Hypertension in pregnancy – docslide.com.br brain anoxia

• 1.Http://crisbertcualteros.Page.Tl HYPERTENSIONIN PREGNANCY

2. DEFINITION OF TERMS

• HYPERTENSION

• bp of 140/90 mm hg or more on two separate occasions with the patient supine or in sitting position (after resting for 5 mins) using korotkoff V to measure the diastolic reading

3. Normal pregnancy blood pressure 4. DEFINITION OF TERMS

• PROTEINURIA

• urinary protein spillage of 300 mg/24 hrs or more or 100 mg/dl concentration or more in 2 random specimens taken 6 hrs apart or +1 on dip stick method

5. HYPERTENSIVE DISORDERS COMPLICATING PREGNANCY

• GESTATIONAL HYPERTENSION

• PREECLAMPSIA

• ECLAMPSIA

• CHRONIC HYPERTENSION


• PREECLAMPSIA SUPERIMPOSED ON CHRONIC HYPERTENSION

6. GESTATIONAL HYPERTENSION

• BP140/90 mm hg for the 1 sttime during pregnancy

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• no proteinuria

• BP returns to normal 140/90 mm hg after 20 wks gestation

• proteinuria300 mg/24 hrs or1+ dipstick

8.

• in which of the ff clinical situations is preeclampsia the most likely consideration:

• +++ bipedal edema, ++ urinary proteins

• BP – 150/100, + urinary proteins

• BP – 160/110, ++ bipedal edema

• +++ urinary proteins, serum creatinine – 3 mg/dl

9. ECLAMPSIA

• seizures that cannot be attributed to other causes in a woman with preeclampsia

• epilepsy, encephalitis, meningitis, cerebral tumor, ruptured cerebral aneurysm

• grand mal type

• may be encountered up to 10 days postpartum

10. CHRONIC HYPERTENSION

• BP140/90 mm hg before pregnancy or diagnosed before 20 wks gestation

• hpn 1 stdiagnosed after 20 weeks gestation and persistent after 12 weeks postpartum

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11. CHRONIC HYPERTENSION

• diagnosis is suggested by:

• hpn antecedent to pregnancy

• hpn detected before 20 weeks (unless there is gestational trophoblastic disease)

• persistent hpn long after delivery

• ( 12 wks postpartum)

12. SUPERIMPOSED PREECLAMPSIA (on chronic hypertension)

• new-onset proteinuria300 mg/24 hrs in hypertensive women but no proteinuria before 20 wks gestation

• A sudden increase in proteinuria or blood pressure or platelet count

• proteinuriatrace- +1persistent+2 or

• headacheabsentpresent

• visual dist.Absentpresent

• upper abd’l painabsentpresent

• oliguriaabsentpresent

• convulsionsabsentpresent (ecl)

• serum creatininenormalelevated

14. PREECLAMPSIA: indications of severity

• ABNORMALITYMILDSEVERE

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• thrombocytopeniaabsentpresent

• hyperbilirubinemiaabsentpresent

• liver enzyme

• elevationminimalmarked

• fetal growth

• restrictionabsentobvious

• pulm. Edemaabsentpresent

15.

• A 39 yr old G1P0, 32 wks gestation was admitted for severe headache. BP was noted to be 170/110. UA: +++ proteins.

• prenatal check-up started at 10 wks gestation.Usual BP 100-110/60-70.

• admitting impression is:

• gestational hypertension

• mild preeclampsia

• severe preeclampsia

• chronic hypertension with severe preeclampsia

16.

• which of the ff women is most likely a chronic hypertensive:

• A.G4P3 with BP of 150/100 at 16 weeks gestation

• B.G1P0 with BP 160/110 at 32 weeks gestation

• C.G2P1 with BP of 140/100 1 day post partum

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• D.G2P1 with BP of 160/110 and history of preeclampsia in the first pregnancy

17.

• preeclampsia is more common in:

• women 25-30 years old than in women 40 years old

• whites than in blacks

• singletons than in multifetal pregnancies

• nulliparous than in multiparous women

18. INCIDENCE

• more likely to develop in:

• woman exposed to chorionic villi for the first time

• woman exposed to a superabundance of chorionic villi

• woman with preexisting vascular disease

• woman genetically predisposed to hpn developing during pregnancy

19. PREECLAMPSIA INCIDENCE

• RISK FACTORS:

• nulliparity

• race/ethnicity

• multifetal pregnancy

• hx of chronic hpn

• maternal age 35 yrs

• obesity

20.

• preeclampsia is more common in:

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• women 25-30 years old than in women 40 years old

• whites than in blacks

• single than in multifetal pregnancies

• nulliparous than in multiparous women

21. TROPHOBLASTIC INVASION before invasion after invasion 22. 23. HELLPSYNDROME

• H EMOLYSIS

• E LEVATEDL IVER ENZYMES

• L OWP LATELETS

• 20% of women with severe preeclampsia

• 3 – 27% recurrence in subsequent pregnancies

24. PREDICTION

• ANGIOTENSIN II INFUSION

• 90 mm hg

• 3 rdtri MAP 105 mm hgppv – 20-40%

• ROLL-OVER TEST

• 28-32 wks gestation

• inc. Of 20 mm hg diastolic bp or PPV – 33%

• URINARY CALCIUM LEVEL

• hypocalciuriappv – 32%sensitivity – 88%

25. PREDICTION

• URINARY KALLIKREIN EXCRETION

• decreasedppv – 91% sensitivity – 83%

• FIBRONECTIN

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• increasedppv – 12%sensitivity – 69%

• DOPPLER VELOCIMETRY OF UTERINE ARTERY

• 18-22 wks gestation ;repeat at 24 wks

• increased uterine artery resistance

• PPV – 28%sensitivity – 78%

26. PREECLAMPSIA PREVENTION

• DIETARY MANIPULATION

• salt restriction – ineffective

• calcium supplementation

• reduce risk of preeclampsia;further studies re ideal dose

• COCHRANE 07

• fish oil – ineffective

• LOW-DOSE ASPIRIN

• 80 mg

• moderate benefits (17% reduction in risk) for prevention of

• preeclampsia; further studies needed (who, when, how much) COCHRANE 07

27. PREECLAMPSIA PREVENTION

• ANTIOXIDANTS

• vitamin C

• vitamin E

• studies are of poor quality; there seems to be a reduction in incidence of preeclampsia but with increased risk for preterm birth

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• COCHRANE 07

28. PREECLAMPSIA MANAGEMENT

• early prenatal detection

• prenatal check-up

• hospital management

• hx and PE

• weight daily

• urinalysis every 2 days

• BP every 4 hrs

29. PREECLAMPSIA MANAGEMENT

• lab:serum creatinine

• hematocrit

• platelet count

• serum liver enzymes

• fetal size and amnionic fluid evaluation

• reduced physical activity

• na and fluid intake not restricted nor

• forced

30. PREECLAMPSIA MANAGEMENT

• further management depends upon:

• severity of preeclampsia

• age of gestation

• condition of the cervix

• DELIVERY– the only cure

31. TERMINATION OF PREGNANCY

• near term

• severe preeclampsia

• labor induction with oxytocin (if not otherwise contraindicated)

• vaginal delivery

• cesarean delivery

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32. PREECLAMPSIA DRUG THERAPY

• MAGNESIUM SULFATE

• to control convulsions

• ANTIHYPERTENSIVE THERAPY

• GLUCOCORTICOIDS

• to enhance fetal maturation in

• pregnancies between 24-34 wks

• decreased incidence of RDS

• does not worsen maternal HPN

• significant but transient improvement in

• platelet count

33.

• which of the ff parameters should be met before giving the subsequent doses of magnesium sulfate:

• liver enzymes should be normal

• serum magnesium levels should not be more than 2 meq/L

• patellar reflexes should be present

• BP should be 160/110 or more

34. MAGNESIUM SULFATE

• effective anticonvulsant

• no CNS depression

• not given to treat hypertension

• indications: severe preeclampsia

• eclampsia

• mild preeclampsia in labor – ?Brain anoxia

• given during labor and for 24 hours postpartum

35. MAGNESIUM SULFATE dosage schedule

• CONTINUOUS IV INFUSION

• loading dose – 4-6 gms mgso4 in 100 ml of IV fluid over 15 – 20 mins

• maintenance infusion – 2 g/hr in 100 ml IV fluid

• discontinue 24 h after delivery.

36. MAGNESIUM SULFATE dosage schedule

• INTERMITTENT IM INJECTIONS

• loading dose – 4g 20% sol mgso4 IV at rate not 1g/min

• 5 g 50% mgso4 deep IM to each buttock (+ 1 ml 2% LIDOCAINE)

• if convulsions persist after 15 mins2 g 20% IV atrate not 1g/min

37. MAGNESIUM SULFATE dosage schedule

• maintenance – 5 g 50% deep IM every 4 hrs provided that:

• – urine output 100ml/4 hrs

• – patellar reflex is present

• – respirations are not depressed

• discontinue 24 hrs after delivery

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38. MAGNESIUM SULFATE toxicity

• plasma mg level

• normal and /or diastolic bp greater than 105 mm hg

• dose:

• 5-10 mg at 15-20 min intervals

• until diastolic bp is 90-100 mm hg

41. ANTIHYPERTENSIVES

• ACE-INHIBITORS

• contraindicated in pregnancy

• complications

• oligohydramnios

• fetal growth restriction

• bony malformations

• limb contractures

• persistent PDA

• pulmonary hypoplasia

• respiratory distress syndrome

• prolonged neonatal hypotension

• neonatal death

42.

• which of the ff antihypertensives is contraindicated in pregnancy:

• methyldopa

• hydralazine

• ace-inhibitors

• beta-blockers

43. DIURETICS

• not used to lower bp

• produce intravascular volume depletion

• worsen maternal hemoconcentration

• use is limited to presence of pulmonary edema (FUROSEMIDE)

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• may be used in persistent severe postpartum hypertension

44. FLUID THERAPY

• LACTATED RINGER SOLUTION

• 60-125 ml/hr

• infusion of large fluid volumes increase the risk of pulmonary and cerebral edema

45. OPERATIVE DELIVERY 46.

• FORCEPS DELIVERY

• TYPES

• outlet forceps

• scalp is visible at introitus without separating the labia

• fetal skull has reached pelvic floor

• sagittal suture is in A-P diameter or right or left OA or OP position

• fetal head is at or on perineum

• rotation does not exceed 45

• degrees

47.

• FORCEPS DELIVERY

• TYPES

• low forceps

• leading point of fetal skull is at st +2 cm or and not on pelvic floor

• rotation is 45 degrees or less to occiput anterior or posterior

• rotation is greater than

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• 45 degrees

• mid forceps

• station above +2 cm but head is engaged

• (high forceps)

48.

• forceps extraction was contemplated at full dilatation with the vertex at the pelvic floor (station +3/3), direct occiput anterior.The type of procedure is:

• A.Outlet forceps extraction

• B.Low forceps extraction

• C.Midforceps extraction

• D.High forceps extraction

49.

• FORCEPS APPLICATION

• PREREQUISITES

• head must be engaged

• fetus must present as vertex or face with chin anterior

• position of head must be precisely known

• cervix must be completely dilated

• membranes must be ruptured

• there should be no suspected cephalo-pelvic disproportion

50.

• in which of the ff conditions can forceps be safely applied:

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• A.Cervix 9 cm station +3 ruptured membranes direct occiput anterior

• B.Cervix 10 cm station +2 ruptured membranes left occiput anterior

• C.Cervix 10 cm station +3 intact membranes direct occiput posterior

• D.Cervix 10 cm station +1 ruptured membranes direct mentoposterior

51. CESAREAN SECTION DEFINITION

• birth of a fetus through incisions in the abdominal wall (laparotomy) and the uterine wall (hysterotomy)

52. CESAREAN SECTION MOST COMMON INDICATIONS

• repeat cesarean

• dystocia or failure to progress in labor

• breech presentation

• fetal distress

53. ABDOMINAL INCISION cosmetic advantage less likely to dehisce pfannenstiel TRANSVERSE when more room needed easier to extend upward less time consuminginfraumbilical; midline VERTICAL 54.Brain anoxia UTERINE INCISION

• CLASSICAL INCISION

• more likely to rupture in the next pregnancy

• LOW VERTICAL (KRONIG) INCISION

• may tear through cervix

• LOW TRANSVERSE (KERR) INCISION

• less blood loss

• easiest to repair

• located at a site least likely to rupture in next pregnancy

• does not promote adherence of bowel or omentum to incisional line

55. CLASSICAL CESAREAN SECTION INDICATIONS

• lower uterine segment not accessible

• bladder adhesions

• lower uterine segment myoma

• invasive carcinoma of cervix

• transverse lie of a large fetus, w/ ruptured membranes impacted shoulder

• anteriorly implanted placenta previa

• lower uterine segment not thinned out

• very small fetuses in breech presentation

56.Brain anoxia KRONIGKERR 57. VAGINAL BIRTH AFTER CESAREAN SECTION

• CRAIGIN’S DICTUM:

• “ once a cesarean,

• always a cesarean”

58. VAGINAL BIRTH AFTER CESAREAN SECTION

• RECOMMENDATIONS FOR SELECTION OF CANDIDATES FOR VBAC

• no more than 1 prior low transverse cesarean delivery

• clinically adequate pelvis

• no other uterine scars or previous rupture

• availability of competent physician

• availability of anesthesia and personnel for emergency cesarean delivery

59. UTERINE RUPTURE INCIDENCE FF TRIAL OF LABOR

• type of prior uterine incision

• classical CS – 12% (7% before labor)

• T-incisions

• number of prior cesareans

• one prior CS – 0.6-0.8%

• two prior CS – 1.8-3.7%

• use of oxytocin

• 2.3% (oxytocin-induced labors) vs 1%

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• oxytocin – may be used w/ caution

60.

• in a patient you are monitoring for a trial of labor after a previous cesarean section, you see sudden severe fetal heart rate decelerations on the cardiotocograph.Which of the ff should you initially consider:

• A.Cord compression

• B.Abruptio placenta

• C.Uterine hyperstimulation

• D.Ruptured uterus

61.

• you see a 30 yr old G2P1, 9 weeks AOG, at the out-patient clinic for her first prenatal check-up.She had a classical cesarean section on her first delivery and she wants a trial of labor for this pregnancy.TVS reveals an 9-week live intrauterine pregnancy.Plan for delivery is:

• A.Induce labor at term

• B.Allow a trial of labor if fetus is of adequate size and in vertex presentation at term

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• C. Repeat cesarean section at the first sign of labor

• D.Repeat cesarean section at term before onset of labor

62.

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