PIH management

Management:
Definitive management of PIH: always it is
termination of pregnancy (delivery)

Condition Time of Mode of

delivery delivery
Mild PE 37 weeks of Vaginal
pregnancy
Severe PE 34 weeks of Vaginal
pregnancy
Eclampsia or Immediate vaginal
HELLP syndrome termination of
pregnancy
irrespective of
gestational age
PE = preeclampsia

Detailed management of mild PE:

Mild PE: BP > 140 / 90 but < 160 / 110
Role of anti-hypertensive: +/-
Bcoz here BP is not much high.
Definitive management: termination of pregnancy

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Detailed management of severe PE:

BP > 160 / 110
Due to this high BP, there is chances of intra
cranial BP.
So we have to high anti hypertensive.
Labetalol is DOC.
There are increased chances of eclampsia.
To prevent and treat convulsion MgSO4 is given.
Termination of pregnancy – delivery.

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Anti hypertensive in pregnancy:

safe Contra indicated

Labetalol ACE inhibitors

( α + β blocker )
Orally 100 mg BID or TDS
Max = 300 mg
α methyl dopa Diuretics
250 – 500 mg TDS
Max = 2g
Hydralazine Beta blockers
Nifedipine Diazoxide
Nitroglycerine losartan
Sodium nitroprusside

DOC for PIH / PE in pregnancy: Labetalol

DOC for chronic HTN in pregnancy: Labetalol, α
methyl dopa
DOC for HTN crisis in pregnancy: IV Labetalol, IV
hydralazine, IV nifedipine.

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Dose of IV Labetalol:
Maximum IV dose 220 mg.
20 mg in 10 minutes
↓
40 mg in 10 minutes
↓
80 mg in 10 minutes
↓
80 mg in 10 minutes

Dose of IV hydralazine
Maximum dose 30 mg
5 -10 mg IV repeat after every 10 minutes.

DOC for refractory HTN:

Sodium nitroprusside

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Detailed management of eclampsia;

1st step: airway management
2nd step: drug to treat convulsion MgSO4
3rd step: control her BP:- iv Labetalol
Definitive management: termination of pregnancy
immediately.

MgSO4:
DOC for preventing and treating eclampsia.
It is not an anti hypertensive drug.
It is not an anti epileptic drug.
Don’t use in Normotensive people with convulsion.

Mechanism of action:
It acts on brain
Blocks NMDA receptors
Brings vasodilatation in brain

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It blocks calcium channel.

Therapeutic range: 4 – 7 mEq / L
(1.8 – 3.5 mmol/L)

Regimes for giving MgSO4

IM and IV: PRITCHARD regime: leads to gluteal
abcess
IV: SIBAI regime
IV: ZUSPAN regime

Pritchard regime:
Loading dose:
IV 4 mg of mgso4 slowly
+
IM 10 mg of mgso4 (5gm in each buttock)
Then, every 4 hours maintenance dose  till 24
hours after delivery or till 24 hours after last
convulsion, whichever is later
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Maintenance dose: 5 gm IM mgso4 on alternate

buttock

Prior to maintenance dose:

Knee jerk
Urine output > 30 ml/hr
Respiratory rate > 14/min
SpO2 > 96%
If this 4 sign are present than give maintenance
dose otherwise wait for next 4 hours and again
check for this 4 signs and then give dose.

Signs and symptoms of MgSO4 toxicity:

Loss of knee jerk
Loss of deep tendon reflexes
Slurring of speech
Diaphoresis – excessive sweating
Respiratory difficulty
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Respiratory arrest ( 15 mEq/L)

Cardiac arrest ( 30 mEq/L)

MgSO4 toxicity DOC: Calcium gluconate

SIBAI regime:
IV MgSO4
Loading dose: 6 gm in 100 mL of NS in 15-20 min
Maintenance: 2 gm/hr

ZUSPAN regime:
IV MgSO4
Loading: 4 gm
Maintenance: 1 gm

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Status eclampticus:
After giving MgSO4, convulsion is not controlled.
DOC for status eclampticus: thiopentone sodium

Predictive test for PIH;

MOST currently used test is: uterine artery Doppler

Uterine artery Doppler: two phase (see image)

Systolic phase
Diastolic phase
Notch in diastolic phase is called diastolic notch.
This notch normally disappears by 24 weeks of
pregnancy.
If this diastolic notch persist after 24 weeks of
pregnancy it predicts that female is going to have
PIH in future.

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Giant roll over test: outdated

Upcoming tests:
PAPPA test: pregnancy associated plasma protein
A test
VEGF test: Helps in trophoblastic
invasion
Placental growth factor:

The following are finding in PIH;

Hemoconcentration
Edema
Increased uric acid

Drug to prevent PIH;

ASPIRIN 75 mg – 150 mg / day
Calcium supplementation
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Calcium helps in only those women who have less

calcium in blood.

Following have no role in preventing PIH;

Dietary salt restriction
Rest
Fish oil
Anti oxidants

HELLP syndrome:
Hemolysis
Elevated liver enzymes
Low platelet count
First described by WEINSTEIN
Complication of severe preeclampsia
BP is increased in most of the patients, but in 15%
cases BP is normal
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Maternal mortality: 1-5%

Recurrence rate: 2-5 %

Hemolysis:
Microangiopathic hemolytic anemia.
RBC is destroyed
Peripheral blood smear: fragmented RBC
Reticulocyte count is increasing
LDH is raised >600 IU
Raised in bilirubin level
Bilirubin bind to heptoglobin and excreted
Decreased level of heptoglobin

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This is TENESSE criteria for diagnosing HELLP

syndrome:
SGOT / SGPT > 70 IU / L
Platelet count: < 1 lac
LDH > 600 IU

Classification of HELLP syndrome: given by

mississipi

class II
class I severe class III mild
moderate
platelet count < 50 000 > 1 00 000
50,000 same same
SGOT/SGPT >70 same same
IU

LDH > 600 IU

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Management of HELLP syndrome:

Anti hypertensive + mgso4
Definitive management: immediate
termination of pregnancy
> 34 weeks of pregnancy: no problem
< 34 weeks of pregnancy: give corticosteroid and
wait for 24-48 hour, then delivery.

D/D of pregnancy: acute fatty liver of pregnancy.

Acute fatty liver of pregnancy:

In Fetus there is deficiency of enzyme – LCHAD
This enzyme responsible for oxidation of long
chain fatty acid
During pregnancy mother will use her LCHAD
enzyme for oxidation of long chain fatty acid of
fetus.

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So, during pregnancy mother will develop

deficiency of LCHAD.
So long chain fatty acid accumulate in the mothers
liver.
Patient will present in the 3rd trimester, sign and
symptoms are similar to HELLP syndrome.
Characteristic feature of acute fatty liver of
pregnancy:
Hypoglycemia
Hepatorenal syndrome
DIC (prothrombin time prolonged)
Secondary complication like pancreatitis
Management: termination of pregnancy.

Indication for immediate termination of pregnancy

irrespective of gestational age;
Eclampsia
Fetal distress / placental abruption
Uncontrolled BP or rising S creatinine levels
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HELLP syndrome
Reversal of end diastolic flow in umbilical artery
Doppler

Doppler of umbilical artery:

In normal pregnancy: as pregnancy advances –
resistance in umbilical artery decreases – so blood
volume during diastolic is increasing. As pregnancy
advances S-D ratio decreases.

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In PIH: resistance in vessels is high, amount of

blood coming to blood vessels during diastole will
decreases.
Lead to high S-D ratio.

If resistance is very high – there is no blood volume

during diastole, called absent end diastolic flow. In
this condition go for termination of pregnancy @
34 weeks.

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If resistance becomes too high – there is back flow

of blood during diastole, this is called as reverse
diastolic blood. Go for immediate termination of
pregnancy.

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