Dr. Noshaba Rafiq M.B.B.S. M.C.P.S F.C.P.S E.mail noshaba_nshyahoo.com

1. Dr. Noshaba Rafiq M.B.B.S. M.C.P.S F.C.P.S E.mail noshaba_nsh@yahoo.com

3. Nothing baffles the researchers more than hypertensive disorders of pregnancy. It is probably the most studied and least understood problem of obstetrics

5. Basic Management Objectives Termination of pregnancy with least possible trauma to the mother and the fetus Birth of an infant who subsequently thrives Complete restoration of health to the mother

6. Prophylaxis There is no true prophylaxis Aspirin does not work (CLASP & ECPPA) Control of diabetes and hypertension (where present) may be helpful in most cases

7. Detection Plasma fibronectin level Platelet A II receptors Urinary calcium Fasting insulin levels

8. Management Look for risk factors Note any change in BP Note any rapid weight change Take symptoms of headache & epigastric discomfort seriously Ask for tightening of rings

10. Fetal Monitoring Repeated antenatal examinations Serial ultrasounds Dopplers TcO2 monitoring Cordocentesis

12. Frequent abdominal examinations Ultrasound and CTG assessment of fetal well being Use of antihypertensive agents Use of anticonvulsants Plan for delivery Hospital Management

13. Delivery is the cure for gestational hypertension When the fetus is preterm there is need to temporize in the hope that a few more weeks may be gained With moderate or severe preeclampsia that does not improve after hospitalization delivery is usually advisable for the welfare of both mother and the fetus Termination of Pregnancy

14. Termination of Pregnancy Try to prolong pregnancy considering safety If a patient needs an anticonvulsant she needs to be delivered Induction can be carried out by prostaglandins or oxytocin No ergometrine C section as a last resort

15. Deciding for the optimal time of delivery?

16. Severity of disease Duration of gestation Condition of cervix It will depend upon

18. MethylDOPA This is thought to act centrally and is now considered a sympathomimetic instead of sympathoplegic It has the longest track record of safety It however possesses side effects of failure to control BP, lassitude, depression and immune mediated haematological changes The oral dose varies between 750 mg to 4 gms daily Intravenously 250-500 mg is used 6 hourly It has a lag period of few hours before it starts to work

19. Nifedipine It is a calcium channel blocker This has rapid onset of action orally and sublingually (10-15 min) It may cause tachycardia and precipitous fall in BP and headaches It is given 4-6 hourly Slow release preparations are given twice daily The tocolytic effect is only theoretical

20. Labetalol This is an alpha and beta adrenergic blocker It can be given orally (100 mg twice daily increased upto 400 mg twice daily) and intravenously (20 mg / hour doubled every 30 minutes) It results in gradual fall in BP and has predictable action

21. Hydralazine It is an arterial dilator It is given orally (25 mg twice daily to 50 mg twice daily), intravenously (50-150 micro grams/min) It has a lag period of 20-30 min It can cause severe headaches, and may fail due to tachyphylaxis A lupus like syndrome is quite rarely seen

22. GTN Causes veno dilatation but some effect on arteries as well Results in significant lowering of systolic and diastolic BP Can be used as an alternative agent to well known drugs* Not however recommended for common use

23. Other Agents Newer agents like amylodipine and nimodipine have also been tried but are just expensive variants of nifedipine ACE inhibitors are contraindicated Diazoxide and minoxidil are not used in Obstetrics Nitroprusside is toxic to the fetus and contraindicated

24. Management of Eclampsia Control of convulsions Correction of hypoxia & acidosis Control of BP Delivery

26. It probably works by neuronal calcium blocking through the glutamate channel It will nearly always arrest convulsions It does not depress the maternal sensorium The fetus is least affected It is currently the anticonvulsant of choice in eclampsia Magnesium Sulphate

27. Magnesium Sulphate Protocol 4 gms IV as 20% soln @ 1 gm/min 10 gms of 50% soln. 5 gms in each buttock If convulsions persist after 15 min give 2 gms IV again as 20 % soln Every 4 hours 5 gms of 50% soln given in alternate buttock Discontinued 24 hours after delivery

28. If Mg levels are monitored it muse be between 4 -7 mEq/L If clinical monitoring only The patellar reflex must be present Respiration not depressed Urine output > 100 mL in the last 4 hours Magnesium Sulphate Protocol

29. Diazepam It is a very good agent to terminate a fit (10 mg IV repeated if necessary) It is not a good agent to prevent a fit If depresses maternal CNS It makes CTG unreliable as a fetal monitor Doses more than 40 mg must not be used in 24 hours It accumulates in the fetus and results in problems after birth

30. Phenytoin It is little used in obstetrics It is a difficult drug to administer If has shown no advantage over magnesium sulphate ECG monitoring is mandatory with its use

31. Other Agents Rarely thiopentone sodium or tribromoethanol are used as adjuvants to magnesium sulphate It is not mandatory to sedate the patient so sedatives are not usually recommended Phenobarbitone and chlordiazepoxide have also been used in the past but are not advocated now Clonazepam can be used instead of diazepam to terminate a fit

33. Postpartum Care After delivery there is usually rapid improvement but eclampsia can appear for the first time or persist postpartum The women is discharged if severe HTN has abated or no fit has occurred for 48 hours

34. Future Counseling There is a higher risk of PIH recurring in subsequent pregnancy There is also a higher risk of developing chronic hypertension