Obstetrics Marrow Pg 395-404 (Medical & Surgical complication of Pregnancy)

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Questions and Answers

Which of the following is considered a risk factor related to being a primigravida?

Singleton pregnancy

New paternity (correct)

Short interpregnancy interval

Previous pregnancy complications

New paternity is a risk factor for pregnant women exposed to the placenta for the first time.

True

What placental condition is associated with twin pregnancies?

Placentomegaly

A woman with a ______ pregnancy is at higher risk for placentomegaly.

twin Signup and view all the answers

Match the condition with its associated risk factor:

Primigravida = Risk due to first-time pregnancy Diabetic patient = Increased placental tissue Molar pregnancy = Early onset PE Rh negative pregnancy = Associated with placentomegaly Signup and view all the answers

What is the first organ involved in pregnancy-induced hypertension (PIH)?

Maternal kidney Signup and view all the answers

Increased blood pressure during pregnancy is primarily associated with increased renal blood flow.

False Signup and view all the answers

What condition is indicated by a serum creatinine level of ≥ 1.1 mg/dL?

End-organ damage Signup and view all the answers

Cerebral ________ occurs due to excessive blood flow to the brain.

hyperperfusion Signup and view all the answers

Match the following pathological processes with their descriptions:

Glomerulo endotheliosis = Narrowing or blockage in kidney blood vessels Oliguria = Decreased urine output Cerebral edema = Swelling of brain tissue Eclampsia = Severe convulsions during pregnancy Signup and view all the answers

What is a common treatment for impending eclampsia?

Magnesium sulfate (MgSO₄) Signup and view all the answers

Visual disturbances are uncommon in patients with pre-eclampsia.

False Signup and view all the answers

What percentage of severe pre-eclampsia cases may result in blindness?

10-15% Signup and view all the answers

The classification for hypertensive retinopathy is via the ______ Classification.

Keith-Wegner Signup and view all the answers

Match the following sign or symptom with its description:

Severe headache = Management: Magnesium sulfate + Anti-hypertensive drugs Epigastric Pain = Often due to Subcapsular hematoma Cerebral infarct = A possible cause of vision problems Visual disturbances = Includes symptoms like blurring of vision and diplopia Signup and view all the answers

Which of the following drugs is NOT a first-line drug for severe hypertensive crisis?

Methyldopa Signup and view all the answers

Oral Nifedipine can be administered sublingually for treating hypertension.

False Signup and view all the answers

What is the target diastolic blood pressure for managing hypertension in pregnancy?

80-90 mmHg Signup and view all the answers

The maximum dose of Labetalol for IV administration is ______ mg.

220 Signup and view all the answers

Match the following drugs with their administration routes:

Labetalol = IV Hydralazine = IV Methyldopa = Oral Nifedipine = Oral Signup and view all the answers

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

34 weeks Signup and view all the answers

Immediate termination of pregnancy is required for eclampsia, regardless of gestational age.

True Signup and view all the answers

List two investigations that should be done for all cases of pregnancy-induced hypertension (PIH).

Liver Function Tests (LFT), Serum Creatinine. Signup and view all the answers

Pregnancy-induced hypertension may lead to serious conditions such as _____ syndrome.

HELLP Signup and view all the answers

Match the following conditions with their recommended termination of pregnancy timing:

Mild pre-eclampsia = 37 weeks Severe pre-eclampsia = 34 weeks PIH with fetal distress = 37-38 weeks Chronic HTN with superimposed PE = 37 weeks Signup and view all the answers

What is the primary use of Magnesium Sulphate in pregnant females?

Prevention and treatment of seizures Signup and view all the answers

Magnesium Sulphate acts on NMDA receptors to increase oxidative stress.

False Signup and view all the answers

What is the therapeutic range for Magnesium Sulphate?

4 to 7 mg Signup and view all the answers

The contraindicated antihypertensives in pregnancy include ACE inhibitors, ARBs, and _____ blockers, except for Labetalol.

beta Signup and view all the answers

Match the following magnesium sulfate regimens with their respective doses:

Intramuscular Loading Dose = 10 gms of 50% MgSO₄ Intravenous Loading Dose = 4 gms of 20% MgSO₄ Intramuscular Dose Preparation = 1 ampoule of MgSO₄ in 2 ml IV Dose Preparation = 4 ampoules of MgSO₄ + 1 ml NS Signup and view all the answers

What is the first clinical sign of placental ischemia related hypertension after 20 weeks of pregnancy?

Increased blood pressure Signup and view all the answers

The brain sparing effect refers to decreased blood flow to the brain during placental ischemia.

False Signup and view all the answers

What are the components of Virchow's triad that increase the risk of thrombosis in placental ischemia?

Thrombosis, stasis, and endothelial injury. Signup and view all the answers

Decreased blood supply to the fetus due to uteroplacental insufficiency can result in ______.

IUGR (Intrauterine Growth Restriction) Signup and view all the answers

Match the mediator changes in maternal blood with their effects:

Increased Vasoconstrictors = Increased blood pressure Decreased Vasodilators = Pathological edema Endothelial injury = Leaky capillaries Platelet activation = Thrombosis Signup and view all the answers

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

Alternate day Signup and view all the answers

Fetal monitoring begins at 34 weeks for mild pre-eclampsia.

False Signup and view all the answers

What is the target systolic blood pressure that indicates the need for antihypertensives in pregnancy?

≥ 160 mmHg Signup and view all the answers

The S/D ratio of umbilical artery being greater than or equal to ______ is a finding in PIH.

3 Signup and view all the answers

Match the type of pregnancy complication with its respective management frequency:

Mild Pre-eclampsia = Weekly biophysical score Severe Pre-eclampsia = Every 2 weeks USG for fetal growth Signup and view all the answers

What is the first treatment administered for convulsions in eclampsia management?

MgSO4 Signup and view all the answers

The only mode of delivery indicated for patients with severe pre-eclampsia is cesarean section.

False Signup and view all the answers

Name one condition that requires the termination of pregnancy in severe pre-eclampsia.

HELLP syndrome Signup and view all the answers

To manage complications during pregnancy with severe pre-eclampsia, one must administer ______ to help prevent seizures.

MgSO4 Signup and view all the answers

Match the emergency condition with its management approach:

Gestational Age < 34 weeks = Continue pregnancy until 34 weeks HELLP syndrome = Terminate pregnancy immediately Eclampsia = Definitive management is termination of pregnancy Fetal distress = Terminate pregnancy immediately Signup and view all the answers

What is the recommended medication dosage for hypertensive mothers?

80-150mg Signup and view all the answers

The diastolic notch in a normal pregnant female disappears around week 18.

False Signup and view all the answers

At what gestational age should medication for hypertensive mothers be started?

12 weeks Signup and view all the answers

The presence of _____ is an indicator of early onset pre-eclampsia.

Pulsatility index Signup and view all the answers

Match each predictor of pregnancy-induced hypertension (PIH) with its description:

Persistence of diastolic notch = Predictor on UAD ↑ Pulsatility Index = Predictor of early onset PE ↑ Resistance Index = Predictor on UAD SFLT-1: PL growth factor = New predictor of PIH Signup and view all the answers

Study Notes

Factors Affecting PIH

Risk factors: Primigravida, new paternity, long interpregnancy interval, Placentomegaly, molar pregnancy
Placental tissue increased: Twin pregnancy, diabetic patient, Rh negative pregnancy.
Molar pregnancy: early onset PE

Impending Eclampsia

Severe headache, epigastric pain, visual disturbances, TOP after stabilization regardless of gestational age
Visual disturbances: Blurring of vision, scotoma, diplopia, occipital blindness (Amaurosis fugax)
Causes of vision problems: Retinal ischemia and detachment, Purtscher Retinopathy
Blindness: Reversible in many cases, retinal artery occlusion or retinal detachment are exceptions

Eclampsia with Fetal Distress

Management: Check fetal heart sound (FHS), rule out abruptio placentae, Cesarean Section +/-

PIH Main Factor

Placenta

Definitive Treatment

Termination of pregnancy

First Organ Involved

Maternal kidney

Pathological Processes

Glomerulo endotheliosis: Narrowing or blockage in the blood vessels of the kidney's glomeruli
Increased Blood Pressure (↑BP): Decreased blood flow to kidneys.
Decreased Renal Blood Flow (↓RBF): Reduced blood flow to the kidneys.
Decreased Glomerular Filtration Rate (↓GFR): Reduced ability of the kidneys to filter waste products.
Oliguria: Decreased urine output.
Increased filtering capacity of kidney: Leads to elevated Urea, uric acid, and creatinine.
Note: Serum creatinine ≥ 1.1 mg/dL indicates end-organ damage.

Cerebrovascular Pathology

Leaky capillary endothelium of brain: Cerebral edema, induced hypoxia, release of excitatory neurotransmitters, eclampsia/convulsions.
Loss of cerebral autoregulation: Cerebral hyperperfusion
Symptoms: Throbbing/severe headache, visual disturbances.

Antihypertensives in PIH

Indications: BP < 160/110 mm Hg, NICE Guidelines: ≥ 150/100 mm Hg persistently.
Target BP: Systolic: 130-140 mmHg, Diastolic: 80-90 mmHg.

Drugs for PE

1st line drugs: Labetalol, Hydralazine, Nifedipine.
Other: Verapamil, Nitroglycerine, Ketanserin, Nimodipine
Severe PE/Hypertensive crisis: IV Anti HTN drugs.
Labetalol (IV Route): 20mg IV → Check BP in 15 min → 40mg. Maximum dose: 220 mg. Contraindicated in bradycardia and asthma.
Hydralazine (IV Route): 5mg IV → 20 min → 10mg IV. Maximum dose: 30 mg.
Oral Nifedipine (Not Sublingual):

Drugs for Chronic Hypertension

First line drugs (Oral Route): Methyldopa, Labetalol, Nifedipine

Magnesium Sulphate

Use: Prevention and treatment of seizure in a hypertensive pregnant female.
Mechanism of Action (MOA): Centrally acting drugs, acts on NMDA receptors → ↓ cerebral edema, ↓ Oxidative Stress, Stabilizing membrane potential.
Therapeutic Range: 4 to 7 mg (Narrow therapeutic range)

Pritchard Regimen

Loading Dose (IM): 10 gms of 50% MgSO₄ (5 gms in each buttock).
Loading Dose (IV): 4 gms of 20% MgSO₄.

Contraindicated Antihypertensives in pregnancy

ACE Inhibitors, Diazoxide, Diuretics, ARBs, β-blockers (except: Labetalol)

Pregnancy Induced Hypertension: Part 3

PIH Management: Proper history taken, LFT, S.Creat, Platelet Count, LDH, Lab tests, Fundal examination, Peripheral Blood Smear,
Check for BP > 160/110 and signs of end organ damage.
Definitive Management: Termination of pregnancy

Management of PIH by Gestational Age

Mild pre-eclampsia: 37 weeks
Severe pre-eclampsia: 34 weeks
Eclampsia, Impending eclampsia, HELLP syndrome, PIH with fetal distress, PIH with abruption: Immediate termination regardless of gestational age
Chronic HTN: 37 weeks
Chronic HTN with superimposed PE: 37 weeks

Placental Ischemia

Decrease in Placental Size -> Uteroplacental Insufficiency -> Decreased Blood Supply to Fetus -> IUGR (Intrauterine Growth Restriction)

Increased mediators in maternal blood

**Increased: ** SFLT (soluble FMS-like tyrosine kinase), S.Endoglin, ILS, TNF α, Thromboxane A2, sensitivity to angiotensin enzyme, antiangiogenic factors
Decreased: VEGF, Placental growth factor, NO, Prostacyclin I, activity of angiotensinase enzyme

Maternal Blood Release of Mediators Outcomes

Vasoconstriction -> Increased Blood Pressure (1st clinical sign of PIH after 20 weeks)
Endothelial Injury -> Leaky Capillaries -> Fluid Accumulation in 3rd Space (Pathological Edema, Ascites)
Inside the Vessel: Hemoconcentration, Stasis of blood flow, Platelet activation and aggregation, Endothelial injury
Virchow's Triad (Increased Risk of Thrombosis): Thrombosis, End Organ Damage (Possible Multiple Organ Failure).

Medical and Surgical Complications: Monitoring in PIH

High risk pregnancy
Fetal monitoring starts from 32 weeks
Daily fetal movement count
Non stress test
Biophysical score
USG for fetal Growth
Umbilical artery doppler

Umbilical Artery Doppler: Findings in PIH and utero-placental insufficiency

Abnormal Findings: S/D ratio of umbilical artery ≥ 3, Absent end diastolic flow, Reversed end diastolic flow.

Termination of Pregnancy

Mild/Severe PE: Vaginal delivery preferred, Cesarean section only for obstetrical indication
Anesthesia: Neuraxial anesthesia > Epidural anesthesia

Management of Mild Pre-eclampsia/PE without Severe Features

OPD Basis Treatment: BP monitoring twice daily, fetal monitoring starting at 32 weeks, education on signs and symptoms of impending eclampsia, Antihypertensives if:
- ≥ 160/110 mmHg: IV
- ≥ 150/100 mmHg &

Management of Severe Pre-eclampsia/PE with Severe Features

Treated Inpatient: Evaluation: Lab investigation + Fundal examination, Treatment MgSO4, Anti HTN, Corticosteroid (First dose)
Prevent: Seizures, Intracranial hemorrhage
Terminate Pregnancy (After 1st dose): Evaluate Conditions:
- No emergency conditions: Complete corticosteroid course
- Emergency conditions:
 - Gestational Age < 34 weeks: Continue pregnancy till 34 weeks
 - Gestational Age ≥ 34 weeks: Induction of labor

Conditions requiring termination of pregnancy:

HELLP syndrome, Impending eclampsia, Eclampsia, Fetal distress, Placental abruption, DIC, Pulmonary edema

Management of Eclampsia

Management Algorithm:
- Step 1: Patient with Convulsions → Raising bed rails/ Airway management
- Step 2: MgSO4 (To treat Convulsions)
- Step 3: Anti-HTN (IV Route)
- Definitive Management: Termination of Pregnancy (TOP) - Irrespective of Gestational age
Additional Notes: Fetal monitoring, Umbilical artery Doppler, Continue Anti-HTN

ACOG Recommendation for Hypertensive Mothers

Mnemonic: All hypertensive mothers can die
Diseases: APLA syndrome, Chronic HTN, Multifetal pregnancy, Kidney disease, Diabetes.
Medication: Give low dose of medication (80-150mg, 1 tab: 75mg)
Start: At 12 weeks, (not later than 16 weeks)
End: At 36 weeks.

Predictors of PIH

New predictors: ↑ SFLT-1, ↑ S.Endoglin, ↓ VGEF, ↓ Placental growth factor. SFLT-1: PL growth factor (Best)
Outdated predictors: Giants roll over test, Angiotensin II challenge test
Others: Uterine artery doppler (UAD)

Uterine Artery Doppler

In a normal pregnant female: The diastolic notch is present initially. As pregnancy progresses, the Peak Velocity Ratio (PVR) decreases. The notch disappears around week 20-22.
Predictors of PIH: Persistence of diastolic notch, ↑ Pulsatility Index, ↑ Resistance Index
Period of Gestation: 22-24 weeks (to predict PIH), 11-13 weeks (Pulsatility index and Resistance index are used to predict early onset PE)

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Description

This quiz covers crucial topics related to pregnancy-induced hypertension (PIH) and eclampsia, including their risk factors, symptoms, and management strategies. Learn about the clinical signs of impending eclampsia and the definitive treatments available, as well as the role of the placenta in these conditions.