hypertensive disorder of pregnancy- an over view prof. s.p.jaiswar department of obst. & gynae....

HYPERTENSIVE DISORDER OF

PREGNANCY- AN OVER VIEW

HYPERTENSIVE DISORDER OF

PREGNANCY- AN OVER VIEW

Prof. S.P.Jaiswar

Department of Obst. & Gynae.K.G. Medical University,

Lucknow

INTRODUCTIONINTRODUCTION

Commonest medical disorders Commonest medical disorders diagnosed by obstetriciandiagnosed by obstetrician

Spectrum of severity ranges mild to Spectrum of severity ranges mild to severe severe

There is controversy and lack of There is controversy and lack of clarity about mild to moderate HDPclarity about mild to moderate HDP


Despite of years of research in this Despite of years of research in this field still there is lack of consensus field still there is lack of consensus about- about- DefinitionDefinition ClassificationClassification Level of blood pressure at which Level of blood pressure at which

antihypertensive therapy needs to be antihypertensive therapy needs to be startedstarted

Responsible for a high proportion ofResponsible for a high proportion of

- - hospital admission hospital admission

- - labour inductionslabour inductions

- - fetal morbidity and mortality (20-25%) fetal morbidity and mortality (20-25%)

- - major cause - maternal mortality (15-20%)major cause - maternal mortality (15-20%)

Incidence: Incidence: 8-10%8-10%



Hypertension in pregnancy complicates Hypertension in pregnancy complicates 5% of all pregnancies & 11% of first 5% of all pregnancies & 11% of first pregnanciespregnanciesLeading cause of Maternal MortalityLeading cause of Maternal MortalityAccount for 40,000 maternal deaths Account for 40,000 maternal deaths annuallyannuallyIn India 30% maternal deaths due to pre- In India 30% maternal deaths due to preeclampsia & eclampsia (Chhabra et al)eclampsia & eclampsia (Chhabra et al)

Measuring Blood PressureMeasuring Blood Pressure

At every visitAt every visit Woman should be sitting with back & arm Woman should be sitting with back & arm

support without crossing legs for 5 minsupport without crossing legs for 5 min BP is lowest in lateral recumbent position, & the BP is lowest in lateral recumbent position, & the

BP of the superior arm in this position is 10-12 BP of the superior arm in this position is 10-12 mm Hg lower than the inferior armmm Hg lower than the inferior arm

Remove all tight clothing Remove all tight clothing Always measure in right armAlways measure in right arm Instrument at level of heart Instrument at level of heart Diastolic BP at Korotkoff VDiastolic BP at Korotkoff V

DEFINITIONAccording to Working Group (2000) of High Blood Pressure Education Programme hypertension is diagnosed when:

Blood pressure Blood pressure >>140/90 mm of Hg140/90 mm of Hg

- >30 mm of Hg or more in SBP.

- >15 mm of Hg or more in DBP.

This rise of BP is observed at interval of 4-6 hrs.

Classification of Hypertensive disorder of Pregnancy

Gestational hypertension (PIH and transient HT) B.P. > 140/90 mm of Hg for first time during

pregnancy. NO proteinuria B.P. return to normal <12 wks post-partum. Final diagnosis made only in post-partum. May be associated with other signs of pre-

eclampsia- headache, epigastric pain, thrombocytopenia.

Pre-eclampsia B.P. > 140/90 mm of Hg. After 20 wks of gestation. Proteinuria >300 mg/24 hrs or >1 + dip stick.

Classification of Hypertensive disorder in Pregnancy (Contd.)

Eclampsia- Convulsion in patients having pre-eclampsia. It may occur during ante-partum intra-partum, post-partum (upto 10 days).

Pre-eclampsia superimposed on chronic hypertension- Chronic hypertension or hypertension with proteinuria after 20 wks gestation or platelet count <100,000mm3.

Chronic hypertension- B.P. >140/90 mm of Hg before 20 wks of gestation or persists after 12 wks of post-partum.

Classification ACOG 2013Classification ACOG 2013

Gestational hypertensionGestational hypertension – evidence for – evidence for pre-eclampsia syndrome does not pre-eclampsia syndrome does not develop & hypertension resolves 12 wks develop & hypertension resolves 12 wks postpartumpostpartum

Pre-eclampsia & eclampsia syndromePre-eclampsia & eclampsia syndrome Chronic hypertensionChronic hypertension of any etiology of any etiology Pre-eclampsia superimposed on chronic Pre-eclampsia superimposed on chronic

hypertensionhypertension

Pre-eclampsiaPre-eclampsia

Hypertension (≥140/90 mmHg) on 2 occasions 4 hours apart Hypertension (≥140/90 mmHg) on 2 occasions 4 hours apart after 20 wks gestation)after 20 wks gestation)

++ Proteinuria Proteinuria − ≥≥300mg/24 hr or300mg/24 hr or− Protein ceratinine ratio ≥ 0.3 orProtein ceratinine ratio ≥ 0.3 or− Dipstick 1+ persistentDipstick 1+ persistent

OROR Thrombocytopenia – Platelets < 1,00,000/µlThrombocytopenia – Platelets < 1,00,000/µl Renal insufficiency – creatinine >1.1 mg% or doubling of Renal insufficiency – creatinine >1.1 mg% or doubling of

baseline (no prior renal disease)baseline (no prior renal disease) Liver involvement – Serum transaminase levels (AST or ALT) Liver involvement – Serum transaminase levels (AST or ALT)

twice normal)twice normal) Pulmonary edemaPulmonary edema Cerebral Symptoms – Headache, Visual, disturbances, Cerebral Symptoms – Headache, Visual, disturbances,

convulsionsconvulsions

Severity of Pre-eclampsiaSeverity of Pre-eclampsia

ACOGACOG SevereSevere Non SevereNon Severe

NICENICE

Systolic BP Diastolic BP

Mild Hypertension 140-149 90-99

Moderate Hypertension 150-159 100-109

Severe Hypertension ≥ 160 ≥ 110

Severity of Pre-Eclampsia

SBPSBP <160mm of Hg <160mm of Hg >160mm of Hg>160mm of Hg

Diastolic BPDiastolic BP <100 mm of Hg<100 mm of Hg >>110 mm of Hg (BP 110 mm of Hg (BP >> 160/110 160/110

ProteinuriaProteinuria < 2 +< 2 + Persistent (>3+)Persistent (>3+)

HeadacheHeadache AbsentAbsent PresentPresent

Visual disturbancesVisual disturbances AbsentAbsent PresentPresent

Upper abdominal painUpper abdominal pain AbsentAbsent PresentPresent

OliguriaOliguria AbsentAbsent PresentPresent

ConvulsionConvulsion AbsentAbsent Present (Eclampsia)Present (Eclampsia)

Serum creatinineSerum creatinine NormalNormal Elevated (>1.2 mg/dl)Elevated (>1.2 mg/dl)

ThrombocytopeniaThrombocytopenia Absent Absent Present (<100,000/mmPresent (<100,000/mm33))

Liver enzyme elevationLiver enzyme elevation MinimalMinimal Marked (Marked ( LDH, ALT or AST) LDH, ALT or AST)

Fetal growth restrictionFetal growth restriction AbsentAbsent ObviousObvious

Pulmonary edemaPulmonary edema AbsentAbsent PresentPresent

Abnormality Mild SevereAbnormality Mild Severe

ACOG Criteria ACOG Criteria (2013)ACOG Criteria ACOG Criteria (2013)AbnormalityAbnormality Non-severeNon-severe SevereSevere

Diastolic BPDiastolic BP < 110mmhg< 110mmhg ≥ ≥ 110mmHg110mmHg

Systolic BPSystolic BP < 160mmhg< 160mmhg ≥ ≥ 160mmHg160mmHg

ProteinuriaProteinuria None to positiveNone to positive None to positiveNone to positive

HeadacheHeadache AbsentAbsent PresentPresent

Visual DisturbanceVisual Disturbance AbsentAbsent PresentPresent

Upper Abdominal PainUpper Abdominal Pain AbsentAbsent PresentPresent

OliguriaOliguria AbsentAbsent PresentPresent

Convulsion (eclampsia)Convulsion (eclampsia) AbsentAbsent PresentPresent

Serum creatinineSerum creatinine NormalNormal ElevatedElevated

Thrombocytopenia Thrombocytopenia (<100,000/µl)(<100,000/µl)

AbsentAbsent PresentPresent

Serum transminase elevationSerum transminase elevation MinimalMinimal MarkedMarked

Fetal Growth restrictionFetal Growth restriction Not includedNot included Not includedNot included

Pulmonary edemaPulmonary edema AbsentAbsent PresentPresent

Young age < 18 yrs, Primi gravida, obese Multiple pregnancy, new paternity Racial genetic factor Poor socioeconomic status H/o chronic hypertension, family, past H/O PET Maternal age >35 yrs Pre-existing vascular disease, DM, APLA, Thrombophilic PET may appear before 20 wks in-

-hydatidform mole -multiple pregnancy

-acute polyhyromnioss

HIGH RISK GROUP

Preconceptional Risk FactorsRates of preeclampsia depend on: severity of underlying complications& combinations of risk factors.

Risk factors Risk%

Chronic hypertension/renal disease 15-40 Pre gestational DM 10-35Connective tissue disease (lupus, rheumatoid arthritis) 10-20Thrombophilia (acquired or congenital) 10-40Obesity/insulin resistance 10-15

Age older than 40 y 10-20Limited sperm exposure 10-35Family history of preeclampsia/ cardiovascular disease 10-15Woman born as SFGA 1.5 fold

Adverse outcome in a previous pregnancy: IUGR, ab placentae, IUFD

2-3 fold

Pregnancy-Related FactorsRegular antenatal care is mandatory for the prevention & early detection of PE.

Risk factors: Magnitude of risk depends on the number of factors

Multifetal gestationUnexplained FGRGestational hypertensionHydrops/hydropic degeneration of the placenta

Incidence of Pre-eclamsia- 5-15%Incidence of Pre-eclamsia- 5-15%

Primi-gravida- 3-10%Primi-gravida- 3-10%

Multi-gravida- 5%Multi-gravida- 5%

The exact pathophysiology is not clear.The exact pathophysiology is not clear. Pre-eclampsia is a disorder of endothelial Pre-eclampsia is a disorder of endothelial

function with vasospasm.function with vasospasm. Histopathology of placenta shows-Histopathology of placenta shows-

Diffuse placental thrombosis Diffuse placental thrombosis Inflammatory placental decidual Inflammatory placental decidual

vasculopathyvasculopathy Abnormal trophoblastic invasion of end Abnormal trophoblastic invasion of end

arteries.arteries. Altered maternal immune response to fetal/ Altered maternal immune response to fetal/

placental tissue.placental tissue.

PATHOPHYSIOLOGY OF PRE-ECLAMSIA

Pathogenesis: •unknown (Barton& Sibai, 2008).

Impaired trophoblast differentiation& invasion Placental & endothelial dysfunction

Immune maladaptation to paternal ages.

Exaggerated systemic inflammatory response.

In PE: Impaired trophoblast differentiation & invasion

PATHOPHYSIOLOGY OF PREECLAMSIAPATHOPHYSIOLOGY OF PREECLAMSIA

Increase vascular sensitivity to angiotensin II.Increase vascular sensitivity to angiotensin II.

Imbalance between prostacyclin and thromboxane Imbalance between prostacyclin and thromboxane A2A2

Increase oxygen free radicalsIncrease oxygen free radicals Abnormal calcium metabolismAbnormal calcium metabolism Vit E, C, Antioxidant and micronutrient deficiencyVit E, C, Antioxidant and micronutrient deficiency Genetic predispositionGenetic predisposition Inhibition of Nitric Oxide synthesis- increases main Inhibition of Nitric Oxide synthesis- increases main

arterial pressure arterial pressure

Pathological deterioration of function in a number of organs and systems presumably as a consequences of vasospasm and ischemia has been identified.Changes in Mother

Vasospasm Resistance to blood flow arterial hypertension.

Release of Angiotensin II endothelial cell to contract endothelial cell damage interendothelial cell leaks subendothelial deposition of platelets and fibrinogen.

Vascular changes local hypoxia hemorrhage and necrosis of tissue end organ disturbances in mother.

Fetus Reduced uteroplacental perfusion fetal compromise

growth retardation, oligohydromnios, IUD

Placenta : Placental infarction, calcification, abruptio placentae

PATHOGENESIS OF PRE-ECLAMPSIA

Cardiovascular SystemIncreased cardiac after load caused by-Hypertenison, endothelial injury, extravasation- especially in lungs (pulm edema)

Haemodynamic ChangesMarked reduction in cardiac outputIncreased peripheral resistance

Blood VolumeHaemoconcentration Increased vascular permeabilityPatients is sensitive to vigorous fluid therapy, even sensitive to blood loss at delivery.

PATHOLOGICAL CHANGES

Haematological ChangesThrombocytopenia- Platelets count <100,000/l, delivery is indicated because platelet count continues to decreaseHELLP Syndrome- Haemolysis, Elevated Liver enzyme, Low Platelets count.Coagulation failure occurs when associated consumptive coagulopathy like Placental abruption, profound haemorrhage.Haemoconcentration


KidneyDecrease glomerular filtrationDecrease renal perfusionIncrease plasma uric acid concentrationIncreased plasma creatinine level (>0.5 mg/dl)Proteinuria >300 mgdl/24 hrs of + 1.Renal failure- tubular necrosis- oliguria, anuria

LiverAlteration in hepatic function testPeriportal haemorrhagic necrosis in periphery of liver lobule- Increased serum liver enzymeHepatic ruptureSub-capsular haemorrhage- abdominal pain and hepatic haemorrhage.HELLP syndrome


HELLP syndromeHELLP syndrome- - characterized bycharacterized by

H- haemolysisH- haemolysis

EL- elevated liver enzymeEL- elevated liver enzyme

LP- low platelet countLP- low platelet count

It occurs in 20% of women with sever PET It occurs in 20% of women with sever PET associated with placental abruption, associated with placental abruption, renal failure, sub capsular hematoma renal failure, sub capsular hematoma

Increase fetal and maternal mortality.Increase fetal and maternal mortality.

Brain- Hypertension is responsible forOedemaHyperemiaThrombosisHaemorrhageConfusion and coma

Eye- Retinal haemorrhage, papilioedema Retinal detachment- retinal ischemia and infarctionVisual loss- cortical blindnessPrognosis is good, changes usually return to normal within a week.


Visual disturbances Convulsions

Prediction of pre-eclampsia depends on variety of biochemical and biophysical markers based on rationale implicated in the pathology and pathophysiology of hypertensive disorder.

Role over test- 28-32 wks lateral to supine DBP >20mmHg.

Angiotensin II infusion Test- 28-32 wks rise of 20 mm of Hg, DBP with < 8 ng/kg/min

Mean arterial Pressure- >90 mm of Hg in 2nd trimester

Doppler ultrasound- Persistent of diastolic notch at 18-24 wks.

None of the prediction test has been found to be very useful.

PREDICTION OF PRE-ECLAMPSIA

Increased impedance to flow in the uterine arteries as Increased impedance to flow in the uterine arteries as indicated by:indicated by:

Diastolic Notch in uterine artery waveformDiastolic Notch in uterine artery waveform Increase in uterine artery pulsatility index .Increase in uterine artery pulsatility index . is associated with increased risk of preeclampsia.is associated with increased risk of preeclampsia.

Uterine artery doppler velocimetry

UTERINE ARTERY DOPPLER VELOCIMETRYUTERINE ARTERY DOPPLER VELOCIMETRY

Development of preeclampsia overall was Development of preeclampsia overall was associated with increased PI, but not the associated with increased PI, but not the presence of notch before 21 weeks of presence of notch before 21 weeks of gestationgestation

The sensitivity was 43% and specificity The sensitivity was 43% and specificity 67% .67% .

(ACOG 2012).(ACOG 2012).

FETOPLACENTAL UNIT DYSFUNCTION FETOPLACENTAL UNIT DYSFUNCTION

• Human chorionic gonadotrophinHuman chorionic gonadotrophin• AlphafetoproteinAlphafetoprotein• EstriolEstriol• Inhibin AInhibin A• Pregnancy associated plasma protein APregnancy associated plasma protein A• Activin AActivin A• Corticotrophin release hormoneCorticotrophin release hormone

As exact etiology is not known, it can not be prevented, only severity of the condition can be prevented by regular ante-natal check-up (BP, urine albumin.).

No drug prevents pre-eclampsia as it has no definite cause of its origin.

But following drugs may prevent severity of disease.High dose calcium - 2gm/day

Decrease intracellular ionSmooth muscle relaxantDecrease responsiveness to pressure stimuli

PREVENTION

Low dose aspirinLow dose aspirin - 50-100mg/day- 50-100mg/dayPrevents platelets aggregationPrevents platelets aggregation

Decrease thromboxane ADecrease thromboxane A22 synthesis synthesis

Fish oilFish oil -- 4-9 cap./day4-9 cap./day

AntioxidantsAntioxidants -- Vit. C, E reduce Vit. C, E reduce oxidative stress oxidative stress

Basic aim of management-Basic aim of management- Termination of pregnancy at appropriate time only Termination of pregnancy at appropriate time only

curative treatment.curative treatment.

Birth of alive and healthy baby.Birth of alive and healthy baby.

Complete restoration of health of mother.Complete restoration of health of mother.

MANAGEMENT

Investigations Investigations

Antenatal Investigation

•Hb

•ABO RH

•Urine Routine Microscopy

•Screening blood sugar

•VDRL

•HbsAg

•HIV

•Obst USG

Specific Investigation

•Complete Haemogram

•General blood picture

•Pletelet Count

•24 hrs urinary protein

•Liver function test

•Kidney function test

•Serum Uric Acid•Coagulation profile•Fundus Examination•Doppler USG

Biochemical Parameters-Value in pregnancy and Preeclampsia

Biochemical Parameters-Value in pregnancy and Preeclampsia

Investigation Normal pregnancy Severe Preeclampsia

S. Bilirubin < 1 mg/dl >1.2 mg/ dl

SGPT 5-40 U/L >70 IU/L

SGOT 5-40 U/L >70 IU/ L

Alkaline phosphatase 100-280 U/L >300 U/ L

LDH 135-225 IU/L > 600 IU/ L

B. Ureas 15 mg/dl >20-25 mg/dl

S. Creatinine 0-8 mg/dl >1 mg/ dl

Biochemical Parameters-Value in pregnancy and Preeclampsia contd..

Biochemical Parameters-Value in pregnancy and Preeclampsia contd..

S. Uric acid 2-5 mg/ dl >6 mg/ dl

General blood picture Normocytic, Normochromic

Haemolytic cells- burr cells, schistocytes

Platelet count >200000 <100000

24 hrs urinary protein <300 mg >500 mg

Fundus examination Normal Constriction of the arterioles, increase in vein to artery ratio, segmental

vasospasm retinal

For early detection- Increase antenatal visit especially 3rd trimester Blood pressure >140/90 mm of Hg- to be admitted

to the hospital for evaluation of severity. Mild disease may often manage as out patient. Hospitalization- Persistent or worsening of

hypertension, Patient develops proteinuria

MANAGEMENT

In Hospital For systemic evaluation detailed history of

headache, visual disturbance, epigastric pain, rapid weight gain.

Daily weight recording Urine for protein- every 2nd day Blood pressure recording 4 hrly in sitting position Estimation of S. creatinine, hematocrit, platelets

count, S. liver enzyme Evaluation of fetal size, ammniotic fluid- clinically,

USG.

MANAGEMENT

Care to be taken Reduced activity is beneficial Absolute bed rest is not necessary Adequate protein and calories should be given Sodium and fluid intake should be adequate Do not give diuretics to correct oliguria or anuria Do not give diazepam to stop convulsion- apnea,

aspiration

MANAGEMENT

Maternal Surveillance in mild Preeclampsia-Maternal Surveillance in mild Preeclampsia-

Measure BP-4 times per dayMeasure BP-4 times per day Measure body weight- weeklyMeasure body weight- weekly Daily urine dipstick evaluation of protein in urineDaily urine dipstick evaluation of protein in urine Proteinuria in a 24 hr specimen every weekProteinuria in a 24 hr specimen every week CBC with platelet count, LDH, AST, ALT twice per CBC with platelet count, LDH, AST, ALT twice per

weekweek Inquire in each contact about fetal movements, Inquire in each contact about fetal movements,

development of scotoma, headache, epigastric pain.development of scotoma, headache, epigastric pain.

Maternal Surveillance in sever Preeclampsia-Maternal Surveillance in sever Preeclampsia-

Measure BP 4 times per day Measure body weight every day Daily input and output Daily urine dipstick evaluation of urine protein Proteinuria in 12 hr specimen CBC with platelet count, LDH, AST, ALT, KFT every CBC with platelet count, LDH, AST, ALT, KFT every

other day or more frequentother day or more frequent Inquire in each contact about fetal movements, Inquire in each contact about fetal movements,

development of scotoma, headache, epigastric pain.development of scotoma, headache, epigastric pain.

Fetal Surveillance in mild Preeclampsia-Fetal Surveillance in mild Preeclampsia-

Daily fetal heart rate monitoringDaily fetal heart rate monitoring

Daily fetal movement countDaily fetal movement count

Modified biophysical profile every weekModified biophysical profile every week

Fetal biometry every 3 weeksFetal biometry every 3 weeks

Umbilical and cerebral doppler every weekUmbilical and cerebral doppler every week

Fetal surveillanceFetal surveillance

Baseline USG for AFI, fetal weight, DopplerBaseline USG for AFI, fetal weight, Doppler DFMCDFMC Weekly NSTWeekly NST

NICE guidelines recommend 2 weekly NICE guidelines recommend 2 weekly Doppler for mild PEDoppler for mild PE

No large prospective studies comparing No large prospective studies comparing frequency of monitoringfrequency of monitoring

Fetal Surveillance in sever Preeclampsia-Fetal Surveillance in sever Preeclampsia-

Daily fetal heart rate monitoringDaily fetal heart rate monitoring Daily fetal movement countDaily fetal movement count Daily NSTDaily NST Amniotic fluid volume twice every weekAmniotic fluid volume twice every week Fetal biometry every 2 weeksFetal biometry every 2 weeks Umbilical and cerebral doppler twice every weekUmbilical and cerebral doppler twice every week

Initial Recommended Management of Severe PETInitial Recommended Management of Severe PET

Immediate hospitalization Immediate hospitalization Detailed history taken to assess severity – Headache, Detailed history taken to assess severity – Headache,

visual disturbance, epigastric pain, rapid weight gain, visual disturbance, epigastric pain, rapid weight gain, bleeding P/V or laborbleeding P/V or labor

Detailed examination done for – edema, brisk reflexes & Detailed examination done for – edema, brisk reflexes & clonus, Chest auscultation for basal crepts, fetal growth & clonus, Chest auscultation for basal crepts, fetal growth & well beingwell being

IV magnesium sulfate started to prevent convulsionsIV magnesium sulfate started to prevent convulsions Anti hypertensive medication administered to lower BP Anti hypertensive medication administered to lower BP

( iv Labetalol plus oral nifedipine)( iv Labetalol plus oral nifedipine) Aim is to keep systolic BP between 140-155 /150 and Aim is to keep systolic BP between 140-155 /150 and

diastolic BP between 90-105/100 mm Hgdiastolic BP between 90-105/100 mm Hg Corticosteroids given between 26-34 weeks gestationCorticosteroids given between 26-34 weeks gestation

Indications for Delivery in Preeclampsia-Indications for Delivery in Preeclampsia-

Maternal indications-Maternal indications-• BP persistently 160/100 or greater despite treatmentBP persistently 160/100 or greater despite treatment• Platelet count 50,000/ cubic mmPlatelet count 50,000/ cubic mm• Urine output <400 ml in 24 hrsUrine output <400 ml in 24 hrs• Progressive deterioration in liver functionProgressive deterioration in liver function• Progressive deterioration in renal functionProgressive deterioration in renal function• Suspected abruptio placentaeSuspected abruptio placentae• Persistent severe headaches, or visual changesPersistent severe headaches, or visual changes• Persistent severe epigastric pain, nausea or vomitingPersistent severe epigastric pain, nausea or vomiting

Fetal indication-Fetal indication-

Severe growth restriction

Nonreassuring fetal cardiotocography

Oligohydramnios

There is general agreement that all such patients should be delivered if the disease develops after 34 weeks gestation

There is general agreement that all such patients should be delivered if the disease develops after 34 weeks gestation

Prompt delivery is Prompt delivery is indicatedindicated

Imminent eclampsiaImminent eclampsia Multi-organ dysfunctionMulti-organ dysfunction Severe IUGR < 5Severe IUGR < 5thth

percentilepercentile Suspected abruption Suspected abruption

placentaeplacentae Non reassuring fetal Non reassuring fetal

testingtesting

There is disagreement about There is disagreement about management of patients with severe management of patients with severe PET before 34 weeks gestationPET before 34 weeks gestation

Some consider delivery as Some consider delivery as the definite treatment the definite treatment regardless of gestational regardless of gestational ageage

Others recommend Others recommend prolonging pregnancy for prolonging pregnancy for fetal lung maturity till 34 fetal lung maturity till 34 weeks weeks

Although delivery is beneficial to mother , it must be weighed against the risk for prematurity

Although delivery is beneficial to mother , it must be weighed against the risk for prematurity

It was believed that It was believed that premature infants of premature infants of severe PET have severe PET have accelerated lung and accelerated lung and neurological maturation as neurological maturation as a result of stress in uteroa result of stress in utero

Had lower rates of Had lower rates of morbidity and mortality morbidity and mortality with similar gestation age with similar gestation age of normal infantsof normal infants

This has been This has been revealed wrong revealed wrong

They have higher They have higher rates of admission rates of admission in neonatal in neonatal intensive care unitintensive care unit

Sibai 2007Sibai 2007

Timing and mode of DeliveryTiming and mode of Delivery

Continue pregnancy till 37weeksContinue pregnancy till 37weeks Expectant management vs Induction of Expectant management vs Induction of

labor (Hypitat trial 2010)labor (Hypitat trial 2010) Reduced rates of severe HT (induction Reduced rates of severe HT (induction

group). group). No difference in CS delivery and neonatal No difference in CS delivery and neonatal

outcome. outcome. Induction prevents complications however Induction prevents complications however

little they are little they are

Anti-hypertensive drug therapy To prolong pregnancy to get better fetal outcome To reduce blood pressure in severe hypertension. Sudden fall in blood pressure must be avoided.

Drugs

Methyl dopa- 250 mg 8 hrly – 2 gm/day orally

Hydralazine- 5 mg I.V. stat. 5 mg ½ hrly.

Nifedipine- 10 mg 6 hrly – 20 mg/4 hrly orally

Labetalol- 250 mg – 8 hrly or 6 hrly. orally

ACE inhibitor are contraindicated during pregnancy.

MANAGEMENTControl of blood pressure

Antihypertensives safe in pregnancyAntihypertensives safe in pregnancy

Drug Starting dose Maximum dose

Methyldopa 250 mg TDS/QID 4 g / day

Labetalol 100 mg BD 2400 mg/ day

Nifedipine 10 mg BD 120 mg / day

Thiazide diuretic 12.5 mg BD 50 mg/day

Antihypertensives for Hypertensive emergencyAntihypertensives for Hypertensive emergency

Drug Starting dose Maximum dose

Contra-indications

Labetalol 20 mg IV every 15minDose doubled to 40-80 mg according to effect

220 mg Asthma, CHF, cardiac conduction abnormality

Hydralazine

5-10 mg every 20 min 20 mg Tachycardia, persistent headache

Nifedipine 10-20 mg every 30 min

50 mg Tachycardia, palpitations & headache

Anti-convulsant drug therapy- in severe pre-eclampsia to prevent convulsion

Magnesium Sulphate Loading Total dose 4+10= 14 gm

4 gm (20 ml of 20% solu.) I.V. within 3-5 mins.

5 gm (10 ml of 50% solu.) deep I.M. in each buttock with 1 ml of 1% of xylocain

If recurrent fits after 30 min of loading dose- repeat 2 gm 20% (4 ml drug with 6 ml NS) slow in 5 min.

MANAGEMENTPrevention of convulsion

Prevention of convulsionPrevention of convulsion

Maintenance dose-Maintenance dose-

5 gm deep IM (50%) alternate buttocks after monitoring every 4 hrs.

Monitoring of toxicityMonitoring of toxicity Presence of patellar reflex- > 10meq/lit, disappear Respiratory rate> 16 min- > 12 meq/lit- respiratory

paralysis Urine output>30 ml/hr in last 4 hrs

Continue till 24 hrs after last fit/ delivery which ever is later

Management of Magsulf toxicity-Management of Magsulf toxicity-

If patellar jerk is absent or urine output < 30 ml/hr- If patellar jerk is absent or urine output < 30 ml/hr- stop magsulf and monitor hourly- restart maintenance stop magsulf and monitor hourly- restart maintenance dose if criteria is fulfilled.dose if criteria is fulfilled.

RR<16 / min- with hold magsulf.RR<16 / min- with hold magsulf. Give antidote- Calcium gluconate 1 gm IV 10 ml of 10% Give antidote- Calcium gluconate 1 gm IV 10 ml of 10%

solution in 10 min solution in 10 min Mechanical ventilation if respiratory paralysis(>15 Mechanical ventilation if respiratory paralysis(>15

meq/lit)meq/lit) Convulsion prevents- when magnesium level Convulsion prevents- when magnesium level

maintained at 4 to 7 meq/litmaintained at 4 to 7 meq/lit

Diuretics in PregnancyDiuretics in Pregnancy

Use throughout pregnancy controversialUse throughout pregnancy controversial Commonly prescribed to women with Commonly prescribed to women with

Essential hypertension prior to pregnancyEssential hypertension prior to pregnancy Here diuretics may be continued alone or in Here diuretics may be continued alone or in

combination with other Antihypertensives in combination with other Antihypertensives in pregnancy because increase in plasma pregnancy because increase in plasma volume during pregnancy lesser than normal volume during pregnancy lesser than normal but not associated with adverse fetal but not associated with adverse fetal outcomeoutcome

Discontinue in case of superimposed preeclampsia or IUGR

Termination of Pregnancy Indications Patient develops signs of imminent eclampsia Severe pre-eclampsia does not respond to

conservative treatment. Eclampsia

Method of Termination Induction of labour at term if favorable cervix. LSCS in unfavorable cervix or other indication.

MANAGEMENTObstetrical management

Obstetrical management-Obstetrical management-

> 37 weeks- Termination of pregnancy. Induction of labour as per the bishop score.

> 34-< 37 weeks-

Treatment should be individualized- BP controlled- explain maternal and fetal adverse effect to

relatives. Regular fetal and maternal surveillance. Terminate at 37 weeks. BP uncontrolled, worsening clinical and biochemical

parameters- terminate the pregnancy.

Obstetrical management-Obstetrical management-

>24- <34 weeks>24- <34 weeks corticosteroid coverage BP controlled- continue maternal and fetal surveillance-

terminate at 37 weeks. BP uncontrolled, worsening clinical and biochemical

parameters- terminate the pregnancy.

< 24 weeks- Fetal salvage difficult- terminate the pregnancy.

During Labour Careful BP monitoring Close watch on fetal heart sound Early ARM to accelerate the labour Analgesia – epidural Early intervention in IInd stage- forceps, ventouse Inj. Oxitocin 10 IU Im. with delivery of baby as active

management of 3rd stage of labour prevent PPH. Watch for PPH- patient does not tolerate slight blood loss. Methyl ergometrine is not to be given

MANAGEMENT

Decision to perform cesarean section is based onDecision to perform cesarean section is based on

Gestational age, FHR tracing, Doppler studies, AFI, fetal Gestational age, FHR tracing, Doppler studies, AFI, fetal presentationpresentation

Condition of cervix (Bishops score)Condition of cervix (Bishops score) Maternal condition specially uncontrolled BP and developing Maternal condition specially uncontrolled BP and developing

complicationscomplications In general the presence of severe PET is not an indication for In general the presence of severe PET is not an indication for

cesarean delivery and decision has to be individualizedcesarean delivery and decision has to be individualized In severe PET for LSCS, GA carries a risk for aspiration and failed In severe PET for LSCS, GA carries a risk for aspiration and failed

intubation owing to airway edema and is associated with marked intubation owing to airway edema and is associated with marked increase in cerebral pressure during intubation & extubationincrease in cerebral pressure during intubation & extubation

These patients may need intubation under fiberoptic observation These patients may need intubation under fiberoptic observation with the availability of immediate tracheostomywith the availability of immediate tracheostomy

Regional anesthesia is contraindicated in presence of coagulopathy Regional anesthesia is contraindicated in presence of coagulopathy or severe thrombocytopeniaor severe thrombocytopenia

Post-natal Period Dose of antihypertensive is usually reducedDose of antihypertensive is usually reduced

Methyl dopa is discontinued- causes post-partum Methyl dopa is discontinued- causes post-partum depressiondepression

ACE inhibitor may be started- if requiredACE inhibitor may be started- if required

Patient must be counseled for recurrence in future Patient must be counseled for recurrence in future pregnancy or develop hypertension in later life.pregnancy or develop hypertension in later life.

MANAGEMENT

Antihypertensives in Postpartum periodAntihypertensives in Postpartum period

Should be started if SP Should be started if SP >> 150 mm Hg & DP 150 mm Hg & DP >> 100 mm 100 mm HgHg

Discontinued if BP remains below hypertensive level Discontinued if BP remains below hypertensive level for atleast 48 hoursfor atleast 48 hours

Causes of exacerbation of Hypertension in Postpartum Causes of exacerbation of Hypertension in Postpartum period:period:- IV fluids given in labour- IV fluids given in labour- IV Oxytocin in labour- IV Oxytocin in labour- Mobilization of extracellular fluid to intravascular - Mobilization of extracellular fluid to intravascular

compartmentcompartment

Antihypertensives in Postpartum period & Breast feedingAntihypertensives in Postpartum period & Breast feeding

All antihypertensives are found in breast milk but All antihypertensives are found in breast milk but plasma: milk ratio of drugs is different plasma: milk ratio of drugs is different

Long term effects of these drugs on Long term effects of these drugs on breastfeeding infants not studiedbreastfeeding infants not studied

Choice of Antihypertensives in Postpartum period Choice of Antihypertensives in Postpartum period

Diuretics- only indicated in Pulmonary edema, Diuretics- only indicated in Pulmonary edema, decrease milk productiondecrease milk production

ACE inhibitors - adverse effect on neonatal renal ACE inhibitors - adverse effect on neonatal renal functionfunction

Methyldopa- Postpartum depressionMethyldopa- Postpartum depression Amlodipine- also a calcium channel blocker but Amlodipine- also a calcium channel blocker but

not used due to limited studies in literature not used due to limited studies in literature supporting usesupporting use

•Labetalol & Nifedipine drug of choice•Labetalol/ Hydralazine (IV)- in Hypertensive emergency

EclampsiaEclampsia

Dr. S.P. JaiswarDr. S.P. Jaiswar

ProfessorProfessorDept. of Obst. & GynaeDept. of Obst. & Gynae

KGMU LucknowKGMU Lucknow

IntroductionIntroduction

Convulsive state of pre-eclampsia is Convulsive state of pre-eclampsia is called eclampsia.called eclampsia.

Pre-eclampsia is complicated by Pre-eclampsia is complicated by generalized tonic and clonic convulsions generalized tonic and clonic convulsions and coma .and coma .

IncidenceIncidence

1 in 500 to 1 in 301 in 500 to 1 in 30 More common in primi-gravidaMore common in primi-gravida Five time more common in twinsFive time more common in twins 50% occur in late pregnancy50% occur in late pregnancy

According to time of onset of convulsions -According to time of onset of convulsions - Ante- partum- 50%Ante- partum- 50% Intra- partum- 30% Intra- partum- 30% IntercurrentIntercurrent Post- partum- 20%Post- partum- 20%

Cause of Convulsions Cause of Convulsions

Cerebral irritation- due to cerebral hypoxia Cerebral irritation- due to cerebral hypoxia

- due to spasm of cerebral vessels- due to spasm of cerebral vessels

Cerebral oedema- perivascular oedemaCerebral oedema- perivascular oedema

Cerebral dysarrythmiaCerebral dysarrythmia

- Following anoxia or oedema- Following anoxia or oedema

Cerebral Pathology-Cerebral Pathology-

Cortical and sub- cortical oedemaCortical and sub- cortical oedema

InfarctionInfarction

HaemorrhageHaemorrhage

Hypoxia, ischaemia or oedemaHypoxia, ischaemia or oedema

Clinical features- Clinical features-

Sometimes patient shows premonitory Sometimes patient shows premonitory symptoms before developing convulsionssymptoms before developing convulsions

Divided into four stages-Divided into four stages- Pre monitory StagePre monitory Stage Tonic StageTonic Stage Clonic StageClonic Stage Stage of ComaStage of Coma

Premonitory Stage-Premonitory Stage-

Patient become unconsciousPatient become unconscious

Twitching of muscles of face, tongue, limbsTwitching of muscles of face, tongue, limbs

Eyeballs roll or turned to one side, become Eyeballs roll or turned to one side, become fixedfixed

Its last for 30 sec.Its last for 30 sec.

Tonic Stage-Tonic Stage-

Whole body goes into a tonic spasmWhole body goes into a tonic spasm

Respiration ceases, tongue protrudes outRespiration ceases, tongue protrudes out

Cyanosis appears, eyeballs become fixedCyanosis appears, eyeballs become fixed

This stage last for 30 secThis stage last for 30 sec

Clonic Stage- Clonic Stage-

Voluntary muscles undergo alternative contraction and Voluntary muscles undergo alternative contraction and relaxationrelaxation

Twitching start from the face then involve one side of Twitching start from the face then involve one side of extremities and ultimately the whole bodyextremities and ultimately the whole body

Biting of tongueBiting of tongue

Breathing is laboured and blood stained frothy secretionsBreathing is laboured and blood stained frothy secretions

Cyanosis gradually disappearCyanosis gradually disappear

Lasts for 1-4 min.Lasts for 1-4 min.

Stage of Coma-Stage of Coma-

Following fits patient passes in stage of comaFollowing fits patient passes in stage of coma

Status eclampticus-Status eclampticus-

Multiple recurring fits at varying intervalsMultiple recurring fits at varying intervals

Differential Diagnosis- Differential Diagnosis-

EpilepsyEpilepsyHysteriaHysteriaEncephalitis and MeningitisEncephalitis and MeningitisPuerperal cerebral thrombosisPuerperal cerebral thrombosisPoisoningPoisoningCerebral malariaCerebral malariaIntra- cranial tumorsIntra- cranial tumors

Prognosis Prognosis

Immediate Mortality-2-30% maternal mortalityImmediate Mortality-2-30% maternal mortality

Causes of Maternal death-Causes of Maternal death- Cardiac FailureCardiac Failure Pulm oedemaPulm oedema Aspiration septic pneumonitisAspiration septic pneumonitis Cerebral hemorrhageCerebral hemorrhage Acute renal failureAcute renal failure Cardiopulmonary arrestCardiopulmonary arrest Adult respiratory distress syndromeAdult respiratory distress syndrome Post partum shockPost partum shock Puerperal sepsisPuerperal sepsis

Fetal Complications- Fetal Complications-

Peri natal mortality- 30-50%Peri natal mortality- 30-50%

Pre maturity- spontaneous, inducedPre maturity- spontaneous, induced

Intra uterine asphyxia- Infarction, retro-Intra uterine asphyxia- Infarction, retro-placental, haemorrhage spasmplacental, haemorrhage spasm

Effect of drugsEffect of drugs

TraumaTrauma

Management-Management-

Prevention-Prevention- To control blood pressureTo control blood pressure

Prophylactic magsulf therapyProphylactic magsulf therapy

Patient to be referred to tertiary centrePatient to be referred to tertiary centre

Hospital Management- Hospital Management- Shout for helpShout for help Maintain airway, breathing and circulationMaintain airway, breathing and circulation Oxygen administration 8-10 L/minOxygen administration 8-10 L/min Arrest convulsionsArrest convulsions Ventilator supportVentilator support Prevention of injuryPrevention of injury Hemodynamic stabilizationHemodynamic stabilization Delivery within 6-8 hr, maximum 12 hrsDelivery within 6-8 hr, maximum 12 hrs Prevention of complicationsPrevention of complications Post partum carePost partum care

Specific Management-Specific Management-

Anti-convulsions-Anti-convulsions- Magnesium sulphate is the drug of choiceMagnesium sulphate is the drug of choice Pritchard regimen (Intramuscular)Pritchard regimen (Intramuscular) 4 gm I/V, over 3-5 min(20 ml of 20% solution)4 gm I/V, over 3-5 min(20 ml of 20% solution) 10 gm I/M deep(5 gm in each buttock-50% solution)10 gm I/M deep(5 gm in each buttock-50% solution) Maintenance dose- 5 gm I.M. 4 hrlyMaintenance dose- 5 gm I.M. 4 hrly

Intravenous- Zuspan or SibaiIntravenous- Zuspan or Sibai

4-6 gm IV over 15-20 min 1-2 gm/hr IV 4-6 gm IV over 15-20 min 1-2 gm/hr IV infusioninfusion

INTRAMUSCULAR DOSAGE SCHEDULEINTRAMUSCULAR DOSAGE SCHEDULE

Magnesium sulphate 8 ml (50% weight by volume Magnesium sulphate 8 ml (50% weight by volume = 4gm) dissolved in 12 ml of saline ( total=20 ml) = 4gm) dissolved in 12 ml of saline ( total=20 ml) for 20 % w/v intravenous dosefor 20 % w/v intravenous dose

Magnesium sulphate 10 ml (5gm) injected deep Magnesium sulphate 10 ml (5gm) injected deep intramuscular in each buttock.(50% w/v dose)intramuscular in each buttock.(50% w/v dose)

Addition of 1 ml of 2% lidocaine reduces pain.Addition of 1 ml of 2% lidocaine reduces pain. LOADING DOSE : 4 gm of magnesium sulphate as LOADING DOSE : 4 gm of magnesium sulphate as

20% solution intravenously at rate of 1 gm/min + 20% solution intravenously at rate of 1 gm/min + 10 gm of 50% magnesium sulphate solution , one 10 gm of 50% magnesium sulphate solution , one half (5 gm) injected deeply in upper outer half (5 gm) injected deeply in upper outer quadrant of each buttock.quadrant of each buttock.

INTRAMUSCULAR DOSAGE SCHEDULEINTRAMUSCULAR DOSAGE SCHEDULE

MAINTAINENCE DOSEMAINTAINENCE DOSE Every four hour give 5 gm of 50% w/v solution Every four hour give 5 gm of 50% w/v solution

(10 ml= 5 gm) injected deep intramuscular in (10 ml= 5 gm) injected deep intramuscular in upper outer quadrant of alternate buttocks upper outer quadrant of alternate buttocks

BUT only after ensuring that :BUT only after ensuring that :1.Patellar reflex is present1.Patellar reflex is present2.Respiration not depressed2.Respiration not depressed3.Urine output in previous 4 hour exceeded 100 ml.3.Urine output in previous 4 hour exceeded 100 ml.

In case of recurrent fits half loading dose : In case of recurrent fits half loading dose : 2gm more intravenously as 20% solution 2gm more intravenously as 20% solution is given. is given.

4 ml of 50% w/v (2 gm of magnesium 4 ml of 50% w/v (2 gm of magnesium sulphate) dissolved in 6 ml of saline to sulphate) dissolved in 6 ml of saline to make 2 gm of 20% w/v solution( 2gm in 10 make 2 gm of 20% w/v solution( 2gm in 10 ml)ml)

ADVERSE EFFECTS OF MAGSULPHADVERSE EFFECTS OF MAGSULPH

Fits controlled at blood levels of 4-7 meq/lFits controlled at blood levels of 4-7 meq/l 10 meq/l: patellar reflexes disappear10 meq/l: patellar reflexes disappear >= 10 meq/l : respiratory depression>= 10 meq/l : respiratory depression >=12 meq/l : respiratory paralysis and >=12 meq/l : respiratory paralysis and

respiratory arrestrespiratory arrest Neonatal respiratory depression only if severe Neonatal respiratory depression only if severe

hypermagnesemia at deliveryhypermagnesemia at delivery Neonatal compromise usually not problematicNeonatal compromise usually not problematic

AntidoteAntidote

Calcium gluconate or calcium chloride 1 Calcium gluconate or calcium chloride 1 gm intravenously and witholding further gm intravenously and witholding further magnesium sulphate reverses mild to magnesium sulphate reverses mild to moderate respiratory depressionmoderate respiratory depression

For severe cases prompt tracheal For severe cases prompt tracheal intubation and mechanical ventilation intubation and mechanical ventilation required.required.

Magnesium Sulphate- Magnesium Sulphate- PreferredPreferred

Control fits without depression in mother and Control fits without depression in mother and foetusfoetus

Reduce of recurrent convulsionsReduce of recurrent convulsions

Significantly reduce maternal death (3%) Significantly reduce maternal death (3%)

Reduce perinatal mortalityReduce perinatal mortality

Anti hypertensive drugs- Anti hypertensive drugs- BP >160/105 mm of BP >160/105 mm of Hg (NHBPEP-2000)Hg (NHBPEP-2000)

Diuretics-Diuretics-In pulmonary oedema(20-40 mg IV)In pulmonary oedema(20-40 mg IV)

Other Regimens-Other Regimens-

Lytic cocktail- Lytic cocktail- Is a combination of Is a combination of chlorpromazine, promethazine and chlorpromazine, promethazine and pethidinepethidine

DiazepamDiazepam Phenyton- in1000mg, iv infusion in one hour, Phenyton- in1000mg, iv infusion in one hour,

500mg oral after 10 hrs ,24hrs postpartum 500mg oral after 10 hrs ,24hrs postpartum

ANTIHYPERTENSIVE THERAPYANTIHYPERTENSIVE THERAPY

HYDRALAZINE-HYDRALAZINE- 5 to 10mg at 15 to 20 min till satisfactory 5 to 10mg at 15 to 20 min till satisfactory BPBP

Drug of choice during pregnancy act on periferal vessels.Drug of choice during pregnancy act on periferal vessels. LABETALOL-LABETALOL- 10mg IV double the dose at every 10 min till 10mg IV double the dose at every 10 min till

get satisfactory response or maximum-220mgget satisfactory response or maximum-220mg NIFEDIPINENIFEDIPINE-10mg oral, repeated in 30 min, if necessary-10mg oral, repeated in 30 min, if necessary VERAPAMIL-VERAPAMIL-5 to 10mg per hour5 to 10mg per hour NIMODIPINENIMODIPINE-continuous infusion or oral.-continuous infusion or oral. KETANSERINKETANSERIN NITROPRUSSIDENITROPRUSSIDE

MANAGEMENTMANAGEMENT

DIURETICS - DIURETICS - causes intravascular volume depletion causes intravascular volume depletion compromise placental perfusion.compromise placental perfusion.

HYPEROSMOTIC AGENTS- HYPEROSMOTIC AGENTS- should be used in pulmonary should be used in pulmonary oedema onlyoedema only

FLUID THERAPY-FLUID THERAPY- Lactated Ringer solution-60-125ml/hr. Lactated Ringer solution-60-125ml/hr. excessive fluid may cause pulmonary oedema. excessive fluid may cause pulmonary oedema.

INVASIVE HEMODYNAMIC MONITORING-INVASIVE HEMODYNAMIC MONITORING-to manage to manage oliguria and to avoid pulmonary oedema.oliguria and to avoid pulmonary oedema.

DELIVERYDELIVERY- prefer vaginal delivery. Less tolerant to blood - prefer vaginal delivery. Less tolerant to blood loss.loss.

ANALGESIA & ANESTHESIA- ANALGESIA & ANESTHESIA- Epidural is prefer then SA Epidural is prefer then SA or GAor GA

Management of complications-Management of complications-

Pulmonary oedemaPulmonary oedema Heart failureHeart failure AnuriaAnuria HyperpyrexiaHyperpyrexia PsychosisPsychosis

Chronic hypertension- Essential hypertension

Secondary hypertension- Renal, endocrinal vascular

Systolic hypertension- Thyrotoxicosis, Hyperkinetic circulation

It should be managed

According to cause and severity- During antenatal, intranatal and postnatal period to reduce maternal and fetal complication and give better outcome.

OTHER HYPERTENSIVE DISORDERS

Severe manifestation and complication can be decreased by-

Early detection Meticulous antenatal care Timely intervention.

To reduce maternal and fetal morbidity and mortality and to get better outcome.

CONCLUSION

Hypertensive Disorders Of PregnancyHypertensive Disorders Of Pregnancy

QuestionaireQuestionaire

1) All are prognostic indicators of pregnancy 1) All are prognostic indicators of pregnancy

induced hypertension , except:induced hypertension , except:

a.a. Low plateletsLow platelets

b.b. Serum sodiumSerum sodium

c.c. Elevated liver enzymesElevated liver enzymes

d.d. Serum uric acid Serum uric acid

B (serum sodium levels)B (serum sodium levels)

2) All of the following can be used in pregnancy 2) All of the following can be used in pregnancy

associated hypertension except:associated hypertension except:

a.a. NifedipineNifedipine

b.b. CaptoprilCaptopril

c.c. MethyldopaMethyldopa

d.d. hydralazinehydralazine

B (captopril)B (captopril)

3) Which is the drug of choice for severe pre 3) Which is the drug of choice for severe pre

eclampsiaeclampsia

a)a) LabetalolLabetalol

b)b) MetaprololMetaprolol

c)c) Alpha methyl dopaAlpha methyl dopa

d)d) NifedipineNifedipine

A ( labetalol)A ( labetalol)

4) Best drug for management of eclampsia is:4) Best drug for management of eclampsia is:

a)a) MgSo4MgSo4

b)b) Lytic cocktail regimenLytic cocktail regimen

c)c) PhenytoinPhenytoin

d)d) diazepamdiazepam

A (MgSO4)A (MgSO4)

5) Concentration of MgSo4 in the treatment of 5) Concentration of MgSo4 in the treatment of

eclampsia in meq/l:eclampsia in meq/l:

a)a) 7-107-10

b)b) 10-1510-15

c)c) 2-42-4

d)d) 4-74-7

D ( 4-7 meq/lt)D ( 4-7 meq/lt)

7) Earliest sign of magnesium toxicity:7) Earliest sign of magnesium toxicity:

a)a) Depression of deep tendon reflexesDepression of deep tendon reflexes

b)b) Respiratory depressionRespiratory depression

c)c) Cardiac arrestCardiac arrest

d)d) Anuria Anuria

A (depression of deep tendon reflexes)A (depression of deep tendon reflexes)

8) Which is not a feature of HELLP syndrome:8) Which is not a feature of HELLP syndrome:

a)a) ThrombocytopeniaThrombocytopenia

b)b) EosinophiliaEosinophilia

c)c) Raised liver enzymesRaised liver enzymes

d)d) Hemolytic anemiaHemolytic anemia

B (eosinophilia)B (eosinophilia)

9) A 28 year old eclamptic woman develop 9) A 28 year old eclamptic woman develop

convulsion. The first measure to be done is:convulsion. The first measure to be done is:

a)a) Give MgSo4Give MgSo4

b)b) Sedation of patientSedation of patient

c)c) Immediate deliveryImmediate delivery

d)d) Care of airwayCare of airway

D ( care of airway)D ( care of airway)

10) In severe pregnancy induced hypertension BP is 10) In severe pregnancy induced hypertension BP is

a)a) 160/110 mm Hg160/110 mm Hg

b)b) 150/100 mm Hg150/100 mm Hg

c)c) 260/100 mm Hg260/100 mm Hg

d)d) 120/80 mm Hg120/80 mm Hg

A ( 160/110 mm Hg)A ( 160/110 mm Hg)

11) Pregnancy induced hypertension is 11) Pregnancy induced hypertension is

hypertension that develops after:hypertension that develops after:

a)a) 18 weeks of pregnancy18 weeks of pregnancy

b)b) 20 weeks of pregnancy20 weeks of pregnancy

c)c) 24 weeks of pregnancy24 weeks of pregnancy

d)d) 28 weeks of pregnancy28 weeks of pregnancy

B ( 20 weeks of pregnancy) B ( 20 weeks of pregnancy)

12) In a patient on magnesium sulphate therapy, 12) In a patient on magnesium sulphate therapy,

usually at what level the knee (patellar) reflex usually at what level the knee (patellar) reflex

disappears:disappears:

a)a) 6-8 meq/l6-8 meq/l

b)b) 10-12 meq/l10-12 meq/l

c)c) 12-14 meq/l12-14 meq/l

d)d) >15 meq/l>15 meq/l

B ( 10-12 meq/lt) B ( 10-12 meq/lt)

THANK YOUTHANK YOU

hypertensive disorder of pregnancy- an over view prof. s.p.jaiswar department of obst. & gynae....

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