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Obs N Gynae > PIH > Flashcards

PIH Flashcards

1
Q

HTN in pregnancy

A

140/90 on 2 occasions 4 hrs apart

SBP-kortokoff sound 1
DBP- Kortokoff sound 5. ( N kortokoff sound 4 )

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2
Q

ACOG classification

A

Cat 1. Pre-eclampsia - Eclampsia syndrome
Cat 2 gestational HTN
Cat 3. Cronic HTN in pregnancy
Cat 4. Cr. HTN with superimposed pre eclampsia

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3
Q

Chronic HTN

A

Bp>/= 140/90. Before 20 weeks of gestation

Not come back to N after 12 w post delivary

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4
Q

PIH

A

POG > 20 w. Comes back to N within 12 w of delivery

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5
Q

Gestational HTN

A

PIH with no proteinuria or signs of end organ damage

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6
Q

Pre eclampsia

A

Proteinuria. ( non selective, only granular cast, not a/with red cell cast or nephritic or nephrotic syndrome &/or Signs of EOD

Dipstick test (screening). >/= +1
Urine protein creatinine ratio >/= 0.3
24 hr urine protein excretion ( gold std ) >/= 300mg

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7
Q

Signs of End Organ Damage

A
  1. Platelet count < 1 lakh
  2. Liver enz raised to 2 times + Epigastric Pain
  3. Serum creatinine >/= 1.1 mg/dl
  4. Pulmonary edema
  5. Visual Symptoms/ headache
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8
Q

Pre eclampsia classification

A

I. Early onset : 20-30 w
Preterm or late onset : 34 w - 37 w
Term onset : >37 w

II. PE without severe features (mild) : BP > 140/90 + no signs of impending eclampsia
PE with severe features (severe) : BP > 160/110 + signs of impending eclampsia + signs of EOD + GTCS

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9
Q

Signs of impending eclampsia

A

Headache ( not relieved by analgesics )
Epigastric pain
Visual symptoms

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10
Q

Eclampsia

A

New oneset of GTCS or coma in a pt. With pre-eclampsia

Types: Antepartum
Intrapartum ( during labour )
Postpartum ( within 48 hrs of delivery )

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11
Q

Cells regulating vascular remodelling

A

Maternal natural killer cell

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12
Q

Stages in PIH

A

I. Placental syndrome (stage 1) : AbN vascular remodelling, AbN placentation , Impaired trophoblastic differentiation/impaired pseudo vasculogenesis

II. Maternal syndrome (stage 2)

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13
Q

Effects of placental ischemia in PIH/PE

A
  1. Placenta : small size
  2. Fetus : IUGR, oliguria, oligohydroamnios
  3. Maternal : Increased BP
    Oedema
    Hemoconcentration
    Virchows triad ( endothelial enjury + stasis + hypercoagubility)
    Hematological changes- Thrombocytopenia, Microangiopathic hemolysis, Intravascular coagulation, Increased LDH levels
    MOD
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14
Q

MOD in mother with PE

A
  1. Kidney : Oliguria -> Increased serum creatinine + urea + uric acid
    Glomeruloendotheliosis
  2. Liver : Stretching of glissons capsule- Epigastric pain
    Periportal haemorrhage, vasospasm
    Hematoma formation
  3. Retina : Vasospasm
    Visual changes scotoma
    HTN retinopathy
    Retinal detachment
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15
Q

Factors increasing in PIH

A

SFLT-1
Endoglin
Thrombaxin A2

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16
Q

Factors decreased in PIH

A

VEGF
Placental growth factors
NO
Prostacyclin

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17
Q

Increased risk for PIH

A
  1. Nulliparous
  2. New paternity
  3. Long inter pregnancy interval
  4. Molar pregnancy
  5. Family history or SGA women
  6. Obese female (BMI>30)
  7. Age <18 >40
  8. Hydrops fetalis
  9. Pregnancy d/t ivf
  10. Use of barrier contraceptive before pregnancy
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18
Q

High Risk for PIH

A
  1. Previous h/o PE
  2. Chronic HTNive
  3. Multiple pregnancy
  4. Diabetic mother
  5. Female with kidney disease
  6. Female with immune disorder like APLA
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19
Q

Indication of Aspirin in PIH

A
  1. Any >/=1 high risk factors
  2. Any >/=2 of following factors
    i. Nulliparous
    ii. Age >35 yrs
    iii. Obese
    iv. Prior h/o LBW or IUGR
    v. Family h/o PE
    vi. Vulnarable sociodemographic factors
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20
Q

Aspirin dose time period

A

Dose - 75-150 mg/day
Time period- <16 w (12-16 w). To 36 w

21
Q

Evaluation for raised bp

A

I. Assess nature of disease
1. Proteinuria - urine dipstick, 24hr urine protein excretion, urine protein/creat ratio

  1. Urine microscopy- Red cell cast (chr. HTN), Granular cast(PE)

II. Assess severity
1. Platelet count
2. Liver enz
3. Serum creat.
4. LDH
5. Peripheral schistocytes

III. Assess fetal well being
1. NST
2. BPS
3. USG- for fetal growth, AFI, Doppler studies

22
Q

Top in case of
1. PE without severe features
2. PE with severe features
3. Chr HTN bt controlled
4. Chr. HTN with superimposed PE
5. On umbilical artery doppler :
S/D ratio increased >/= 3
Absent end diastolic flow
Reversal of end diastolic flow
6. Ductus venous doppler : absent a wave

A
  1. > /= 37 w
  2. > /= 34 w
  3. 37-38+6/7d
  4. 37 w
  5. > /=37 w
    33-34 w
    30-32 w
  6. At 30 w
23
Q

Immediate TOP

A
  1. Eclampsia or impending eclampsia
  2. HELP syndrome
  3. Fetal distress
  4. Abruption of placenta
  5. Uncontrolled HTN
  6. Progressive organ damage
24
Q

Management severe PE

A

Measure- BP half hourly, Urine O/P hourly, Proteinuria 4hrly

Evaluate signs of impending eclampsia

Assess fetal well being

Drugs:
Anti hypertensive : Hydralazine iv Labetalol iv , Niedipine oral
MgSO4
Corticosteroid-28 to 34 w

> /=34 w & <28 w - Immediate delivery

25
Q

Mgt of severe PE b/w 28 - 34 w

A

I. Delivery after first dose of corticosteroid
1. Impending eclampsia
2. Placenta abruptio
3. HELP syndrome
4. DIC
5. Pulmonary oedema
6. Fetal compromise
7. Uncontrolled severe HTN

II. Delivery after 48 hrs of corticosteroid - PROM
1. PROM
2. Renal dysfunction/ fetal growth restriction
3. Oligohydromnios
4. Umbilical doppler- reversed diastolic flow

III. Expectant Mgt

26
Q

HELLP syndrome

A

Microangiopathic hemolysis
Eevated liver enzymes
Low platelet count

27
Q

Presentation of HELLP

A

Sudden onset of pain (colicky) in abd at mid epigastrium or rt upper quad.
Appears in3rd trimester

Other:
BP increase 85% cases
Proteinuria

28
Q

Diagnosis of HELLP syndrome

A

TENESSE criteria :

H= Hemolysis +nt if any two seen:
1. Schistocytes or helmet cells or burr cells in peripheral smear
2. Increase in indirect bilirubin >/=1.2
3. Increase LDH >2 time (600 IU) & decrease heptoglobin (<25mg/dl)
3. Severe anemia unrelated to blood loss

EL= Elevated Liver enzymes >2 times (70 IU)

LP= Low platelet count (<1lakh)

29
Q

D/d of HELLP syndrome

A

Acute Fatty liver of pregnancy

30
Q

Mgt of HELLP synd

A
  1. MgSO4
  2. Anti hypertensive
  3. Corticosteroids if <34 w
  4. Definitive- TOP
31
Q

Anti HTNive in severe PE first line

A

Hydralazine i.v
Labetalol iv
Nifedipine oral

32
Q

Indication to start Anti HTNive

A

BP>/= 150/100 mmHg persistantly (4hrs apart)

BP>/= 160/110 2 readings 15 min apart. (Hypertensive Crisis)

33
Q

Other drugs for PE

A

Nitroglycerin
Nitroprusside
Nimodipine
Nicardipine
Veropamine
Ketanserine

34
Q

DOC for refractory HTN
Its S/E

A

Na Nitroprusside

Cyanide poisoning

35
Q

Hydralazine dose S/E

A

Starting - 5mg im/iv
3 doses of 10 mg 15-20 mins apart
Max dose = 30 mg

S/E : Tachycardia, Hypotension, Headache, Palpitations

36
Q

Labetalol dose S/E

A

10 mg -> 20 mg -> 80 mg
Max - 220 mg

S/E : Bradycardia, Hypotension, Asthma

37
Q

Nifedipine dose. S/E

A

10 mg after 20 mins -> 20 mg 2 doses

S(E : Tachycardia, Headaches

38
Q

Anti HTNive in Chronic HTN
1. Indication
2. Target BP

A
  1. BP>/=160/100 or co morbidities at lower BP
  2. Generally: <150/100
    In case or end organ damage like LVH or renal insufficiency : <140/90
39
Q

1st line anti HTNive in chronic HTN

A

Labetalol oral
Nifedipine oral
Methyldopa oral

40
Q

Other anti HTNive chronic HTN

A

Beta blocker : Propronalol, Metaprolol

Ca channel blockers

Diuretics

41
Q

Anti HTNive absolutely C/I in pregnancy

A

ACE inhibitors
Angiotensin receptor blocker - Losartan
Diazoxide

42
Q

Mechanism of action of MgSO4

A

Centrally acting drug
Blocks NMDA receptors in brain
CCB - membrane stabalisation
Decrease release of acetylcholine
Cerebral vasodilation
High dose blocks peripheral calcium channels

43
Q

Pritchard regimen

A

Loading dose : IM - 10 g, 50% solution (10 ampules) ;upper outer quad using 3
inch 30 guage needle
IV - 4 g, 20% solution ( 4 ampules + 12 ml NS) ; over 10-15 mins
Max infusion rate 1g/min
Check maternal heart rate is giving high iv dose
If seizures persist after 15 min repeat iv 2g in 20% solution

Maintenance dose : 4 hourly till 24 hrs after delivery or last seizure whichever is
last
IM - 5 gm, 50% solution every 4hrly in alternate buttock
Before giving check :
1. Knee jerk or patellar reflex intact
2. Urine O/P >/=100 ml in 4hrs
3. Respiratory rate >/= 12/min

44
Q

MgSO4 toxicity
1. First sign @ 10mEq/L
2. 12mEq/L
3.@ 15mEq/L
4. @ >24 mEq/L
5. Other symptom

A
  1. -nt Patellar reflex
  2. Respiratory paralysis
  3. Cardiac conduction defects
  4. Cardiac arrest
  5. Diaphoresis, Flushing, Slurring of speech
45
Q

MgSO4 Toxicity Antidote

A

Calcium gluconate 1gm iv or
CaCl2

46
Q

ACOG recommendations for IV dose of MgSO4

A

Loading- 4-6 gm in 100 ml iv over 15-20 mins

Maintenance: 1-2 gm/hr in 10 ml

47
Q

Use of MgSO4 in obstetrics

A
  1. DOC for neuroprotection in preterm labour- prevent CP in newborns
  2. Prevention of seizures in impending PE, HELLP syndrome
  3. Mgt of seizure in eclampsia
48
Q

Mgt of Eclampsia

A
  1. Airways mgt
  2. MgSO4
  3. Anti HTNive labetalol or Hydralazine
  4. After stabalization TOP

Mode of delivery - vaginal
If delivary not within 24 hrs - Csection
Anaesthesia- neuraxial

Obs N Gynae (10 decks)

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