Belgyógyászati KlinikaBudapest, Korányi S. A társaságok tagjai számára ingyenes. A folyóiratban megjelenõ közleményekrõl külön lenyomat Antihypertensive drugs avoided in pregnancy folyóiratban valamennyi írásos és képi anyag közlési joga a szerkesztõséget illeti. A megjelent anyag, illetve annak egy részének bármilyen formában történõ másolásához, ismételt megjelentetéséhez a szerkesztõség hozzájárulása szükséges. Hein J. Severe pre-eclampsia antihypertensive drugs avoided in pregnancy eclampsia have grave antihypertensive drugs avoided in pregnancy for the mother and fetus or newborn.
This antihypertensive drugs avoided in pregnancy a real problem in developing countries, where sufficient numbers of trained personnel and adequate facilities are just not available. These limited resources over many years have forced one to avoid unnecessary special investigations and use intensive care facilities as effectively as possible without unnecessarily endangering the lives of the mother or the baby.
It is hoped that this information will be of use to obstetricians in developing countries, but also in developed countries where active attempts are made to curb the spiralling costs of medical care. The management of the mother with early onset severe pre-eclampsia depends much on the availibility of neonatal intensive care facilities and gestational age.
Szerintem a leggyakoribb tumorfajtak a megfelelö informaciok birtokaban nagyon jol kezelhetök. Mivel nehanyan erdeklödtek, neha kiteszek nehany igeretes termeszetes alapu chemoterapiaval hasznalhato tumorellenes szerröl informaciot. Az un.
If facilities are lacking, there is little chance for very premature newborns to survive. It is therefore recommended to give priority to the mother and enhance delivery after her condition has been stabilised. For the very preterm fetus, neonatal survival is dependent on the gestational age at delivery 3, 4. Every week gained in gestational age from 26 to 33 weeks has a marked effect on the perinatal mortality rate. Providing it is safe for the mother and if facilities are available, one could therefore try to prolong the gestational age for one or two crucial weeks.
In this small study 20 patients were electively delivered 48 hours after admission and 18 when either maternal or fetal indications necessitated delivery Table 1.
The two groups of patients were comparable regarding the severity of preeclampsia and results of special investigations. Pregnancy was prolonged with a mean of 7. Gestational age at delivery was significantly longer, fewer babies were ventilated and total neonatal mortality and morbidity was lower in the expectantly managed group. In a subsequent much larger randomised controlled trial, Sibai et al 7pregnancy was prolonged by a mean of No perinatal deaths were encountered in either group Table 1.
The expectant management resulted in a significantly higher gestational age at delivery, higher birth weight, lower incidence of admission to the neonatal intensive care unit, lower mean days in the neonatal intensive care unit and lower incidence of neonatal complications. Sibai et al 8 also compared aggressive and expectant management between 24 and 28 weeks gestation. Gestational age at entry to the two groups were similar, but the admission delivery interval 11 days longer in the expectantly managed group.
Antihypertensive drugs avoided in pregnancy led to a reduction in the perinatal mortality rate from In another study on the conservative management of severe early pre-eclampsia, Olah et al 9 compared the management of women, between 24 and 32 weeks gestation, of two centres. Oxford managed conservatively, while Birmingham stabilised the patient and intervened early. There were 28 patients in each group.
Expectant or active management of patients with early severe preeclampsia Author No of patients A-D interval Gestationa l age at delivery Birth weight RDS or neonatal ventilation Perinatal deaths Odendaal et antihypertensive drugs avoided in pregnancy 6 Aggressive management Expectant management days 7.
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Reprinted from Hypertensive disorders in Women, Sibai BM, Severe preeclampsia and eclampsia, page 42,with permission of Elsevier Science gained a mean of 9. Babies of these women had greater birth weights, stayed shorter in the neonatal intensive care unit magas vérnyomás és menstruáció had fewer neonatal complications.
All the women who were managed by early intervention recovered with no severe complications. One case required temporary renal dialysis. Visser et al 10 compared two methods of delaying the delivery in women with severe pre-eclampsia at or before 35 weeks gestation Table 1.
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In Rotterdam plasma volume expansion was used with central haemodynamic monitoring control. Antihypertensive medication was given when diastolic blood pressure was mmhg or more. Methyldopa was the drug of choice. In both groups the pregnancy was prolonged with days.
A low maternal morbidity was seen in both groups and there were no complications of hemodynamic monitoring. Gestational age at delivery was Perinatal mortality was 7. Neonatal ventilation and patent antihypertensive drugs avoided in pregnancy arteriosus occurred significantly more in the study group, but they had fewer growth retarded babies. In a subsequent study Visser and Wallenburg 11 reviewed their temporising management in consecutive patients with severe pre-eclampsia, remote from term, from to The median prolongation of pregnancy was 14 days with a range of 0 to 62 days.
The mean gestational age at delivery was Perinatal morbidity was From these studies it is clear that conservative management of severe antihypertensive drugs avoided in pregnancy pre-eclampsia enables one to postpone the delivery of the fetus by one or two weeks with subsequent reduction in neonatal complications and improvement in the perinatal mortality rate.
Reprinted from Hypertensive disorders in Women, Sibai BM, Severe preeclampsia and eclampsia, page 42,with permission of Elsevier Science gained a mean of 9.
However, expectant therapy should only be performed in tertiary centres where the obstetricians have adequate experience in obstetric intensive or high-risk care. One should be aware that deterioration of the maternal or fetal condition could occur rapidly. Careful monitoring of the condition of both the mother and fetus is therefore absolutely essential. It is also important to take the severity of the pre-eclampsia into account, the prevalence in underlying hypertension, patient compliance and delay in referral to a tertiary center.
The latter is of utmost importance as it is more difficult to treat patients with antihypertensive drugs avoided in pregnancy advanced stage of severe pre-eclampsia expectantly As maternal and fetal complications can develop very rapidly, a magas vérnyomású kártyák leírása facilities for monitoring the mother and fetus should be available.
Where such facilities do not exist, and when the fetus is not yet viable, it may be safer for the mother to have the pregnancy terminated soon after the diagnosis of severe pre-eclampsia is certain.
Fetal viability, is also a relative term as it mainly depends on neonatal intensive care facilities, adequately trained people and the financial resources to support these tertiary care facilities. At Tygerberg Hospital, a gestational age of 28 weeks or rarely 26 or 27 weeks is accepted for fetal viability.
However, in developed countries fetal viability may start at 22 weeks or, in many developing countries, at weeks.
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As mentioned earlier, expectant management succeeded in prolonging the pregnancy with a mean of 7. It may therefore be unrealistic to introduce expectant management much longer than two weeks before fetal viability.
On the other hand, the upper range of the prolongation of pregnancy may be as high as 62 days Too early termination of pregnancy will therefore sometimes deprive a patient from having a baby. This very difficult decision antihypertensive drugs avoided in pregnancy and when expectant management should be started, should always be individualised and discussed with the patient, her family and the neonatologist.
Care should be taken to explain all the advantages and disadvantages to the patient and involve her in the decision-making.
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The upper limit of gestational age at which a patient does not qualify for expectant management also differs. At Tygerberg Hospital a gestational age of 34 weeks is recommended as the neonatal survival at later deliveries is not better and worse when delivered at 33 weeks or earlier 4.
Sibai et al 7 used 32 weeks as the upper limit for entry in their study, but delivered at 34 weeks. Thirty-two weeks was also accepted as the upper limit for entering to their study by Olah et al 9while Visser et al 10 accepted 35 weeks. After a gestational age of weeks has been reached, delivery is safer for the mother and safe for the fetus.
The main reason for this is that the condition of the mother or the fetus can change suddenly, necessitating speedy delivery. Severe placental insufficiency and abruptio placentae are the two most common causes of intrauterine death in patients with severe pre-eclampsia, but can be detected by the abnormal fetal heart rate FHR pattern they cause.
It is also necessary to exclude fetal distress before any antihypertensive therapy is initiated, because drugs such as dihydralazine may cause sudden hypotension and therefore worsen the fetal distress. Parenterally administered drugs are usually used, although oral nifedipine can also be used Table 2. Intravenous hydralazine is the parenteral drug of choice in many units.
Patients with severe pre-eclampsia are often hypovolemic, therefore intravenous administration of hydralazine may occasionally cause antihypertensive drugs avoided in pregnancy hypotension with subsequent fetal distress To prevent this ml fluid should be given intravenously prior to the administration of this drug.
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As an alternative to dihydralazine, nifedipine may also be used. It has the advantage that it may be given orally Table 2. Treatment of severe acute hypertension I. Hydralazine mg doses at minute intervals IV initial dose 5 mg or 25 mg in ml normal saline, starting at 3. Give 1 ml 1. Nifedipine mg orally. Repeat after 30 minutes. Although experience with nifedipine is less than that with dihydralazine there seem to be few disadvantages. A third drug that is often used for the acute control of blood pressure is labetalol It is seldom antihypertensive drugs avoided in pregnancy at Tygerberg Hospital because many of the patients with severe preeclampsia have intrauterine growth retardation.
Labetalol possesses both alpha and beta-adrenoceptor antihypertensive drugs avoided in pregnancy properties. However, it appears to be a more potent inhibitor of beta-adrenoceptors Betablocking agents may inhibit the fetal adaptation to stress antihypertensive drugs avoided in pregnancy cause neonatal hypoglycemia In addition, it has been shown that black patients do not respond well on beta-adrenegic blocking agents Although there was initial concern regarding its safety for the fetus when administered to patients with severe pre-eclampsia, later studies failed to confirm these observed risks for fetal death.
Administration of glucocosteroids to patients with pregnancy induced hypertension also did not have an aggravating effect on maternal blood pressure Kirsten 34 followed up neonates, born to mothers with early onset severe pre-eclampsia. Multiple logistic regression to determine the association between RDS and various categories of the umbilical artery flow velocity waveforms, adjusting for many confounding variables, showed antihypertensive drugs avoided in pregnancy only birth weight above g, gestational age above 30 weeks and antenatal steroids reduced köles magas vérnyomás kezelés likelihood of RDS.
These findings once again support the beneficial effects of the antenatal administration of steroids on fetal lung maturity.
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There is no evidence that administration of these drugs improve maternal outcome. In contrast, it may hamper the interpretation of FHR patterns, as both these drugs reduce accelerations and baseline variability 35, 37 making it difficult to distinguish from poor variability caused by asphyxia Mothers should be informed about the importance of symptoms such as headache, epigastric pain, uterine contractions and also about vaginal bleeding and a decrease in fetal movements.
These abnormalities should immediately be reported to the nursing staff. Blood pressure. Blood antihypertensive drugs avoided in pregnancy should be recorded antihypertensive drugs avoided in pregnancy minutes or continuously during treatment of acute hypertension. Thereafter it should be taken every hours. Urine testing for protein.
However, in some very preterm pregnancies, delivery could be deferred for 3 weeks or more. They concluded that in some cases pregnancy could be prolonged for significant periods of time, thereby improving the chances of better neonatal outcome, without apparent risk to the mother. Kirsten 34 analysed the neonatal outcome of babies born to mothers with severe pre-eclampsia and compared the maternal parameters of the 49 who died neonatally with those antihypertensive drugs avoided in pregnancy the who survived.
The grade of proteinuria, blood pressure, parity and umbilical artery flow velocity waveforms did not differ between the two groups. However, outcome was significantly better in newborns when the gestational age at delivery was greater. It therefore seems that severe proteinuria as such, is not an antihypertensive drugs avoided in pregnancy for delivery.
However, it signifies severe disease with a high perinatal mortality rate. Since proteinuria as such does not seem to influence maternal outcome, precise quantification is probably not necessary for clinical practice.
However, as dipstix findings may vary much from test to test, more precise measurements are necessary for research purposes. Platelet count. There is a risk of HELLP syndrome in patients with severe pre-eclampsia, and platelets should be done at least twice weekly, or more often when initial or subsequent values are low.
Liver function tests. Tests should be repeated at least twice weekly or more often when platelet counts remain low. Abnormal liver functions as such in patients with antihypertensive drugs avoided in pregnancy pre-eclampsia are usually not an indication for immediate delivery as they may improve after therapy For these reasons, accurate fetal monitoring is an essential part of the management of patients with severe pre-eclampsia.
Fetal heart rate monitoring. It has been shown that the fetal heart rate FHR pattern becomes abnormal in many cases of abruptio placentae before the mother perceives any abdominal pain or vaginal bleeding Therefore, at Tygerberg Hospital it is recommended that the fetal heart rate is monitored every 6 hours.
As the baseline variability of the FHR is a reliable way of fetal assessment 44, 45we use it for the management of our patients. It has been shown that a nonreactive FHR pattern with good baseline variability is not associated with fetal asphyxia at birth, provided that the FHR is monitored 4 times a day The baseline variability can usually be assessed within minutes and therefore monitoring of the FHR every 6 hours does not place a heavy workload on the staff. A variability less than 5 bpm is a cause for concern.
In these cases monitoring is continued for one hour. Poor variability lasting longer than an hour, in the absence of any sedation, is an indication for immediate repeat of the nonstress test NST. Poor variability for longer than 2 hours is an indication for delivery. Antihypertensive drugs avoided in pregnancy patterns occur less frequently in growth retarded babies.
Waiting for accelerations antihypertensive drugs avoided in pregnancy occur in preterm pregnancies with a high prevalence of intrauterine growth retardation will prolong the monitoring time unneccessarily, placing an extra work load on the nursing staff. No intrauterine deaths occurred in the last patients. In units where the prevalence of abruptio placentae is low, less frequent monitoring is adequate. Chari et al antihypertensive drugs avoided in pregnancy encountered no stillbirths in 68 women where the fetus was assessed daily.
Their assessment included an NST, biophysical profile and amniotic fluid volume. Doppler flow velocity waveforms of the umbilical artery.