4. Preeclampsia Chronic
superimposed on Hypertension
Chronic Hypertension
New-onset proteinuria≥ 300mg/24hours BP ≥140/90 mmHg before pregnancy or
in hypertensive women but no proteinuria diagnosed before 20weeks’ gestation (not
before 20 weeks’ gestation attributable to gestational trophoblastic
disease)
A sudden increase in proteinuria Hypertension first diagnosed after
blood pressure 20weeks’ gestation and persistent after
platelet count <100,000/mm3 12weeks’ postpartum
in women with hypertension and
proteinuria before 20weeks’ gestation
5. Classification and Management of BP for
Adults
Classification Systolic Diastolic Lifestyle Without With
mm Hg mm Hg Modification Compelling Compelling
Indication Indicationsb
Normal <120 And<80 Encourage Treatment not Chronic renal
indicated disease or diabetes
Prehypertension 120-139 or80-90 Yes
Stage 1 140-159 or90-99 Yes Thiazide-type Chronic renal
diuretics for disease or diabetes
Hypertension most. May Other drugs as
consider ACE needed: diuretics,
inhibitor, ARB, ACE inhibitors,
blocker, CCB, or ARB, -blocker,
combination CCB
Stage 2 >=160 or>=100 Yes Two-drug
combination for
Hypertension mostc: usually
thiazide-type
diuretic and
ACEI, or ARB, or
-blocker, or
CCBc
6. Chronic hypertension
One of the most common medical complications
encountered during pregnancy
Systemic vascular resistance index, pulse wave velocity
higher during whole pregnancy
-- include hypertensive or ischemic cardiac disease, renal
insufficiency, or a prior cerebrovascular event
obesity
DM
Heredity
ethnic and gender difference
(African- and Latino-Americans)
8. Preconceptional and Early Pregnancy Evaluation
Counseling prior to pregnancy
(degree of blood-pressure control, and current therapy)
Home BP>=130/85 HTN
General health, daily activities, diet,
Cerebrovascular accident , myocardial infarction, cardiac
or renal dysfunction
Ophthalmological evaluation and echocardiography
Renal function (serum creatinine , quantification of
proteinuria)
Multiple medication and poorly controlled increased
risk for adverse pregnancy outcomes
Cunningham, 1990; Lindheimer, 2007;
Ramin, 2006, and all their associates
9. Severity of renal insufficiency is proportional to the risk
of hypertensive complications during pregnancy
Pregnancy 의 relative CIx Strong CIx
Persistent diastolic BP>=110 Prior cerebrovascular
hemorrhage or thrombosis
Multiple hypertensive drug MI
S-Cr>2mg/dL Cardiac failure
Cunningham, 1990; Lindheimer, 2007;
Ramin, 2006, and all their associates
11. Management in chronic hypertension
Lifestyle modification to manage hypertension
Modification Recommendation Systolic Blood Pressure
Reduction(Range)
Weight redection Maintain normal body weight: BMI 18.5–24.9 kg/m2 5–20 mm Hg/10 kg weight loss
DASH eating Diet rich in fruits, vegetables, and low-fat dairy 8–14 mm Hg
plan products with a reduced content of saturated and
total fat
Dietary sodium Reduce dietary sodium intake to no more than 100 2–8 mm Hg
reduction mmol per day: 2.4 g sodium or 6 g sodium chloride
Physical activity Engage in regular aerobic physical activity such as 4–9 mm Hg
brisk walking, at least 30 min per day, most days of
the week
Alcohol Limit consumption to no more than 2 drinks—1-oz 2–4 mm Hg
consumption or 30-mL ethanol, e.g., 24-oz beer, 10-oz wine, or 3-
moderation oz 80-proof whiskey—per day in most men and to
no more than 1 drink per day in women and lighter
weight persons
12. Antihypertensive drug-Diuretics
Thiazide and loop-acting diuretics such as furosemide are
commonly used in nonpregnant hypertensives
Sodium and water diuresis with volume depletion
Plasma volume during pregnancy in 20 chronically hypertensive
women. Plasma volume expanded only about 20 percent in the
half who continued diuretic therapy throughout pregnancy
compared with 50 percent in the other half who discontinued
treatment early in pregnancy
Sibai and colleagues (1984)
Diuretics are usually not given as first-line therapy during
pregnancy, particularly after 20 weeks
13. Medical Choices in Chronic hypertension of
Pregnancy
Drug/Class* Doses Adverse Events in Eviden Comments
Pregnancy ce
Methyldopa (B) 500 mg–3 g in Peripheral edema, Large Large post
2 divided doses anxiety, night marketing
mares, drowsiness, dry evidence on
mouth,hypotension, safety
maternal hepatitis,
no major fetal adverse
events
Labetalol (C) 200 mg–1200 Persistent fetal Large
mg/d in bradycardia,
2–3 divided hypotension, neonatal
doses hypoglycemia
Hydrochlorothi 12.5 mg–25 Fetal malformations, Large
azide (C) mg/d electrolyte
abnormalities, volume
depletion
Belindam. Cardiology in review 2010
14. Drug/Class* Doses Adverse Events in Evidenc Comments
Pregnancy e
Nifedipine (C) 30 mg–120 Hypotension and inhibition Small Immediate
(CCB) mg/d of particularly if used in release
combination with nifedipine
magnesium sulfate not
recommended
Hydralazine (C) 50 mg–300 Hypotension, neonatal Moderate
mg/d in 2– thrombocytopenia
4divided
doses
Angiotensin Contraindica Oligohydraminos, IUGR, Large
converting ted in renal failure, low birth
enzyme inhibitor pregnancy weight, cardiovascular
(ACEI) (D) anomalies, polydactyly,
hypospadias,ands
pontaneous abortions,
fetal hypocalvaria, renal
failure, oligohydraminos,
pulmonary hypoplasia,
craniofacial, limb
Belindam. Cardiology in review 2010
15. Drug Treatment during Pregnancy
Continuation of prepregnancy antihypertensive treatment
when women become pregnant is debated
약물로 인한 BP reductionbeneficial to the mother in the
long term decrease uteroplacental perfusion
feus 악화 가능 ?
BP감소시 생기는 FGR은 Tx때문인지 worse HTN의 fetal
effect 인지 혼란
임신중의 mild to moderate HTN Tx(?)
16. Randomized Trials of Antihypertensive Drug Therapy
in Pregnancies Complicated by Mild Chronic
Hypertension
Study No Mean Mean DBP Treatment Principal
Gestation at Entry Findings
at Entry (mm Hg)
(weeks)
Redman 208 21–22 88–90 Methyldopa ± Fewer
(1976) hydralazine vs no midpregnancy
drug losses in treated
women
Arias 58 15-16 90-99 Methyldopa, Compromised
and diuretics, or infants born to
Zamora hydralazine vs no mothers in whom
(1979) drug severe
hypertension
developed despite
treatment
Haddad B, Sibai BM: Chronic hypertension in
17. Randomized Trials of Antihypertensive Drug Therapy
in Pregnancies Complicated by Mild Chronic
Hypertension
Butters et al. 29 16 86 Atenolol vs Poor fetal
(1990) placebo growth in
treated
women
Sibai et al. 263 <11 91-92 Methyldopa No
(1990a) vs labetalol differences
vs no drug in outcomes
Gruppo di 283 24 95-96 Slow-release No
Studio nifedipine vs differences
Ipertensione no drug in outcomes
in
Gravidanza
(1998)
Haddad B, Sibai BM: Chronic hypertension in
pregnancy, Ann Med 31(4):246, 1999
18. Antihypertensive Therapy Selection
No evidence of major adverse fetal or maternal events.
Methyldopa : no fetal anomaly in the first trimester
vascular stiffness improved
Khalil and colleagues (2009)
Atenolol : FGR
Birth weight
Butters and colleagues (1990)
β -blocker : ominous intrapartum FHRs in 20 %
Montan and Ingemarsson (1989)
Nifedipine for pregnant women with chronic hypertension :
Experiences and newer safety concerns are not sufficient to
permit recommendations
19. Drug Treatment during Pregnancy
antihypertensive treatment
healthy pregnant women with With end-organ dysfunction,
150 to 160 mm Hg systolic or (left ventricular hypertrophy
100 to 110 mm Hg diastolic renal insufficiency)
pressures greater
August and Lindheimer, 1999; Working Group Report, 2000
limited data to treat mild chronic hypertension in
pregnancy
The Working Group on High Blood Pressure in Pregnancy 2000
Early Tx for HTN -> pregnancy 동안 subsequent
hospitalization 감소
20. Pregnancy-Aggravated Hypertension or
Superimposed Preeclampsia
Pregnancy outcome prognosis는 임신전 ds severity연관
25%에서 superimposed preeclampsia in chronic HTN
Caritis and co-workers (1998)
Some chronic HTN
worsening during pregnancy with no other findings of
superimposed preeclampsia
M/C end of the second trimester
Antihypertensive Tx 시작 or dose 증량
21. Early Diagnosis of Preeclapsia
Detailed examination such as headache, visual disturbances, epigastric pain, and rapid
weight gain
Weight determined daily
Analysis for proteinuria at least every 2 days thereafter
Blood pressure readings for every 4 hours
Measurements of plasma or serum creatinine and liver transaminase levels, and
hemogram , platelet quantification.
Evaluation of fetal size and well-being and amnionic fluid volume either clinically or
using sonography.
21
22. Management
Supportive care (mild preeclampsia)
Reduced physical activity throughout much of the day
Absolute bed rest is not necessary
Sedatives and tranquilizers are not prescribed
Ample, but not excessive, protein and calories should be
included in the diet
Sodium and fluid intakes should not be limited or forced
24. Management
Termination of pregnancy
Delivery is the cure for preeclampsia
Indication
: moderate to severe preeclampsia without
improvement in hospital treatment
The prime objectives
To forestall convulsion
To prevent intracranial hemorrhage
To prevent serious damage to vital organs
To delivery a healthy infant
Induced by intravenous oxytocin
Subarachnoid or epidural block
-> Induce severe hypotension
25. Indications for Delivery with Early-Onset Severe Preeclampsia
Maternal Fetal
Persistent severe headache or visual Severe growth restriction—< 5th
changes; eclampsia percentile for EGA
Shortness of breath; chest tightness with Persistent severe oligohydramnios—AFI
rales and/or SaO2 < 94 percent breathing < 5 cm
room air; pulmonary edema
Uncontrolled severe hypertension despite Biophysical profile 4 done 6 hr apart
treatment
Oliguria < 500 mL/24 hr or serum Reversed end-diastolic umbilical artery
creatinine 1.5 mg/dL flow
Persistent platelet counts < 100,000/L Fetal death
Suspected abruption, progressive labor,
and/or ruptured membranes
26. Postpartum observation
In severe chronic hypertension and in severe preeclampsia–
eclampsia.postpartum adverse outcome 치료가 비슷
Cerebral or pulmonary edema, heart failure, renal dysfunction,
or cerebral hemorrhage is especially high within the first 48
hours after delivery
Delivery후 maternal peripheral resistance증가left
ventricular workload 증가 상당한 interstitial fluid 양이
excretion위해 이동Pulmonary edema 가능
즉각적 severe HTN Tx+ diuretics(furosemide)
28. Introduction
Heart disease is the leading cause of death in women
who are 25 to 44 years old (Kung and colleagues, 2008).
Cardiac disorders of varying severity complicate
approximately 1 percent of pregnancies and contribute
significantly to maternal morbidity and mortality rates
29. Physiological change in pregnancy
Hemodynamic Changes in 10 Normal Pregnant
Women at Term Compared with Their 12-Week
Postpartum Values
Parameter Change(Percent)
Cardiac output +43
Heart rate +17
Left ventricular stroke work index +17
Vascular resistance
Systemic -21
Pulmonay -34
Mean arterial pressure +4
Colloid osmotic pressure -14
Data from Clark and colleagues (1989).
30. Clinical indication of Heart Disease
during pregnancy
Symptoms Clinical Findings
Progressive dyspnea or orthopnea Clinical Findings
Nocturnal cough Cyanosis
Hemoptysis Clubbing of fingers
Syncope Persistent neck vein distension
Chest pain Systolic murmur grade 3/6 or greater
Diastolic murmur
Cardiomegaly
Persistent split second sound
Criteria for pulmonary hypertension
32. Clinical classification of the New York Heart
Association (NYHA)
Class I. Uncompromised—no limitation of physical activity
Class II Slight limitation of physical activity
Class III Marked limitation of physical activity
Class IV Severely compromised—inability to perform any physical activity
without discomfort
33. Predictors of cardiac complications
Prior heart failure, transient ischemic attack, arrhythmia, or stroke.
Baseline NYHA class III or IV or cyanosis
Left-sided obstruction ( mitral valve area < 2 cm2, aortic valve area <1.5 cm2, peak
left ventricular outflow tract gradient >30 mm Hg )
EF<40%
34. Management of NYHA Class I and II Disease
Pneumococcal and influenza vaccines.
Cigarette smoking - prohibited
Vaginal delivery
Induction - safe
During labor - in a semirecumbent position with lateral
tilt.
Vital signs - frequently between contractions.
PR>100 bpm , RR>24 -impending ventricular failure.
Evidence of cardiac decompensation - intensive medical
management
35. Management of Class III and IV Disease
Epidural analgesia
Vaginal delivery
Labor induction- safe (Oron and associates, 2004).
36. Surgically Corrected Heart Disease
Valve Replacement before Pregnancy
The maternal mortality rate is 3 to 4 percent with
mechanical valves, and fetal loss is common.
Management
American College of Chest Physicians Guidelines for Anticoagulation of
Pregnant Women with Mechanical Prosthetic Valves
Adjusted-dose LMWH twice daily throughout pregnancy. The doses should be adjusted
to achieve the manufacturer's peak anti-Xa level 4 hours after subcutaneous injection
Adjusted-dose UFH administered every 12 hours throughout pregnancy. The doses
should be adjusted to keep the midinterval aPTT at least twice control or attain an anti-
Xa heparin level of 0.35 to 0.70 U/mL.
LMWH or UFH as above until 13 weeks' gestation with warfarin substitution until close
to delivery when LMWH or UFH is resumed.
Very high risk of thromboembolism : Warfarin is suggested throughout pregnancy with
replacement by UFH or LMWH (as above) close to delivery. In addition, low-dose
aspirin—75 to 100 mg daily—should be orally administered
Bates and colleagues (2008)
37. Valvular Heart Disease
Type Pregnancy Management
Mitral Heart failure •Limited physical activity
stenosis from fluid •Pulmonay congestion Sx->Na+restriction,
overload, diuretics
tachycardia •β -blocker drug
•new-onset atrial fibrillation –verapamil,
electrocardioversion
•chronic fibrillation-digoxin, β -blocker, CCB
•Labor and delivery - stressful
•Epidural analgesia
•Vaginal delivery(Elective induction )
•heparinization with severe stenosis even if
there is a sinus rhythm.
38. Valvular Heart Disease
Type Pregnancy Management
Aortic Moderate stenosis •Asymtomatic -close observation
stenosis tolerated; severe is •Symtomatic - strict limitation of
life-threatening with activity
decreased preload, •Prompt treatment of infections
•Valve replacement or valvotomy using
e.g., obstetrical cardiopulmonary bypass
hemorrhage or •Narcotic epidural analgesia
regional analgesia •Forceps or vacuum delivery
39. Congenital Heart Disease
Eisenmenger Syndrome
Secondary pulmonary hypertension that develops from
any cardiac lesion
M/C underlying defects : ASD, VSD, PDA
The prognosis for pregnancy - the severity of pulmonary
hypertension
Maternal and perinatal mortality rates to approximate 50
percent
40. Pulmonary Hypertension and Pregnancy
진단기준 : a mean pulmonary pressure >25 mm Hg. (non
pregnant)
Diagnosis : echocardiography , right-sided catheterization
Maternal mortality 상승(65-30%)
Severe disease –CIx to pregnancy
Treatment of symptomatic -limitation of activity and
avoidance of the supine position in late pregnancy.
Diuretics, supplemental oxygen, and vasodilator drugs
Greatest risk : diminished venous return and right
ventricular filling maternal deaths
Epidural analgesia induction
41. Peripartum Cardiomyopathy
Diagnostic criteria (Pearson and associates, 2000):
임신 마지막달 또는 분맊후 5개월 이내에 cardiac failure
Absence of an identifiable cause for the cardiac failure
Absence of recognizable heart disease prior to the last month
of pregnancy
Left ventricular systolic dysfunction
• HF 연관 질환 : hypertensive heart ds, MS, obesity, viral
myocarditis
• Chronic HTN with superimposed preeclampsiaHF
during pregnancy의 common cause
• Peripartum HF 의 obstetrical complication
Preeclampsia, acute anemia, infection
• Specific human pregnancy-related cardiomyopathies
are yet undiscovered
42. Idiopathic Cardiomyopathy in Pregnancy
Cardiomyopathy -the hallmark finding
Signs and symptoms of congestive heart failure.
(dyspnea , orthopnea, cough, palpitations, and chest pain)
Echocardiographic findings
( ejection fraction <45 percent or a fractional shortening
< 30 percent, an end-diastolic dimension > 2.7 cm/m2)
Tx : HF Tx Diuretics, hydralazine, another vasodilator
ACEI-Cix
Digoxin
Prophylactic heparin->thromboembolism
44. Hypertrophic Cardiomyopathy
Concentric left ventricular hypertrophy may be familial,
and there also is a sporadic form not related to
hypertension
Autosomal dominant(inheritance)
Congestive heart failure is common
Strenuous exercise –CIx (in pregnancy)
Abrupt positional changes are avoided
β -adrenergic or calcium-channel blocking drugs (Sx시,
angina)
Spinal , Epidural analgesia-CIx
분맊시 infective endocarditis prophylaxis
Delivery mode –Ix 따라
45. Infective Endocarditis
This infection involves cardiac endothelium and produces
vegetations that usually deposit on a valve
Associated with intravenous drug abuse
Subacute bacterial endocarditis - native valve infections
Viridans-group streptococci or Enterococcus species
Among intravenous drug abusers, S. aureus is the
predominant organism
Dx :murmur ultimately is heard in 80 to 85 percent of
cases
Anorexia, fatigue, and other constitutional symptoms
"flulike."
46. Infective Endocarditis
Management
• Most viridans streptococci
: penicillin G + gentamicin for 2 weeks.
• Allergic to penicillin
:intravenous ceftriaxone or vancomycin for 4 weeks
• Staphylococci, enterococci : 4-6wks Tx
• Prosthetic valve infection : 6-8wks Tx
