This document discusses the management of antihypertensive medications during pregnancy. It begins with an introduction to hypertensive disorders in pregnancy, which affect up to 10% of pregnancies and can cause serious maternal and fetal complications if not properly managed. The document then covers prevention, obstetric management including hospitalization indications, and recommendations for antihypertensive drug treatment. First-line options for mild to moderate chronic or gestational hypertension include methyldopa and labetalol, though treatment may not improve outcomes and could potentially harm the fetus. ACE inhibitors are contraindicated in all trimesters due to significant risk of fetal anomalies. The document concludes with a summary of guidelines regarding treatment thresholds, targets, and drug
childhood hypertension is unique presentation by Dr. Hemraj Soni,
very compressive, complied,upgraded, presentation......will definative helpfull for paediatrician n resident doctor............
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
11. Prevention -1-
Diatery Manipulation
• Low-salt diet
• Calcium supplement
• Fish oil supplement
→ Not effective
Cardiovascular drug
• Diuretics
• Antihypertensive drug
→ Not effective
12. Prevention -2-
Low dose aspirin or LMWH with low dose aspirin
Selective supression of throboxane synthesis by the plt
& sparing endothelial prostacyclin production
Not effective in preventing preeclampsia
But advise women at high risk of preeclampsia to
take 75mg of aspirin daily from 12wks until the birth
– High Risk; HTN during a previous pregnancy, Chronic renal dz,
Autoimmune dz such SLE or antiphospholipid SD, , Chronic HTN,
Type 1 or type 2 DM heart (2011)
Antioxidants : Vit C & E supplementation
Significant reduction in preeclampsia (Poston, 2006, Villar, 2007)
13. Management
Goals
• Minimize maternal end-organ damage
• Prevent seizure
• Terminaton of pregnancy with the least possible
trauma to the mother & fetus
Steps of management
• Evaluation of HTN
• Admission vs OPD f/u
• No medication or medication
1. Antihypertensive therapy
2. Anticonvulsant therapy; MgSO4
14. Management
Hospitalization
• Women with new onset BP ≥ 140/90
• Worsening BP
• Development of proteinuria in addition to existing BP
Depends on:
• Severity of HTN in pregnancy
• Duration of gestation
• Condition of the cervix
15. Management
Check up
• Serial U/S for fetal growth. BPP, NST 34wk
• Follow up every 2 wks till 30, then weekly
• Warn the mother about symptoms of superimposed PET
• Investigations ; Renal function test, uric a , calcium ,LFT,
• 24hrs urine for Cr clearance & protein, CBC, U/A, ECG.GTT
• Not allowed to continue past 40wks → consider induction
• Regular diet no salt restriction
• Indication of induction
• For superimposed PET,IUGR, fetal distress, worsening renal
function
16. Management
Indications of Termination of Pregnancy
• Term pregnancy with mild or severe PET
• Severe PET regardless of the gestational age
• Warning signs
headache , visual disturbance, epigastric pain, oliguria
• Eclampsia
Pt must be stabilized & delivered immediately
• Preterm with mild PET
Assess fetal wellbeing by NST, BPP, Doppler
17. Drug Treatment During Pregnancy
• Continuation of prepregnancy antihypertensive Tx
when women become pregnant is debated
Beneficial to mother in the long term, but
theoretically can decrease uteroplacental perfution
• IUGR; from drug or effect from worsening of HTN ?
• Mild to moderate HTN Tx (?)
Antihypertensive Drugs -1-
18. Blood Pressure Classification; JNC-7 Compared with NHBPEP
JNC-7 Blood Pressure Classification
(Nonpregnant), mmHg
NHBPEP Blood Pressure
Classification(Pregnant), mmHg
Normal: SBP≤120, DBP≤80
PreHTN: SBP 120-139 or DBP 80-89
Stage 1 HTN: SBP 140-159 or DBP 90-99
Stage 2 HTN: SBP 160-179 or DBP 100-110
Stage 3 NTN: SBP 180-209 or DBP 110-119
Normal/acceptable in pregnancy:
SBP≤140 and DBP≤90
Mild HTN: SBP 140-150 or DBP 90-109
Severe HTN: SBP≥ 160 or DBP≥110
JNC-7: Ther Seventh Report of the Joint National committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure.
NHBPEP: National High Blood Pressure Education Program Working Group Report on
High Blood Pressure in Pregnancy
Am J Obstet Gynecol. 2000
Antihypertensive Drugs -2-
Grade of HTN BP levels EITHER
systolic OR
diastolic (mmHg)
Treat Levels after Tx
Mild Diastolic: 90-99
Systolic: 140-149
No Not applicable
Moderate Diastolic: 100-109
Systolic: 150-159
Yes <150 systolic
< 100 diastolic
Severe HTN Diastolic: ≥ 110
Systolic: ≥ 160
Yes <150 systolic
< 100 diastolic
19. • Randomized trials of antihypertensive drug therapy in
Pregnancies Complicated by Mild Chronic Hypertension
PIH
Antihypertensive Drugs -3-
20. • Randomized trials of antihypertensive drug therapy in
Pregnancies Complicated by Mild Chronic Hypertension
PIH
Antihypertensive Drugs -4-
21. Mild to moderate chronic or gestational HTN
• Less likely to produce end-organ-disorders
• So, Treatment neither improve neonatal outcomes nor
prevent superimposed preeclampsia
• A Cochrane review of 46 trials
• 4282 patients with modest BP increases
• Showed no benefits of Tx in terms of stillbirth, PTL, or SGA
• Excessive BP lowering in such patients
-> May even prove detrimental to fetal growth via placental
hypoperfusion
Von Dadelszen P, et al. J Obstet Gynaecol Can 2002;24:941–5.
Antihypertensive Drugs -5-
23. Antihypertensive Drugs -6-
• Therapy Recommendation
– By the Working Group on High BP in Pregnancy(2000)
– Indication for empirical therapy
• BP ≥ Systolic 150~160mmHg &/or
≥ Diastolic 100~110mmHg
by NHBPEP & ACOG guidelines 2012
• With target-organ damage
(Left ventricular hypertrophy or renal insufficiency)
Treatment Goal; DBP =90~100mmHg(Grade D)
24. Antihypertensive Drugs -7-
• Severe or Chronic PTN in pregnancy
• Used to control BP until the Pt delivers or in preterm
for 48 hrs to allow time for glucocorticoid
administration for fetal lung maturity then delivery
• Drugs
• Adrenergic-Blocking Agents
• Diuretics
• Vasodilators
• CCB(Calcium channel blockers)
• ACE inhibitors -CIx
25. Antihypertensive Drugs -8-
Drug/Class Doses/
half life
Adverse Events in pregnancy Eviden
ce
Comments
Methyldopa
(FDA-B, L2)
; Adrenergic
Blocking agents,
centrally
500mg~3g
In 2 divided
Peripheral edema, anxiety,
night mares, drowsiness, dry
mouth, hypotension, maternal
hepatitis, but no major fetal
adverse events
Large Large post
marketing
evidence on
safety
1st choice drug in
preg by Cardio
Labetalol
(FDA-C, L2)
; α,B-blocker
200~1,200
mg/d in 2-3
divided
Persistent fetal bradycardia,
hypotension, neonatal
hypoglycemia
Large 1st recom. By
ACOG 2012
Nifedipine
(FDA-C, L2)
; CCB
30mg~120
mg /d of a
slow-
release prep.
Hypotension & inhibition of
particularly if used in
combination with
magnesium sulfate
Small Immediate
release
nifedipine not
recommend
Hydralazine
(FDA C, L2);
Vasodilator
50~300mg/
d in 2~4
divided
Potential ass. With
Hypospadia, neonatal
thrombocytopenia and lupus
Mode
rate
Especially
peripartum IV
26. Antihypertensive Drugs -9-
Drug/Class Doses/
half life
Adverse Events in
pregnancy
Evidence Comments
Atenolol
(FDA-C, L2)
;pure b-
blocker
Depends on
specific
agent
May decrease uteroplacental
blood flow, IUGR when
started 1,2nd trimester,
preterm birth, bradycardia
neonatal hypoglycemia,
Hydrochloro-
thiazide
(FDA- C, L2)
; Diuretics
12.5~25mg/
d
No fetal anomaly, electrolyte
abnormalities, neonatal
hypoglycemia, volume
depletion
Large Not 1st line Tx
during preg,
esp after
20wks
ACE inhibitor
(FDA C/D in
2nd & 3rd ∆,
L2)
Contraindic
ated in
pregnancy
Oligohydramnios, IUGR,
Fetal renal failure, Heart
anomalies, Polydactyly,
Hypospadias, SA, limb,
pulmonary hypoplasia,
craniofacial anomaly
Large
27. Antihypertensive Drugs -10-
ACEI(Angiotnesin-Converting Enzyme Inhibitors)
or angiotnesin receptor blockers ; Captopril, Lisinopril
• Contraindicated during all trimesters of pregnancy
Magee LA, et al. BJOG. 2007;114(6):770. e13–20.
ACOG. Obstet Gynecol 2001;98(1):177–85.
• Complication
• Severely underdeveloped calvarial bone, renal agenesis
Pulmonary hypoplasia, IUGR, fetal death, neonatal renal
failure, oilgohydramnios, anuria & neonatal death,
multiple cardiovascular malformations
Others to avoid during pregnancy –FDA D category
– Losartan, Valsartan, Aliskiren(direct renin inhibitor)
28. Antihypertensive Drugs -11-
Summary of Antihypertensive Therapy Selection
• No evidence of major adverse fetal or maternal events.
• Methyldopa
• 1st Choice of Tx by NHBPEP working group
• No fetal anomaly in the first trimester
• Vascular stiffness improved Khalil & colleagues (2009)
• Labetalol
• May ass with fetal growth restriction
• No advantages over Methyldopa Sibai & colleagues (1990)
• Nifedipine
• Experiences and newer safety concerns are not sufficient to
permit recommendations
29. Antihypertensive Drugs -12-
Drugs for urgent control of severe acute HTN in pregnancy
Drug(FDA risk) Dosage Maternal adverse effects
Hydralazine (C) 5mg IV or IM, then 5-10mg
every 20-40min; or
constant infusion of 0.5-
10mg/hr
Long experience of safety &
efficacy . Risk of delayed
maternal hypotension, fetal
bradycardia
Labetalol (C) 20mg IV, then 20-80mg
every 5-15min, up to a
mazimum of 300mg; or
constant infusion of 1-2mg
/min
Probably less risk of tachycardia
& arrhythmia than with other
vasodilators; increasingly
perferred as 1st-line agents
Nifedipine (C) 10-30mg PO, repeat in
45min if needed
Possible interference with labor
Diazoxide (C) 30-50mg IV every 5-15 min Use is waning; may arrest labor;
cause hyperglycemia
30. Fluid Therapy
Hyperosmotic agents not recommended because
Intravascular influx of fluid
Subsequent escape of fluid to vital organs
Pulmonary edema & cerebral edema
LR 60-120 ml/hr Excessive fluid administration
Pulmonary edema & cerebral edema
31. Postpartum Considerations
• Similar with severe chronic HTN & severe preeclampsia-
eclampsia
• Development of cerebral or pulmonary edema,
heart failure, renal dysfunction or cerebral hemorrhage
– Especially high within the 1st 48hrs after delivery
Cunningham, 2005
– Following delivery, as maternal pph resistance ↑,
left ventricular workload ↑
–> further aggrevated by appreciable amounts of
interstitial fluid that are mobilized for extcretion as
endothelial damage is repair
So Promptly HTN control with diuretic therapy
for resolving pulmonary edema
32. Prognosis
Maternal death; rare
– Due to cerebral Hg, aspiration pneumonia, hypoxic
encephalopathy, thromboembolism, hepatic rupture,
renal failure, ansthesia
Recurrence
– Gestational HTN in a future pregnancy; 13~ 53%
– Pre-eclampsia in a future preg; 16%
– Severe preeclampsia, HELLP syndrome or eclampsia
or birth before 34wks -> Preeclampsia in a future; 25%
– Birth before 28wks -> 55% heart, 2011
33. Summary
Level A
– ACE inhibitors & angiotensin receptor blockers
; Contraindicated in all trimesters of pregnancy
Level B
• Woman with severe HTN
-> require antihypertensive medication for acute ↑BP
• Methyldopa & Labetalol ; a good option for 1st line tx of chronic HTN
in pregnancy -> Based on the overall low rate of adverse effects &
good efficacy
• Atenolol ; not currently recommended d/t IUGR
• Thiazide used in women before pregnancy
• No need to be discontinued during pregnancy. ACOG,2012
34. Reference
1. Clinical Obstetrics and Gynecology
vol 48(2) June 2005, pp441~459
2. NICE Guidelines on hypertension in Pregnancy
SpR Training Day,21/01/2011
3. District I ACOG Medical Student Education Module 2011
– Pregnancy induced hypertension
4. Hypertension in Pregnancy.
Amanda R. Vest, et al. Calrdiol Clin 30 (2012 407~423)
5. Chronic Hypertension in Pregnancy
Practice bulletin, Vol 119, No 2, part 1, Feb 2012. ACOG