Obstetrics Pg No 393 -402
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Which of the following is a risk factor involving female exposure to placenta for the first time?

  • Multiparous women
  • Primigravida (correct)
  • Short interpregnancy interval
  • Delayed paternity

    • Twin pregnancies are associated with placentomegaly, which is a risk factor for PIH.

    True

    Name one condition that is linked to increased placental tissue and is a risk factor for PIH.

    Diabetic patient

    A ______ pregnancy is associated with early onset pre-eclampsia due to abnormal placentation.

    <p>molar</p> Signup and view all the answers

    Match the following risk factors with their descriptions:

    <p>Primigravida = Pregnant for the first time Molar pregnancy = Abnormal growth of placental tissue Rh negative pregnancy = Potential for incompatibility issues Twin pregnancy = Presence of two fetuses</p> Signup and view all the answers

    What is the definitive treatment for complications arising from pregnancy involving the placenta?

    <p>Termination of pregnancy</p> Signup and view all the answers

    The maternal kidney is the first organ affected in Pregnancy-Induced Hypertension (PIH).

    <p>True</p> Signup and view all the answers

    What primarily induces cerebral edema during pregnancy-related complications?

    <p>Leaky capillary endothelium</p> Signup and view all the answers

    In Pregnancy-Induced Hypertension, an increase in serum creatinine is noted when it is greater than or equal to ______ mg/dL.

    <p>1.1</p> Signup and view all the answers

    Match the following conditions with their associated symptoms:

    <p>Cerebral edema = Eclampsia/convulsions Cerebral hyperperfusion = Throbbing/severe headache Loss of cerebral autoregulation = Visual disturbances Glomerulo endotheliosis = Increased Urea levels</p> Signup and view all the answers

    What is the main role of extravillous trophoblast in normal pregnancy?

    <p>To convert high resistance vessels to low resistance vessels</p> Signup and view all the answers

    Phase 1 of trophoblastic invasion occurs at approximately 20 weeks of gestation.

    <p>False</p> Signup and view all the answers

    What leads to placental ischemia in the context of incomplete trophoblastic invasion?

    <p>High resistance remains and decreased blood volume in the intervillous space</p> Signup and view all the answers

    The trophoblastic invasion in normal pregnancy occurs in two phases, starting with phase 1 at ______ weeks.

    <p>12</p> Signup and view all the answers

    Match the following phases of trophoblastic invasion with their corresponding characteristics:

    <p>Phase 1 = Lining of decidual segment replaced Phase 2 = Lining of myometrial segment replaced Phase 3 = Incomplete trophoblastic invasion</p> Signup and view all the answers

    What is the recommended period to start low-dose medication for hypertensive mothers?

    <p>12 weeks</p> Signup and view all the answers

    The diastolic notch in the uterine artery disappears by 14 weeks of pregnancy.

    <p>False</p> Signup and view all the answers

    Name one predictor of PIH that can be assessed using Uterine Artery Doppler.

    <p>Persistence of diastolic notch</p> Signup and view all the answers

    The recommended dose for low-dose medication for hypertensive mothers ranges from ______ mg.

    <p>80-150</p> Signup and view all the answers

    Match the predictors of PIH with their classification:

    <p>↑ SFLT-1 = New predictors Giants roll over test = Outdated predictors Uterine artery doppler (UAD) = Others ↑ Pulsatility index = New predictors</p> Signup and view all the answers

    What is the primary medication used to prevent seizures in impending eclampsia?

    <p>Magnesium sulfate</p> Signup and view all the answers

    Visual disturbances in pre-eclampsia are irreversible in all cases.

    <p>False</p> Signup and view all the answers

    List one symptom associated with impending eclampsia.

    <p>Severe headache</p> Signup and view all the answers

    The classification system used for hypertensive retinopathy is called ______.

    <p>Keith-Wagner</p> Signup and view all the answers

    Match the following visual disturbances with their descriptions:

    <p>Blurring of vision = Loss of sharpness in eyesight Scotoma = Partial loss of vision or a blind spot Diplopia = Seeing double Blindness = Complete loss of vision</p> Signup and view all the answers

    What is a consequence of placental ischemia?

    <p>Oliguria</p> Signup and view all the answers

    Increased levels of vasodilators are released into maternal blood during placental ischemia.

    <p>False</p> Signup and view all the answers

    What effect does placental ischemia have on fetal growth?

    <p>Intrauterine Growth Restriction (IUGR)</p> Signup and view all the answers

    The release of mediators in maternal blood leads to __________ and increased blood pressure.

    <p>vasoconstriction</p> Signup and view all the answers

    Match the following mediators with their roles in placental ischemia:

    <p>sFLT = Increased Vasoconstriction VEGF = Decreased Vasodilation TNF α = Increased Inflammation Prostacyclin I2 = Decreased Vasodilation</p> Signup and view all the answers

    What is the recommended termination of pregnancy for severe pre-eclampsia?

    <p>Immediate termination irrespective of gestational age</p> Signup and view all the answers

    All cases of Pregnancy Induced Hypertension (PIH) require outpatient management.

    <p>False</p> Signup and view all the answers

    Name one laboratory test that is performed to rule out HELLP syndrome in PIH cases.

    <p>Platelet Count</p> Signup and view all the answers

    In cases of pregnancy with fetal distress, termination should occur at __________ weeks.

    <p>37-38</p> Signup and view all the answers

    Match the conditions to their recommended termination of pregnancy timing:

    <p>Mild pre-eclampsia = 37 weeks Eclampsia = Immediate termination PIH with abruption = 37 weeks Chronic HTN with superimposed PE = Immediate termination</p> Signup and view all the answers

    What is the primary purpose of administering MgSO₄ in cases of severe pre-eclampsia?

    <p>To prevent seizures</p> Signup and view all the answers

    The termination of pregnancy is not necessary if there are no emergency conditions present in severe pre-eclampsia.

    <p>True</p> Signup and view all the answers

    List two conditions that would require the termination of pregnancy in cases of severe pre-eclampsia.

    <p>HELLP syndrome, Eclampsia</p> Signup and view all the answers

    In cases where the gestational age is less than _____ weeks, pregnancy should be continued until 34 weeks.

    <p>34</p> Signup and view all the answers

    Match the emergency condition with its related action for management:

    <p>HELLP syndrome = Terminate pregnancy Impending eclampsia = Terminate pregnancy Fetal distress = Terminate pregnancy Gestational Age ≥ 34 weeks = Induction of labor</p> Signup and view all the answers

    What is the frequency of non-stress tests for a patient with severe pre-eclampsia?

    <p>Alternate day</p> Signup and view all the answers

    Umbilical artery Doppler should be conducted only for severe pre-eclampsia cases.

    <p>False</p> Signup and view all the answers

    At what week should fetal monitoring start for mild pre-eclampsia?

    <p>32 weeks</p> Signup and view all the answers

    Termination of pregnancy is recommended at ______ weeks for managing both mild and severe cases of pre-eclampsia.

    <p>34</p> Signup and view all the answers

    Match the following findings with their characteristics in relation to PIH:

    <p>S/D ratio of umbilical artery ≥ 3 = Indicative of increased placental resistance Absent end diastolic flow = Suggests compromised blood flow Reversed end diastolic flow = Indicates severe utero-placental insufficiency</p> Signup and view all the answers

    Which type of eclampsia has the worst prognosis?

    <p>Antepartum</p> Signup and view all the answers

    Atypical eclampsia seizures can occur less than 20 weeks into pregnancy.

    <p>True</p> Signup and view all the answers

    What imaging technique is used for the initial investigation of atypical eclampsia?

    <p>MRI</p> Signup and view all the answers

    Gestational hypertension is diagnosed when blood pressure is equal to or greater than ______ mmHg.

    <p>160/110</p> Signup and view all the answers

    Match the type of eclampsia with its occurrence period:

    <p>Antepartum = During antenatal period Intrapartum = During labor Post Partum = After delivery within 48 hours</p> Signup and view all the answers

    Study Notes

    Risk Factors for Preeclampsia

    • Primigravida: women pregnant for the first time
    • New paternity: the father is having a child for the first time
    • Long interpregnancy interval: time between pregnancies is long
    • Increased placental tissue:
      • Placentomegaly: abnormally large placenta
      • Twin pregnancy
      • Diabetic patients
      • Rh negative pregnancy
      • Molar pregnancy: early onset preeclampsia

    Events in Normal Pregnancy

    • Extravillous trophoblast: plays a major role in remodeling spiral arteries during pregnancy.
      • Phase 1 (12 weeks): Trophoblast invades and replaces the lining of the decidual segment of the spiral artery.
      • Phase 2 (16-20 weeks): Trophoblast invades and replaces the lining of the myometrial segment of the spiral artery.
    • NK Cells assist in remodelling.

    Pathophysiology of Preeclampsia

    • Incomplete trophoblastic invasion:
      • There is incomplete invasion in phase 1 and phase 2
      • Results in high resistance in spiral arteries and decreased blood flow to the intervillous space.
      • Placental ischemia: reduced blood flow to the placenta

    Medical and Surgical Complications in Pregnancy

    • Placenta is the primary factor
    • Termination of pregnancy is the definitive treatment
    • The first organ involved in preeclampsia is the maternal kidney.
      • Glomeruloendotheliosis: damage to the blood vessels in the kidneys
      • Increased blood pressure and reduced renal blood flow (RBF)
      • Decreased glomerular filtration rate (GFR)
      • Impaired kidney filtering capacity
      • Elevated urea, uric acid, and serum creatinine.
      • Serum creatinine levels ≥ 1.1 mg/dL indicate end-organ damage

    Cerebrovascular Pathology

    • Leaky capillary endothelium of the brain:
      • Cerebral edema: swelling of the brain
      • Hypoxia: lack of oxygen in the brain
      • Release of excitatory neurotransmitters
      • Eclampsia: convulsions
    • Loss of cerebral autoregulation:
      • Cerebral hyperperfusion: increased blood flow to the brain
      • Severe headache: throbbing and intense.
      • Visual disturbances: involving the occipital lobe

    ACOG Recommendations for Hypertensive Mothers

    • APLA syndrome: antiphospholipid antibody syndrome

    • Chronic hypertension

    • Multifetal pregnancy

    • Kidney disease

    • Diabetes

    • Low dose aspirin therapy:

      • Start at 12 weeks, no later than 16 weeks.
      • End at 36 weeks.
      • Dose: 80-150 mg

    Predictors of PIH

    • New predictors:
      • Elevated sFLT-1: a marker of placental stress
      • Elevated s.Endoglin: another marker of placental stress
      • Decreased VEGF: a key factor in blood vessel formation
      • Decreased placental growth factor
    • Outdated predictors:
      • Giants roll over test
      • Angiotensin II challenge test
    • Others:
      • Uterine artery Doppler (UAD): assesses blood flow in the uterine arteries

    Uterine Artery Doppler

    • Normal pregnant female:
      • Diastolic notch present: a normal finding in the waveform.
      • Decreased PVR (pulsatility variance ratio) as pregnancy progresses.
      • Notch disappears by 20-22 weeks.
    • Abnormal findings:
      • Persistence of diastolic notch
      • Increased pulsatility index (PI)
      • Increased resistance index (RI)

    Period of Gestation

    • To predict preeclampsia: 22-24 weeks
    • To predict early onset preeclampsia: 11-13 weeks
      • Pulsatility index (PI)
      • Resistance index (RI)

    Impending Eclampsia

    • Severe headache (70%)
    • Epigastric pain
    • Visual disturbances
    • Management:
      • Magnesium sulfate (MgSO4): to prevent seizures
      • Antihypertensive drugs: to lower blood pressure

    Visual Disturbances in Pre-eclampsia (PE)

    • Blurred vision
    • Scotoma: blind spot in the visual field
    • Diplopia: double vision
    • Blindness: 10-15% of severe PE cases, usually reversible.
      • Exception: retinal artery occlusion or retinal detachment

    Causes of Visual Disturbances

    • Occipital blindness (amaurosis fugax): temporary loss of vision in one eye
    • Cerebral infarct: stroke in the brain
    • Retinal ischemia and detachment: lack of blood flow and detachment of the retina
    • Retinal infarction (Purtscher retinopathy): blockage of blood vessels in the retina.

    Classification of Hypertensive Retinopathy

    • Keith-Wagner classification

    Eclampsia with Fetal Distress

    • Stepwise Management:

      • Check fetal heart sound (FHS)
      • If fetal distress present: rule out abruptio placentae
      • If FHS becomes normal: continue eclampsia management.
      • Cesarean section: if necessary

    • Mode of Delivery:

      • Vaginal delivery
      • Cesarean section: if needed

    • Anesthesia: General anesthesia

    Indications for Cesarean Section

    • Presence of obstetrical indications
    • Eclampsia with fetal distress

    Placental Ischemia

    • Effects:
      • Decreased size of the placenta
      • Uteroplacental insufficiency
      • Decreased blood supply to the fetus
      • Intrauterine growth restriction (IUGR): fetus is not growing properly
      • Brain sparing effect: increased blood flow to the fetal brain
      • Reduced renal blood flow
      • Oliguria: decreased urine production
      • Oligohydramnios: low levels of amniotic fluid

    Release of mediators into maternal blood

    • Increased Vasoconstrictors*

    • sFLT: a potent anti-angiogenic factor

    • s.Endoglin: another anti-angiogenic factor

    • ILs: inflammatory cytokines.

    • TNF α: inflammatory cytokine.

    • Thromboxane A2: vasoconstrictor

    • Increased sensitivity to angiotensin enzyme

    • Antiangiogenic factors: prevent the formation of new blood vessels

    • Decreased Vasodilators*

    • VEGF: a key factor in blood vessel formation

    • Placental growth factor: another factor that promotes blood vessel growth.

    • NO: nitric oxide, a potent vasodilator.

    • Prostacyclin I2: a potent vasodilator.

    • Angiogenic factors: promote blood vessel formation and growth.

    • Reduced activity of angiotensinase enzyme: an enzyme that breaks down angiotensin

    Mechanism

    • Release of mediators: triggers a cascade of events, leading to vasoconstriction.
    • Vasoconstriction: causes an increase in blood pressure, first clinical manifestation of preeclampsia.
    • Endothelial injury: vessels become leaky
    • Fluid accumulation in the 3rd space: pathological edema, ascites
    • Virchow triad: Increased risk of thrombosis and end organ damage: Multiple organ failure.

    Management of PIH

    Investigations

    • Admit all PIH cases
    • Take a detailed history
    • Liver function tests (LFT)
    • Serum creatinine (S.Creat)
    • Platelet count
    • Lactate dehydrogenase (LDH)
    • Lab tests: to assess organ function and presence of complications
    • Fundal examination: to assess the uterus
    • Peripheral Blood Smear: to look for schistocytes, a sign of red blood cell damage
    • Check for:
      • Blood pressure > 160/110 mmHg.
      • Signs of end organ damage

    Definitive Management: Termination of Pregnancy (Induction of labour)

    • **Conditions | Termination of Pregnancy at **

      • Mild pre-eclampsia | 37 weeks
      • Severe pre-eclampsia | 34 weeks
      • Eclampsia | Immediate, irrespective of gestational age
      • Impending eclampsia | Immediate, irrespective of gestational age
      • HELLP syndrome | Immediate, irrespective of gestational age
      • PIH with fetal distress | 37-38 weeks
      • PIH with abruption | 37 weeks
      • Chronic HTN | 37 weeks
      • Chronic HTN with superimposed PE | Immediate, irrespective of gestational age

    • Severe PE: Remain admitted

    • Mild PE: Managed on OPD basis

    Management of Severe Pre-eclampsia/PE with Severe Features

    • Treated Inpatient:

      • Evaluation: lab investigations + fundal examination
      • Treatment:
        • MgSO₄: to prevent seizures
        • Anti-HTN: to prevent intracranial hemorrhage
        • Corticosteroid: first dose

    • Emergency Conditions:

      • Terminate Pregnancy: after the first dose of corticosteroids
        • Conditions:
          • HELLP syndrome
          • Impending eclampsia
          • Eclampsia
          • Fetal distress
          • Placental abruption
          • DIC: Disseminated Intravascular Coagulation.
          • Pulmonary edema: fluid in the lungs

    • No Emergency Conditions:

      • Evaluate conditions

      • Complete corticosteroid course

      • Gestational Age < 34 weeks: continue pregnancy until 34 weeks.

      • Gestational Age ≥ 34 weeks: Induce labor.

      • Additional Considerations:

        • Fetal monitoring + umbilical artery doppler
        • Continue anti-HTN
        • Complications: Abruptio placentae (most common)
        • Termination of pregnancy in mild/severe PE:
          • Mode of delivery: Vaginal
          • Cesarean Section: Only for obstetrical indications
          • Anesthesia: Neuraxial (e.g., epidural)

    Management of Eclampsia

    • Algorithm:
    • Step 1: Patient with convulsions:
      • Raising bed rails
      • Secure airway
    • Step 2: MgSO₄: to treat convulsions.
    • Step 3: Anti-HTN: IV route
    • **Definitive Management: ** Termination of pregnancy (TOP): irrespective of gestational age

    Monitoring in Pregnancy-Induced Hypertension (PIH)

    Fetal Monitoring Tests

    • Test | Mild Pre-eclampsia | Severe Pre-eclampsia
      • Daily fetal movement count | Daily | Daily
      • Non-stress test | Weekly | Alternate day
      • Biophysical score | Weekly | Alternate day
      • USG for fetal growth | Every 3 weeks | Every 2 weeks
      • Umbilical artery doppler | Should be done | Should be done

    Umbilical Artery Doppler: Findings in PIH and Utero-Placental Insufficiency

    • **Finding | **
      • S/D ratio of umbilical artery ≥ 3 |
      • Absent end diastolic flow |
      • Reversed end diastolic flow |

    Termination of Pregnancy

    • **Weeks | **
      • 37 |
      • 33-34 |
      • 31-32 |

    Management of Mild Pre-eclampsia/PE Without Severe Features (OPD Basis Treatment)

    • Approach:

      • BP monitoring: twice daily
      • Fetal monitoring: start at 32 weeks
      • Treatment:
        • Antihypertensives: if blood pressure ≥ 160/110 mmHg: IV (ACOG)
        • Antihypertensives: if blood pressure ≥ 150/100 mmHg and < 160/110 mmHg: oral (NICE)
      • Education: education on signs and symptoms of impending eclampsia.
      • No Role of:
        • Aspirin
        • Bed rest
        • Salt reduction
        • $MgSO_4$

    • Definitive Management: For both mild and severe cases, terminate pregnancy at 34 weeks (Induce labor).

    Eclampsia

    • Definition: severe pre-eclampsia + Generalised tonic clonic seizures
    • Types:
      • Antepartum: before delivery (most common, worst prognosis)
      • Intrapartum: during labor.
      • Postpartum: within 48 hours of delivery.

    Atypical Eclampsia

    • Signs:

      • Onset of Seizure:

        • 48 hours after delivery

        • < 20 weeks pregnancy
      • Prolonged loss of consciousness
      • Imaging of choice: MRI. In posterior reversible encephalopathy, edema is localized to the posterior cerebral hemisphere.

    • Note: Gestational Hypertension:

      • 50% of gestational HTN cases.
      • If gestational HTN and BP ≥ 160/110 mmHg: manage like severe PE.
      • The first antenatal visit after 20 weeks: if pregnant woman is hypertensive, and HTN status is unknown.
      • No proteinuria or signs of end organ damage.

    • Provisional diagnosis: Gestational Hypertension

    • Recheck BP After 12 weeks of delivery:

    • BP (Normal values)- Gestational HTN/Transient HTN in pregnancy.

    • BP (Still raised): Revised diagnosis → Chronic HTN.

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    Description

    Test your knowledge on Pregnancy-Induced Hypertension (PIH) and associated placental conditions. This quiz covers risk factors, conditions linked to placental tissue, and symptoms associated with PIH. Engage with matching questions and explore the pivotal role of extravillous trophoblast in normal pregnancy.

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