PIH Flashcards
Hypertension in pregnancy
Chronic HTN in pregnancy
Hypertensive before 20 wks of pregnancy.
Pt htn before pregnancy.
bP doesn’t come back to normal after delivery.
PIH
HTN more than 20 wks of pregnancy.
Due to placental pathology.
BP will come back to normal within 12 wks.
GESTATIONAL HTN PREECLAMPSIA
- Proteinuria
- End organ damage
- Absent present
* Absent present
End organ damage
Any one of the following shld be present Platelet count less than 1 lakh S creatinine more than 1.1 Liver enzymes raised 2x than normal value Presence of cerebral or visual symptoms Pulmonary edema.
Chronic HTN with superimposed preeclampsia
A hypertensive female conceives and suddenly at 20 wks if she notice any one of the following
1 uncontrolled BP
2. New onset proteinuria
3. New onset end organ damage.
Signs of impending eclampsia in severe preeclampsia pt
Symptoms
Tx
- epigastric pain ± nausea, vomiting
Due to formation of subcapsular hematomas causing liver capsule to stretch. - headache which is not responding to usual Tx
± dizziness due to cerebral hypoxia - New onset visual disturbance
Convulsions. Hypertensive retinopathy
KEITH WAGNER BAKER CLASSIFICATION
Tx: mgso4
Doc for treating and preventing convulsions in a pt with pih.
HELLP SYNDROME Pt came with epigastric pain on right upper quadrant pain in third trimester. H hemolysis EL elevated liver enzymes LP low platelet count
HEMOLYSIS any two of four + 1. On peripheral blood smear: schistocytes/ helmet cells/ burr cells + 2. Serum bilirubin levels ≥ 1.2 3. Decreased haptoglobin 4. LDH increase ≥ 600 IU. EL: SGOT & SGPT ≥ 70 IU/L LP: platelet count< 1 lakh
Risk factors for PIH or preeclampsia
- Previous history of preeclampsia/ past history of chr HTN/ family history of HTN
- Chr kidney disease.
- Primigravida female
- New paternity.
- Diabetes placentomegaly
- syndromes APLA, metabolic X syndrome
- Pregnancy twin preg, molar preg, Rh neg preg.
How to prevent PIH
Aspirin 50 – 150 mg/d
Started from 12 wks of pregnancy not later than 16 wks and continued throughout pregnancy.
Given only to females who have identifiable symptoms.
Tests to predict preeclampsia
Most common uterine A Doppler
Outdated test gaints roll over test
Recent predictors :
Increases :- anti angiogenic factors
Sflt 1
S endoglin
Vasoconstrictors
Thromboxane A2
Decreases :- angiogenic factors
VEGF
Placental gf
Vasodilator
Nitric oxide.
Management of PIH
2 types
1. Non specific management
2. Definitive management or specific
- Use of anti HTN therapy
- Anti convulsant
- Termination of pregnancy.
PIH CONDITION TOP
- mild preeclampsia
- severe preeclampsia
- impending eclampsia
- eclampsia
- HELLP SYNDROME
- Complication
- Fetal disturbances
- Kidney failure
- Abruptio
TOP
- ≥ 37 wks
- ≥ 34 wks
- Immediately top
- Immediate top
- Immediate top
- Immediate top
Anti hypertensive therapy:
- Most common mode of delivery
- Indications for cesarean
- Medication, management of preeclampsia
- vaginal delivery
1. Epidural analgesia
2. Catheterization in eclampsia
3. Cut short 2nd stage by intermediate delivery
Prophylactic use of forceps or vaccum.- After delivery: methylergometrine is C/I.
- Poor bischop score
AEDF
REDF - Oral therapy given if BP ≥ 150/100 but ≤160/110
IV therapy if BP ≥ 160/110. Hypertensive crisis
¶CAN BE GIVEN ¶ CONTRAINDICATED - Labetalol * ace inhibitors
- Methyldopa * losartan
- Nifedipine * diuretics
- Hydralozine * all beta
- Ntg blockers
- Sodium Except
Nitroprusside Labetalol.
- DOC for PIH:
- DOC for hypertensive crisis in preg
- DOC for chr. HTN in preg
- DOC for refractory HTN in preg
- DOC for acute hypertensive crisis in preg
- Labetalol
- IV labetalol max dose 220mg
Initially give 20 mg.. if not decreased give 40 mg…..80mg……..80mg.
Labetalol is C/I in asthamatic pts.
For asthamatic IV hydralozine - Labetalol > methyldopa
- sodium nitroprusside usually not given bcz it can lead to cyanide toxicity.
- 1st DOC: IV labetalol 220mg
2nd DOC: IV hydralozine
Sustained release nifedipine
IV NTG drip
Refractory cases: sodium nitroprusside
- What is eclampsia?
- Why seizure?
- Which eclampsia has worst prognosis?
- When a pt with preeclampsia throw generalized tonic clonic seizures.
- In eclampsia BP increases……… vasoconstriction……. decrease blood flow in brain…….central hypoxia.
- Antepartum eclampsia M.C worst prognosis.
#Management of eclampsia # Definitive management
1st step: secure the airway ( mouth gag, O2 by masks, aspirate the secretions)
2nd step: Anti convulsant therapy MgSo4.
3rd step: IV anti HTN like labetalol.
# TOP immediate.
MgSo4 role in treating convulsions
MgSo4 can prevent convulsions only if thy are due to vasoconstriction bcz of PIH.
Not an anti HTN Drug
*Acts on NMDA receptors in brain… Blocks them….
Cerebral vasodilation….. Decreases cerebral hypoxia…… convulsions treated.
* Blocks ca channel’s. Ca channel blockers shldnt be combined with MgSo4 it can lead to respiratory arrest.
Pritchard regime: dose of MgSo4
* Loading dose: 14gms IV 4gms 20% solution IM 10gms 50% solution. 5gms in left buttock and 5gms in right buttock. * Maintanence dose: 5gms IM 5gms 50% in alternate buttocks.
Therapeutic range of MgSo4
4 – 7 meq/ L
Or
2 – 3.5 mmol/L
Or
4.8 – 8.4 mg/ dlMaintanence dose of MgSo4
Shld be given every 4 hourly Before each dose check 1. Patellar reflex 2. Urine output 3. RR ≥ 12 breath/ min 4. Spo2 ≥ 96% If any of these is abnormal donot give maintanence dose. This dose shld be given till 24 hrs after last convulsion or 24 hrs after delivery.
Signs and symptoms of MgSo4 toxicity
Antidote?
1st sign loss of patelar reflex ≥10 meq/L Slurring of speech, diaphoresis Resp depression ≥ 12 meq/L Resp arrest occurs ≥ 15 meq/L Cardiac arrest occurs ≥ 30meq/L
Antidote: ca gluconate IV 10ml of 10%
