toxaemiapregnancy - Dr. Mehdi Hasan Mumtaz

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HYPERTENSIVE DISEASE OF
PREGNANCY
Prof. Mehdi Hasan Mumtaz
1
MATERNAL PHYSIOLOGY

Anaemia.

Hyperventilation.

Hypovolaemia.

Hyper-coagubility.
2
HYPERTENSIVE DISEASE OF
PREGNANCY

Pre-eclampsia.

Eclampsia.

HELLP syndrome.
3
PRE-ECLAMPTIC TOXEMIA
(PET)
TRIAD

Hypertension.

Proteinurea.

Oedema.
4
SEVERE-PRE-ECLAMPSIA
Definitions
 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.
SPB
=
DBP
=
PROTEINUREA
OR
>
170
>
110
>0.5 G/24h OR > 2+ URINE ANALYSIS.
5
HAEMODYNAMIC FINDINGS
Severe Pre-eclampsia
 Low plasma volume.
 Low /Normal CO.
 Low/ Normal CVP/PCWP.
 myocardial contractility.
 Low COP.
6
ECLAMPSIA

Hypertension.

Protein urea.

Oedema.

Convulsion.
7
HELLP SYNDROME
“Mos severe end of pre-eclamptic
condition”
 H – Haemolysis.
 EL -  Liver enzyme.
 LP -  Platelet count.
“Additional: Haemopoietic system”
“Liver involvement”
8
PATHOLOGICAL FEATURES
 Hypertension.
 Renal functions.
 Hypovolaemia.
 Hypoproteinaemia.
 Coagulation/fibrinolytic imbalance.
 Cerebral irritability.
 Placental perfusion.
9
NORMAL PREGNANCY
 Vasoconstriction
 Vasoconstriction
 Platelet aggregations
 Platelet aggregations
 Uterine activity
 Uterine activity
 Utero-placental blood flow
 Utero-placental blood flow


Prostacyclin
Thromboxane
10
PRE-ECLAMPSIA
 Vasoconstriction
 Platelet aggregations
 Uterine activity
 Utero-placental blood flow

Prostacyclin
 Vasoconstriction
 Platelet aggregations
 Uterine activity
 Utero-placental blood flow

Thromboxane
11
FLUID MANAGEMENT
“Important”
 Relatively
Low PV
Low PAWP
CO
 Endothelial damage.
 Low COP
 Excessive fluid therapy
fetal distress
oligurea
risk pulmonary
oedema
12
MANAGEMENT
 Definitive
 Delivery of baby
 Delivery of plaenta
Symptometic
 Control
 Blood pressure.
 Convulsions.
 Fluid balance
13
MANAGEMENT
SYMPTOMATIC
HIGH BLOOD PRESSURE
 Dangers:
Cerebral haemorrhage.
Pul oedema
 Objective:
DBP 90-100mmHg
<90 uteroplacentl perfusion
14
BLOOD PRESSURE
 CAUTION.
 4.5% HES 500ml preload.
Before IV anti-hypertensive.
 EXCEPTION.
 Patient post delivery.
 Who has 4.5% HES already.
 DBP >120.
15
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
16
BLOOD PRESSURE
 Labetalol.
 10-20mg boluses/15min.
 If DBP 90-100.
 Infusion 5mg/ml (0-160mg/hr).
 Ca+ channel blockers.
 Nitrates.
 Adrenergic neuron blockers.
17
ECLAMPSIA ROOM
 Indications.
1. Eclampsia.
2. Hypertension > 170/110
+
Proteinurea > 2+
3. Hypertension > 140/90
Proteinurea 2+
+
One of the symptom/signs
18
SYMPTOM/SIGNS








Headaches.
Visual disturbances.
Hyper-reflexia.
Clonus (>3beats).
Nausea & vomiting.
Epigastric pain.
Raised liver enzymes.
Thrombocytopenia<100x10/L.
19
“MONITORING”
Eclampsia Room







ECG.
NIBP.
SPO2.
Fluid balance.
Urine output.
CTG.
CVP.
20
INTRACELLULAR
INTERSTITIAL
VASCULAR
CAPILLARY
EG
CELL
OSMOLALITY
Na+
COP
21
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.
22
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 1-3g/kg/min.
 Pulmonary oedema present.


Frusemide 20mg.
Refer to ICU.
23
SEIZURE PROPHYLAXIS
“Severe pre-eclampsia”
“Controversial”
 Magnesium sulphate.
 Loading dose
4G.
 Infusion
2G/hr.
 Optimum level
2-4mmol/L.
24
MAGNESIUM SULPHATE
Blood Levels





Mgnesium
(mmol/L)
0.7-1
2-4
>5
>7.5
>10
Effect





Normal
Therapeutic range.
Loss of reflexes.
Respiratory depression
Cardiac arrest
25
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.
26
MONITORING DURING MAGNESIUM
INFUSION
 Patellar reflex.
 ECG.
 SPO2.
 Mgnesium level.
27
MANAGEMENT
MAGNESIUM TOXICITY
 Loss of patellar reflex.




Stop infusion.
Measure level.
Withold till reflex returns.
Once reflex return – 1G/h.




Give O2.
Stop maintenance dose.
Measure level.
Inform anaesthetist.




Stop infusion.
CPR.
Calcium gluconate.
Intubation/ventilation.
 SPO2 <90%.
 Cardio-respiratory arrest.
28
MAGNESIUM THERAPY
Considerations
 Tocolytic effect.
 Interaction – muscle relaxants.
 Interaction – calcium antagonists.
29
“INDICATIONS”
ICU – ADMISSION
 Severe coagulopathy or DIC.
 Recurrent seizures.
 Hypertension – poor control.
 Persistant oligurea.
 Pulmonary oedema + oligurea.
 Compromised myocardial function.
30
MANAGEMENT
Definitive
Delivery of baby
Delivery of plaenta
31
MANAGEMENT
Severe Cases
 Arrest & prevention of convulsion.




Barbituates.
Benzodiazepines.
Megnesium SO4.
Paralyse & IPPV.
 Blood pressure.
 Hypertension – vasodilatation.
 Hypotension – inotropics.
32
MANAGEMENT
Severe Cases
 Restoration of blood volume.
 Low proteins.
 Colloids.
 Colloid substitutes.
 Progressive dehydration.
 Replace out put.
 Keep BV normal.
33
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.
34
IN ICU
 B. P. < 80 Torr.
 Urine output – nil.
 Convulsions.
 Pulmonary oedema.
 Cyanosis.
35
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.
36
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.
37
IDEAL MANAGEMENT
 Routine investigations.




Hb.
HCT.
Plasma proteins.
Serum Na+ K+.
 Monitoring.





Urine output.
ECG.
BP.
Pulse
CVP.
38
HELLP SYNDROME
 H – Haemolysis.
 EL – elevated Liver enzyme activity.
 LP -  Platelet count.
“most sevre end of pre-eclamptic
condition”
39
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.
40
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.
41
MANAGEMENT
 Pre-op investigations.











Platelet count.
PCV.
Hb.
PTT.
Fibrinogen concentration.
FDP.
LFTs.
Creatinine.
Urea.
Uric acid.
X-ray chest.
42
 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.
43
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