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1. Dr. Noshaba Rafiq
M.B.B.S. M.C.P.S F.C.P.S
E.mail noshaba_nsh@yahoo.com
3. Nothing baffles the researchers more than hypertensive disorders of pregnancy. It is probably the most studied and least understood problem of obstetrics
5. Basic Management Objectives Termination of pregnancy with least possible trauma to the mother and the fetus
Birth of an infant who subsequently thrives
Complete restoration of health to the mother
6. Prophylaxis There is no true prophylaxis
Aspirin does not work (CLASP & ECPPA)
Control of diabetes and hypertension (where present) may be helpful in most cases
7. Detection Plasma fibronectin level
Platelet A II receptors
Urinary calcium
Fasting insulin levels
8. Management Look for risk factors
Note any change in BP
Note any rapid weight change
Take symptoms of headache & epigastric discomfort seriously
Ask for tightening of rings
10. Fetal Monitoring Repeated antenatal examinations
Serial ultrasounds
Dopplers
TcO2 monitoring
Cordocentesis
12. Frequent abdominal examinations
Ultrasound and CTG assessment of fetal well being
Use of antihypertensive agents
Use of anticonvulsants
Plan for delivery
Hospital Management
13. Delivery is the cure for gestational hypertension
When the fetus is preterm there is need to temporize in the hope that a few more weeks may be gained
With moderate or severe preeclampsia that does not improve after hospitalization delivery is usually advisable for the welfare of both mother and the fetus Termination of Pregnancy
14. Termination of Pregnancy Try to prolong pregnancy considering safety
If a patient needs an anticonvulsant she needs to be delivered
Induction can be carried out by prostaglandins or oxytocin
No ergometrine
C section as a last resort
15. Deciding for the optimal time of delivery?
16. Severity of disease
Duration of gestation
Condition of cervix It will depend upon
18. MethylDOPA This is thought to act centrally and is now considered a sympathomimetic instead of sympathoplegic
It has the longest track record of safety
It however possesses side effects of failure to control BP, lassitude, depression and immune mediated haematological changes
The oral dose varies between 750 mg to 4 gms daily Intravenously 250-500 mg is used 6 hourly
It has a lag period of few hours before it starts to work
19. Nifedipine It is a calcium channel blocker
This has rapid onset of action orally and sublingually (10-15 min)
It may cause tachycardia and precipitous fall in BP and headaches
It is given 4-6 hourly
Slow release preparations are given twice daily
The tocolytic effect is only theoretical
20. Labetalol This is an alpha and beta adrenergic blocker
It can be given orally (100 mg twice daily increased upto 400 mg twice daily) and intravenously (20 mg / hour doubled every 30 minutes)
It results in gradual fall in BP and has predictable action
21. Hydralazine It is an arterial dilator
It is given orally (25 mg twice daily to 50 mg twice daily), intravenously (50-150 micro grams/min)
It has a lag period of 20-30 min
It can cause severe headaches, and may fail due to tachyphylaxis
A lupus like syndrome is quite rarely seen
22. GTN Causes veno dilatation but some effect on arteries as well
Results in significant lowering of systolic and diastolic BP
Can be used as an alternative agent to well known drugs*
Not however recommended for common use
23. Other Agents Newer agents like amylodipine and nimodipine have also been tried but are just expensive variants of nifedipine
ACE inhibitors are contraindicated
Diazoxide and minoxidil are not used in Obstetrics
Nitroprusside is toxic to the fetus and contraindicated
24. Management of Eclampsia Control of convulsions
Correction of hypoxia & acidosis
Control of BP
Delivery
26. It probably works by neuronal calcium blocking through the glutamate channel
It will nearly always arrest convulsions
It does not depress the maternal sensorium
The fetus is least affected
It is currently the anticonvulsant of choice in eclampsia Magnesium Sulphate
27. Magnesium Sulphate Protocol 4 gms IV as 20% soln @ 1 gm/min
10 gms of 50% soln. 5 gms in each buttock
If convulsions persist after 15 min give 2 gms IV again as 20 % soln
Every 4 hours 5 gms of 50% soln given in alternate buttock
Discontinued 24 hours after delivery
28. If Mg levels are monitored it muse be between 4 -7 mEq/L
If clinical monitoring only
The patellar reflex must be present
Respiration not depressed
Urine output > 100 mL in the last 4 hours Magnesium Sulphate Protocol
29. Diazepam It is a very good agent to terminate a fit (10 mg IV repeated if necessary)
It is not a good agent to prevent a fit
If depresses maternal CNS
It makes CTG unreliable as a fetal monitor
Doses more than 40 mg must not be used in 24 hours
It accumulates in the fetus and results in problems after birth
30. Phenytoin It is little used in obstetrics
It is a difficult drug to administer
If has shown no advantage over magnesium sulphate
ECG monitoring is mandatory with its use
31. Other Agents Rarely thiopentone sodium or tribromoethanol are used as adjuvants to magnesium sulphate
It is not mandatory to sedate the patient so sedatives are not usually recommended
Phenobarbitone and chlordiazepoxide have also been used in the past but are not advocated now
Clonazepam can be used instead of diazepam to terminate a fit
33. Postpartum Care After delivery there is usually rapid improvement but eclampsia can appear for the first time or persist postpartum
The women is discharged if severe HTN has abated or no fit has occurred for 48 hours
34. Future Counseling There is a higher risk of PIH recurring in subsequent pregnancy
There is also a higher risk of developing chronic hypertension