis (microangiopathic H.A.) Burr cells, schistocytes on PBS bilirubin > 1.2mg/dl absent plasma haptoglobin

2) Elevated liver enzymes AST > 72 IU/L LDH > 600 IU/L

3)Low platelets

TREATMENT OF HELLPTREATMENT OF HELLP

• Immediate delivery is indicated once diagnosis of HELLP established

• Vaginal or LSCS• Platelets if count < 50000 or if s/o altered

hemostasis• Plasmapheresis is lifesaving if deterioration in

course of disease• Better to err by delivering preterm fetus than

to conserve for further harm

• Daily BP monitoring till pt is indoor• Once discharged, BP on alt days till normal value

settles in• Continue antihypertensive till normalization of

BP postpartum• Repeat lab after 48hrs• If abnormal monitor weekly• Do reagent strip for proteinuria at 6wks follow up.

If absent, repeat at 3months• Counseling of pt about recurrence of PIH and risk

of chronic HTN

Book References

Few more book references…