Dr. Gitanjali presented a case of a 36-year-old primigravida woman at 38 weeks and 2 days of pregnancy who presented with raised blood pressure of 200/150 mmHg. She was diagnosed with chronic hypertension, superimposed preeclampsia, anemia, fetal growth restriction, and hypothyroidism. Despite treatment with antihypertensive medications, her blood pressure remained elevated. She underwent an emergency cesarean section under spinal anesthesia and delivered a baby. Her case highlights the importance of monitoring and managing the multiple complications that can arise in hypertensive disorders of pregnancy.
This document provides guidelines for the use of anti-D immunoglobulin (anti-D Ig) for Rhesus D prophylaxis. It discusses the history and pathogenesis of Rh isoimmunization, appropriate dosing and administration of anti-D Ig, sensitizing events requiring prophylaxis, and the implementation of routine antenatal anti-D prophylaxis programs. The guidelines aim to prevent RhD alloimmunization in RhD-negative women by outlining evidence-based best practices for anti-D Ig administration.
Preterm labor is the labor that starts before the 37th completed week. In this presentation, we will discover causes, pathogenesis, diagnosis, clinical features, and management principles for preterm labor along with the most recent evidence.
ESHRE Guideline on Recurrent Pregnancy Loss (RPL)Sujoy Dasgupta
Dr Sujoy Dasgupta invited to deliver a lecture on "RPL- ESHRE Guideline" in the Annual Conference of RCOG (Royal College of Obstetricians and Gynaecologists) IRC (International Representative Committee) India East held on 20-21 May, 2023
MANAGEMENT OF VAULT PROLAPSE BY DR SHASHWAT JANIDR SHASHWAT JANI
This document discusses the management of vault prolapse, which is the descent of the vaginal cuff after a hysterectomy. It defines vault prolapse and lists risk factors. Conservative management includes pessaries but surgery is often needed. Surgical options include vaginal approaches like sacrospinous ligament fixation or abdominal approaches like sacral colpopexy. The document compares techniques and factors to consider in surgical planning like prolapse severity and patient factors. Prevention techniques like culdoplasty at time of hysterectomy are also discussed.
POST DATED PREGNANCY AND INTRA-UTERINE FETAL DEATH, IUFD, Mob: 7289915430, w...Pradeep Garg
This document discusses post-dated pregnancy and intra-uterine fetal death (IUFD). It defines IUFD as the death of a fetus in the uterus and lists various potential causes including pregnancy complications, fetal issues, and idiopathic causes. The document outlines methods for diagnosing IUFD such as symptoms, signs, investigations including ultrasound and biophysical profile, and management approaches including expectant management, induction of labor, and fetal surveillance. It also discusses post-dated pregnancy risks and recommendations for induction of labor at or beyond 41 weeks gestation.
The document discusses preterm labour and provides information on its definition, incidence, neonatal outcomes, aetiology, risk factors, and management approaches. It defines preterm labour as deliveries occurring between 24 and 36 weeks of gestation. It notes the condition is a leading cause of newborn deaths worldwide and can cause neurological impairments and disabilities in surviving infants. The document outlines various risk factors and approaches to managing asymptomatic high-risk women, including screening, prevention methods, and lifestyle modifications. It also discusses evaluating and treating symptomatic women, including assessing maternal and fetal status, administering corticosteroids and tocolytics, providing antibiotics if indicated, and considering emergency cerclage or in utero transfer.
The document discusses intrauterine fetal demise (IUFD), defined as the death of a fetus weighing over 500g or over 24 weeks gestation before the onset of labor. It notes that the cause is unknown in 25-60% of cases. Identifiable causes include maternal conditions like diabetes or hypertension, fetal conditions like birth defects or infections, and placental conditions like abruption or insufficiency. Evaluation of an IUFD involves examining the mother's medical history and current pregnancy, evaluating the stillborn infant, investigating the placenta, and certain laboratory tests. Management depends on factors like gestation, number of fetuses, and the parents' wishes regarding expectant or active management such as labor induction. Complications can
This document provides guidelines for the use of anti-D immunoglobulin (anti-D Ig) for Rhesus D prophylaxis. It discusses the history and pathogenesis of Rh isoimmunization, appropriate dosing and administration of anti-D Ig, sensitizing events requiring prophylaxis, and the implementation of routine antenatal anti-D prophylaxis programs. The guidelines aim to prevent RhD alloimmunization in RhD-negative women by outlining evidence-based best practices for anti-D Ig administration.
Preterm labor is the labor that starts before the 37th completed week. In this presentation, we will discover causes, pathogenesis, diagnosis, clinical features, and management principles for preterm labor along with the most recent evidence.
ESHRE Guideline on Recurrent Pregnancy Loss (RPL)Sujoy Dasgupta
Dr Sujoy Dasgupta invited to deliver a lecture on "RPL- ESHRE Guideline" in the Annual Conference of RCOG (Royal College of Obstetricians and Gynaecologists) IRC (International Representative Committee) India East held on 20-21 May, 2023
MANAGEMENT OF VAULT PROLAPSE BY DR SHASHWAT JANIDR SHASHWAT JANI
This document discusses the management of vault prolapse, which is the descent of the vaginal cuff after a hysterectomy. It defines vault prolapse and lists risk factors. Conservative management includes pessaries but surgery is often needed. Surgical options include vaginal approaches like sacrospinous ligament fixation or abdominal approaches like sacral colpopexy. The document compares techniques and factors to consider in surgical planning like prolapse severity and patient factors. Prevention techniques like culdoplasty at time of hysterectomy are also discussed.
POST DATED PREGNANCY AND INTRA-UTERINE FETAL DEATH, IUFD, Mob: 7289915430, w...Pradeep Garg
This document discusses post-dated pregnancy and intra-uterine fetal death (IUFD). It defines IUFD as the death of a fetus in the uterus and lists various potential causes including pregnancy complications, fetal issues, and idiopathic causes. The document outlines methods for diagnosing IUFD such as symptoms, signs, investigations including ultrasound and biophysical profile, and management approaches including expectant management, induction of labor, and fetal surveillance. It also discusses post-dated pregnancy risks and recommendations for induction of labor at or beyond 41 weeks gestation.
The document discusses preterm labour and provides information on its definition, incidence, neonatal outcomes, aetiology, risk factors, and management approaches. It defines preterm labour as deliveries occurring between 24 and 36 weeks of gestation. It notes the condition is a leading cause of newborn deaths worldwide and can cause neurological impairments and disabilities in surviving infants. The document outlines various risk factors and approaches to managing asymptomatic high-risk women, including screening, prevention methods, and lifestyle modifications. It also discusses evaluating and treating symptomatic women, including assessing maternal and fetal status, administering corticosteroids and tocolytics, providing antibiotics if indicated, and considering emergency cerclage or in utero transfer.
The document discusses intrauterine fetal demise (IUFD), defined as the death of a fetus weighing over 500g or over 24 weeks gestation before the onset of labor. It notes that the cause is unknown in 25-60% of cases. Identifiable causes include maternal conditions like diabetes or hypertension, fetal conditions like birth defects or infections, and placental conditions like abruption or insufficiency. Evaluation of an IUFD involves examining the mother's medical history and current pregnancy, evaluating the stillborn infant, investigating the placenta, and certain laboratory tests. Management depends on factors like gestation, number of fetuses, and the parents' wishes regarding expectant or active management such as labor induction. Complications can
This presentation describes in detail about managing Rh negative pregnancy- to identify and manage Rh non-isommunized and Rh isoimmunized pregnancies, with recent advances
This document discusses fertility and pregnancy outcomes in kidney transplant recipients. It notes that fertility usually returns within months of transplantation as endocrine function improves. Successful pregnancies are possible if pre-pregnancy renal function is stable, with live birth rates around 73.5% and risks of preeclampsia and preterm delivery elevated compared to the general population. Immunosuppressant use requires careful management due to risks of rejection and fetal exposure. Pregnancy is considered low risk if renal function is optimal and dosing is stable for over 12 months after transplantation.
PUBERTY MENORRHAGIA & BLEEDING DISORDERS Made Easy Dr Sharda Jain Lifecare Centre
This document discusses evaluation and treatment of puberty menorrhagia and bleeding disorders. It begins with classifications of abnormal uterine bleeding and an overview of common causes of puberty menorrhagia such as dysfunctional uterine bleeding and bleeding disorders. Evaluation involves a detailed history, physical exam, ultrasound, and lab tests to rule out other causes before screening for bleeding disorders. Common bleeding disorders seen in puberty menorrhagia are von Willebrand disease, platelet function defects, and coagulation factor deficiencies. Treatment depends on the underlying cause but may include combined oral contraceptives, antifibrinolytic agents, plasma concentrates, and managing anemia.
THROMBOPROPHYLAXIS DURING PREGNANCY, LABOUR AND AFTER DELIVERYAboubakr Elnashar
The document provides guidelines for assessing risk of venous thromboembolism (VTE) in pregnancy and recommending thromboprophylaxis. It states that all women should be assessed for VTE risk factors in early pregnancy and if risk factors develop. It recommends screening women with a previous VTE for inherited thrombophilia. Women with a previous VTE or additional risk factors may qualify for low molecular weight heparin prophylaxis during pregnancy and for 6 weeks postpartum depending on their specific risks.
Cervical insufficiency, also known as cervical incompetence, is a condition where the cervix is unable to retain a pregnancy at term due to a functional or structural defect. It is characterized by painless dilatation of the cervix resulting in premature rupture of membranes and delivery, usually occurring in the second or third trimester. Cervical cerclage procedures aim to surgically suture the cervix closed to prevent premature opening. There are several techniques for cervical cerclage placement depending on the location and indication, including McDonald, Shirodkar, emergency/rescue cerclages, and pessary or balloon alternatives. Cerclage procedures can be done through the vagina or abdomen depending
This document discusses ovarian hyperstimulation syndrome (OHSS). It begins with background information on OHSS, noting that it is an exaggerated response to ovulation therapy typically associated with gonadotropin stimulation. It then covers the epidemiology, pathophysiology, risk factors, clinical presentation and classification, prognosis, and prevention of OHSS. The pathophysiology involves an increase in vascular permeability leading to a fluid shift. Risk factors include high ovarian response, high estradiol levels, and pregnancy. Prevention strategies aim to individualize stimulation protocols based on risk factors to minimize ovarian response.
The document discusses various uterus sparing techniques for prolapse surgery in young women who desire to preserve fertility and menstrual function. It describes Shirodkar's sling operation, which has been shown to have high rates of normal vaginal delivery and low recurrence rates of prolapse. Laparoscopic sacrohysteropexy is indicated for young women with prolapse as it has better efficacy than vaginal sacrospinous fixation and results in fewer mesh complications compared to sacral colpopexy with hysterectomy. While sacral colpopexy has high success rates, it also carries risks of serious mesh-related complications requiring reoperation years later.
Progesterone plays an important role in pregnancy. While progesterone supplementation may reduce miscarriage rates in women with threatened miscarriage or recurrent miscarriage, evidence is still preliminary. The PROMISE trial found no significant difference in live birth rates between progesterone and placebo in women with unexplained recurrent miscarriage. Guidelines provide consensus recommendations but state evidence is still limited. Progesterone appears safe with no significant adverse maternal or fetal effects reported. Further research is still needed to define optimal formulations, doses and durations of progesterone supplementation.
Postpartum Haemorrhage : Case Illustrationlimgengyan
A 35-year-old woman experienced postpartum hemorrhage (PPH) after delivering a 3.9kg baby at a private facility. Despite treatments including ergometrine injections and oxytocin infusion, her uterus remained atonic and she experienced massive bleeding. She was transferred to a general hospital in a moribund state and died soon after arrival. A 30-year-old woman at a district hospital also experienced PPH after a vaginal delivery. Despite treatments including ergometrine, oxytocin, and uterine massage, she continued to bleed heavily and became lethargic with low blood pressure. She was transferred to a general hospital where a cervical laceration was suture
Recurrent pregnancy loss (RPL), also referred to as recurrent miscarriage or habitual abortion, is historically defined as 3 consecutive pregnancy losses prior to 20 weeks from the last menstrual period.
This Presentation is made by Dr.Laxmi Shrikhande
Lecture by Dr Sujoy Dasgupta in BOGSCON 2015, the Annual Conference of Bengal Obstetric and Gynaecological Society, held at Hotel Novotel, Kolkata in January, 2015; where he had been invited as FACULTY to deliver his lecture
The document describes the Manchester Repair procedure, which is designed to correct uterine prolapse while preserving the uterus. The key steps are: 1) preliminary dilation and curettage of the uterus, 2) amputation of the cervix, 3) plication of the Mackenrodt's ligaments in front of the cervix, 4) anterior colporrhaphy, and 5) colpoperineorrhaphy. Additional details provided include techniques for covering the amputated cervix with vaginal flaps and suturing the Mackenrodt's ligaments to the cervix to elevate it. Potential complications of the surgery are also outlined.
Bad obstetric history (BOH) refers to previous unfavorable fetal outcomes such as recurrent pregnancy loss, stillbirth, neonatal death, or congenital anomalies. The document defines BOH and provides examples of conditions that can contribute to BOH, such as preeclampsia, gestational diabetes, thyroid disorders, thrombophilia, and other medical complications. It also discusses evaluating and managing patients with a history of BOH to help identify underlying causes and improve future obstetric outcomes.
Cervical cerclage is a surgical procedure where stitches are placed around the cervix to help prevent preterm birth. There are different types of cerclage indicated for various high-risk situations like previous preterm births, cervical insufficiency, or short cervix found on ultrasound. Cerclage can be placed transvaginally or transabdominally depending on the situation. Risks include infection or early rupture of membranes, but cerclage has been shown to delay delivery by 5 weeks on average in rescue situations. The cerclage is usually removed between 36-37 weeks to allow for normal vaginal delivery. Cervical pessaries are a non-surgical alternative that can also help support the
This document discusses hypertension in pregnancy and preeclampsia. It begins by defining hypertension and preeclampsia and discussing their incidence and complications. It then covers prediction and prevention of preeclampsia, including optimal aspirin dosage and timing. The document recommends tight blood pressure control and lists antihypertensive agents. It provides guidance on managing severe hypertension, including intravenous drugs and magnesium sulfate administration. Throughout, it compares guidelines from ISSHP 2018, NICE 2010, and other sources.
This document discusses systemic lupus erythematosus (SLE) during pregnancy. It notes that SLE occurs more frequently in women, especially during childbearing years. Pregnancy can cause flares in 40-60% of cases, most likely immediately postpartum. Good pregnancy outcomes require quiescent SLE for at least 6 months before conception with no active renal involvement or antiphospholipid antibodies. Management involves preconception counseling and multidisciplinary monitoring of disease activity and fetal wellbeing. Corticosteroids are the treatment of choice for flares.
This document discusses management considerations for pregnancies following previous caesarean sections. It finds that pregnancies after a previous classical/hysterotomy scar carry a higher risk of uterine rupture compared to those with a previous lower segment transverse scar. For classical scars, an elective repeat caesarean is recommended at 38 weeks. Those with a previous lower segment scar can attempt a vaginal birth after caesarean (VBAC) if certain criteria are met, like a prior nonrecurring indication and adequate monitoring resources. Strict monitoring during labour is needed for all previous scar pregnancies to detect any signs of scar rupture.
The document provides protocols and guidelines for the Department of Obstetrics including definitions, classifications, investigations, and management guidelines for various obstetric conditions. It covers protocols for pre-eclampsia and eclampsia, liver diseases in pregnancy, deep venous thrombosis in pregnancy, preterm labour, preterm PROM, breech presentation, APH, induction of labour, normal labour and delivery, PPH, umbilical cord prolapse, Rh prophylaxis, and GDM. The department aims to provide high quality, empathetic and research-based care through comprehensive training and by reviewing and creating protocols according to population needs.
Gynae- pre eclampsia gynecology obstetrics final prof mbbs.pptxKevinSojuDaniel
This document defines and discusses pre-eclampsia, including its diagnostic criteria, etiology, clinical presentation, complications, management, and prevention. Pre-eclampsia is a multisystem disorder characterized by new onset hypertension and proteinuria after 20 weeks of gestation. It is caused by endothelial dysfunction and an imbalance of vasoactive factors. Clinical features may include edema, headaches, visual disturbances, and epigastric pain. If left untreated, it can progress to eclampsia or other serious complications for both mother and baby. Management focuses on monitoring, controlling blood pressure, delivering the baby if indicated, and preventing future occurrences.
This presentation describes in detail about managing Rh negative pregnancy- to identify and manage Rh non-isommunized and Rh isoimmunized pregnancies, with recent advances
This document discusses fertility and pregnancy outcomes in kidney transplant recipients. It notes that fertility usually returns within months of transplantation as endocrine function improves. Successful pregnancies are possible if pre-pregnancy renal function is stable, with live birth rates around 73.5% and risks of preeclampsia and preterm delivery elevated compared to the general population. Immunosuppressant use requires careful management due to risks of rejection and fetal exposure. Pregnancy is considered low risk if renal function is optimal and dosing is stable for over 12 months after transplantation.
PUBERTY MENORRHAGIA & BLEEDING DISORDERS Made Easy Dr Sharda Jain Lifecare Centre
This document discusses evaluation and treatment of puberty menorrhagia and bleeding disorders. It begins with classifications of abnormal uterine bleeding and an overview of common causes of puberty menorrhagia such as dysfunctional uterine bleeding and bleeding disorders. Evaluation involves a detailed history, physical exam, ultrasound, and lab tests to rule out other causes before screening for bleeding disorders. Common bleeding disorders seen in puberty menorrhagia are von Willebrand disease, platelet function defects, and coagulation factor deficiencies. Treatment depends on the underlying cause but may include combined oral contraceptives, antifibrinolytic agents, plasma concentrates, and managing anemia.
THROMBOPROPHYLAXIS DURING PREGNANCY, LABOUR AND AFTER DELIVERYAboubakr Elnashar
The document provides guidelines for assessing risk of venous thromboembolism (VTE) in pregnancy and recommending thromboprophylaxis. It states that all women should be assessed for VTE risk factors in early pregnancy and if risk factors develop. It recommends screening women with a previous VTE for inherited thrombophilia. Women with a previous VTE or additional risk factors may qualify for low molecular weight heparin prophylaxis during pregnancy and for 6 weeks postpartum depending on their specific risks.
Cervical insufficiency, also known as cervical incompetence, is a condition where the cervix is unable to retain a pregnancy at term due to a functional or structural defect. It is characterized by painless dilatation of the cervix resulting in premature rupture of membranes and delivery, usually occurring in the second or third trimester. Cervical cerclage procedures aim to surgically suture the cervix closed to prevent premature opening. There are several techniques for cervical cerclage placement depending on the location and indication, including McDonald, Shirodkar, emergency/rescue cerclages, and pessary or balloon alternatives. Cerclage procedures can be done through the vagina or abdomen depending
This document discusses ovarian hyperstimulation syndrome (OHSS). It begins with background information on OHSS, noting that it is an exaggerated response to ovulation therapy typically associated with gonadotropin stimulation. It then covers the epidemiology, pathophysiology, risk factors, clinical presentation and classification, prognosis, and prevention of OHSS. The pathophysiology involves an increase in vascular permeability leading to a fluid shift. Risk factors include high ovarian response, high estradiol levels, and pregnancy. Prevention strategies aim to individualize stimulation protocols based on risk factors to minimize ovarian response.
The document discusses various uterus sparing techniques for prolapse surgery in young women who desire to preserve fertility and menstrual function. It describes Shirodkar's sling operation, which has been shown to have high rates of normal vaginal delivery and low recurrence rates of prolapse. Laparoscopic sacrohysteropexy is indicated for young women with prolapse as it has better efficacy than vaginal sacrospinous fixation and results in fewer mesh complications compared to sacral colpopexy with hysterectomy. While sacral colpopexy has high success rates, it also carries risks of serious mesh-related complications requiring reoperation years later.
Progesterone plays an important role in pregnancy. While progesterone supplementation may reduce miscarriage rates in women with threatened miscarriage or recurrent miscarriage, evidence is still preliminary. The PROMISE trial found no significant difference in live birth rates between progesterone and placebo in women with unexplained recurrent miscarriage. Guidelines provide consensus recommendations but state evidence is still limited. Progesterone appears safe with no significant adverse maternal or fetal effects reported. Further research is still needed to define optimal formulations, doses and durations of progesterone supplementation.
Postpartum Haemorrhage : Case Illustrationlimgengyan
A 35-year-old woman experienced postpartum hemorrhage (PPH) after delivering a 3.9kg baby at a private facility. Despite treatments including ergometrine injections and oxytocin infusion, her uterus remained atonic and she experienced massive bleeding. She was transferred to a general hospital in a moribund state and died soon after arrival. A 30-year-old woman at a district hospital also experienced PPH after a vaginal delivery. Despite treatments including ergometrine, oxytocin, and uterine massage, she continued to bleed heavily and became lethargic with low blood pressure. She was transferred to a general hospital where a cervical laceration was suture
Recurrent pregnancy loss (RPL), also referred to as recurrent miscarriage or habitual abortion, is historically defined as 3 consecutive pregnancy losses prior to 20 weeks from the last menstrual period.
This Presentation is made by Dr.Laxmi Shrikhande
Lecture by Dr Sujoy Dasgupta in BOGSCON 2015, the Annual Conference of Bengal Obstetric and Gynaecological Society, held at Hotel Novotel, Kolkata in January, 2015; where he had been invited as FACULTY to deliver his lecture
The document describes the Manchester Repair procedure, which is designed to correct uterine prolapse while preserving the uterus. The key steps are: 1) preliminary dilation and curettage of the uterus, 2) amputation of the cervix, 3) plication of the Mackenrodt's ligaments in front of the cervix, 4) anterior colporrhaphy, and 5) colpoperineorrhaphy. Additional details provided include techniques for covering the amputated cervix with vaginal flaps and suturing the Mackenrodt's ligaments to the cervix to elevate it. Potential complications of the surgery are also outlined.
Bad obstetric history (BOH) refers to previous unfavorable fetal outcomes such as recurrent pregnancy loss, stillbirth, neonatal death, or congenital anomalies. The document defines BOH and provides examples of conditions that can contribute to BOH, such as preeclampsia, gestational diabetes, thyroid disorders, thrombophilia, and other medical complications. It also discusses evaluating and managing patients with a history of BOH to help identify underlying causes and improve future obstetric outcomes.
Cervical cerclage is a surgical procedure where stitches are placed around the cervix to help prevent preterm birth. There are different types of cerclage indicated for various high-risk situations like previous preterm births, cervical insufficiency, or short cervix found on ultrasound. Cerclage can be placed transvaginally or transabdominally depending on the situation. Risks include infection or early rupture of membranes, but cerclage has been shown to delay delivery by 5 weeks on average in rescue situations. The cerclage is usually removed between 36-37 weeks to allow for normal vaginal delivery. Cervical pessaries are a non-surgical alternative that can also help support the
This document discusses hypertension in pregnancy and preeclampsia. It begins by defining hypertension and preeclampsia and discussing their incidence and complications. It then covers prediction and prevention of preeclampsia, including optimal aspirin dosage and timing. The document recommends tight blood pressure control and lists antihypertensive agents. It provides guidance on managing severe hypertension, including intravenous drugs and magnesium sulfate administration. Throughout, it compares guidelines from ISSHP 2018, NICE 2010, and other sources.
This document discusses systemic lupus erythematosus (SLE) during pregnancy. It notes that SLE occurs more frequently in women, especially during childbearing years. Pregnancy can cause flares in 40-60% of cases, most likely immediately postpartum. Good pregnancy outcomes require quiescent SLE for at least 6 months before conception with no active renal involvement or antiphospholipid antibodies. Management involves preconception counseling and multidisciplinary monitoring of disease activity and fetal wellbeing. Corticosteroids are the treatment of choice for flares.
This document discusses management considerations for pregnancies following previous caesarean sections. It finds that pregnancies after a previous classical/hysterotomy scar carry a higher risk of uterine rupture compared to those with a previous lower segment transverse scar. For classical scars, an elective repeat caesarean is recommended at 38 weeks. Those with a previous lower segment scar can attempt a vaginal birth after caesarean (VBAC) if certain criteria are met, like a prior nonrecurring indication and adequate monitoring resources. Strict monitoring during labour is needed for all previous scar pregnancies to detect any signs of scar rupture.
The document provides protocols and guidelines for the Department of Obstetrics including definitions, classifications, investigations, and management guidelines for various obstetric conditions. It covers protocols for pre-eclampsia and eclampsia, liver diseases in pregnancy, deep venous thrombosis in pregnancy, preterm labour, preterm PROM, breech presentation, APH, induction of labour, normal labour and delivery, PPH, umbilical cord prolapse, Rh prophylaxis, and GDM. The department aims to provide high quality, empathetic and research-based care through comprehensive training and by reviewing and creating protocols according to population needs.
Gynae- pre eclampsia gynecology obstetrics final prof mbbs.pptxKevinSojuDaniel
This document defines and discusses pre-eclampsia, including its diagnostic criteria, etiology, clinical presentation, complications, management, and prevention. Pre-eclampsia is a multisystem disorder characterized by new onset hypertension and proteinuria after 20 weeks of gestation. It is caused by endothelial dysfunction and an imbalance of vasoactive factors. Clinical features may include edema, headaches, visual disturbances, and epigastric pain. If left untreated, it can progress to eclampsia or other serious complications for both mother and baby. Management focuses on monitoring, controlling blood pressure, delivering the baby if indicated, and preventing future occurrences.
Hypertensive Disorders in Pregnancy.pptxHAJARASHAJEEA
This document defines hypertension and preeclampsia in pregnancy. It states that hypertension is defined as blood pressure over 140/90 mmHg on two occasions, while blood pressure over 160/110 mmHg on two occasions within 15 minutes requires immediate treatment. Preeclampsia is hypertension with proteinuria or organ damage after 20 weeks gestation. It can be mild without severe features like headaches or organ damage, or severe with these features. Chronic hypertension is high blood pressure before or early in pregnancy that does not resolve after delivery.
Management of Pre-eclampsiaand eclampsia Case discussionsMouafak Alhadithy
The document discusses the management of pre-eclampsia and eclampsia, defining the conditions and outlining diagnostic criteria and treatment approaches. It provides case studies of patients presenting with hypertension in pregnancy and describes how to evaluate and treat the patients, including through antihypertensive medication, magnesium sulfate administration, and decisions around delivery timing and method. The goal of management is to terminate the pregnancy safely while restoring the health of both the mother and newborn.
This document provides definitions and guidelines for diagnosing and managing preeclampsia and related hypertensive disorders during pregnancy. It discusses:
- Definitions of preeclampsia, severe preeclampsia, gestational hypertension, and chronic hypertension
- Diagnosis criteria for preeclampsia of new hypertension and proteinuria or organ dysfunction after 20 weeks
- Tests to evaluate severity and organ involvement
- General management principles of expectant monitoring or delivery depending on gestational age and severity
- Specific guidelines for magnesium sulfate administration, fetal monitoring, hypertension treatment, and postpartum care
Mrs. N presented with pre-eclampsia at 38 weeks gestation. She had hypertension, headache and was treated with magnesium sulfate and antihypertensive drugs. During labor, she had a seizure and was taken for an emergency C-section. Her blood pressure was monitored closely during admission and treatment. She received standard postpartum care including blood pressure monitoring before being discharged.
The document summarizes the management of hypertensive disorders in pregnancy. It defines hypertension and the different types of hypertensive disorders that can occur during pregnancy including gestational hypertension, preeclampsia, eclampsia, chronic hypertension, and preeclampsia superimposed on chronic hypertension. It discusses the risk factors, pathogenesis, clinical manifestations, diagnostic criteria, and management approaches for non-severe and severe preeclampsia, including antihypertensive treatment and seizure prophylaxis.
Hypertensive disorders in pregnancy (HDP) are a common cause of maternal and infant health problems and death. HDP include gestational hypertension, preeclampsia, and eclampsia. Risk factors include being young, older than 35, having previous HDP, obesity, diabetes, or kidney disease. Symptoms of severe preeclampsia include headaches, vision issues, low platelets, elevated liver enzymes, pain in the upper right abdomen, HELLP syndrome, or high creatinine. All pregnant people should take calcium and those at higher risk may benefit from low-dose aspirin. HDP requires frequent monitoring, control of blood pressure, delivery by 38 weeks for gestational hypertension or earlier for pre
Pregnancy Induced Hypertension - Pre eclampsiaomar143
This document provides information about a 33-year-old pregnant woman admitted to the hospital with mild preeclampsia at 36 weeks of gestation. It includes her medical history, symptoms, physical exam findings, lab results, diagnosis, and notes on preeclampsia and its management. The key details are that she presented with swelling in her lower limbs and a history of amenorrhea for 8 months, and was found to have elevated blood pressure and mild preeclampsia at 36 weeks of pregnancy.
This document discusses hypertension in pregnancy, including classifications of hypertensive disorders, epidemiology and risk factors, predicting and diagnosing preeclampsia, assessing severity, chronic hypertension, gestational hypertension, management of preeclampsia and HELLP syndrome, and preconceptual counseling. It covers diagnostic criteria, monitoring, treatment including antihypertensive therapy and magnesium sulfate, timing of delivery, and postpartum care. Prevention strategies like low-dose aspirin are also reviewed.
Hypertensive disorders during pregnancy pptxShabnam Shaikh
Hypertensive disorders are a major cause of maternal and neonatal morbidity and mortality globally. This document discusses the classification, risk factors, signs and symptoms, diagnosis, and management of hypertensive disorders in pregnancy including gestational hypertension, preeclampsia, chronic hypertension, and eclampsia. It provides guidelines for monitoring, treatment with antihypertensive medications, delivery timing, and postpartum care for women with mild or severe forms of these conditions. The goal of treatment is to prevent maternal complications while allowing for fetal lung maturity as determined by gestational age.
This document summarizes a case of pre-eclampsia seen in the emergency department. A 32-year-old pregnant woman presented with sudden onset of hypogastric pain and elevated blood pressure of 180/140 mmHg. Tests showed signs of pre-eclampsia with severe features including elevated liver enzymes and proteinuria. She was given antihypertensives and magnesium sulfate. Her condition was closely monitored in the emergency room and labor room. She eventually underwent cesarean section under regional anesthesia, delivering a live preterm baby boy. Her postpartum course was unremarkable.
This document defines terms related to hypertension in pregnancy such as gestational hypertension, preeclampsia, and eclampsia. It discusses risk factors and incidence of preeclampsia. It outlines management of preeclampsia including magnesium sulfate administration and antihypertensive treatment. It also covers indications and types of forceps delivery and cesarean section.
Preeclampsia is a pregnancy complication defined by new onset hypertension and proteinuria after 20 weeks of gestation. It occurs in up to 7.5% of pregnancies worldwide and increases risks for both mother and baby. While the exact cause is unknown, it involves abnormalities in placental development. Preeclampsia is diagnosed based on blood pressure and urine protein thresholds. It can range from mild to severe, with severe preeclampsia posing greater health risks. Delivery is usually recommended for management, with timing based on severity and gestational age. Magnesium sulfate is given to prevent seizures. Complications for both mother and baby include death if left untreated.
1) Pregnancy induced hypertension (PIH) refers to gestational hypertension, preeclampsia, and eclampsia that can occur during pregnancy. The document outlines the signs, symptoms, classifications, risk factors, management, and nursing responsibilities for PIH conditions.
2) Preeclampsia is diagnosed in a pregnant woman after 20 weeks gestation with new onset hypertension and proteinuria. Severe preeclampsia requires immediate delivery of the baby and mother.
3) Eclampsia occurs when a woman with preeclampsia experiences seizures in addition to her other symptoms. It is a medical emergency treated with magnesium sulfate and delivery of the baby.
4 High risk preganancy and complications of child birth.pdfmeethsrivastava1
Three high-risk conditions in pregnancy and childbirth are discussed:
1) Gestational diabetes, which requires screening and careful management to prevent complications for both mother and baby.
2) Placental abruption, a serious condition where the placenta separates from the uterus, can cause life-threatening bleeding and often requires emergency delivery.
3) Premature rupture of membranes increases the risks of infection and problems for the baby if labor does not begin on its own in a timely manner.
Pre-Eclampsia and Hypertensive Disease in Pregnancymeducationdotnet
This document discusses pre-eclampsia and hypertensive disease in pregnancy. It begins by outlining normal blood pressure changes during pregnancy and then defines different types of hypertension including chronic hypertension, pregnancy-induced hypertension, and pre-eclampsia. Pre-eclampsia is described as a multi-system disorder specific to pregnancy caused by placental dysfunction. The document details diagnostic criteria, clinical features, complications, investigations, and stepwise management of pre-eclampsia including delivery timing and postpartum care. Management involves treating hypertension, preventing eclampsia with magnesium sulfate if needed, and delivery to cure the condition, balancing risks of preterm birth.
This document defines hypertension in pregnancy as a systolic blood pressure of 140 mmHg or higher or a diastolic blood pressure of 90 mmHg or higher on more than one occasion. Preeclampsia is a multifactorial condition affecting 3% of pregnancies that is characterized by poor placentation leading to endothelial dysfunction and clinical manifestations including hypertension and proteinuria after 20 weeks of gestation. Magnesium sulfate is the drug of choice for preventing seizures in women with moderate to severe preeclampsia, given either as a continuous intravenous infusion or intermittent intramuscular injections to control blood pressure and prevent complications.
The document summarizes information about menopause and the hormonal changes that occur during this transition period. It discusses how menopause is defined and characterized by the depletion of ovarian follicles and reduction in ovarian hormones. It describes the stages of reproductive aging and changes in hormones like FSH, LH, estradiol, and testosterone during the menopausal transition. It also outlines some of the problems that can result from estrogen deficiency after menopause such as hot flashes, mood changes, cognitive issues, and loss of collagen in skin.
This document discusses pre-cancerous lesions of the cervix. It begins by defining premalignant lesions and explaining the multi-step process of carcinogenesis. It then discusses specific pre-cancerous lesions including hyperplasia, metaplasia, dysplasia, and cervical intraepithelial neoplasia (CIN). High-risk HPV infection plays a key role in the development of these lesions. Screening methods like the Pap test and HPV testing can detect pre-cancerous lesions early. Colposcopy is used to examine the cervix in more detail when abnormalities are found. Biopsies of suspicious lesions allow diagnosis and treatment if needed to prevent progression to invasive cancer.
The document discusses menopause and hormone replacement therapy. It defines menopause and describes the hormonal changes that occur during the menopausal transition as ovarian follicles are depleted and estrogen levels decline. This leads to symptoms like hot flashes, mood changes, and effects on the brain, skin and bones. Diagnosis of menopause is confirmed after 12 months of amenorrhea when FSH and estradiol levels indicate ovarian failure. Management of menopausal symptoms includes lifestyle changes, medications like estrogen therapy, and alternative therapies.
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2. Patient Mrs. khan Salamat 36 years old Primigravida with 9 months of amenorrhea came to
Bharati hospital referred from a private practioner in view of raised BP i.e of 200/150mmhg
At presentation she complained of headache and blurring of vision since 1 day
Headache was localized in the occipital region, throbbing type, not relieved on rest
No c/o nausea, vomiting, epigastric pain etc
No c/o pain in abdomen, pv discharge
Fetal movements well appreciated
2
3. Menstrual history->
LMP- not known
PMH- 4-5 days/28-30days/RMF
AGA- 38 weeks 32days (BUSG @ 12 weeks 3 days on 13/7/20)
EDD- 26/1/21
Obstetric history-
Married since 1 year, On consanguineous marriage
G1- present pregnancy, spontaneous conception, Registered at a private practioner.
diagnosed with increased BP at 3rd month of amenorrhoea -> was started on Tab Labetalol 100mg bd
Diagnosed with Hypothyroidism since 3rd month of amenorrhoea->was started on Tab Thyrox 25 mcg
OD
3
4. Antihypertensives were stepped to Tab Nefidepine Retard 20mg Bd together with Tab Labetalol
100mg BD since 1 month
H/o anemia present -> was given 5 injection Iron Sucrose 15 days back
Past history- NAD
Family history- Mother and Father are Hypertensives on treatment
4
5. Patient was seen in EMD
GENERAL PHYSICAL EXAMINATION
Height-154 cm Weight- 80kg BMI-33 kg/m2
Afebrile,
P-84bpm;pallor +, bilateral pedal oedema + , U/a- 4+
DTR- BRISK
BP-200/150mmHg in right brachial artery
INJ labetalol 10mg iv given , INJ MGSO4 4gm iv given Repeat BP 150/100mmhg (in 10 minutes)
RS-airway entry equal on both sides, no basal crepitations,
CVS-S1 S2 normal
5
6. PER ABDOMEN EXAMINATION-
INSPECTION-
Abdomen longitudinally ovoid
Linea nigra,stria gravidarum seen,abdominal wall oedema +
PALPATION-
Uterus- 34 WK period of geststion,Relaxed
6
7. Fundal grip-soft,non ballotable part s/o breech
Lateral grip-Irregular, knob like structure on right side s/o limbs; smooth, curved shaped structure on
left side s/o back
Pawlik grip-hard,globular,ballotable structure s/o head
Pelvic grip-hands converging-head not engaged
AUSCULTATION-
FHS +,regular,148bpm on left spinoumbilical line
Pv-cervix soft, posterior, os closed ,uneffaced
7
8. Diagnosis-Primigravida with 38 weeks 2 days pregnancy with chronic hypertension with
superimposed preeclampsia with anaemia with FGR with hypothyroidism with impending
eclampsia in Hypertensive emergency.
Patient was shifted to LR for further management after starting zuspan regimen
In LR -> Foleys catherization done, Her BP was 220/140mmhg -> INJ Labetalol 20mg iv given-
BP repeated after 15 mins , which was 190/120mmhg IN Labetalol 40 mg given Repeat
BP after 20 min was 190/120mmhg
8
9. Capsule Nifedepin 10 mg given Repeat BP after 20 mins was 220/150mmhg Cap Nifedepine 10mg repeated -
BP was 170/110mmhg after 10 minutes
1 PCV was issued ivo anaemia (HB=8.8 %) and , patient was shifted for Emergency LSCS
On table was 140/90 mmhg -> LScs was done under spinal anaesthesia.
LSCS done uneventfully -> Patient was shifted to Icu for further management.
9
12. Discussion
Hypertensive disorders in pregnancy (HDP) are the spectrum of disorders ranging from already
existing chronic hypertension in the index pregnancy to complex multisystem disorder like
preeclampsia leading to the complications like eclampsia, HELLP syndrome, acute renal failure,
pulmonary edema, stroke and left ventricular failure.
12
13. Classifications-
Gestational hypertension: Blood pressure =/> 140/90 mmHg, detected beyond 20 weeks of
gestation and returns to normal within 42nd postpartum day and is not associated with any other
features of preeclampsia.
Chronic hypertension: Known case of hypertension or a case of hypertension detected before 20
weeks of gestation in absence of neoplastic trophoblastic disease and multiple pregnancies.
Preeclampsia: It is a multisystem inflammatory disorder beyond 20 weeks of pregnancy with
significant proteinuria characterized by de novo onset of hypertension (BP =/>140/90 mmHg).
More recently, atypical variant of preeclampsia is recognized which is accompanied by
neurological, hematological, hepatic, renal manifestations or fetal growth restriction, in absence
of proteinuria
Eclampsia: It is occurrence of seizures in association with preeclampsia. It can also occur as
atypical eclampsia.
Superimposed Preeclampsia: It is the occurrence of preeclampsia in women with chronic
hypertension.
(Blood pressure reading should be reconfirmed after 4-6 hours before classifying a patient in
particular group.)
13
14. Preeclampsia can be further classified as non severe and severe.
It can also be classified as early onset and late onset as below.
Non severe preeclampsia: Blood pressure =/>140/90 mm Hg and <=/ 160/110 mm Hg
No premonitory symptoms and a normal HDP lab parameters
Severe preeclampsia: Blood pressure > 160/110 mm Hg with/without premonitory symptoms with
/ without abnormal HDP laboratory parameters.
Or Blood pressure >/=140/90 mm Hg with premonitory symptoms and /or abnormal HDP
laboratory parameters.
14
15. Premonitory symptoms: Headache, blurring of vision, vomiting, right upper quadrant pain,
sudden excessive weight gain and severe edema.
Abnormal HDP lab: Low platelets, elevated liver enzymes, elevated serum creatinine, and
abnormal coagulation profile.
15
16. Early onset preeclampsia: Onset of proteinuric hypertension is before 34 weeks of pregnancy.
The maternal complications are more severe.
Low birth weight, fetal growth restriction and iatrogenic prematurity are common.
Late onset preeclampsia: Onset of proteinuric hypertension is after 34 weeks of pregnancy.
The maternal complications are less severe. Low birth weight and fetal growth restriction is less
common.
16
17. What is HDP gestosis score
Primary clinical assessment for screening and prediction of preeclampsia can be objectively
performed by ‘easy to use’ HDP-Gestosis score.
Process of risk scoring:
This score involves all the existing and emerging risk factors in the pregnant woman.
Score 1, 2 and 3 is allotted to each clinical risk factor as per its severity in development of
preeclampsia.
With careful history and assessment of woman a total score is obtained time to time.
When total score is =/> 3; pregnant woman should be marked as ‘At risk for Preeclampsia’.
17
19. Prevention of Preeclampsia
All ‘at risk ’women should be started with Aspirin 75-150 mg
Dose-The optimum dose of aspirin is unclear; studies have used 60-75-100-150 mg.
Low-dose aspirin has a good maternal and fetal safety profile.
Aspirin for this indication should be started even earlier than 12 weeks.
Mechanism-> Defective placentation is considered as the causative factor of preeclampsia. Early
aspirin balances the levels of thromboxane A2 and prostacyclin which will maintain adequate
uteroplacental blood flow and improve placentation without increasing the risks of adverse
maternal and perinatal outcomes. Therefore, it appears safe to use low-dose aspirin as a
prophylaxis to prevent preeclampsia throughout pregnancy until 2 days prior to delivery or
cesarean section.
Along with aspirin, calcium 1-1.5 gm10 daily (in low calcium intake group) is to be started.
19
20. Diagnosis
1. Blood pressure measurement is the most important clinical test to diagnostic HDP.
• The position of the pregnant mother especially after 20 weeks of gestation should be either in the
sitting position or left lateral position with the zero level at the level of the heart.
20
21. 2)Proteinuria
• Significant proteinuria is urinary excretion of > 300 mg protein in a 24-hour period.
• Once significant proteinuria is established, further quantification is not required as proteinuria does
not have prognostic value from management point of view.
• However, if proteinuria is absent, pregnant woman with hypertension still requires frequent
monitoring.
The HDP Gestosis scientific group recommends the following methods till further research findings
are out –
o Urinary dipstick method (Visual / by automated device)
o Spot urine protein: creatinine ratio
• Significant proteinuria: can be assessed by urinary dipstick: >/= 2+ Or urinary protein: creatinine
ratio >/= 30 mg/mmol.
• Urinary dipstick method is quick and allows women with negative result to return home quickly. It
also helps quick assessment of severe proteinuria.
• The results of spot protein: creatinine also would be available within 2 - 4 hours.
• The gold standard of assessing proteinuria is 24-hour urine protein assessment.
21
22. Laboratory Investigations -When blood pressure reading of a pregnant woman is =/> 140/90 mmHg
(or known case of chronic hypertension visits first time to the antenatal clinic), following investigations
are advisable to assess severity of the disease.
•Baseline HDP lab
Urine albumin- by dipstick method or urine protein: creatinine ratio ✓ Complete blood count:
Platelet count and anaemia assessment
Liver enzymes- Alanine aminotransferase (ALT), Aspartate transaminase (AST), Lactate
Dehydrogenase (LDH).
Serum bilirubin
Serum creatinine
Serum uric acid
Additional laboratory investigations
Coagulation profile (when platelet count is < 1,00000 /mm3 )
Serum electrolytes (in severe disease),
22
23. Ultrasonography
• Maternal ultrasonography (USG abdomen and pelvis)
Following things are suggested to be assessed in addition to obstetric evaluation:
Liver: sub-capsular hematoma, hepatomegaly.
Kidney: signs of renal causes of hypertension, other changes in renal parenchyma
Ascites and pleural effusion: as other worsening signs of preeclampsia.
Fetal surveillance and placental morphology (Obstetric USG with doppler)
Fetal biometry, amniotic fluid volume (AFI), uterine artery doppler and umbilical artery doppler
should be performed at the first diagnosis of preeclampsia.
In confirmed preeclampsia or in cases of fetal growth restriction, serial evaluation of fetal growth,
AFI, uterine artery umbilical artery doppler is recommended.
More frequent ultrasound measurements and color doppler study are needed if there is a high
resistance or absent or reversed end-diastolic flow in uterine artery with appropriate further
management.
Placental location, morphology and any evidence of placental bed hemorrhage, abnormal
adherence and presence of sinusoids should be documented. 23
24. Fundoscopy
✓ Fundoscopy may be required to differentiate chronic and new onset disease and to diagnose
papilledema/ hemorrhages as these have ominous prognosis.
24
25. Medical management –
World Organization Gestosis recommends that a systolic BP of =/>140 and/or a diastolic BP of
=/>90 mm Hg warrants antihypertensive therapy.
Target range of Blood Pressure to be kept: Systolic < =140
Diastolic <= 90 mmhg
25
26. Labetalol: 200 - 1200 mg / day in 2 divided doses It is accepted as the first line and effective
medication during pregnancy. Preferred medication when baseline pulse is >100/min It is
contraindicated in asthma, CCF, DM and cases of bradycardia.
Nifedipine- 20-120 mg / day of slow releasing preparations in 2-3 divided doses Preferred
medication when baseline pulse is < 100/min .Maternal adverse effects include tachycardia,
palpitations, headaches, and facial flushing.
Methyldopa : 500-2000 mg per day orally in 2-3divided doses. Methyl dopa is the most time
tested and safe anti-hypertensive. Nowadays it is not routinely available. Drug is to be
discontinued in postpartum period to avoid postpartum depression.
Drugs contraindicated in pregnancy: ACE inhibitors, ARBs, ß- blockers and diuretics.
26
28. Delivery decision
Gestational Hypertension: Pregnancy can be continued till the term
Mild Preeclampsia: To be delivered at 37 completed weeks.
Severe Preeclampsia: To be delivered after 34 completed weeks.
Eclampsia: Should be delivered once mother is stabilized after MgSO4.
Labor induction with appropriate method can be carried out safely.
Cesarean section is done for obstetric indications only.
Delivery decision should be carefully decided after assessing maternal and fetal risks.
Corticosteroids
Corticosteroids are recommended in all women delivering before 34 completed weeks and in case of elective
cesarean delivery before 38 completed weeks.
Intramuscular dexamethasone: 6 mg 12 hourly 4 doses or
Intramuscular betamethasone: 12 mg 24 hourly 2 doses can be used for reducing neonatal respiratory
distress.
Even a single dose of steroid at least an hour prior to delivery can reduce the neonatal respiratory distress
syndrome remarkably
28
29. Management of eclampsia -Eclampsia is a situation needs to follow the principles of ABCD of
critical management.
Principles of management of eclampsia “Call for help”
timely additional help is essential for effective management
A: Airway: Lateral decubitus position, mouth gag and neck extension Avoid injury to the mother
B: Breathing: Nasal oxygen and suction Pulse oximeter: oxygen saturation >96%
C: Circulation: IV access for maternal resuscitation Laboratory investigations are sent.
Crystalloids: Ringer Lactate or Normal Saline 80 ml/hr.
Control of convulsions: Magnesium sulphate-Loading and maintenance dose. Catheterization:
Foley’s catheter is inserted.
Control of blood pressure: With anti-hypertensives
Corticosteroids: For gestational age < 34 weeks
D: Delivery: Baby should be delivered once mother is stabilized
29
31. Management after stabilization ->
Deliver the patient after stabilization in the situations like eclampsia, HELLP, severe preeclampsia,
chronic hypertension with superimposed preeclampsia and if gestational age is more than or equal to
34 weeks.
Vaginal delivery may be considered if attainable in reasonable amount of time.
In case of preterm pregnancy, expectant management can be considered with individual assessment
and antenatal steroids and rationale use of antihypertensive medications with close supervision.
Intrapartum management: It is preferable to conduct delivery in a well-equipped birthing centre with
facility of obstetrical expertise and accessible obstetric high dependency and/or critical care units with
blood bank, anesthesiologist, neonatologist and a transfer facility.
Mode of delivery: It depends upon the urgency to deliver, cervical Bishop’s score, gestational age,
severity of FGR and doppler study findings in the umbilical artery
31
32. Induction of labor: Induction of labor should be offered to mothers eligible for vaginal delivery.
Prostaglandins (PGs) (dinoprostone gel, suppositories or tablets) can be used for induction.
Misoprostol may be used in patients remote from term.
Mechanical dilatation of the cervix with Foley’s balloon or vaginal hygroscopic dilators may be
considered.
Augmentation of labor is to be done only with oxytocin
32
33. Caesarean delivery: Severe FGR or REDF in the umbilical artery on color Doppler or any
obstetric contraindication for vaginal delivery or failure of induction may make cesarean delivery
a preferred choice.
Fluid Management: Inappropriate use of fluids can cause pulmonary edema and maternal death.
Intrapartum fetal monitoring: Close monitoring of the fetus with continuous or intermittent Doppler
device or EFM (electronic fetal heart monitoring) is preferred. Laboratory investigations may be
repeated when required.
33
34. Preventing PPH: Active management of third stage of labour and prophylactic administration of
oxytocics in case of cesarean delivery should be followed in all cases.
It is safe to use oxytocin 5 U bolus equally diluted over 2-3 minutes or prostaglandin (PG)
injections.
PG can be used also as misoprostol sublingual, transrectal or transvaginal. Average blood loss
of labour may not be well tolerated by these patients due to hemoconcentration.
Underlying endothelial dysfunction, hypertension and use of magnesium sulphate may make the
mother more susceptible to PPH.
The use of fluids should be judicious. Recommendation is 80 ml/hr or1ml/kg/hr as overinfusion
can cause pulmonary edema in these women.
34
35. Post-delivery management-> It involves close vigilance for eclampsia, PPH, HELLP, pulmonary
edema, cardiovascular, cerebrovascular events and thrombo-embolic complications.
Continued postpartum surveillance has to be the norm to prevent additional morbidity as gestosis
can develop post-delivery.
During the hospital stay, blood pressure should be closely monitored for first 48 hours post
delivery.
Postpartum use of NSAIDs should be avoided.
Antihypertensive therapy is recommended for persistent BP of SBP > 150 and DBP > 100 mm
Hg.
Persistent BP of >= 160 SBP and or DBP of >=110 mm Hg should be treated within one hour and
magnesium sulphate considered for seizure prophylaxis
35
38. Gestational hypertension
Pre eclampsia and eclampsia syndrome .
Chronic hypertension
Pre eclampsia superimposed on chronic hypertension .
Classification of HDP
39. Defined as blood pressure 140mmhg (systolic)and 90 mmhg
(diastolic) without proteinuria on atleast 2 occasions,at least 4
hours apart after 20 th week of gestation in women known to be
normotensivebefore pregnancy .
GESTATIONAL HYPERTENSION
40. CHRONIC HYPERTENSION
Chronic hypertension in pregnancy is defined as
hypertension before pregnancyor before 20 th week of
gestation ,on more than one occasion at least 4-6 hours
apart
Systolic Bp of 140 mmhg or greater ,or diastolic Bpof 90
mmhg or greater or both .
Persistent hypertension for 12 weeks postpartum is also
retrospectively described as chronic hypertension .
41. It is best described as pregnancy specific syndrome that
can affect virtually every organ system .
Defined as Bp ->140/90mmhgtaken 2 ocassion 4-6hours
apart taken in sitting position with proteinuria .
Appearance of proteinuria with hypertension is an
important diagnostic criteria .
visual dipstick test.
Trace- 0.15to0.3g/I
1+= 0.3g/l
2+=1g/l
3+=3g/l
According to new guidelines – Proteinuria is not a specific
marker of pre eclampsia .
PRE-ECLAMPSIA
43. 8) SERUM CREAT
9)THROMBOCYTOPE
NIA (<100,000/UL)
10)SERUM
TRANSAMINASE
ELEVATION
11)FETAL GROWTH
RESTRICTION
12)PULMONARY
EDEMA
13)GESTATIONAL
AGE
Not elevated
absent
minimal
absent
absent
late
elevated
present
marked
present
present
early
44. It is diagnosed when one or more features ofpreclampsia (e.g elevated
liver enzymes ,low platelets , proteinuria ) develop for first time during
pregnancy after 20 weeks in a women with pre existing chronic
hypertension .
PRE-ECLAPSIA SUPERIMPOSED ON
CHRONIC HYPERTENSION
45. Incidence of pre eclampsia in nulliparous ranged from
3 to 10 %.
In multipara ranged from 1.4 to 4 %
Young and nulliparous women are vulnearble to
developing pre eclampsia .
Incidence
46. Couple related risk factor :
Primipaternity.(exposure of chronic villi for the firsttime)
Limited sperm exposure
Pregnancyafter donar insemination ,donar egg , donar
embryo .
Maternal or pregnancy related risk factor :
Extremes of age ( teenage / elderly primigravida )
Smoking
Obesity and insulin resistance/ gestationaldiabetes
Multifetal pregnancies.
Pre eclampsia in previous pregnancy.
RISK FACYTOR FOR PRE ECLAMPSIA
47. Maternal low birth weight .
Family history of pre eclampsia .
Pre existing medical disease :
Pre gestational diabetes ,
Chronic hypertensiveor renal disease .
Maternal immunological disease.
Pre existing thrombophilia , anti phospholipidsantibody
syndrome .
48. Stage1 – abnormal placentation .
(faulty endovascular trophoblastic remodeling ).
Stage 2 – clinical syndrome .
Pre existing maternal condition that are also manifest by
endothelial cell activation or inflammation .
TWO STAGE DISORDER HYPOTHESIS
51. Fibronectin - fibronectin is a high molecular
weight glycoprotein that has important role in all
cellular adhesions and is component of connective
to tissue and basement membranes .increased level
of fibronectin preeceds clinical signs of pre
eclampsia and useful for prediction of disease.
MARKER OF PRE ECLAMPSIA
52. Symptoms
• Headache- mild to severe and intermittent to constant.
Pain may be frontal or occipital , may be pulsatile or dull
Headache may arise from cerebrovascularhyperperfusion .
• Eye symptoms:scotoma ,transientperceptionof brightor black spot –
can lead to diplopia ,blurred vision and in severe cases complete
blindness , visual symptoms can be cause by vasospams and due to
occipital vasogenic oedema .
• Blindnesssecondaryto retinal ischaemia or infarctionis
called purtscherretinopathy.
53. • Epigastric or right upper quadrant pain:frequently
accompanies hepatocellular necrosis, ischemia, and edema that
stretches Glissoncapsule.
Severe form of disease – leads to HELLP SYNDROME.
Marked alteration in AST (aspartateaminotransferase),ALT-
(alanine aminotransferase)and LDH value .
• Diminished urinary output—Urinary output of less than 400 ml
in 24 hours is the alarming symptoms.
• Edema - Swelling of the leg , hands , face , abdomen .
54. Signs
• Abnormal weight gain:
A rapid gain in weight of more than 5 lb a month or more than 1 lb a week in later month
of pregnancyis significant.
• Rise of blood pressure
• Edema
• Proteinuria .
55.
56. LABORATORY FINDINGS
Laboratory changes reflect the effectsof the disease on the renal ,hepatic,
hematological systems.
Hematological abnormalities– Increase in
haemoglobin . Increase in hematocrit level.
Decrease in plasma fibrinogen level (<200 mg/dl) Platelet count – below
100,000/mm3.
Liver function test .
Elevation in serum transaminase is most common . An AST or ALT levels of
about 70 IU/L is seen as significant as a level above 150 iu/l
associatedwith increase morbidity to the mother.
57. Serum bilirubin level – elevated bilirubin level (>1.2g/dl)
Lactate dehydrogenase – markerof hemolysis (increased Ldh >600
u/l).
Altered renal functions :
Serum creatnine (increase upto 1.2 mg /dl )
Increased blood urea nitrogen ( normal value in pregnancy is 15 mg /dl
Increased uric acid ( normal value upto 6 mg /dl)- hyperuricemia associated with renal
dysfunction,glomerular endothelosis and decreased tubular secretion)
58. Opthalmic assessment :Retinal detachment.
Retinal ischaemia /infarction Occipital lobe
vasogenic edema . Retinal arteryocclusion
Ultrasonography :
FTS SCREENING .
Low PAPP-A levels associated with development of pre eclampsia
uterine artery doppler usg is the best available test for early detection of pre eclampsia
of placental origin .
Doppler study at 11-13 weeks demonstrated that impedance to blood
flow is increased in pregnancies which subsequently develop hypertensive disorders-
correlation with BETA-hcg and PAPP-A .
59. At 20 weeks , uterine artery doppler is a part of initial evaluation–
disapperance of diastolic notching .
Umbilical artery doppler provides as assessment of placental-
umbilical circulation .
An abnormally elevated umbilical artery PI with absent diastolic flow and reversed
diastolic flow – worsening indicator of resistance to blood flow in fetal side of of placental
circulation .
MCA ( middle cerebral artery )-brain sparing effect – indicated by low PI (pulsality index)
CP RATIO- cerebroplacental ratio .
Calculated by MCA(S/D RATIO)/UA (S/D RATIO) .
If cp ratio >1 – no brain sparing effect .
If cp ratio<1 - brain sparing effect present
61. REST
In left-lateral position as muchas possible.
It lessen the effectsof vena caval compression.
Increases the renal bloodflow→diuresis
Increases the uterine bloodflow →improvesthe placental perfusion
Reduces the blood pressure.
62. • According toBMI
Should containadequate amount of daily protein (about 100 gm). Total calorie
approximate1600 cal/day.
Usual salt intakeis permitted.
Fluids need not be restricted
63. MANAGEMENT
• CONTROL OVER HYPERTENSION
• PREVENTION OF CONVULSION
• TREATMENT ARELATED TO COMPLICATION
64. Drug MOA route Action Dose on set
of
action
Side effect
Labetel
olo
(1st
line of
manag
ement)
(c)
Alpha 1
and
non
selectiv
e beta1
blocker
Iv/oral Decrea
sing
PVR
with
little or
no
effect
on
cardiac
output
Initial
i/v
dose-
20 mg
,max-
220
mg/hr.
Oral
dose-
100
mg
i/v
route- 5
mins .
Oral
route-
20 mins
Maternal
hypotension .
Bradycardia
Nifidepi
ne
(C)
CCB Oral Decrea
se PVR
10-20
mg
Max-
120
mg
/day
Can be
repeate
d in 30
minutes
Hedache
Palpitation
Flushing
ANTI- HYPERTENSIVE DRUGS
65. drug MOA Route Action Dose Onset
of
action
s/e
Hydralaz
ine
(c)
Arterial
Vasodilat
i/v Rapid
lowering
of blod
pressure
Act
directly
on
arterial
smooth
muscles
.
5-10 mg Can be
repeated
every 20
mins
Duration
1-4 hrs
Maternal
tachycar
dia .
palpitati
on
Methyldo
pa
(B)
Centrally
Acting
sympath
olytic
i/v Smooth
muscle
relaxant
500-750
mg .
Maintain
1-2 gm
4-6 hrs .
Duration
- 12-24
hrs
Drowsin
ess
Headach
e
Lack of
energy
66. Magnesium sulfate is effectiveanti- convulsant and is used as neuro prophylaxis.
During labour and delivery more chances of convulsion to develop ,women with pre
eclampsia and eclampsiausually given mgso4 during labour and for 24 hrs post partum .
It can be given intravenous route and intra muscular route .
Mechanism of action–
1)reduced pre synaptic release of neuro transmitter glutamate . 2)blockade of glutamergic N-
methyl –d-aspartate
(NMDA)receptor.
3)improve calcium buffering by mitochondria 4)blockage of calcium entry via voltage
gated channel.
MGSO4
67. CONTINOUS INTRAVENOUS INFUSION
:(ZUSPAN REGIME)
GIVE 4 TO 6 gm loading dose of magnesium sulfate diluted in 100 ml iv fluid over 15-
20mins.
Begin 2g/hr in 100 ml iv maintenance infusion . Some recommends 1 g/dl .
INTERMITTENT INTRAMUSCULAR INJECTION (PITCHARDS
REGIME)
10 gm of 50% magnesium sulphate , ½ (5g) injected deeply in upper outer quadrant of
each buttock .
If convulsion persist after 15 mins , give up 2 gm more intravenously as a 20 % solution
not to exceed 1 gm /min . If the woman is large , upto 4 g may be
given .
68. Pulse ,BP monitoring 1 hrly.
Respiratory rate
urine output 1 hrly
Deep tendonreflexes
premonitory signs and symptoms.
Monitoring for magnesium toxicity.
Urine output should be at least 30 ml /hr , 400 ml/24 hrs.
Deep tendon reflex should be present .
Respiratory rateshould be >14 breaths /min
Pulse oximetry should be >equal to96%
MONITORING OF ZUSPAN REGIMEN
69. Magnesium toxicity .
Normal serum magnesium level is 4- 7 meq /L .,4.8to8.4 mg
/dl , 2 to 3.5 mmol/l.
Magnesium is cleared totally by renal excretion.serum
creatinine levels must be measured to detect GFR .
Serum magnesium level- at which toxicity.
8-10 meq/l- patellar reflex absent.
>10 meq/l –breathing become weakend.
>12 meq/l – respiratoryarrest /respiratoryparalysis .
70. Antidote of Magnesium toxicity .
1 gm intravenously calcium gluconate or calcium chloride.
Fetal and neonatal effects .
Magnesium sulphate is protective effect against development of cerebral palsy in
very low birth weight newborn
72. Outpatient management – not severe
features (fetal and maternal assessment)
FETALASSESSMENT :
Fetal growth assessment every 3-4weeks AFI assessment
weekly.
Antenatal testing 1-2 times per week.
MATERNAL ASSESSMENT :
Labs weekly .
Atleast 1 visit per week inclinic
Bp and symptoms assessment arerecommended serially
73. Decision regarding management based on gestationalage
and result from following evaluation.
Maternal- bp recording , proteinuria ,premonitory sign and symptoms ,PIH labs
status.
Fetal- EFW/ANTENATAL TESTING(BPP,NST).
CANDIDATE FOR EXPECTANT MANAGEMENT : Pre eclampsia without
severe features <37 weeks . controlled blood pressure.
normal biochemical and pre eclampsia marker.
74. Mode of delivery determined after considering presentation of fetus ,fetal condition ,
maternal condition
, gestational age, laboratory markers .
Vaginal delivery is generally preferred.
75. WEEKS OF PREGNANCY TIMING OF BIRTH
BEFORE 34 WEEKS continuous survillance unless
there are indication for
blanned birth .off intravenous
mgso4 and a course of
antenatal corticosteroid in line
with nice guidelines on
preterm labor and birth .
FROM 34 TO 36 +6 WEEKS Continous survillance unless
indication for planned early
birth
37 weeks on wards Offer planned birth within 24-
48 hours
76. Patient should be monitored closely with Bp measurement at least four times aday
for first 2 days followed by once daily for next 2 weeks or more till they are off anti
hypertensive and blood pressure normalize .
Same anti – hypertensive treatment should be continued in post partum period
.dosage can be reduced once bp falls below 130/80 mmhg .
Anti – hypertensive can be stopped once bp become normal for
atleast 48 hrs
Careful for the omnious signs.
Careful evaluation of intake and output and chest auscultation is necessary in
postpartum period .