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Hypertensive Disease in Pregnancy
Sabaratnam Arulkumaran, Sanjay A Gupte, Evita Fernandez
1:
Classification and Diagnosis of Hypertensive Disorders of Pregnancy: A Practical Approach
INTRODUCTION
DEFINITION OF HYPERTENSION DURING PREGNANCY
Gestational Hypertension
Preeclampsia
Atypical Preeclampsia
Gestational Hypertension and Preeclampsia
Chronic Hypertension
Preeclampsia Superimposed on Chronic Hypertension
Paradox
CLINICAL CLASSIFICATION OF PREECLAMPSIA
SEVERITY CLASSIFICATION OF PREECLAMPSIA
HELLP SYNDROME
Classification of HELLP
DIAGNOSIS OF HYPERTENSION IN PREGNANCY
Proteinuria
Weight Gain and Edema
SYMPTOMS
LABORATORY EVALUATION
Hemodynamic Investigations
DIFFERENTIAL DIAGNOSIS
CHALLENGES IN THE LOW RESOURCE SETTINGS
CONCLUSION
2:
Etiology and Pathophysiology of Hypertensive Diseases
INTRODUCTION
PLACENTATION
HYPERTENSIVE DISORDERS OF PREGNANCY
Chronic Hypertension
Gestational Hypertension
PREECLAMPSIA
Risk Factors for Preeclampsia
The Cardiovascular System and Preeclampsia
Renal Function and Preeclampsia
Placentation and Preeclampsia
Oxidative Stress and Preeclampsia
Antioxidant Supplementation in Preeclampsia
Endothelial Dysfunction and Preeclampsia
Markers for Endothelial Dysfunction in Preeclampsia
Endothelial Vasoactive Hormones
Growth Factors and Preeclampsia
Immunology and Preeclampsia
Inflammatory Responses, Cytokines and Preeclampsia
Paternal Contribution
Genetics and Preeclampsia
CONCLUSION
ACKNOWLEDGMENTS
3:
Prediction of Preeclampsia: Biochemical and Biophysical Parameters
INTRODUCTION
PREECLAMPSIA AS A SPECTRUM OF DISEASE AND “EARLY” VERSUS “LATE” ONSET PREECLAMPSIA
PREDICTIVE TESTS FOR PREECLAMPSIA
BIOPHYSICAL PARAMETERS
Clinical Factors (Maternal History and Examination)
Clinical History
Clinical Examination
Doppler Ultrasound of Uteroplacental Circulation
Structural Capillary Rarefaction and the Onset of Preeclampsia
BIOCHEMICAL PARAMETERS
Free Fetal Nucleic Acids
Pregnancy Associated Protein A
Placental Protein 13
Cystatin C
Fetal Hemoglobin and Alpha1-Microglobulin
Pentraxin 3
Markers Related to Angiogenesis
Vascular Endothelial Growth Factor
Soluble fms-like Tyrosine Kinase 1
Placental Growth Factor
Soluble Endoglin
Other Markers
COMBINING BIOPHYSICAL AND BIOCHEMICAL MARKERS FOR PREECLAMPSIA PREDICTION
SCREENING—NEED FOR SIMPLICITY AS WELL AS ACCURACY
CONCLUSION
4:
Prevention Strategies in Preeclampsia
INTRODUCTION
IDENTIFYING RISK FACTORS FOR DEVELOPING PREECLAMPSIA
SCREENING TESTS FOR PREECLAMPSIA
INTERVENTIONS FOR THE PREVENTION OF PREECLAMPSIA
Antiplatelet Agents
Studies of Aspirin Therapy in Prevention of Preeclampsia
Meta-analysis of Antiplatelet Therapy in Prevention of Preeclampsia
Women Who Should Receive Aspirin
Dose of Aspirin
Timing of Initiating Aspirin
Discontinuing Aspirin
Safety of Aspirin
Low Molecular Weight Heparin
Calcium
Antioxidant Therapy
Nitric Oxide
Other Measures
CONCLUSION
5:
Maternal Vascular Differences in Preeclampsia
INTRODUCTION
EARLY VASCULAR CHANGES IN THE UTEROPLACENTAL CIRCULATION IN NORMAL PREGNANCY AND PREECLAMPSIA
DOPPLER ASSESSMENT OF UTERINE VASCULATURE
MICROCIRCULATION IN NORMAL PREGNANCY AND PREECLAMPSIA
VASCULAR ENDOTHELIUM IN NORMAL PREGNANCY AND PREECLAMPSIA
Role of Nitric Oxide, Prostacyclins and Other Molecules
CHANGES IN CIRCULATING ANGIOGENIC FACTORS IN PREECLAMPSIA
CONCLUSION
6:
Antihypertensive Therapy in Hypertension
INTRODUCTION
SEVERITY OF HYPERTENSION
GOAL OF TREATMENT
ANTIHYPERTENSIVE RATIONALE—HOW DOES IT DIFFER FROM NONPREGNANT ADULTS?
CHRONIC HYPERTENSION
Preconception Counseling
Antenatal Period
Postnatal Period
GESTATIONAL HYPERTENSION AND PREECLAMPSIA
Antenatal Period
Postnatal Period
ANTIHYPERTENSIVE AGENTS IN PREGNANCY
Angiotensin-converting Enzyme Inhibitors
Methyldopa
Beta-Blockers
Nifedipine
Hydralazine
Sodium Nitroprusside
Diuretics
Ketanserin
WHEN TO START ANTIHYPERTENSIVE THERAPY?
Severe Hypertension
Mild to Moderate Hypertension
WHAT IS THE TARGET BLOOD PRESSURE TO BE ACHIEVED?
WHICH ANTIHYPERTENSIVE MEDICATION IS PREFERRED?
Nonsevere Hypertension
Severe Hypertension
Very High Blood Pressure
HOW TO ADMINISTER THERAPY?
ANTIHYPERTENSIVES IN THE POSTPARTUM PERIOD
CONCLUSION
7:
Fetal Assessment in Hypertensive Diseases in Pregnancy
INTRODUCTION
RATIONALE FOR FETAL ASSESSMENT IN HYPERTENSIVE DISEASE IN PREGNANCY
EVIDENCE FOR FETAL ASSESSMENT IN HYPERTENSIVE DISEASE IN PREGNANCY
FETAL ASSESSMENT IN EARLY PREGNANCY
GENERAL PRINCIPLES FOR FETAL ASSESSMENT IN LATE PREGNANCY
Fetal Movement Counting
Electronic Fetal Heart Rate Monitoring
Fetal Biometry
Amniotic Fluid Index and Biophysical Profile
Color Doppler Velocimetry—Umbilical Artery
Color Doppler Velocimetry— Other Vessels
CONCLUSION
8:
Maternal Assessment in Hypertensive Disease of Pregnancy
INTRODUCTION
SEVERITY OF HYPERTENSION
CLASSIFICATION
Gestational Hypertension
Preeclampsia
Chronic Hypertension
Preeclampsia Superimposed on Chronic Hypertension
Eclampsia
MEASUREMENT OF BLOOD PRESSURE
Measurement Devices
Twenty-four Hour Ambulatory Blood Pressure Monitoring
INVESTIGATION OF NEW ONSET HYPERTENSION IN PREGNANCY
Measurement of Proteinuria
Complete Blood Count
Liver Function Tests
Renal Function Tests
Special Investigations
MONITORING
The Research Need of the Hour
Fetal Surveillance
9:
Medical Disorders Presenting with Hypertension in Pregnancy— Renal, Vascular, Connective Tissue and Endocrine Disease: Diagnosis and Management
INTRODUCTION
DEFINITION AND MAGNITUDE OF THE PROBLEM
RISKS TO MOTHER AND FETUS
ETIOLOGY OF CHRONIC HYPERTENSION IN PREGNANCY
DIAGNOSIS AND INVESTIGATION OF MEDICAL CONDITIONS PRESENTING WITH HYPERTENSION IN PREGNANCY
History
Clinical Examination
Blood, Urine and Imaging Investigations
MANAGEMENT OF CHRONIC HYPERTENSION IN PREGNANCY
Rationale Behind Treatment
Prepregnancy Care and Counseling
Antenatal Care and Antihypertensive Therapy
Timing of Initiation and Goals of Therapy
Choice of Antihypertensive Agent
Fetal Surveillance
Intrapartum and Postpartum Care
SPECIFIC MEDICAL CONDITIONS IN PREGNANCY
Renal Disorders in Pregnancy
Coarctation of the Aorta
Connective Tissue Disorders
Systemic Lupus Erythematosus
Rheumatoid Arthritis
Conn's Syndrome, Pheochromocytoma and Cushing's Syndrome
CONCLUSION
10:
HELLP Syndrome
INTRODUCTION
DEFINITION
INCIDENCE
Maternal and Perinatal Risks
PATHOPHYSIOLOGY
CLINICAL FEATURES AND LABORATORY FINDINGS
Symptoms and Signs
Laboratory Findings
Hemolysis
Liver Enzymes
Platelets
Ultrasonography
DIFFERENTIAL DIAGNOSIS
Acute Fatty Liver of Pregnancy
Thrombotic Thrombocytopenic Purpura
Hemolytic Uremic Syndrome
MANAGEMENT
Intrapartum Management
CORTICOSTEROIDS FOR TREATMENT OF HELLP SYNDROME
POSTPARTUM CARE AND COUNSELING FOR FUTURE PREGNANCIES
SUMMARY
11:
Atypical Presentations in Hypertensive Disease in Pregnancy
INTRODUCTION
AREAS OF CONTENTION IN THE CONVENTIONAL DIAGNOSIS OF PREECLAMPSIA
THE CHALLENGE OF SEVERE ATYPICAL PREECLAMPSIA
ATYPICAL ECLAMPSIA IN EPIDEMIOLOGIC AND CLINICAL CONTEXT
CONCLUSION
12:
Timing and Mode of Delivery in Hypertensive Disorders of Pregnancy
INTRODUCTION
TIMING OF DELIVERY
Evaluation/Stabilization Window
Factors to Decide Timing of Delivery
SEVERE PREECLAMPSIA/GESTATIONAL HYPERTENSION PRIOR TO 34 WEEKS
Aggressive Management
Expectant Management
Where can Expectant Management be Done?
Who should Receive Expectant Management?
Guidelines for Expectant Management13
SEVERE PREECLAMPSIA PRIOR TO 28 WEEKS
MILD PREECLAMPSIA/ GESTATIONAL HYPERTENSION
ROUTE OF DELIVERY
Factors to Decide Route of Delivery
Cesarean Delivery
Indications for Cesarean Delivery in Hypertensive Disorders
Induction of Labor
ECLAMPSIA
CHRONIC HYPERTENSION AND SUPERIMPOSED PREECLAMPSIA
MANAGEMENT OF LABOR
First Stage
Second Stage
Third Stage
POSTPARTUM MANAGEMENT
INDICATIONS FOR CRITICAL CARE UNIT AND INVASIVE MONITORING
KEY POINTS
13:
Anesthetic Considerations for Hypertensive Disease in Pregnancy
INTRODUCTION
DEFINITIONS AND CLASSIFICATION
Preeclampsia
Severe Preeclampsia
Eclampsia
Hemolysis, Elevated Liver Enzymes and Low Platelet Count (HELLP) Syndrome
EFFECT OF PREECLAMPSIA ON ORGAN SYSTEMS AND ANESTHETIC IMPLICATIONS
Central Nervous System
Respiratory System
Airway
Lungs
Cardiovascular System
Hepatic System
Renal System
Hematologic System
Uteroplacental System
ANTENATAL MANAGEMENT
High Dependency Care
Monitoring
Blood Pressure Control
Fluid Management
Eclampsia Prophylaxis
Analgesia and Anesthesia
Labor Analgesia
Anesthesia for Operative Interventions
POSTPARTUM MANAGEMENT
14:
Management of Second and Third Stages of Labor in Hypertensive Disorders
INTRODUCTION
DYNAMICS OF THE SECOND AND THIRD STAGE OF LABOR— DIFFERENCE IN HYPERTENSIVE DISORDER
Maternal Considerations— Second Stage Delays
Fetal Considerations—Fetal Hypoxia
MATERNOFETAL CONSIDERATIONS DURING AN ECLAMPTIC CONVULSION
RISK ASSESSMENT IN SECOND STAGE OF LABOR IN PREGNANCY HYPERTENSION
Monitoring of Mother and Fetus in Second Stage of Labor
Maternal Monitoring during Second Stage
Onset of New Symptoms Suggesting Severe Disease
Additional Maternal Monitoring during Second Stage of Labor in Patients with Severe Preeclampsia/Eclampsia
Additional Maternal Monitoring for Patients on Magnesium Sulfate
Fetal Monitoring during Second Stage of Labor
Obstetric Assessment
MANAGEMENT IN SECOND STAGE OF LABOR IN PREGNANCY HYPERTENSION
Prevention of Seizure and Control of Hypertension
Reduction of the Duration of the Second Stage of Labor
Management in Second Stage of Labor in HELLP Syndrome
Interventions that may be needed and Caution to be exercised
Oxytocins and Fluids
Pain Relief
Positioning during Labor
Pregnant Women with Chronic Hypertension
THIRD STAGE MANAGEMENT IN HYPERTENSION
SUMMARY POINTS AND CONCLUSION
15:
Care of the Critically ill Mother
INTRODUCTION
SEVERE PREECLAMPSIA
Hydralazine
Labetalol
Nitrates
Nifedipine
ECLAMPSIA
COMPLICATIONS RELATED TO SEVERE PREECLAMPSIA
Acute Respiratory Failure
Altered Neurology
Acute Kidney Injury
HELLP Syndrome
SUMMARY
16:
Immediate Postpartum and Long-Term Care following Hypertension Disease in Pregnancy
INTRODUCTION
CARDIOVASCULAR PHYSIOLOGY IN THE POSTPARTUM PERIOD
IMMEDIATE CARE DURING THE PUERPERIUM
ANALGESIA AND THROMBOPROPHYLAXIS
MONITORING
Blood Pressure Control
Other Therapeutic Strategies
LONG-TERM RISKS ASSOCIATED WITH HYPERTENSIVE DISEASES OF PREGNANCY
Risk of Recurrence in Subsequent Pregnancies
Risk of Cardiovascular Diseases and Stroke
PREDICTING FUTURE DISEASE
PREVENTATIVE STRATEGIES
CONCLUSION
17:
Lesson Learnt from Confidential Enquiries
INTRODUCTION
MATERNAL MORTALITY
THE UNITED KINGDOM PERSPECTIVE
The Early Years
The Early 1990s (1994–1996)
The Late 1990s (1997–1999)
The Early 2000s (2000–2002)
The Mid 2000s (2003–2005)
The Late 2000s (2006–2008)
The Saving Mothers Report (2006–2008)
INTERNATIONAL PERSPECTIVES
South African Perspective
New Zealand Perspective
Australian Perspective
United States of America Perspective
Canadian Perspective
CONCLUSION
INDEX
TOC
Index
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