1 hypertensive disease of pregnancy prof. mehdi hasan mumtaz
TRANSCRIPT
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HYPERTENSIVE DISEASE OF PREGNANCY
Prof. Mehdi Hasan Mumtaz
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MATERNAL PHYSIOLOGY
Anaemia.
Hyperventilation.
Hypovolaemia.
Hyper-coagubility.
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HYPERTENSIVE DISEASE OF PREGNANCY
Pre-eclampsia.
Eclampsia.
HELLP syndrome.
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PRE-ECLAMPTIC TOXEMIA(PET)
TRIAD
Hypertension.
Proteinurea.
Oedema.
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SEVERE-PRE-ECLAMPSIADefinitions
BP> 140/90. Proteinurea >0.5 G/24h or
>2+ urine analysis+
Epigastric pain.Haedache.Visual disturbances.Clonus> 3beats.Platelet count <100x109.ALT>50IU/L.
OR
SPB = > 170DBP = > 110PROTEINUREA >0.5 G/24h OR > 2+ URINE ANALYSIS.
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HAEMODYNAMIC FINDINGSSevere Pre-eclampsia
Low plasma volume.
Low /Normal CO.
Low/ Normal CVP/PCWP.
myocardial contractility.
Low COP.
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ECLAMPSIA
Hypertension.
Protein urea.
Oedema.
Convulsion.
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HELLP SYNDROME
“Mos severe end of pre-eclamptic condition”
H – Haemolysis. EL - Liver enzyme. LP - Platelet count.
“Additional: Haemopoietic system”
“Liver involvement”
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PATHOLOGICAL FEATURES
Hypertension.
Renal functions.
Hypovolaemia.
Hypoproteinaemia.
Coagulation/fibrinolytic imbalance.
Cerebral irritability.
Placental perfusion.
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NORMAL PREGNANCY
Vasoconstriction
Platelet aggregations
Uterine activity
Utero-placental blood flow
Prostacyclin
Vasoconstriction
Platelet aggregations
Uterine activity
Utero-placental blood flow
Thromboxane
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PRE-ECLAMPSIA
Vasoconstriction
Platelet aggregations
Uterine activity
Utero-placental blood flow
Prostacyclin Vasoconstriction
Platelet aggregations
Uterine activity
Utero-placental blood flow
Thromboxane
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FLUID MANAGEMENT“Important”
Relatively Low PVLow PAWPCO
Endothelial damage. Low COP Excessive fluid therapy
fetal distress oligurea
risk pulmonary oedema
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MANAGEMENT
Definitive
Delivery of baby Delivery of
plaenta
Symptometic
Control Blood pressure. Convulsions. Fluid balance
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MANAGEMENT
SYMPTOMATICHIGH BLOOD PRESSURE
Dangers: Cerebral haemorrhage.Pul oedema
Objective: DBP 90-100mmHg<90 uteroplacentl
perfusion
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BLOOD PRESSURE
CAUTION. 4.5% HES 500ml preload.
Before IV anti-hypertensive.
EXCEPTION. Patient post delivery. Who has 4.5% HES already. DBP >120.
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BLOOD PRESSURE
HYDRALLAZINE 5mg/5min in 20 min.If BP 90-100 40mg/N-saline, 1-5mg/h.
IF AT 20min DBP >100 5mg/min in 20 min.If BP 100 40mg/N-saline, 1-5mg/h.
IF AT 20min DBP >100 LABETALOL 10-20mg IV/10min If DBP 90-100 or Total 220mg given
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BLOOD PRESSURE
Labetalol. 10-20mg boluses/15min.
If DBP 90-100.
Infusion 5mg/ml (0-160mg/hr).
Ca+ channel blockers.
Nitrates.
Adrenergic neuron blockers.
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ECLAMPSIA ROOM
Indications.1. Eclampsia.2. Hypertension > 170/110
+Proteinurea > 2+
3. Hypertension > 140/90Proteinurea 2+
+ One of the symptom/signs
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SYMPTOM/SIGNS
Headaches. Visual disturbances. Hyper-reflexia. Clonus (>3beats). Nausea & vomiting. Epigastric pain. Raised liver enzymes. Thrombocytopenia<100x10/L.
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“MONITORING” Eclampsia Room
ECG. NIBP. SPO2. Fluid balance. Urine output. CTG. CVP.
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CELL
CAPILLARY
EG
OSMOLALITY
Na+
COP
INTRACELLULAR INTERSTITIAL VASCULAR
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FLUID BALANCE
Restrict fluids.
(2000ml/24hrs)
Urine output <25ml/hr.
Pass CVP catheter.
CVP
Group A: CVP <4mmHg- underfilled.
Group B: CVP 4-8mmHg- optimialy
filled.
Group C: CVP >8mmHg- over filled.
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CVP GROUP - A.
Fluid challenge. HES 4.5% 100ml. Bring CVP 4-8.
GROUP - B. Fluid challenge careful. CVP 4-8. Urine O/P <25ml give dopamine..
GROUP - C. No pul oedema.
Dopamine 1-3g/kg/min. Pulmonary oedema present.
Frusemide 20mg. Refer to ICU.
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SEIZURE PROPHYLAXIS
“Severe pre-eclampsia”“Controversial”
Magnesium sulphate. Loading dose 4G.
Infusion 2G/hr.
Optimum level 2-4mmol/L.
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MAGNESIUM SULPHATEBlood Levels
Mgnesium (mmol/L)
0.7-1 2-4 >5 >7.5 >10
Effect
Normal Therapeutic range. Loss of reflexes. Respiratory
depression Cardiac arrest
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MAGNESIUM SULPHATE
Magnesium level >4 = dose (.5-1G/h)
Magnesium level <1.7=give 2G bolus.
dose 2.5G/h.
Magnesium level 1.7-2 continue 2G/h.
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MONITORING DURING MAGNESIUM INFUSION
Patellar reflex.
ECG.
SPO2.
Mgnesium level.
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MANAGEMENT MAGNESIUM TOXICITY
Loss of patellar reflex. Stop infusion. Measure level. Withold till reflex returns. Once reflex return – 1G/h.
SPO2 <90%. Give O2. Stop maintenance dose. Measure level. Inform anaesthetist.
Cardio-respiratory arrest. Stop infusion. CPR. Calcium gluconate. Intubation/ventilation.
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MAGNESIUM THERAPY
Considerations
Tocolytic effect.
Interaction – muscle relaxants.
Interaction – calcium antagonists.
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“INDICATIONS”ICU – ADMISSION
Severe coagulopathy or DIC.
Recurrent seizures.
Hypertension – poor control.
Persistant oligurea.
Pulmonary oedema + oligurea.
Compromised myocardial
function.
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MANAGEMENT
Definitive
Delivery of baby
Delivery of plaenta
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MANAGEMENTSevere Cases
Arrest & prevention of convulsion. Barbituates. Benzodiazepines. Megnesium SO4. Paralyse & IPPV.
Blood pressure. Hypertension – vasodilatation. Hypotension – inotropics.
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MANAGEMENTSevere Cases
Restoration of blood volume.
Low proteins. Colloids.
Colloid substitutes.
Progressive dehydration.
Replace out put.
Keep BV normal.
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ECLAMPSIA“Labour Room”
S.B.P. > 160 Torr. DBP > 110 Torr. Protein urea >5G/24h. Oligurea 500ml or less. Epigastric pain. Cyanosis. Pulmonary oedema. Convulsions.
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IN ICU
B. P. < 80 Torr.
Urine output – nil.
Convulsions.
Pulmonary oedema.
Cyanosis.
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ROUTINE
CVP Monitoring. Urinary
catheter. Nasogastric
catheter. Heavy sed with:
Valium. Pheno.
IPPV. Aemocel 500ml
daily
Blood 500ml/day.
Digitalise. Inotropes if
needed. Balance.
Negative 7-10day=10-14L
Ventilator off 3-4 day.
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IDEAL MANAGEMENT
Pass CVP catheter. Pass urinary catheter. Pass nasogastric tube. Replace obvious loss by crystaloids. Normalise blood volume by colloids. Remove excess fluids.
From ext vascular comp. By forced diuresis.
Keep the body in electrolyte balance.
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IDEAL MANAGEMENT
Routine investigations. Hb. HCT. Plasma proteins. Serum Na+ K+.
Monitoring. Urine output. ECG. BP. Pulse CVP.
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HELLP SYNDROME
H – Haemolysis. EL – elevated Liver enzyme
activity. LP - Platelet count.
“most sevre end of pre-eclamptic condition”
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CLINICAL FEATURES Epigastric pain. Upper abdominal tenderness. Proteinurea. Hypertension. Jaundice. Nausea & vomiting.
Haematuria. Oligurea. A T necrosis. Cortical necrosis. Pan-hypopituitarism. Actue liver rupture RDS.
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MANAGEMENT
Early diagnosis. Stbilization. Prompt delivery if.
Pre-eclampsia worsens. Worsening of hepatic renal functions. Severe thrombocytopenia. Gestational age at or beyond 32-
34wks. Evidence of foetal distess. Evidence of foetal maturity.
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MANAGEMENT
Pre-op investigations. Platelet count. PCV. Hb. PTT. Fibrinogen concentration. FDP. LFTs. Creatinine. Urea. Uric acid. X-ray chest.
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Platelet infusion if. <50000mm-3 cs. <20000mm-3 vag.D.
Blood transfusion if. B <10.0G/dl. Hb.
PPF. FFP. CVP. Urine output. Maternal blood glucose control. IPPV.