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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 β‰₯ 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
Q

Theories of PET

  • Immunlogical Factors
A
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26
Q

Theories of PET

  • Inflammatory Factors
A
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27
Q

Theories of PET

  • PGs
A
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28
Q

Theories of PET

  • NO
A
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29
Q

Theories of PET

  • Endothelin-1
A
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30
Q

Theories of PET

  • VEGF
A
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31
Q

Theories of PET

  • Free Radicals
A
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32
Q

Theories of PET

  • Vit E / Lipid Peroxides Imbalance
A
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33
Q

Theories of PET

  • Prorenin
A
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34
Q

Theories of PET

  • Endothelial Cell Activation
A
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35
Q

Pathology in PET

  • CVS
A
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36
Q

CVS Pathology in PET

  • Genralized Arteriolar Vasospasm
A

↑↑ peripheral resistance & endothelial cell dysfunction & damage.

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37
Q

CVS Pathology in PET

  • Increased Pressor effect
A

See before

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38
Q

CVS Pathology in PET

  • Hemodynamic Changes
A
  • Cardiac Preload: Normal or low in severe cases (due to VC & hypovolemia).
  • Cardiac afterload: ↑↑ (due to HTN).
  • COP: ↓↓ (due to ↑↑ peripheral resistance).
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39
Q

CVS Pathology in PET

  • Blood Volume
A
  • Hemoconcentration & ↑↑ Hct value (due to ↑↑ capillary permeability β†’ excessive shift of intravascular fluid to extravascular compartment).
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40
Q

CVS Pathology in PET

  • Blood Cells
A

 RBCs: Become bizarre shaped (easily hemolysed) in severe cases.

 WBCs: ↑↑ eosinophils (denoting immunological nature).

 Platelets: Thrombocytopenia.

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41
Q

CVS Pathology in PET

  • Activation of Coagulation system
A

In severe Cases

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42
Q

CVS Pathology in PET

  • Salt & Water Retention
A

Due to ↑↑ DOC & ↑↑ sensitivity to ADH.

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43
Q

Pathology in PET

  • Endocrine
A
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44
Q

Endocrine Pathology in PET

  • RAAS
A

In uteroplacentalhypoperfusion, there is ↑↑ rennin β†’ ↑↑ angiotensin-II β†’ compensatory ↑↑ in PGI2 production β†’ uteroplacental VD.

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45
Q

Endocrine Pathology in PET

  • Deoxycortisone
A

↑↑ β†’ Na+ retention

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46
Q

Endocrine Pathology in PET

  • ADH
A

↑↑ sensitivity to ADH β†’ edema & oliguria.

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47
Q

Endocrine Pathology in PET

  • Placental Hormones
A

↑↑ HCG, estrogen & progesterone

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48
Q

Pathology in PET

  • uteroplacental
A
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49
Q

Pathology in PET

  • Renal
A
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50
Q

Renal Pathology in PET

  • RBF & GFR
A

Decreased

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51
Q

Renal Pathology in PET

  • PTNuria
A

Due to damage of tubular epithelium

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52
Q

Renal Pathology in PET

  • Glomerular Capillaries
A
  • Glomerular cell swelling, mesangeal cell proliferation & fibrin like deposits intraendothelially & subendotheliall
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53
Q

Renal Pathology in PET

  • Renal Tububles
A

(reversible) or acute cortical necrosis (irreversible).

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54
Q

Pathology in PET

  • Liver
A

In severe cases.

  1. Periportal vasospasm, focal Hge & hematoma (subcapsular or in hepatic substance).
  2. Acute fatty degeneration
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55
Q

Liver Pathology in PET

A

In severe cases.

  1. Periportal vasospasm, focal Hge & hematoma (subcapsular or in hepatic substance).
  2. Acute fatty degeneration
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56
Q

CNS Pathology in PET

A

In severe cases.
1. Cerebral edema & hyperemia.
2. Thrombosis or Hge

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57
Q

Retinal Pathology in PET

A
  1. Retinal arterial vasospasm.
  2. Retinal exudate, Hge or detachment.
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58
Q

Pathology in PET

  • Hge
A

As adrenal glands, stomach & intestine.

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59
Q

Complications of PET

A

Maternal & fetal

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60
Q

Maternal Complications of PET

A
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61
Q

Maternal Complications of PET

  • ICH
A

Due to severe HTN.

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62
Q

Maternal Complications of PET

  • Blindness
A

Due to retinal detachment & it is reversible.

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63
Q

Maternal Complications of PET

  • HF & PE
A

Treated by immediate IV furosemide (lasix).

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64
Q

Maternal Complications of PET

  • PPH
A
  • In preeclampsia & eclampsia, PPH is diagnosed if there is blood loss > 200 ml (normally, > 500 ml) because there are hypovolemia & hemoconcentration.
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65
Q

Maternal Complications of PET

ARF

A

Acute tubular necrosis or acute cortical necrosis

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66
Q

Maternal Complications of PET

  • Mortality
A
  • Incidence: 2% in severe preeclampsia & 10% in eclampsia.
  • Etiology: Due to complications (commonest cause is ICH).
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67
Q

Maternal Complications of PET

  • Remote Complications
A
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68
Q

Maternal Complications of PET

  • HELLP Syndrome
A
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69
Q

Def of HELLP Syndrome

A

Fatal condition characterized by:

  • Hemolysis: Bilirubin β‰₯ 1.2 mg/dl.
  • Elevated Liver enzymes: SGOT > 70 IU/L.
  • Low Platelet count: < 100000/mm3.
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70
Q

DDx of HELLP Syndrome

A

 Acute fatty liver in pregnancy.

 Thrombotic thrombocytopenic purpura.

 Hemolytic uremic syndrome.

 Hepatitis (viral or drug induced).

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71
Q

Maternal Mortality in HELLP Syndrome

A

80-90%.

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72
Q

RR in HELLP Syndrome

A

5%

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73
Q

Fetal Complications in PET

A
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74
Q

Fetal Complications in PET

  • Prematurity
A

Due to preterm labor or premature TOP in severe cases.

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75
Q

Fetal Complications in PET

  • IUGR
A

Due to placental insufficiency.

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76
Q

Fetal Complications in PET

  • Fetal asphyxia or IUFD
A

Due to marked impairment of placental circulation or placental separation

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77
Q

Fetal Complications in PET
- Perinatal Mortality

A
  • 5% in mild preeclampsia & 25% in severe preeclampsia & 30% in eclampsia.
78
Q

Prediction of PET

  • Hx
A

High risk factors (from history since 1st antenatal visit).

79
Q

Prediction of PET

  • Ex
A
80
Q

Prediction of PET

  • Vascular Reactivity Tests
A
81
Q

Prediction of PET

  • Labs
A

↑↑ serum uric acid, hypocalciuria & ↑↑ fibronectin levels.

82
Q

Prediction of PET

  • Uterine Artery Doppler
A

To detect uteroplacental hypoperfusion

83
Q

Clinical Signs of PET

A

Signs: Preeclampsia is a disease of signs & it has the following 3 cardinal signs:

  • HTN
  • PTNuria
  • Edema
84
Q

Clinical Signs of PET

  • HTN
A
85
Q

Clinical Signs of PET

  • PTNuria
A
86
Q

Clinical Signs of PET

  • Edema
A
87
Q

Clinical Symptoms of PET

A
88
Q

Clinical Symptoms of PET

  • Epigastric Pain
A

Due to distension of liver capsule.

88
Q

Clinical Symptoms of PET

  • Headache
A

Due to HTN & cerebral edema.

89
Q

Clinical Symptoms of PET

  • Persistent N&V
A

Due to cerebral edema, congestion of gastric mucosa or liver affection.

90
Q

Investigations for PET

  • Labs
A
91
Q

Lab Investigations for PET

  • CBC
A

Hemoconcentration, hemolysis & thrombocytopenia

92
Q

Lab Investigations for PET

  • Coagulation Profile
A

Disturbed in DIC

93
Q

Lab Investigations for PET

  • LFTS
A

Bilirubin (↑↑ Γ¨ hemolysis) & SGOT & SGPT (↑↑ Γ¨ liver impairment & HELLP synd..

94
Q

Lab Investigations for PET

  • KFTs
A

Deteriorated only in severe cases.

95
Q

Lab Investigations for PET

  • urine Analysis
A

Oliguria & proteinuria.

96
Q

Rad Investigations for PET

A

US: To Determine fetal life, age, maturity & wellbeing.

CT scan or MRI brain: To Dx intracranial Complications

97
Q

Other Investigations for PET

A
  • Fundus examination: To detect retinal exudate, Hg or detachment.
  • Fetal wellbeing tests
98
Q

Assessment of Severity of PET

A
99
Q

Def of Imminent eclampsia (preeclamptic state)

A

Worse type of severe preeclampsia which will end in eclampsia if not urgently treated.

100
Q

Dx of Imminent eclampsia (preeclamptic state)

A
101
Q

TTT of Imminent eclampsia (preeclamptic state)

A

Immediate control & TOP Γ¨in 6 hours.

102
Q

DDx of PET

A
  • Causes of HTN with pregnancy
  • Causes of proteinuria with pregnancy
  • Causes of edema with pregnancy
103
Q

DDx of PET

  • Causes of HTN with Pregnancy
A

 Preeclampsia (commonest cause) & eclampsia.

 Gestational HTN

 Chronic HTN.

 2ry HTN: As in chronic nephritis, coarctation of aorta & Cush ing syndrome.

104
Q

DDx of PET

  • Causes of PTNuria with pregnancy
A

 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
Q

DDx of PET

  • Causes of edema with Pregnancy
A

 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
Q

Prevention of PET

A
107
Q

Prevention of PET

  • Prediction
A

See before.

108
Q

Prevention of PET

  • Lifestyle
A

Rest, exercise & ↓↓ dietary salt.

109
Q

Prevention of PET

  • Supplements
A
  • 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
Q

Prevention of PET

  • Drugs
A
111
Q

Plan of TTT of Mild PET

A
112
Q

Plan of TTT of Severe Preclampsia

A
113
Q

Plan of TTT of Imminent Eclampsia

A

Immediate control & TOP ein 6 hours.

114
Q

Lines of TTT of PET

A
  • Expectant treatment
  • Control of HTN
  • Prevention & control of convulsions
  • Termination of pregnancy
  • Postnatal care
  • Treatment of complications
115
Q

Expectant TTT of PET

A
116
Q

Expectant TTT of PET

  • Rest
A

Complete physical & mental rest.

117
Q

Expectant TTT of PET

  • Diet
A

High protein & CHO e low Na+ diet.

118
Q

Expectant TTT of PET

  • Sedation
A

Benzodiazepines or phenobarbitone.

119
Q

Expectant TTT of PET

  • Observation
A
120
Q

Control of HTN in PET

  • Indications
A

Severe cases (antihypertensives have doubtful value in mild cases)

121
Q

Control of HTN in PET

  • Rationale
A

Prevention of maternal complications & not fetal complications ( dec BP β†’ dec placental perfusion β†’ fetal distress & may be IUFD).

122
Q

Control of HTN in PET

  • Precautions
A

Dec BP should be gradual & DBP should be around 100 mmHg (below that β†’ dec placental perfusion).

123
Q

Control of HTN in PET

  • Disadvantages
A
124
Q

Control of HTN in PET

  • Used Drugs
A

Parenteral drugs:

  • Hydralazine
  • Labetalol
  • Diazoxide

Oral Drugs:

  • Methyl DOPA
  • Nifidiopine
  • Adrenergic blockers (Atenolol)
  • Mono-Hydralazine
  • Prazosin
125
Q

Control of HTN in PET

  • Hydralazine
A
126
Q

Control of HTN in PET

  • Labetalol
A

A & non-selective B-adrenergic blocker β†’ VD.

127
Q

Control of HTN in PET

  • Diazoxide
A

Used in severe resistant HTN as a last resort.

128
Q

Control of HTN in PET

  • Methyl DOPA
A
129
Q

Control of HTN in PET

  • Nifidipine
A
130
Q

Control of HTN in PET

  • Mono-hydralazine
A

Weak antihypertensive used in combination
é ß blockers to inc their efficacy & dec their side effects.

131
Q

Control of HTN in PET

  • Prazosin
A

Weak antihypertensive - used in combination Γ© other drugs.

132
Q

TTT of PET

  • Prevention & control of convulsions
A
  • Magnesium sulfate (MgSo4): Drug of choice
  • Diazepam (valium)
  • Phenytoin (Epanutin)
133
Q

Prevention & control of convulsions in PET

  • Action of MgSO4
A
  1. Curare like action on motor end plate β†’ paralysis of peripheral muscles.
  2. Weak CNS depressant.
  3. Mild VD & diuretic.
  4. inc PGI2 production & dec platelet aggregation.
134
Q

Prevention & control of convulsions in PET

  • Indications of MgSO4
A

Used to prevent convulsions in cases in which delivery is decided.

135
Q

Prevention & control of convulsions in PET

  • Routes of MgSO4
A

IV (preferred rout), IM (painful) or SC (not used now).

136
Q

Prevention & control of convulsions in PET

  • Doses of MgSO4
A
137
Q

Prevention & control of convulsions in PET

  • Duration of MgSO4
A

Maintenance therapy is continued for 24 h after delivery.

138
Q

Prevention & control of convulsions in PET

  • Monitoring of MgSO4
A
139
Q

Prevention & control of convulsions in PET

  • SE of MgSO4
A
140
Q

Maternal SE of MgSO4

A
141
Q

Maternal SE of MgSO4

  • Toxicity
A
142
Q

Maternal SE of MgSO4

  • Drug Interactions
A
  1. Enhances action of curare like drugs.
  2. Synergistic action if given Γ© CCB.
143
Q

Fetal SE of MgSO4

A

dec beat to beat variability in FHR pattern

144
Q

Neonatal SE of MgSO4

A

Hypermagnesemia, hypotonia & poor suckling.

145
Q

Antidote of MgSO4

A

Ca++ gluconate.

146
Q

Stroganoff method

A

Use of MgSo4 + morphine.

147
Q

Prevention & control of convulsions in PET

  • Action of Diazepam
A

Central inhibitory effect

148
Q

Prevention & control of convulsions in PET

  • Dose of Diazepam
A

Initially, 20-40 mg IV slowly then 10-20 mg/6 hrs.

149
Q

Prevention & control of convulsions in PET

  • SE of Diazepam
A

Neonatal hyperbilirubinemia & low APGAR score.

150
Q

Indications of TOP in PET

A
151
Q

Methods of TOP in PET

A

Vaginal & CS

152
Q

Vaginal Delivery in PET

  • Prerequisities
A
153
Q

Vaginal Delivery in PET

  • Precautions
A
154
Q

Precautions of Vaginal Delivery in TOP

  • Rest
A

In eclampsia room (see later)

155
Q

Precautions of Vaginal Delivery in TOP

  • Analgesia & Anesethia
A

Analgesia & anesthesia: Epidural anesthesia is the best.

156
Q

Precautions of Vaginal Delivery in TOP

  • Gaurd against PPH
A

By uterine massage + oxytocin + PGs (if needed) & avoid ergometrine (it causes VC & inc BP).

157
Q

Precautions of Vaginal Delivery in TOP

  • Guard against PP eclampsia
A

(by MgSo4 , for 24-48 hours after delivery).

158
Q

CS Delivery in PET

  • Indications
A
159
Q

CS Delivery in TOP

  • Disadvantages
A

adds surgical stress to disease stress.

160
Q

Postnatal Care in PET

  • Observation
A
161
Q

Signs of Improvement in Postnatal Care in PET

A
162
Q

Postnatal Care in PET

  • Drugs
A

MgSO4, should be continued for 24-48 hours after delivery.

163
Q

TTT of Complications in PET

A

…

164
Q

Def of Eclampsia

A

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

165
Q

Incidence of Eclampsia

A
  • Depends largely on management of pre-eclampsia.
  • in some areas, it is 1/500 where in others, it is 1/2300.
166
Q

RF for Eclampsia

A

As pre-eclampsia.

167
Q

Types of Eclampsia

A
  • According to time of occurrence of fits
  • According to recurrence
168
Q

Types of Eclampsia

  • Acc to time of occurence
A
169
Q

Types of Eclampsia

  • Acc to recurrence
A
170
Q

Pathology of Eclampsia

A
  • As preeclampsia + Coma.
171
Q

Complications of Eclampsia

A
  • Complications during fit
  • Complications of preeclampsia
172
Q

Dx of Eclampsia

A
173
Q

Clinical manifestations of eclamptic fits

A
174
Q

Clinical manifestations of eclamptic fits:

  • Premonitory Stage
A
175
Q

Clinical manifestations of eclamptic fits:

  • Tonic Stage
A
176
Q

Clinical manifestations of eclamptic fits:

  • Clonic Stage
A
177
Q

Clinical manifestations of eclamptic fits:

  • Coma Stage
A
178
Q

INVx in Eclampsia

A

As preeclampsia.

179
Q

Criteria of severity of eclampsia (Eden’s criteria)

A
180
Q

DDx of Eclampsia

  • Causes of Convulsion with pregnancy
A
181
Q

DDx of Eclampsia

  • Causes of Coma with pregnancy
A
182
Q

Prevention of Eclampsia

A

Good ANC for prevention, detection & early treatment of preeclampsia.

183
Q

TTT of Eclampsia

A
  • During Fit
  • In Between Fits
184
Q

TTT of Eclampsia

  • During Fit
A
185
Q

TTT of Eclampsia

  • In between Fits
A
  • General measures
  • Prevention of further attacks of convulsions
  • Control of HTN
  • Termination of pregnancy
  • Postnatal care
  • Treatment of complications
186
Q

General Measures of TTT of Eclampsia in between fits

  • Isolation
A
187
Q

General Measures of TTT of Eclampsia in between fits

  • Position
A

Trendelenburg position to help drainage of bronchial secretions.

188
Q

General Measures of TTT of Eclampsia in between fits

  • Sedation
A

Morphine (10-20 mg IM) initially then maintain by diazepam (10 mg/8 h IV or IM).

189
Q

General Measures of TTT of Eclampsia in between fits

  • Observation
A
190
Q

TTT of Eclampsia in between fits

  • TOP
A

Y4R2 - Obstetrics I 🀰 (52 decks)

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