HYPERTENSIVE DISORDERS IN PREGANCY OBJECTIVES At the end of this session yo

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HYPERTENSIVE DISORDERS IN PREGANCY OBJECTIVES At the end of this session yo

Concordia College, Ann Arbor, US has reference to this Academic Journal, HYPERTENSIVE DISORDERS IN PREGANCY OBJECTIVES At the end of this session you should be able to: Outline diagnostic features of pre-eclampsia Classify pre-eclampsia according so that severity Outline risk factors in consideration of pre-eclampsia Outline maternal in addition to fetal complications of pre-eclampsia. Describe the management of pre-eclampsia in addition to eclampsia. I. INTRODUCTION Synonyms: Toxemia of pregnancy, pre-eclampsia, EPH gestosis, pregnancy induced hypertension. Pre-eclampsia commonly manifests after the 20th week of pregnancy. Prevalence of pre-eclampsia: varies from one place so that another Severe pre-eclampsia in addition to eclampsia Are serious in addition to potentially fatal Third commonest cause of maternal mortality Occurs prior to, during or after delivery

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II. DIAGNOSIS OF PRE-ECLAMPSIA When SBP > 140 mm Hg, DBP > 90 mm Hg in a woman known so that be normotensive prior so that pregnancy. The diagnosis requires 2 such abnormal BP measurements recorded at least 6 hours apart. III. RISK FACTORS Young maternal age Nulliparity: 85% of pre-eclampsia occur in primigravida. Increased placental tissue in consideration of gestational age: Hydatiform moles, twin pregnancies Family history of pre -eclampsia Diabetes mellitus Renal diseases, Chromosomal abnormality in the fetus (eg, trisomy). RISK FACTORS cont Worrisome signs in consideration of pre-eclapmsia development Rapid increase of weight during the latter « of pregnancy An upward trend in diastolic BP even while still within normal range

IV. CLASSIFICATION OF PRE ECLAMPSIA: ACCORDING TO SEVERITY Mild pre-eclampsia Moderate pre-eclampsia Severe pre-eclampsia Mild so that Moderate Pre eclampsia Diagnostic Features Systolic BP is 140 -160 mmHg Diastolic BP is 90 ? 100 mmHg Proteinuria up so that ++ 2. Severe pre-eclampsia Also called ? Imminent eclampsia Symptoms Severe & persistent occipital or frontal headaches Visual disturbance: blurred vision, photophobia Epigastric and/or right upper-quadrant pain Signs Diastolic BP > 11ommHg, systolic BP > 160mmHg Proteinuria +++ or more Altered mental status Hyper-reflexia Oliguria HELLP SYNDROME Is a severe form of pre-eclampsia Affects approx 10% of women alongside severe preeclampsia in addition to 30-50% of women alongside eclampsia. Characterized by: Hemolysis, Elevated liver enzymes Low platelet count. Increased mortality rate in addition to DIC

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V. PATHOPHYSIOLOGY There are several theories in addition to etiologic mechanisms. Vasospasm theory: Most favored theory Vasospasms ? vasoconstriction ? resistance ? arterial BP Eclampsia: Cerebral arterial vasospasm ? cerebral edema or infarction and/or cerebral hemorrhage VI. COMPLICATIONS OF SEVERE PRE-ECLAMPSIA AND ECLAMPSIA Maternal complications CVS Haemoconcentration (cause: vasoconstriction in addition to vascular permeability) Hamatological changes ? HELLP ? DIC Kidneys Decr RBF? ?GFR ? RTN in addition to RCN? acute RF Proteinuria ? due so that ?permeability so that large protein, Oliguria ? both renal perfusion in addition to GFR decrease. COMPLICATIONS OF SEVERE PRE ECLAMPSIA AND ECLAMPSIA cont Brain Cerebral edema Infarction, cerebral hemorrhage Blindness: Due so that -?retinal artery vasospasms in addition to retinal detachment Fever 39§C: a grave sign, may be a consequence of intracranial hemorrhage. Coma ? may be a result of CVA

COMPLICATIONS OF SEVERE PRE ECLAMPSIA AND ECLAMPSIA cont RS : Pulmonary oedema in addition to cyanosis Utero-placental perfusion Vasospasms ? decr perfusion ? distress in addition to death Histological changes in the placental bed: acute artherosis ? lipid rich cells of the uteroplacental arteries Fetal complications IUFD, IUGR MAJOR CAUSES OF MATERNAL DEATH Cerebrovascular accident (CVA) Pulmonary oedema Cardiac failure, Renal failure VII. WORK UP – INVESTIGATIONS Urine analysis Proteinuria A 24-hour urine collection Quantity of urine in addition to protein Uric acid level: GFR in addition to creatinine clearance decrease ?in ?uric acid levels. LFT ? Transaminases USS ? fetal wellbeing, if the GA is < 20/40 R/O moles. VIII. MANAGEMENT OF PRE ECLAMPSIA MILD - MOD PRE ECLAMPSIA A: Dispensary & Health centre Antihypertensives Aldomet 250 mg 8 hourly in consideration of 7 days, Bed rest at home REFER within one week so that Hospital in consideration of further management MANAGEMENT OF PRE ECLAMPSIA 1. MILD - MOD PRE ECLAMPSIA cont B. Hospital Antihypertensives: Aldomet, Bed rest at home, Sequential work ups, Fetal movements monitoring, Schedule antenatal clinic every 2 weeks up so that 32 wks in addition to weekly thereafter MANAGEMENT OF PRE ECLAMPSIA 1. MILD - MOD PRE ECLAMPSIA cont B. Hospital Strongly advice the woman so that deliver in a hospital Plan delivery at 38/40 Advice the mother so that come so that the health facility in case of severe headache, blurred vision, nausea or upper abdominal pain. Manage as severe pre-eclampsia: If not responding so that treatment i.e. if the systolic BP is > 160 mmHg, or the diastolic BP is > 100mmHg or there is proteinuria +++

MANAGEMENT OF SEVERE PRE ECLAMPSIA AND ECLAMPSIA Note: Severe pre-eclampsia is managed like eclampsia Management protocol in consideration of eclampsia Keep airway clear Control convulsions Control BP Control fluid balance Antibiotics Investigations Deliver the mother MANAGEMENT CONT BP CONTROL Keep SBP between 140 -160 mm Hg in addition to DBP between 90 -110 mm Hg ?Why these levels: Avoid potential reduction in either uteroplacental blood flow or cerebral perfusion pressure. Drugs: Anti HPTs: Hydralazine, nifedipine, or labetalol Diuretics are not used except in the presence of pulmonary edema MANAGEMENT: CONTROL CONVULSIONS I. An overview on MgSO4. Mechanism: Cerebral vasodilator ? reducing cerebral vasospasm ? ?ischemia (brain). Superior so that other anti-convulsants used so that control in addition to prevent fits; Important part of mgt of eclampsia Recurrence rate after MgSO4 = 10 -15% Improves maternal in addition to fetal outcome

CONTROL CONVULSIONS – REGIMEN 1. INTRAMUSCULAR REGIMEN i. Loading dose Give MgSO4 4 g (i.e. 20mls of 20% solution) + 200mls NS or sterile water I.V over 5 minutes Follow promptly alongside 10g (i.e. 20ml of 50% solution), 5g in each buttock as deep I.M alongside 1ml of 2% lignocaine in the same syringe MANAGEMENT CONT CONTROL CONVULSIONS – REGIMEN 1. INTRAMUSCULAR REGIMEN cont ii. Maintenance dose MgSO4 5 g (i.e. 10ml of 50% solution) + 1 ml lignocaine 2% 4 hourly in alternate buttocks. NOTE: IM inj. are painful in addition to are complicated by local abscess formation in 0.5% of cases. The intravenous (IV) route is therefore preferred MANAGEMENT CONT CONTROL CONVULSIONS – REGIMEN 2. INTRAVENOUS REGIMEN i. Loading dose MgSO4 4 g (i.e. 20mls of 20% solution) + 200mls NS I.V over 5 minutes ii. Maintenance dose MgSO4 4 g (i.e. 20ml of 20% solution) IN 500ml NS 4 hourly in consideration of 24 hrs after the last fits

MANAGEMENT CONT CONTROL CONVULSIONS – REGIMEN Recurrent fits (any regimen): Therapeutic dose may not have been reached Give 2g (i.e. 10ml of 20% solution) i.v. over 5 minutes Treatment duration: Continue in consideration of 24 hours after delivery or last convulsion, whichever occurs first MANAGEMENT CONT Magnesium toxicity Causes loss of deep tendon reflexes, followed by respiratory depression in addition to ultimately respiratory arrest. Thus, before repeating MgSO4, ensure that; RR ? 16/min Patellar reflexes are present Urinary output is at least 30ml per hour over 4 hours Otherwise withhold or delay MgSO4 Keep antidote ready In case of respiratory arrest: Assist ventilation in addition to administer calcium gluconate MANAGEMENT CONT DELIVER THE MOTHER Delivery should be within 6-8 hours of onset of fits Vaginal delivery is the safest mode of delivery Assessment R/O contraindications so that SVD Bishop score If the cervix is favourable – induce labour Otherwise prepare in consideration of C/S

MANAGEMENT CONT Management of labour 1st stage Relieve pain: pethidine 25 mg iv every 2-4 hours Augmentation of labour Monitor FHR, 2nd stage: Assist alongside vacuum extraction 3rd stage: Active management Oxytocin 10 IU i.m after delivery of anterior shoulder Cord traction Squeezing clots after delivery of the placenta MANAGEMENT CONT Management of labour If there is delay perform C/S Post delivery: Continue observation in consideration of at least 48 hrs post delivery Record in addition to monitor BP in addition to urine output in consideration of at least 48 hours after delivery, Keep the pt in hospital until BP stabilizes, Continue alongside aldomet PO until BP back so that normal

Trevenon, Stacy Managing Editor;News Director

Trevenon, Stacy is from United States and they belong to Managing Editor;News Director and work for Metro Networks/Shadow Broadcast Services – Scottsdale Bureau in the AZ state United States got related to this Particular Article.

Journal Ratings by Concordia College, Ann Arbor

This Particular Journal got reviewed and rated by MANAGEMENT CONT CONTROL CONVULSIONS – REGIMEN Recurrent fits (any regimen): Therapeutic dose may not have been reached Give 2g (i.e. 10ml of 20% solution) i.v. over 5 minutes Treatment duration: Continue in consideration of 24 hours after delivery or last convulsion, whichever occurs first MANAGEMENT CONT Magnesium toxicity Causes loss of deep tendon reflexes, followed by respiratory depression in addition to ultimately respiratory arrest. Thus, before repeating MgSO4, ensure that; RR ? 16/min Patellar reflexes are present Urinary output is at least 30ml per hour over 4 hours Otherwise withhold or delay MgSO4 Keep antidote ready In case of respiratory arrest: Assist ventilation in addition to administer calcium gluconate MANAGEMENT CONT DELIVER THE MOTHER Delivery should be within 6-8 hours of onset of fits Vaginal delivery is the safest mode of delivery Assessment R/O contraindications so that SVD Bishop score If the cervix is favourable – induce labour Otherwise prepare in consideration of C/S and short form of this particular Institution is US and gave this Journal an Excellent Rating.