logging in or signing up PIH dranishjoshi Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 2055 Category: Education License: All Rights Reserved Like it (0) Dislike it (0) Added: December 01, 2008 This Presentation is Public Favorites: 2 Presentation Description No description available. Comments Posting comment... By: kenilvpatel (13 month(s) ago) thank you..sirrr Saving..... Post Reply Close Saving..... Edit Comment Close By: dr.glnar (19 month(s) ago) thank you very much :) Saving..... Post Reply Close Saving..... Edit Comment Close By: dranishjoshi (31 month(s) ago) DOWNLOAD NOW... ENJOY Saving..... Post Reply Close Saving..... Edit Comment Close By: dr_mini (31 month(s) ago) how cn i download it as ppt? Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript Pregnancy-induced Hypertension : 1 Pregnancy-induced Hypertension ANISH JOSHI Preeclampsia Hypertension Proteinuria 1. Greater than 300 mg in 24 hour period2. Greater than 100 mg/dl dipstick (sustainable)Edema After the twentieth week of gestation ,Although the signs and symptoms may appear earlier with H.mole.Resolving within 48 hours after deliveryEclampsia Seizures + preeclampsia. : 2 Preeclampsia Hypertension Proteinuria 1. Greater than 300 mg in 24 hour period2. Greater than 100 mg/dl dipstick (sustainable)Edema After the twentieth week of gestation ,Although the signs and symptoms may appear earlier with H.mole.Resolving within 48 hours after deliveryEclampsia Seizures + preeclampsia. Slide 3: 3 Classification : 1. Mild : Bp ≥140/90mmHg or a rise of 30mmHg systolic pressure or 15 mmHg diastolic pressure over the prepregnant level,with or without trace proteinuria or edema. 2. Severe : BP > 160/110 mmHg Proteinuria > 5 gm/24hr, > ++ Azotemia/oliguria (< 400 mL/24 hr) Microangiopathic hemolysis Thrombocytopenia End organ symptoms: 1. CNS 2. Visual 3. Hepatic Intrauterine growth delay (oligohydramnios?) Roll over test: increase of >20mmHg of DBP on turning from left lateral position to supine position Slide 4: 4 TYPES- 1) PIH 2) CHRONIC HYPERTENSION ESSENTIAL / RENAL / Others MOSTLY OBESE, ELDERLY, PAROUS & LIKELY TO BE ON ANTIHYPERTENSIVE DRUGS USUALLY PREEXISTS / APPEARS EARLY (<20WKS) & PERSISTS POSTPARTUM END ORGAN DAMAGE MAYBE PRESENT A) COINCIDENTAL - sustained high BP throughout pregnancy & postpartum B) AGGRAVATED BY PREGNANCY - I) SUPERIMPOSED PREECLAMPSIA II) SUPERIMPOSED ECLAMPSIA Slide 5: 5 Nulliparity Young or elderly gravidas Family history Chronic HTN Renal disease Antiphospholipid syndrome Diabetes Multiple gestation Angiotensinogen gene T235 (?) Previous severe PIH before 28 weeks Risk Factors Slide 6: 6 Normal Preeclampsia 3rd trimester Etiology :1. Utero-placental ischaemia : Abnormal development of the placental bed vessels / shallow trophoblast invasion in spiral arteries 2. Endothelial cell activation/dysfunction:Cytotoxic factors : oxygen free radicals /lipid peroxidation / VLDL /fibronection / platelet derived growth factor( PDGF) / TNF-α /IL-6 / anti-vascular endothelial factor /endothelial inhibitive factor 3. Immunity ;Failure to express HLA-G mRNA or protein .4. Genetics :Recessive trait . : 7 Etiology :1. Utero-placental ischaemia : Abnormal development of the placental bed vessels / shallow trophoblast invasion in spiral arteries 2. Endothelial cell activation/dysfunction:Cytotoxic factors : oxygen free radicals /lipid peroxidation / VLDL /fibronection / platelet derived growth factor( PDGF) / TNF-α /IL-6 / anti-vascular endothelial factor /endothelial inhibitive factor 3. Immunity ;Failure to express HLA-G mRNA or protein .4. Genetics :Recessive trait . Pathology : 1. Placenta : (1) premature aging of villi (2) hemorrhage (3) necrosis 2. Kidney (1) swelling of endothelial cells because of deposition of amorphous materials (2) swelling of the glomerular capillarities.3. Liver : periportal areas 4. Brain :cortical /subcortical areas 5. Heart :increase of cardiac afterload , prelod may or . 6. Hematological: Hypercoagulation status, HELLP : 8 Pathology : 1. Placenta : (1) premature aging of villi (2) hemorrhage (3) necrosis 2. Kidney (1) swelling of endothelial cells because of deposition of amorphous materials (2) swelling of the glomerular capillarities.3. Liver : periportal areas 4. Brain :cortical /subcortical areas 5. Heart :increase of cardiac afterload , prelod may or . 6. Hematological: Hypercoagulation status, HELLP Clinical finding : Headache Visual disturbances Tightness of chest Convulsion : 9 Clinical finding : Headache Visual disturbances Tightness of chest Convulsion Slide 10: 10 Maternal complications Liver Jaundice HELLP Hepatic rupture Coagulation DIC Microangiopathic haemolysis HELLP CNS Eclamptic convulsions Cerebral haemorrhage Cerebral oedema Cortical blindness Retinal detachment Renal Cortical necrosis Tubular necrosis Pulmonary oed. Electrolyte disturbances Slide 11: 11 LOOK FOR APPEARANCE OF OMINOUS FEATURES DAILY- RECORD B.P 4 TIMES, MONITOR U.O & TEST FOR PROTEINURIA QUALI. / QUANT ALT.DAY- BODY WEIGHT EVERY 4TH DAY- URIC ACID, PLATELET COUNT, L.F.T. (LDH) WEEKLY- CREATININE MONITORING MATERNAL Refractory HTN Unresponsive oliguria Unresponsive pulmonary edema PAC/CVC Slide 12: 12 DAILY -FHS, FUNDAL Ht. ABDOMINAL GIRTH, LIQUOR, FOETAL MOVEMENT COUNT, USG - ON ADMISSION & THEN 3 WEEKLY FOR FOETAL BIOPHYSICAL PARAMETERS, PLACENTA AND LIQUOR VOLUME DOPPLER USG FOR PLACENTAL BLOOD FLOW VELOCITY EVERY 4TH DAY MONITORING FOETAL Slide 13: 13 HOSPITALISATION - FOR MONITORING SEDATIVES - DIAZEPAM / PHENOBARBITONE / ALPRAZOLAM ? NUTRITIONAL SUPLEMENTS - PROTEIN, IRON, CALCIUM (1000 MG), VITAMIN E & C, MICRONUTRIENTS STOP - SMOKING & ALCOHOL 1. Antihypertensive drugs: SNP / NTG GENERAL MEASURES TREATMENT MethylDOPA : 14 MethylDOPA Centrally acting sympathomimetic It has the longest track record of safety Side effects: failure to control BP, lassitude, depression and immune mediated haematological changes 750 mg to 4 gms daily po, i.v 250-500 mg QID It has a lag period of few hours before it starts to work Nifedipine : 15 Nifedipine CCB This has rapid onset of action orally and sublingually (10-15 min) It may cause tachycardia and precipitous fall in BP and headaches Given 4-6 hourly Slow release preparations are given twice daily The tocolytic effect is only theoretical Labetalol : 16 Labetalol & blocker 100 – 400 mg BD po & i.v 20 mg / hour doubled every 30 minutes It results in gradual fall in BP and has predictable action Hydralazine : 17 Hydralazine Arterial dilator 25 - 50 mg BD, iv 50-150 g/min It has a lag period of 20-30 min Severe headaches, & may fail due to tachyphylaxis A lupus like syndrome is quite rarely seen Magnesium Sulphate : 18 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 Magnesium Sulphate Protocol : 19 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 Magnesium Sulphate Protocol : 20 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 Diazepam : 21 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 Doses more than 40 mg must not be used in 24 hours It accumulates in the fetus and results in problems after birth Slide 22: 22 3 ) ALLYLESTRENOL : - TO PROMOTE FOETAL GROWTH IN DOSES OF 5-10 Mg. 3 - 4 TIMES / DAY DRUGS TREATMENT 4 ) DIURETICS ? : - AVOID ONLY IN PULMONARY OEDEMA, CCF, RENAL HYPERTENSION, SEVERE OLIGURIA / ANURIA. CHLORTHIAZIDE, FRUSEMIDE SHOULD BE STOPPED WELL BEFORE TERMINATION OF PREGNANCY Slide 23: 23 6 ) GLUCOCORTICOIDS: - <34 WEEKS BETAMETHASONE / DEXAMETHASONE -12 MG, 2 DOSES AT 12 HOURS INTERVAL FOLOWED BY WEEKLY INJ. TILL DELIVERY / 34 WEEKS. DRUGS TREATMENT 5 ) TOCOLYTICS : - ISOXSUPRINE + 7 ) THYROTROPIN RELEASING HORMONE : - ? DOSE - 400 µGm, 8 HOURLY FOR 4 DOSES, TO PROMOTE FOETAL MATURITY IF DELIVERY <34 WEEKS. Slide 24: 24 1 ) AT 36 WEEKS: - IN ALL CONTROLLED CASES 2 ) AFTER 32 WEEKS: - FOR FOETAL SALVAGE DECREASED FOETAL MOVEMENT SEVERE IUGR WITH OLIGOHYDRAMNIOUS LATE DECELERATION WITH POOR VARIABILITY REVERSED UMBILICAL DIASTOLIC BLOOD FLOW DELIVERY TREATMENT BEST DAY - WHEN ? 3 ) ANY TIME : - IF PROGRESSIVE INSPITE OF TREATMENT, WHEN - BP >160 /100 MM OF HG URINE OUTPUT < 400 ML / 24 HOURS PLATELET COUNT < 50000 / CMM SERUM CREATININE INCREASES PROGRESSIVELY LDH >1000 IU / L Slide 25: 25 1 ) INDUCTION WITH OXYTOCIN: -After 36 weeks IF FOETAL CONDITION IS GOOD CERVIX IS FAVOURABLE / Cerviprime APPLICATION OF FORCEPS / VENTOUSE DELIVERY TREATMENT BEST WAY - HOW ? 2 ) BY LSCS: - IF TERMINATION BEFORE 36 WEEKS IN CASES OF MATERNAL / FETAL JEOPARDY BEST PLACE - WHERE ?- HIGH-RISK PREGNANCY UNIT / TERTIARY WELL EQUIPED HOSPITAL Slide 26: 26 Slide 27: 27 Differential Diagnosis - HELLP 1. Sepsis 2. TTP 3. SLE 4. HUS 5. DIC 6. Abruptio placentae 7. Amniotic fluid embolism 8. Drug induced hemolytic anaemia 9. Cholecystitis/ Appendicitis Mississipi Tenessi Slide 28: 28 Thanks for your attention ! You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
PIH dranishjoshi Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 2055 Category: Education License: All Rights Reserved Like it (0) Dislike it (0) Added: December 01, 2008 This Presentation is Public Favorites: 2 Presentation Description No description available. Comments Posting comment... By: kenilvpatel (13 month(s) ago) thank you..sirrr Saving..... Post Reply Close Saving..... Edit Comment Close By: dr.glnar (19 month(s) ago) thank you very much :) Saving..... Post Reply Close Saving..... Edit Comment Close By: dranishjoshi (31 month(s) ago) DOWNLOAD NOW... ENJOY Saving..... Post Reply Close Saving..... Edit Comment Close By: dr_mini (31 month(s) ago) how cn i download it as ppt? Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript Pregnancy-induced Hypertension : 1 Pregnancy-induced Hypertension ANISH JOSHI Preeclampsia Hypertension Proteinuria 1. Greater than 300 mg in 24 hour period2. Greater than 100 mg/dl dipstick (sustainable)Edema After the twentieth week of gestation ,Although the signs and symptoms may appear earlier with H.mole.Resolving within 48 hours after deliveryEclampsia Seizures + preeclampsia. : 2 Preeclampsia Hypertension Proteinuria 1. Greater than 300 mg in 24 hour period2. Greater than 100 mg/dl dipstick (sustainable)Edema After the twentieth week of gestation ,Although the signs and symptoms may appear earlier with H.mole.Resolving within 48 hours after deliveryEclampsia Seizures + preeclampsia. Slide 3: 3 Classification : 1. Mild : Bp ≥140/90mmHg or a rise of 30mmHg systolic pressure or 15 mmHg diastolic pressure over the prepregnant level,with or without trace proteinuria or edema. 2. Severe : BP > 160/110 mmHg Proteinuria > 5 gm/24hr, > ++ Azotemia/oliguria (< 400 mL/24 hr) Microangiopathic hemolysis Thrombocytopenia End organ symptoms: 1. CNS 2. Visual 3. Hepatic Intrauterine growth delay (oligohydramnios?) Roll over test: increase of >20mmHg of DBP on turning from left lateral position to supine position Slide 4: 4 TYPES- 1) PIH 2) CHRONIC HYPERTENSION ESSENTIAL / RENAL / Others MOSTLY OBESE, ELDERLY, PAROUS & LIKELY TO BE ON ANTIHYPERTENSIVE DRUGS USUALLY PREEXISTS / APPEARS EARLY (<20WKS) & PERSISTS POSTPARTUM END ORGAN DAMAGE MAYBE PRESENT A) COINCIDENTAL - sustained high BP throughout pregnancy & postpartum B) AGGRAVATED BY PREGNANCY - I) SUPERIMPOSED PREECLAMPSIA II) SUPERIMPOSED ECLAMPSIA Slide 5: 5 Nulliparity Young or elderly gravidas Family history Chronic HTN Renal disease Antiphospholipid syndrome Diabetes Multiple gestation Angiotensinogen gene T235 (?) Previous severe PIH before 28 weeks Risk Factors Slide 6: 6 Normal Preeclampsia 3rd trimester Etiology :1. Utero-placental ischaemia : Abnormal development of the placental bed vessels / shallow trophoblast invasion in spiral arteries 2. Endothelial cell activation/dysfunction:Cytotoxic factors : oxygen free radicals /lipid peroxidation / VLDL /fibronection / platelet derived growth factor( PDGF) / TNF-α /IL-6 / anti-vascular endothelial factor /endothelial inhibitive factor 3. Immunity ;Failure to express HLA-G mRNA or protein .4. Genetics :Recessive trait . : 7 Etiology :1. Utero-placental ischaemia : Abnormal development of the placental bed vessels / shallow trophoblast invasion in spiral arteries 2. Endothelial cell activation/dysfunction:Cytotoxic factors : oxygen free radicals /lipid peroxidation / VLDL /fibronection / platelet derived growth factor( PDGF) / TNF-α /IL-6 / anti-vascular endothelial factor /endothelial inhibitive factor 3. Immunity ;Failure to express HLA-G mRNA or protein .4. Genetics :Recessive trait . Pathology : 1. Placenta : (1) premature aging of villi (2) hemorrhage (3) necrosis 2. Kidney (1) swelling of endothelial cells because of deposition of amorphous materials (2) swelling of the glomerular capillarities.3. Liver : periportal areas 4. Brain :cortical /subcortical areas 5. Heart :increase of cardiac afterload , prelod may or . 6. Hematological: Hypercoagulation status, HELLP : 8 Pathology : 1. Placenta : (1) premature aging of villi (2) hemorrhage (3) necrosis 2. Kidney (1) swelling of endothelial cells because of deposition of amorphous materials (2) swelling of the glomerular capillarities.3. Liver : periportal areas 4. Brain :cortical /subcortical areas 5. Heart :increase of cardiac afterload , prelod may or . 6. Hematological: Hypercoagulation status, HELLP Clinical finding : Headache Visual disturbances Tightness of chest Convulsion : 9 Clinical finding : Headache Visual disturbances Tightness of chest Convulsion Slide 10: 10 Maternal complications Liver Jaundice HELLP Hepatic rupture Coagulation DIC Microangiopathic haemolysis HELLP CNS Eclamptic convulsions Cerebral haemorrhage Cerebral oedema Cortical blindness Retinal detachment Renal Cortical necrosis Tubular necrosis Pulmonary oed. Electrolyte disturbances Slide 11: 11 LOOK FOR APPEARANCE OF OMINOUS FEATURES DAILY- RECORD B.P 4 TIMES, MONITOR U.O & TEST FOR PROTEINURIA QUALI. / QUANT ALT.DAY- BODY WEIGHT EVERY 4TH DAY- URIC ACID, PLATELET COUNT, L.F.T. (LDH) WEEKLY- CREATININE MONITORING MATERNAL Refractory HTN Unresponsive oliguria Unresponsive pulmonary edema PAC/CVC Slide 12: 12 DAILY -FHS, FUNDAL Ht. ABDOMINAL GIRTH, LIQUOR, FOETAL MOVEMENT COUNT, USG - ON ADMISSION & THEN 3 WEEKLY FOR FOETAL BIOPHYSICAL PARAMETERS, PLACENTA AND LIQUOR VOLUME DOPPLER USG FOR PLACENTAL BLOOD FLOW VELOCITY EVERY 4TH DAY MONITORING FOETAL Slide 13: 13 HOSPITALISATION - FOR MONITORING SEDATIVES - DIAZEPAM / PHENOBARBITONE / ALPRAZOLAM ? NUTRITIONAL SUPLEMENTS - PROTEIN, IRON, CALCIUM (1000 MG), VITAMIN E & C, MICRONUTRIENTS STOP - SMOKING & ALCOHOL 1. Antihypertensive drugs: SNP / NTG GENERAL MEASURES TREATMENT MethylDOPA : 14 MethylDOPA Centrally acting sympathomimetic It has the longest track record of safety Side effects: failure to control BP, lassitude, depression and immune mediated haematological changes 750 mg to 4 gms daily po, i.v 250-500 mg QID It has a lag period of few hours before it starts to work Nifedipine : 15 Nifedipine CCB This has rapid onset of action orally and sublingually (10-15 min) It may cause tachycardia and precipitous fall in BP and headaches Given 4-6 hourly Slow release preparations are given twice daily The tocolytic effect is only theoretical Labetalol : 16 Labetalol & blocker 100 – 400 mg BD po & i.v 20 mg / hour doubled every 30 minutes It results in gradual fall in BP and has predictable action Hydralazine : 17 Hydralazine Arterial dilator 25 - 50 mg BD, iv 50-150 g/min It has a lag period of 20-30 min Severe headaches, & may fail due to tachyphylaxis A lupus like syndrome is quite rarely seen Magnesium Sulphate : 18 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 Magnesium Sulphate Protocol : 19 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 Magnesium Sulphate Protocol : 20 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 Diazepam : 21 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 Doses more than 40 mg must not be used in 24 hours It accumulates in the fetus and results in problems after birth Slide 22: 22 3 ) ALLYLESTRENOL : - TO PROMOTE FOETAL GROWTH IN DOSES OF 5-10 Mg. 3 - 4 TIMES / DAY DRUGS TREATMENT 4 ) DIURETICS ? : - AVOID ONLY IN PULMONARY OEDEMA, CCF, RENAL HYPERTENSION, SEVERE OLIGURIA / ANURIA. CHLORTHIAZIDE, FRUSEMIDE SHOULD BE STOPPED WELL BEFORE TERMINATION OF PREGNANCY Slide 23: 23 6 ) GLUCOCORTICOIDS: - <34 WEEKS BETAMETHASONE / DEXAMETHASONE -12 MG, 2 DOSES AT 12 HOURS INTERVAL FOLOWED BY WEEKLY INJ. TILL DELIVERY / 34 WEEKS. DRUGS TREATMENT 5 ) TOCOLYTICS : - ISOXSUPRINE + 7 ) THYROTROPIN RELEASING HORMONE : - ? DOSE - 400 µGm, 8 HOURLY FOR 4 DOSES, TO PROMOTE FOETAL MATURITY IF DELIVERY <34 WEEKS. Slide 24: 24 1 ) AT 36 WEEKS: - IN ALL CONTROLLED CASES 2 ) AFTER 32 WEEKS: - FOR FOETAL SALVAGE DECREASED FOETAL MOVEMENT SEVERE IUGR WITH OLIGOHYDRAMNIOUS LATE DECELERATION WITH POOR VARIABILITY REVERSED UMBILICAL DIASTOLIC BLOOD FLOW DELIVERY TREATMENT BEST DAY - WHEN ? 3 ) ANY TIME : - IF PROGRESSIVE INSPITE OF TREATMENT, WHEN - BP >160 /100 MM OF HG URINE OUTPUT < 400 ML / 24 HOURS PLATELET COUNT < 50000 / CMM SERUM CREATININE INCREASES PROGRESSIVELY LDH >1000 IU / L Slide 25: 25 1 ) INDUCTION WITH OXYTOCIN: -After 36 weeks IF FOETAL CONDITION IS GOOD CERVIX IS FAVOURABLE / Cerviprime APPLICATION OF FORCEPS / VENTOUSE DELIVERY TREATMENT BEST WAY - HOW ? 2 ) BY LSCS: - IF TERMINATION BEFORE 36 WEEKS IN CASES OF MATERNAL / FETAL JEOPARDY BEST PLACE - WHERE ?- HIGH-RISK PREGNANCY UNIT / TERTIARY WELL EQUIPED HOSPITAL Slide 26: 26 Slide 27: 27 Differential Diagnosis - HELLP 1. Sepsis 2. TTP 3. SLE 4. HUS 5. DIC 6. Abruptio placentae 7. Amniotic fluid embolism 8. Drug induced hemolytic anaemia 9. Cholecystitis/ Appendicitis Mississipi Tenessi Slide 28: 28 Thanks for your attention !