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Y4R2 - Obstetrics I 🤰 > L11: HTN in Pregnancy > Flashcards

L11: HTN in Pregnancy Flashcards

1
Q

Def of HTN in Pregnancy

A

HTN during pregnancy is defined as BP ≥ 140/90 mmHg measured on 2 different occasions with at least 4-6 hours apart

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2
Q

Classification of HTN in Pregnancy

A
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3
Q

Chronic HTN

A

HTN that antedates pregnancy, is diagnosed before 20 weeks gestation or lasts for > 12 weeks postpartum.

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4
Q

Gestational HTN

A

HTN without proteinuria that is 1st diagnosed after 20 weeks gestation with return of BP to normal within 12 weeks postpartum

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5
Q

Preeclampsia

A

HTN with pathological proteinuria after 20 weeks gestation

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6
Q

Eclampsia

A

Occurrence of tonic-colonic convulsive seizures that can’t be attributed to other causes in woman with preeclampsia

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7
Q

Superimposed preeclampsia on chronic HTN

A

New development of pathological proteinuria after 20 weeks gestation in woman with chronic HTN

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8
Q

ACOG classification of HTN in pregnancy

A
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9
Q

Def of PET

A
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10
Q

Synonyms of PET

A

Preeclamptic toxemia (PET) or Toxemia of pregnancy

(these old names had originated from old belief that these cases were caused by placental toxin).

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11
Q

Incidence & RF for PET

A

Disease of human only affecting 5-15 % of all pregnancies, Commonest hypertensive disorder in pregnancy

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12
Q

RF for PET

  • Maternal Specific
A
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13
Q

RF for PET

  • Pregnancy Specific
A
  • Vesicular mole
  • Multifetal Pregnancy
  • Polyhydraminos
  • Seasonal variation: More common in winter
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14
Q

Maternal Specific RF for PET

  • Age
A

< 20 or > 35 years.

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15
Q

Maternal Specific RF for PET

  • Gravidity & Parity
A

More in primigravidas specially elderly primigravidas.

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16
Q

Maternal Specific RF for PET

  • Race
A

More in black races

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17
Q

Maternal Specific RF for PET

  • SES
A

Low

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18
Q

Maternal Specific RF for PET

  • Medical Disorders
A

Chronic HTN, chronic nephritis or DM

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19
Q

Maternal Specific RF for PET

  • Obesity
A

Present

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20
Q

Maternal Specific RF for PET

  • Past & Family Hx of HTN in Pregnancy
A

Present

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21
Q

Etiology of PET

A

Theories Include:

  • Increased Pressor Effect
  • Abnormal Placentation
  • Genetic Factors
  • Immunological Factors
  • Inflammatory Factors
  • Biochemical Factors
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22
Q

Theories of PET

  • Increased Pressor Effect
A
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23
Q

Theories of PET

  • Abnormal Placentation
A
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24
Q

Theories of PET

  • Genetic Predisposition
A

Risk of Preclampsia ↑↑ in women when their mothers or grandmothers had

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25
Theories of **PET** - Immunlogical Factors
26
Theories of **PET** - Inflammatory Factors
27
Theories of **PET** - PGs
28
Theories of **PET** - NO
29
Theories of **PET** - Endothelin-1
30
Theories of **PET** - VEGF
31
Theories of **PET** - Free Radicals
32
Theories of **PET** - Vit E / Lipid Peroxides Imbalance
33
Theories of **PET** - Prorenin
34
Theories of **PET** - Endothelial Cell Activation
35
Pathology in **PET** - CVS
36
CVS Pathology in **PET** - Genralized Arteriolar Vasospasm
↑↑ peripheral resistance & endothelial cell dysfunction & damage.
37
CVS Pathology in **PET** - Increased Pressor effect
See before
38
CVS Pathology in **PET** - Hemodynamic Changes
- Cardiac Preload: Normal or low in severe cases (due to VC & hypovolemia). - Cardiac afterload: ↑↑ (due to HTN). - COP: ↓↓ (due to ↑↑ peripheral resistance).
39
CVS Pathology in **PET** - Blood Volume
- Hemoconcentration & ↑↑ Hct value (due to ↑↑ capillary permeability → excessive shift of intravascular fluid to extravascular compartment).
40
CVS Pathology in **PET** - Blood Cells
 RBCs: Become bizarre shaped (easily hemolysed) in severe cases.  WBCs: ↑↑ eosinophils (denoting immunological nature).  Platelets: Thrombocytopenia.
41
CVS Pathology in **PET** - Activation of Coagulation system
In severe Cases
42
CVS Pathology in **PET** - Salt & Water Retention
Due to ↑↑ DOC & ↑↑ sensitivity to ADH.
43
Pathology in **PET** - Endocrine
44
Endocrine Pathology in PET - RAAS
In uteroplacentalhypoperfusion, there is ↑↑ rennin → ↑↑ angiotensin-II → compensatory ↑↑ in PGI2 production → uteroplacental VD.
45
Endocrine Pathology in PET - Deoxycortisone
↑↑ → Na+ retention
46
Endocrine Pathology in PET - ADH
↑↑ sensitivity to ADH → edema & oliguria.
47
Endocrine Pathology in PET - Placental Hormones
↑↑ HCG, estrogen & progesterone
48
Pathology in PET - uteroplacental
49
Pathology in PET - Renal
50
Renal Pathology in PET - RBF & GFR
Decreased
51
Renal Pathology in PET - PTNuria
Due to damage of tubular epithelium
52
Renal Pathology in PET - Glomerular Capillaries
- Glomerular cell swelling, mesangeal cell proliferation & fibrin like deposits intraendothelially & subendotheliall
53
Renal Pathology in PET - Renal Tububles
(reversible) or acute cortical necrosis (irreversible).
54
Pathology in PET - Liver
In severe cases. 1. Periportal vasospasm, focal Hge & hematoma (subcapsular or in hepatic substance). 2. Acute fatty degeneration
55
Liver Pathology in PET
In severe cases. 1. Periportal vasospasm, focal Hge & hematoma (subcapsular or in hepatic substance). 2. Acute fatty degeneration
56
CNS Pathology in PET
In severe cases. 1. Cerebral edema & hyperemia. 2. Thrombosis or Hge
57
Retinal Pathology in PET
1. Retinal arterial vasospasm. 2. Retinal exudate, Hge or detachment.
58
Pathology in PET - Hge
As adrenal glands, stomach & intestine.
59
Complications of **PET**
Maternal & fetal
60
Maternal Complications of **PET**
61
Maternal Complications of **PET** - ICH
Due to severe HTN.
62
Maternal Complications of **PET** - Blindness
Due to retinal detachment & it is reversible.
63
Maternal Complications of **PET** - HF & PE
Treated by immediate IV furosemide (lasix).
64
Maternal Complications of **PET** - PPH
- In preeclampsia & eclampsia, PPH is diagnosed if there is blood loss > 200 ml (normally, > 500 ml) because there are hypovolemia & hemoconcentration.
65
Maternal Complications of **PET** ARF
Acute tubular necrosis or acute cortical necrosis
66
Maternal Complications of **PET** - Mortality
- Incidence: 2% in severe preeclampsia & 10% in eclampsia. - Etiology: Due to complications (commonest cause is ICH).
67
Maternal Complications of **PET** - **Remote Complications**
68
Maternal Complications of **PET** - **HELLP Syndrome**
69
Def of **HELLP Syndrome**
Fatal condition characterized by: - Hemolysis: Bilirubin ≥ 1.2 mg/dl. - Elevated Liver enzymes: SGOT > 70 IU/L. - Low Platelet count: < 100000/mm3.
70
DDx of **HELLP Syndrome**
 Acute fatty liver in pregnancy.  Thrombotic thrombocytopenic purpura.  Hemolytic uremic syndrome.  Hepatitis (viral or drug induced).
71
Maternal Mortality in **HELLP Syndrome**
80-90%.
72
RR in **HELLP Syndrome**
5%
73
Fetal Complications in **PET**
74
Fetal Complications in **PET** - Prematurity
Due to preterm labor or premature TOP in severe cases.
75
Fetal Complications in **PET** - IUGR
Due to placental insufficiency.
76
Fetal Complications in **PET** - Fetal asphyxia or IUFD
Due to marked impairment of placental circulation or placental separation
77
Fetal Complications in **PET** - Perinatal Mortality
- 5% in mild preeclampsia & 25% in severe preeclampsia & 30% in eclampsia.
78
Prediction of **PET** - Hx
High risk factors (from history since 1st antenatal visit).
79
Prediction of **PET** - Ex
80
Prediction of **PET** - Vascular Reactivity Tests
81
Prediction of **PET** - Labs
↑↑ serum uric acid, hypocalciuria & ↑↑ fibronectin levels.
82
Prediction of **PET** - Uterine Artery Doppler
To detect uteroplacental hypoperfusion
83
Clinical Signs of **PET**
Signs: Preeclampsia is a disease of signs & it has the following 3 cardinal signs: - HTN - PTNuria - Edema
84
Clinical Signs of **PET** - HTN
85
Clinical Signs of **PET** - PTNuria
86
Clinical Signs of **PET** - Edema
87
Clinical Symptoms of **PET**
88
Clinical Symptoms of **PET** - Epigastric Pain
Due to distension of liver capsule.
88
Clinical Symptoms of **PET** - Headache
Due to HTN & cerebral edema.
89
Clinical Symptoms of **PET** - Persistent N&V
Due to cerebral edema, congestion of gastric mucosa or liver affection.
90
Investigations for **PET** - Labs
91
Lab Investigations for **PET** - CBC
Hemoconcentration, hemolysis & thrombocytopenia
92
Lab Investigations for **PET** - Coagulation Profile
Disturbed in DIC
93
Lab Investigations for **PET** - LFTS
Bilirubin (↑↑ è hemolysis) & SGOT & SGPT (↑↑ è liver impairment & HELLP synd..
94
Lab Investigations for **PET** - KFTs
Deteriorated only in severe cases.
95
Lab Investigations for **PET** - urine Analysis
Oliguria & proteinuria.
96
Rad Investigations for **PET**
US: To Determine fetal life, age, maturity & wellbeing. CT scan or MRI brain: To Dx intracranial Complications
97
Other Investigations for **PET**
- Fundus examination: To detect retinal exudate, Hg or detachment. - Fetal wellbeing tests
98
**Assessment of Severity** of PET
99
Def of **Imminent eclampsia (preeclamptic state)**
Worse type of severe preeclampsia which will end in eclampsia if not urgently treated.
100
Dx of **Imminent eclampsia (preeclamptic state)**
101
TTT of **Imminent eclampsia (preeclamptic state)**
Immediate control & TOP èin 6 hours.
102
DDx of **PET**
- Causes of HTN with pregnancy - Causes of proteinuria with pregnancy - Causes of edema with pregnancy
103
DDx of **PET** - Causes of HTN with Pregnancy
 Preeclampsia (commonest cause) & eclampsia.  Gestational HTN  Chronic HTN.  2ry HTN: As in chronic nephritis, coarctation of aorta & Cush ing syndrome.
104
DDx of **PET** - Causes of PTNuria with pregnancy
 Preeclampsia & eclampsia.  Contamination of specimen e vaginal discharge (commonest cause) .  UTI.  Renal hypoxia: As in CHF & severe anemia.  Hyperemesis gravidarum: Rarely occurs in severe cases.  Orthostatic proteinuria.
105
DDx of **PET** - Causes of edema with Pregnancy
 Preeclampsia & eclampsia.  Gestational edema.  Local causes: Leading to unilateral edema as inflammations or DVT.  Generalized edema: Cardiac, hepatic, renal, nutritional or angioneurotic edema.  Orthostatic edema.
106
Prevention of **PET**
107
Prevention of **PET** - Prediction
See before.
108
Prevention of **PET** - Lifestyle
Rest, exercise & ↓↓ dietary salt.
109
Prevention of **PET** - Supplements
- Ca++: 1.5-2 gm/d (it ↑↑ production of PGI2 from endothelial cells). - Others: Mg++, antioxidants (as vitamin C & E), folic acid & omega-3 fatty acids.
110
Prevention of **PET** - Drugs
111
Plan of TTT of **Mild PET**
112
Plan of TTT of **Severe Preclampsia**
113
Plan of TTT of **Imminent Eclampsia**
Immediate control & TOP ein 6 hours.
114
Lines of TTT of **PET**
- Expectant treatment - Control of HTN - Prevention & control of convulsions - Termination of pregnancy - Postnatal care - Treatment of complications
115
Expectant TTT of **PET**
116
Expectant TTT of **PET** - Rest
Complete physical & mental rest.
117
Expectant TTT of **PET** - Diet
High protein & CHO e low Na+ diet.
118
Expectant TTT of **PET** - Sedation
Benzodiazepines or phenobarbitone.
119
Expectant TTT of **PET** - Observation
120
Control of HTN in **PET** - Indications
Severe cases (antihypertensives have doubtful value in mild cases)
121
Control of HTN in **PET** - Rationale
Prevention of maternal complications & not fetal complications ( dec BP → dec placental perfusion → fetal distress & may be IUFD).
122
Control of HTN in **PET** - Precautions
Dec BP should be gradual & DBP should be around 100 mmHg (below that → dec placental perfusion).
123
Control of HTN in **PET** - Disadvantages
124
Control of HTN in **PET** - Used Drugs
**Parenteral drugs:** - Hydralazine - Labetalol - Diazoxide **Oral Drugs:** - Methyl DOPA - Nifidiopine - Adrenergic blockers (Atenolol) - Mono-Hydralazine - Prazosin
125
Control of HTN in **PET** - Hydralazine
126
Control of HTN in **PET** - Labetalol
A & non-selective B-adrenergic blocker → VD.
127
Control of HTN in **PET** - Diazoxide
Used in severe resistant HTN as a last resort.
128
Control of HTN in **PET** - Methyl DOPA
129
Control of HTN in **PET** - Nifidipine
130
Control of HTN in **PET** - Mono-hydralazine
Weak antihypertensive used in combination é ß blockers to inc their efficacy & dec their side effects.
131
Control of HTN in **PET** - Prazosin
Weak antihypertensive - used in combination é other drugs.
132
TTT of **PET** - Prevention & control of convulsions
- Magnesium sulfate (MgSo4): Drug of choice - Diazepam (valium) - Phenytoin (Epanutin)
133
Prevention & control of convulsions in **PET** - Action of MgSO4
1. Curare like action on motor end plate → paralysis of peripheral muscles. 2. Weak CNS depressant. 3. Mild VD & diuretic. 4. inc PGI2 production & dec platelet aggregation.
134
Prevention & control of convulsions in **PET** - Indications of MgSO4
Used to prevent convulsions in cases in which delivery is decided.
135
Prevention & control of convulsions in **PET** - Routes of MgSO4
IV (preferred rout), IM (painful) or SC (not used now).
136
Prevention & control of convulsions in **PET** - Doses of MgSO4
137
Prevention & control of convulsions in **PET** - Duration of MgSO4
Maintenance therapy is continued for 24 h after delivery.
138
Prevention & control of convulsions in **PET** - Monitoring of MgSO4
139
Prevention & control of convulsions in **PET** - SE of MgSO4
140
Maternal SE of MgSO4
141
Maternal SE of MgSO4 - Toxicity
142
Maternal SE of MgSO4 - Drug Interactions
1. Enhances action of curare like drugs. 2. Synergistic action if given é CCB.
143
Fetal SE of MgSO4
dec beat to beat variability in FHR pattern
144
Neonatal SE of MgSO4
Hypermagnesemia, hypotonia & poor suckling.
145
Antidote of MgSO4
Ca++ gluconate.
146
Stroganoff method
Use of MgSo4 + morphine.
147
Prevention & control of convulsions in **PET** - Action of Diazepam
Central inhibitory effect
148
Prevention & control of convulsions in **PET** - Dose of Diazepam
Initially, 20-40 mg IV slowly then 10-20 mg/6 hrs.
149
Prevention & control of convulsions in **PET** - SE of Diazepam
Neonatal hyperbilirubinemia & low APGAR score.
150
Indications of TOP in **PET**
151
Methods of TOP in **PET**
Vaginal & CS
152
Vaginal Delivery in **PET** - Prerequisities
153
Vaginal Delivery in **PET** - Precautions
154
Precautions of Vaginal Delivery in TOP - Rest
In eclampsia room (see later)
155
Precautions of Vaginal Delivery in TOP - Analgesia & Anesethia
Analgesia & anesthesia: Epidural anesthesia is the best.
156
Precautions of Vaginal Delivery in TOP - Gaurd against PPH
By uterine massage + oxytocin + PGs (if needed) & avoid ergometrine (it causes VC & inc BP).
157
Precautions of Vaginal Delivery in TOP - Guard against PP eclampsia
(by MgSo4 , for 24-48 hours after delivery).
158
CS Delivery in PET - Indications
159
CS Delivery in TOP - Disadvantages
adds surgical stress to disease stress.
160
Postnatal Care in **PET** - Observation
161
Signs of Improvement in Postnatal Care in **PET**
162
Postnatal Care in **PET** - Drugs
MgSO4, should be continued for 24-48 hours after delivery.
163
TTT of Complications in **PET**
...
164
Def of **Eclampsia**
Occurrence of tonic-colonic convulsive seizures that can't be attributed to other causes in woman e preeclampsia.
165
Incidence of **Eclampsia**
* Depends largely on management of pre-eclampsia. * in some areas, it is 1/500 where in others, it is 1/2300.
166
RF for **Eclampsia**
As pre-eclampsia.
167
Types of **Eclampsia**
- According to time of occurrence of fits - According to recurrence
168
Types of **Eclampsia** - Acc to time of occurence
169
Types of **Eclampsia** - Acc to recurrence
170
Pathology of **Eclampsia**
* As preeclampsia + Coma.
171
Complications of **Eclampsia**
…
172
Dx of **Eclampsia**
173
Clinical manifestations of eclamptic fits
174
Clinical manifestations of eclamptic fits: - Premonitory Stage
175
Clinical manifestations of eclamptic fits: - Tonic Stage
176
Clinical manifestations of eclamptic fits: - Clonic Stage
177
Clinical manifestations of eclamptic fits: - Coma Stage
178
INVx in **Eclampsia**
As preeclampsia.
179
Criteria of severity of eclampsia (Eden's criteria)
180
DDx of **Eclampsia** - Causes of Convulsion with pregnancy
181
DDx of **Eclampsia** - Causes of Coma with pregnancy
182
Prevention of **Eclampsia**
Good ANC for prevention, detection & early treatment of preeclampsia.
183
TTT of **Eclampsia**
- During Fit - In Between Fits
184
TTT of **Eclampsia** - During Fit
185
TTT of **Eclampsia** - In between Fits
- General measures - Prevention of further attacks of convulsions - Control of HTN - Termination of pregnancy - Postnatal care - Treatment of complications
186
General Measures of TTT of **Eclampsia** in between fits - Isolation
187
General Measures of TTT of **Eclampsia** in between fits - Position
Trendelenburg position to help drainage of bronchial secretions.
188
General Measures of TTT of **Eclampsia** in between fits - Sedation
Morphine (10-20 mg IM) initially then maintain by diazepam (10 mg/8 h IV or IM).
189
General Measures of TTT of **Eclampsia** in between fits - Observation
190
TTT of **Eclampsia** in between fits - TOP

Y4R2 - Obstetrics I 🤰 (59 decks)

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