Hypertension and Gestational Diabetes in Pregnancy PDF

HYPERTENSION AND GESTATIONAL Women’s Health DIABETES IN PREGNANCY Spring 2024 Professor Greenfield 1 TOPICS Hypertension in Pregnancy Gestational Diabetes ­ Chronic HTN ­ Pregnancy Induced HTN ­ Pre-eclampsi...

HYPERTENSION AND GESTATIONAL Women’s Health DIABETES IN PREGNANCY Spring 2024 Professor Greenfield 1 TOPICS Hypertension in Pregnancy Gestational Diabetes ­ Chronic HTN ­ Pregnancy Induced HTN ­ Pre-eclampsia ­ Eclampsia ­ HELLP Syndrome 2 OBJECTIVES Compare and contrast hypertension (HTN) that is present before pregnancy with that found during pregnancy. Discuss the effects and complications of hypertension (HTN) and gestational diabetes (GDM) upon the mother and fetus. Recommend a comprehensive treatment plan; other diagnostic tests needed, future treatments, and education of a pregnant female with either hypertension or gestational diabetes. 3 HYPERTENSION IN PREGNANCY 4 5 HYPERTENSION IN PREGNANCY* Transient HTN - occurs in late pregnancy w/o any other features of preeclampsia & with normalization of BP postpartum ­Pathophysiology of transient HTN is unknown ­ May be a forerunner of chronic HTN later in life 6 HYPERTENSION IN PREGNANCY Chronic HTN: BP ≥140 mm Hg systolic &/or 90 mm Hg diastolic ­Before pregnancy, or ­Before 20 wks gestation, or ­Use of antihypertensive meds before pregnancy, or ­Persistence of HTN >12 wks after delivery 7 HYPERTENSION IN PREGNANCY Pregnancy-Induced Hypertension (PIH) AKA Gestational HTN ­2nd half of pregnancy (after 20 wks) ­ No proteinuria Pre-eclampsia ­ HTN with proteinuria 8 CHRONIC HYPERTENSION Management of chronic HTN: ­ Goal - to reduce risk of CV & cerebrovascular events ­ 2 criteria: ­ Mild – systolic BP 140-159 mmHg; diastolic BP 90-109 mmHg ­ Severe – systolic BP ≥ 160 mmHg; diastolic BP ≥ 110mg Hg ­ Medication is reserved unless systolic pressure is ≥160mmHg or diastolic pressure is ≥110mmHg ­ Major risk – development of preeclampsia or eclampsia later on 9 PREGNANCY INDUCED HYPERTENSION (PIH) AKA Gestational Hypertension Develops in: ­ 5 -10% of pregnancies ­ 30% in multiple gestations Causes approx 20% of maternal deaths in US Associated with increased perinatal morbidity & mortality for mother and fetus 10 PREGNANCY INDUCED HYPERTENSION (PIH) Definition: Systolic BP ≥ 140 OR Diastolic BP ≥ 90 on 2 readings in one week at least 4 hours apart ­ Develops after 20 weeks gestation ­ Resolved by 12 weeks postpartum ­ 25% will progress to preeclampsia 11 PIH 12 HTN IN PREGNANCY Treat: SBP ≥160mmHg OR DBP ≥110mmHg 13 HTN IN PREGNANCY Drugs to avoid in pregnancy ­ACE Inhibitors ­ARBs ­Direct renin inhibitors Exposure is associated with fetal renal & cardiac abnormalities 14 HTN IN PREGNANCY Options for breastfeeding mothers: ­ Beta-blockers, alpha-blockers ­ Labetalol, Propranolol, Metoprolol ­ Avoid atenolol & acebutolol ­ CCBs ­ Diltiazem (Cardizem), Nifedipine (Procardia), Nicardipine (Cardene), Verapamil (Calan) ­ Avoid amlodipine (Norvasc) ­ ACE Inhibitors ­ Captopril (Capoten), Enalapril (Vasotec) ­ Diuretics can be added prn 15 PREECLAMPSIA Definition: Systolic BP ≥ 140 OR Diastolic BP ≥ 90 + proteinuria ­ Develops after 20 weeks gestation ­ Proteinuria ­ 0.3 g or higher in 24 h urine collection ­ Urine dipstick reading of 1+ 16  PREECLAMPSIA* Criteria for the diagnosis of preeclampsia Systolic BP ≥ 140 mmHg OR Diastolic BP ≥ 90 mmHg AND Proteinuria of 0.3 grams or greater in a 24- hour urine specimen **BP elevation should be two measurements at least 6 hours apart 17  PREECLAMPSIA Mild ­ BP < 140/90 AND ­ 300 mg /24 hr urine or 1+ on dipstick Severe ­ SBP ≥ 160mm Hg or DBP ≥110mmHg, AND ­ ≥5 g protein/24 hr urine 18 PREECLAMPSIA Risk Factors: S&S: ­ Nulliparous women ­ H/A ­ Age >35 yrs ­ Visual disturbances ­ FMH of eclampsia ­ Blurred vision or spots ­ Pre-existing HTN, renal ­ Weight gain disease ­ Edema* ­ Multiple gestation ­ Esp in the hands and/or face ­ Pre-gestational DM ­ Elevated BP ­ Obesity ­ Proteinuria 19 20 PREECLAMPSIA Management of Mild Preeclampsia ­Before 37 wks: ­ Expectant management ­ Rest, frequent monitoring of mom & baby ­ Medication – Labetalol, Methyldopa, Nifedipine ­ Test for fetal growth restriction twice weekly ­ Assess amniotic fluid q 3wks ­At or beyond 37wks: ­ Induce labor or schedule C-section 21 PREECLAMPSIA Management of Severe Preeclampsia ­ Admit to L&D ­ MgSO4: ­ Loading dose followed by maintenance dose ­ Monitor for therapeutic levels ­ Meds: ­ Titrate Hydralazine to reach an acceptable BP ­ Can also give Labetalol IV and Nifedipine PO ­ IV Fluids ­ Delivery is the ultimate Rx ­ ≥ 34 wks: induce labor or perform C-Section ­ < 34 wks: hospital admission with expectant management if mother is stable and fetal condition is reassuring ­ Corticosteroids for fetal lung maturity prior to delivery 22 ECLAMPSIA Presence of convulsions in a woman with preeclampsia that are not explained by another neurologic disorder §Occurs in 0.5 – 4% of patients with preeclampsia §Usually occur within 24 hrs of delivery 23 ECLAMPSIA Eclampsia Management ­Seizure precautions ­ Protect the airway; pulse ox; O2 via face mask; fetal monitoring after mother is stable ­BP management with hydralazine (Apresoline) and/or labetalol (Trandate) ­Usually self-limited ­ MgSO4: 4-6g IV; additional 2g with seizures ­Await delivery until seizure subsides 24 25 HELLP SYNDROME Preeclampsia with: ­ Hemolysis ­ Elevated Liver enzymes ­ Low Platelet count Life threatening condition Occurs in 4 – 12% of pts with severe preeclampsia or eclampsia ­ Usually develops before 37th wk but can occur shortly after delivery ­ 20% of patients will be normotensive or lack proteinuria 26 HELLP SYNDROME Diagnosis requires >2 of the following: Hemolysis ­ Abnormal peripheral blood smear (schistocytes, burr cells) ­ Elevated Liver Enzymes ­ At least twice the upper limit of nl concentration Low Platelets ­ 34 wks: delivery (natural or Caesarian) 29  HELLP SYNDROME Complications: ­ Mother: ­ Placental abruption ­ Pulmonary edema ­ DIC (Disseminated Intravascular Coagulation) ­ ARDS (Adult Respiratory Distress Syndrome) ­ ARF (Acute renal failure) ­ Hepatic Rupture ­ Retinal Detachment ­ Death 30  HELLP SYNDROME Complications: ­ Infant ­ IUGR (Intrauterine Growth Restriction) ­ Infant Respiratory Distress Syndrome 31 GESTATIONAL DIABETES 32 GESTATIONAL DIABETES (GDM) 7% of all pregnancies Clinical features: ­Usually asx 33 GESTATIONAL DIABETES (GDM) Risk Factors ­ GDM in previous pregnancy ­ Impaired glucose tolerance ­ HbA1C>5.7% Elevated fasting glucose ­ FHX of Diabetes ­ Obesity (BMI>30) ­ AMA – age 35 y/o or greater ­ Certain groups which have a high prevalence of type 2 diabetes: Hispanic American; Native American; Alaska native; Native Hawaiian; South or East Asian, Pacific Islander 34 GESTATIONAL DIABETES Pathophysiology: ­ Physiologic insulin resistance occurs during pregnancy due to placental secretion of hormones ­ These cause postprandial hyperglycemia & carbohydrate intolerance which allows the fetus to consume more nutrients ­ In pregnant women with normal glucose metabolism, this causes a lower fasting blood glucose level. The pancreas can compensate here. ­ GDM develops when the pancreas cannot compensate for insulin resistance ­ Due to beta cell deficits ­ A subclinical metabolic dysfunction prior to conception may exist 35 GESTATIONAL DIABETES Screening Guidelines ­ Low risk women: screen at 24-28 weeks* ­ High risk women: screen at their first prenatal visit ­ If negative at this time, retest at 24-28 weeks ­ Women with +GDM in pregnancy: retest 4-12 weeks postpartum ­ Any woman with a hx of GDM should be screened for prediabetes or diabetes at least every 3 years ­ Higher risk of developing non-pregnancy associated Diabetes later in life 36 GESTATIONAL DIABETES 1 hour GTT ­ 50 g oral glucose loading dose ­ Abnormal: >130-140 If abnormal, perform 3 hour GTT ­ 100 g oral glucose loading dose ­ Abnormal: >95/180/155/140 ­ One abnormal value – glucose intolerance ­ Two or more abnormal values – GDM *Any value >200 automatically meets criteria for GDM 37  GESTATIONAL DIABETES Test Results Fasting 95 mg/dL Diagnosis of Gestational DM 1 hour 180mg/dL with 100-g oral glucose load (3 hour GTT) 2 hour 155 mg/dL 3 hour 140 mg/dL ­ Diagnosis is made if ≥ 2 of the values are abnormal GDM Rx: ­Lifestyle modifications – conservative Rx is best ­ Diet - Registered Dietitian can be helpful here ­ Exercise – at least 4 or more hrs/wk ­Insulin – first line therapy* safest !! Not does crosener ­ Frequent blood sugar monitoring (fasting & postprandial levels) ­ Multiple daily injections OR ­ Continuous sc infusions ­ Goal: FBS < 95 mg/dL 1 hr postptandial < 140 mg/dL 2 hr postprandial < 120 mg/dL 39 GDM Rx: ­Oral Medications ­ Metformin – Pregnancy category B ­ Glyburide – Pregnancy category C 40 GDM: RISKS Gaby big too Mother: Fetus: ­ ↑ rate of C-section ­ Macrosomia (>4500 g) ­ Spontaneous abortion, ­ Shoulder dystocia intrauterine fetal demise & ­ Neonatal hypoglycemia after stillbirth birth ­ Preeclampsia ­ Polyhydramnios ­ Increases risk of placental abruption, pre term labor & PP uterine atony ­ Infection 41 GESTATIONAL DIABETES Consider induction in well controlled patients w/o complications at 38 - 39 wks ­ C-section if estimated fetal weight >4500g Lifetime risk of developing DM after pregnancy increased to >50% ­ Glucose tolerance screening 2-4 months post-partum ­ Recurrence of GDM is 60%-90% of subsequent pregnancies Children born to mothers with GDM are up to 8x more likely to develop T2DM & obesity in their teens or early adulthood 42 QUESTIONS? Questions? 44 45