Obstetrics 5

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Obstetrics 5
2014-11-18 23:53:37
hypertension mild severe preeclampsia eclampsia HELLP syndrome
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  1. What is the effect of Hypertension on placental  blood vessels?
    The  blood vessels supplying the spiral arteries constrict on response to  raised BP leading to hypoxic damage to the placenta.
  2. What is the earliest manifestation of pre-eclampsia? [AIIMS 96]
    Edema - rapid development of edema, particularly of the face and hands, along with a rise in blood pressure, often signals the onset of the condition.
  3. What are the criteria for Gestational HTN, Mild preeclampsia and sever preeclampsia?
    • Gestational HTN
    • - >20wks, BP >140/90, no proteinuria.  No symptoms /signs

    • Mild Preeclampsia –
    • > 20wks,   BP - >140/90,  proteinuria (≥ 300mg/24hrs), no symptoms /signs 

    • Sever preeclampsia -  
    • >20wks, BP ≥160/110, Proteinuria ≥5gms,   Symptoms like Headache, epigastric pain, Visual changes. Signs – Pulmonary edema, Oliguria, Cyanosis

    Eclampsia  -  Symptoms  - Tonic clonic seizures
  4. What are the risk factor for preeclampsia?
    Demographic – Nullipara (8 times more risk, most important risk factor), age extremes (<20yrs, >34yrs) 

    Obstetric – Multiple gestation, Molar pregnancy (preeclampsis before 20 weeks), Non immune Hydrops

    Medical  -  DM, HTN, Renal diseases, SLE (all are diseases of small vessels)
  5. What is the pathophysiology of Mild Preeclampsia, severe preeclampsia and Eclampsia?
    • Mild and severe Preeclampsia - Diffuse vasospasm leading to capillary injury (preeclampsia is sometimes named as diffuse vasospastic disease of pregnancy). Normally, there is vasodilatation in pregnancy leading in lowering in BP. 
    • Prostaglandins like Thromboxane  and prostacyclins are involved in vasospasm.  
    • In eclampsia,  Cerebral Vasospasm, ischemia and edema.
  6. What  is the lab finding in Mild preeclampsia and Severe Preeclampsia?
    • Mild Preeclampsia - Proteinuria (1-2+), hemoconcentration (increased Hb, GFR is decreased [AI 12]- increased BUN, Creatinine)
    • Severe preeclampsia – DIC, raised Liver enzymes
    • Eclampsia – same as severe preeclampsia
  7. Which is the drug that has least effect on neonate in treatment of eclampsia? [AI 98, IOM 11]
    Magnesium sulphate. 

    Immediate and most effective treatment in eclamptic fit is magnesium sulphate. [IOM 04]
  8. What is Pritchard regimen and Zuspan regimen  of MgSO4 in management of eclampsia?
    • Pritchard regimen(IM)  - 
    • Loading dose - 4gm iv over 3-5 min, followed by 10gm deep IM (5gm in each buttock)
    • Maintenance dose - 5gm IM 4 hourly in alternate buttock

    • Zuspan regimen (IV)  
    • Loading dose - 4-6gm IV over 15-20 minutes. 
    • Maintenance dose - 1-2gm/hr IV infusion.
  9. What is the side effect of MgSO4?
    • Respiratory depression
    • Muscle weakness
  10. What should  you monitor in patient  treated with MgSO4?
    • Monitor deep tendon reflexes.
    • Loss of deep tendon reflex is the first sign of magnesium toxicity. [AI 11]
    • Monitor oxygen saturation/respiratory rate.Respiratory depression follows loss of DTR. 
    • Monitor Urine output. 

    Repeated injections or MgSO4 are given only if the knee jerk is present, urine output exceeds 30ml/hour and the respiratory rate is more than 12 per minute.
  11. What  is the treatment of magnesium  sulphate  overdose?
    • Stop magnesium infusion 
    • Calcium gluconate
  12. How do  you manage Mild preeclampsia  and severe Preeclampsia and Eclampsia? [remember there is no moderate preeclampsia]
    • Mild Preeclampsia: 
    • - <36 wks - conservative
    • - >36 weeks - deliver and MgSO4 to pevent seizure, continue MgSO4 24 hrs postpartum. 

    • Severe Preeclampsia: 
    • - aggressive management, IV MgSO4 to prevent convulsions and continue 24 hrs postpartum, lower BP to diastolic 90-100 by use of Hydralazine. If hydralazine is not available, use Labetalol. 
    • - Induce labor if mother and fetus are stable
    • - If they are not stable, go for C/S.

    • Eclampsia
    • - stop convulsions by MgSO4, continue for 24 hrs postpartum
    • - Prompt delivery at any gestational age
    • - Lower diastolic BP to 90-100mm/Hg. 
    • - Maternal Steroids not for fetal lung maturity, but to normalize the lab values and platelet counts.

    • In managing Preeclampsia, diastolic BP should be maintained to 90-100 mmHg. It is because, in Pregnancy also, the uterus is non prioritized. Blood first goes to brain, heart, kidney and if any blood is left, it only goes to uterus.
  13. What are the drugs used to control BP is pregnancy?
    • \The drug of choice for hypertension in pregnancy is Methyldopa. Methyldopa remains the agent of choice for chronic hypertension in pregnancy. 
    • The drug of choice for control of severe hypertension (hypertensive emergencies) in pregnancy as in severe preeclampsia is Hydralazine > Labetalol (if hydralazine is not available). 
    • The drug of choice for control of hypertensive crisis/emergencies (except in pregnancy) is sodium nitropruside.
  14. What part of the brain is hypoperfused  most commonly in severe preeclampsia?
    • Occipital lobe.
    • This is the reason for occipital headache and visual changes.
  15. What  is the reason for mid epigastic pain in Eclampsia?
    Swelling of Glisson's capsule of liver.
  16. How do you diagnose Chronic HTN?
    • Gestational age < 20wks or previous to pregnancy 
    • BP >140/90
    • Proteinuria = +/-
  17. Which antihypertensive drugs are never used in pregnancy?
    • ACE inhibitors – Fetal renal failure [AI 96,04, AIIMS 04,05,UP 00,IOM 09] 
    • Diuretics – decreases the  plasma volume and thus, decreases the placenta perfusion.
  18. What is HELLP syndrome? [AIIMS 97]
    • Hemolysis
    • Elevated Liver enzymes 
    • Low platelet count
  19. What is the most common cause of maternal death in eclampsia? [IOM 08]
    Cardiac failure