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Hypertension in Gestation

Jan 05 | 1:30 PM

Between 5% and 10% of all pregnancies are complicated by hypertensive problems. The pathogenesis of hypertension during pregnancy is still unknown. Systolic blood pressure above 140mmHg and/or diastolic blood pressure above 90mmHg are the most prevalent physical exam results in both chronic and pregnant hypertension. Blood pressures in the severe range are above 160mmHg systolic and/or 110mmHg diastolic. Let's hear more from Dr. Girija Wagh on how she manages it.

[Music] good evening everyone um i'm dr naveda and on behalf of netflix i welcome you all uh today we have with us uh dr ghiricha work she's a highly qualified obstetrician and a gynecologist with over 29 years of experience she's currently practicing at bharti vidya university medical college and hospital as a professor and head of high-risk obstetrics and perinatology unit uh she's also a consultant gynecologist at clown cloud 9 hospitals she is a certified fertility and ivf specialist and her expertise are in high risk pregnancies and all gynecological procedures good evening everybody and it's indeed a pleasure to be here this evening with you all at the netflix and it's again a privilege to be the first presenter of this year and i hope that all of us have an extremely safe and productive year ahead of us with all the challenges that we are currently facing past that we have chosen to talk about is pre-columbian eclampsia the medical and diopside management because despite this disease being there in place for a long long period of time yet we find that there are challenges mounting increasing and we are also finding that loads and loads of women are getting affected further and more on so let's look at the learning objectives today diagnosis of the disorder clinically the differentials that we have to keep in mind essential investigations and their frequency material features surveillance emergency management and delivery decision and conduct are going to be our forte now diagnosis of pre-eclampsia actually requires a very very strong clinical suspicion the strong clinical suspicion is necessary because many times it's asymptomatic it many at times is atypical so you would have protein urea you may not have blood pressure so you have to look at the patient individually and very carefully and early detection and prompt and appropriate treatment is the key to the successful outcome of this disease now how do you define preeclampsia it's a systemic syndrome characterized by new onset of hypertension that is blood pressure more than 140 systolic and diastolic 90 on two occasions at least four hours apart and in severe cases you wouldn't be waiting for four hours to diagnose this the moment you diagnose severe hypertension 160 110 range or 1 1500 also you will start looking at this woman with care proteinuria associated especially the significant protein area where either by doing a dipstick method or by measuring the protein in the urine you could see all the protein creatine ratio which is another point of care spot test which we can embark upon when it is more than 0.3 proteins more than 5 grams in 24 urine sample which we know is the gold standard of assessment and more than 3 grams in two samples taken six hours apart from a patient who is in bed rest beyond 20 weeks of gestation in pregnant women and which resolves before the end of the sixth week postpartum typically so it is a very pregnancy specific kind of a condition and if there is no proteinuria preeclampsia may present with hypertension associated with any features of organ damage so a lot of time now we have spent in identifying protein idiopathic procedure but today we understand that it is not always essential that it would be protein india the one which results at the end of six weeks is typically preclassia and then we have eclampsia which is characterized by seizures in pregnant women with preeclampsia now many other features have to be looked into because today we see that we are looking at preeclampsia specifically the one which would have certain severe features or mild features so whenever there is hypertension developing after 20 weeks of gestation along with one or more of the following new onset conditions it would be specifically defined as pre-eclampsia has been proposed by the issp and which is very very practical at this point in time so 24-hour urine protein more than 300 milligrams per deciliter urine dipstick test more than one plus or spot urine creating ratio of more than 0.3 renal insufficiency when the creation is more than 90 micro moles per liter or more than 1 milligram because we all know that there is increased jfr so even 0.9 created in would put you on guard maternal organ dysfunction in the form of liver involvement where there are elevated trans amino acids and or severe right of a quadrant or epigastric pain neurological complications including eclampsia altered mental state blindness stroke or more commonly hyper reflexive when accompanied by clonus severe headaches and persistent visuals quota motor so you have to be very sensitive to what the patient is talking about she you may think that she's malignant you may think that she's pretending but you may have to proactively ask her these questions and look at her and hematological complications such as thrombocytopenia when the platelet counts are less than one point five that is one one lakh fifty thousand and disseminated intravascular coagulation signs or occurrence of hemolysis now uteroplacental deficiency was something which was taken away from the previous definitions but again has come back into understanding why because preeclampsia has been identified to be essentially a placental disease and many times in the indian settings and many other countries also we've observed that sometimes the patient may present to you first with the fetal growth restriction and then her blood pressure may start rising so we have to be looking at this carefully now what is important just looking at the signs and symptoms and blood pressure and urine doesn't suffice you have to do yes why because hemolysis elevated liver functions and low platelets are only laboratory diagnosis so the moment you have an abnormal hypertension or a blood pressure recording in pregnancy please feel free to do these tests because these are the tests which will clinch your diagnosis of the h-e-l-l-p syndrome which is called as hemolysis elevated liver function and low platelet count we are going to discuss more about this as we go by now why should we be on guard and about this disease burden greek lampshade rank second to hemorrhage as a specific and direct cause of maternal deaths mother of preeclampsia in later life is much at risk of developing cardiovascular disorders chronic hypertension ihd and stroke children born to mothers who have preeclampsia many a times are small for gestational age or people growth restricted and they have an increased risk of stroke coronary heart disease and metabolic syndrome during adult life much early onset and preeclampsia happens to be one of the most commonly occurring hypertensive disorders of pregnancy so if you look at the various disorders such as gestational hypertension preeclampsia small for gestational age baby and preterm deliveries as the woman goes by there would be certain predisposing risk factors such as overweight obesity diabetes and a chronic hypertension which with the pregnancy would go ahead and take her on to a risk within the 10 years of this occurrence of cardiovascular disorders or hypertension which can be chronic and this woman is at risk of having these disorders along with stroke heart failure and mortality so if you want to look at women's health and the future generations one has to be very very sensitive and careful in diagnosing and identifying this condition now let's look at the problem in india which is a truly gigantic task because in our country through the national eclampsia registry where i am the coordinator we found that the incidence of pre-eclampsia is about 10 to 11 percent compared to the five to six percent what the global statistics tells us and in incidence of eclampsia is two percent of all the pregnancies what does that mean that in our country we have 26 million deliveries per year we are dealing with 26 lakhs 78 000 cases of preeclampsia and 4 lakh 94 000 cases of eclampsia yearly and you can identify that this is a huge problem now preeclampsia is typically called as an iceberg phenomenon come on so uh maximum votes have gone to 140 by 90. absolutely i want to congratulate all those maximum 80 of voters who have congress who have mentioned 1490 and i love you guys because it's very important that even at 140 90 you become cautious and start acting and don't wait it to rise love you truly so deaths and near miss cases hellp and eclampsia these are the iceberg phenomenons associated with preeclampsia so you will feel that the patient is apparently normal she may be even normal tensive but would have help and eclampsia secondly if you look at 140 90 blood pressure alone and if she doesn't if you say okay it's a mild blood pressure it's highly possible that this mother is already sitting on a huge hidden iceberg of various problems where the mother and both the infant are at risk so therefore it is extremely important to be very very sensitive even to a blood pressure of 1490 because if you look at the typical indian women they would normally record a blood pressure of 110 by 17 so 140 90 definitely is a significant rise and if that sign we can use we are nearly lucky we have to look at it carefully because what would happen is sometimes there would be a typical presentations where the bp would be completely normal but there would be all the other signs of preeclampsia now why is this condition occurring there is a problem with the invasion of the cytotrephoblast and this is a wonderful theory which is now we are able aware of for nearly one and half decade where the invasive cytotrophoblast you can see on the left side of the screen in the upper part of the screen you can see a normal pregnancy cytoplast spiral arterial direction while in the lower part of the picture you can see that the vessels are still constricted while they are still going through the decidueye and the myometrium so there is deficiency in the citrotrophoblastic invasion of the maternal spiral arterioles and they foil to transform them into small caliber resistance vessels to high caliber capacitance vessels which are going to give a lot of placental perfusion and then what happens at the much cellular level it has been found that even the cytotophoplast normally would undergo a differentiation in an epithelial phenotype to endothelial phenotype giving rise to wonderful vascular genes this doesn't happen in pre-eclampsia because of that from the time that the trophoblastic invasion is starting as early as eight to nine weeks of pregnancy which keeps on continuing till the second wave that is 16 weeks of pregnancy if this invasion is deficient we are going to have challenges and that is the reason why the foundation of this disorder sets in at the time of implantation so as you can see here that you can see a cut section of the first trim decidua and the biometrium in the first trimester and the second trimester on the top of the screen the very very corner picture is showing you a wonderful embryo trying to get implanted into the decidua so in the first trimester itself if this invasion is deficient then this disease would start as early as that time and you can see in the first trimester there is dilatation of the spiral arterials and in the second trimester they really become very very big capacitance vessels now what will happen when there is no proper dilation there will be placental ischemia and this placental ischemia will give rise to various kinds of cytokines inflammatory markers noxious substances which develop into the mother's body and these are responsible for placental tissue apoptosis that is destruction over a chronic period of time creation of immunological complexes in the body and giving rise to then a sort of an allergic response from the entire vascular immunological system of the mother and this maternal syndrome basically rests upon the endothelial damage we know the entire body is made up of capillary network and these capillaries are lined by endothelium so the entire endothelium throughout the body gets disrupted and then naturally it's going to satin the cascade of all the problems that we face such as liver damage renal damage hypertension cerebral issues giving rise to eclampsia stroke cortical blindness and coagulation before this defect such as thrombocytopenia liver damage can lead to heal llp and liver failure renal damage can cause proteinuria edema and renal impairment and all this is finally going to affect the placenta if the placenta doesn't form well it is not well perfused then this baby is going to suffer from chronic little restriction so if you look at the two stages in the evolution of preeclampsia there is placental ischemia which gives rise to formation of placental debris and these are actually destroying or destructive trophoblast cell deportations which give rise to formation of sincere seotrophoblast microvascular membranes giving rise to systemic inflammatory response kind of a syndrome and therefore there is also inflammation on one side and inflammatory markers such as lipid peroxidation reactive oxygen species activated neutrophils dnf alpha cytokines all seem to be increased and they all go and attack the endothelium giving rise to release of prostate cyclings thromboxin a nitrous oxide is reduced humor human factors of endothelin are increased and entire inflammatory process sets in and therefore we believe that rather than calling it as greek lambsia it would be smarter to call it as gestosis wherein there is some sort of an inflammatory syndrome in the mother's body now this entire system will cause systemic affection and what is this systemic affection it will give rise to cardiac evil problems such as contractility would fail there would be increased systemic vascular resistance and so many other things happen many times we consider women are young nothing's going to happen to them but there are cardiomyopathies associated with greek ones there can be encephalopathy eclampsia and issues in the brain there can be ards leaky capillaries pulmonary edema in the lungs preterm deliveries abruption and growth restriction in the phytoplacental unit and the liver as well as the kidneys can get challenged so it finally starts off as a small failure of dilatation of the spinal arterioles leading to an entire cascade of pathogenesis and we as clinicians have to stand there by the mother to interrupt it in its various stages and try to modify the cross over the disease which is believed that we cannot prevent preeclampsia which i don't agree because if you have a proper preconception optimization of woman's health that can also be curved and but we definitely can prevent the complications that occur because of pre-eclampsia so if you look at the clinical sub classification pre-eclampsia is decide is for our convenience understanding of the severity is classified as early onset preeclampsia when you have protein uric hypertension occurring before 34 weeks of the gestation mandating and delivery preterm preeclampsia which will be before 37 weeks of gestation late onset preglancer would be after the completion of 34 weeks and term preeclampsia would be after 37 weeks usually the late onset and the term pre-plumsias are maternal disorders while the early onset preeclampsia e o p e or e o p e g or greeting preeclampsia are extremely challenging disorders so we have learned the criteria for diagnosis of preeclampsia already what i want to bring to you through this particular table is go at the last two columns rows which are talking about superimposed preclass today with women choosing to become pregnant little later having underlying disorders like pcod obesity diabetes and hypertension many a times women already have chronic hypertension which never gets identified before because they don't go for preconception optimization so their blood pressure gets first diagnosed during pregnancy for a long period of time there would be no protein urea then it would be called as if it has been detected before 20 weeks of gestation it will be called as chronic hypertension if it is detected after 20 weeks of gestation it will be called as gestational hypertension the moment it gets added upon with protein urea it will be called as super impose free equilibria on this so women who are chronic hypertensives or women who have gestational hypertension both of them are at risk of developing pre-eclampsia during their pregnancy now i am coming back to you to generally gently introduce you to the concept of just losses because you understood that blood pressure may or may not be present proteinuria may or may not be present typically we learned in our long times back that there was a triad of preeclampsia there was hypertension there was edema there was petroleum over a period of time edema was taken off from the definition now protein urea also has been taken off we are going to deal with why and now even in the absence of hypertension sometimes women may have these inflammatory responses so therefore the entire conglomerate is called as hypertensive disorder of pregnancy the terminology such as pregnancy induced hypertension impending eclampsia all have now become obsolete the current important terminologies are hypertensive disorders of pregnancy under which you identify chronic hypertension because that is also important why we are going to learn as we go by gestational hypertension early onset preeclampsia that is protein uric hypertension divided into early onset and late onset pre-eclampsia all the other multi-systemic disorders and the entire spectrum of disorders ranging from already existing chronic hypertension to eclampsia help syndrome pulmonary edema stroke and envious all of them together come under this understanding now why do we think that we must call it as gestosis because pre-eclampsia seems to be something which is occurring before eclampsia unfortunately eclampsia this word doesn't have a synonym in many languages across the world we don't have any synonym for this eclampsia means convergence in pregnancy associated with hypertension but today we are understanding that always hypertension may not land a patient into eclampsia she may have so many other things also so then is it right to call this disorder as pre-eclampsia is a question which we need to answer and therefore we believe that is rather better to put in the entire conglomerate into calling it as just losses and not only do we talk of pregnancy associated issues but we also include the post-partum gestures what is that i'm going to discuss as we go back so then what happened is we have this association in our country which is called as gastrosis india association which happens to be associated with the world organization just process and this is the community which has decided to introduce this word as dystosis believing that it will include the entire spectrum of disorder and make us more sensitive to looking at these mothers with more care so we cannot do all those expensive biomarkers that sonography color doppler are we having any simple ways in finding out which are these women who are going to have risk of developing pre-eclampsia now if you look at the nice guidelines the cog guidelines all of them have made their own risk factors but these are their own country's specific risk factors we as indians have to identify our own risk factors and therefore this is that ready reckoner of early and easy identification of testosterone so there are various low risk factors which have been taken into account such as maternal anemia extremes of age even teenager pregnancies women bond themselves as hgm others obesity nulli gravity that is primary short duration of sperm exposure she just got married and immediately became pregnant because her immunological system is yet not adjusted to that semen exposure family history of hypertension and pcos and so many other factors have been included in this identification maternal hypothyroidism chronic vascular diseases excessive maternal weight gain during pregnancy and mean arterial pressure of 85 millimeters of mercury then so these will be graded as one point for these because these are little bit low risk factors while you will have moderate risk factors such as gestational diabetes obesity great to multiple pregnancies and hypertensive disease during previous pregnancy they will be awarded two points now you to understand that to know whether she is hypothyroid whether she has diabetes whether her map is 85 millimeters or she's having excessive weight gain you will have to be vigilant during her pregnancy and then high risk factors such as pre-gestational diabetes chronic hypertension where the mother is having antiphospholipid antibody syndrome mental disorders such as schizophrenia is known to cause five times more risk than if the patient has chronic renal disease and whether she has become pregnant with assisted reproduction now just pregnancy with an art which is ivf or xc is awarded one point but if this woman has undergone pregnancy as a result of over donation then she gets awarded three points now you will calculate all these points and if you find that the risk is less than three then be vigilant she has risk factors be a little closely vigilant if the risk is more than or equal to 3 then you will have to modify her surveillance make her a close surveillance give her low dose aspirin ensure that she's coming for color dopplers and you are able to identify placental insufficiency in its early happening so let's come to the clinical presentation swelling over feet headache feeds fits vomiting breathlessness blurring of vision epigastric and right abdominal pain reduced quantity of urine symptoms can be some of the signs but remember symptoms can be non-specific and vague and many times patients may be asymptomatic so many times hungry they're tired they are sleepless they'll not complain about anything if you ask them how are you doing today many times she'll be able to tell you doc i'm not feeling well the moment a woman says i'm not feeling well look at her correctly she may be having some problem don't just say many times half of the histories are taken from the relatives from the family don't do that you need to speak to the patient talk to her whenever the woman says i am not feeling well that requires attention signs are very important that is where your role as a clinician comes correctly measuring blood pressure that i am going to deal with protein urea is very very important then non-dependent edema rapid weight gain brisk reflexes ankle clonus more than three beats retinal vasospasm or retinal edema on fendoscopy right upper quadrant pain or abdominal tenderness can be a result of liver stretch or hemorrhage so these are certain important signs which you have to elicit and carefully examine and hypertension and pregnancy should be predefined and based on two measurements we've already run and six 160 or 100 is taken as severe hypertension so this we have to remember do you think that gestosis score is useful yes or no if your answer is yes just type yes no then type no in the answer box and if it's unsure type you so that was my third question so i hope you have been able to answer it why and and you do you think that the dos destroys score is useful in assessing risk in these patients so i hope we understood the science in this patient now there is another question which i want to ask you how will you measure the blood pressure in a pregnant mother so there are two answers which are going to give in a sitting position you'll answer s in a lying down position you will answer l so if you think it is in a sitting position say s if you think it is in the lying down position say m so we move on to the prerequisites of correct blood pressure measurement the bladder should be empty there should be a quiet environment the patient should be comfortable and resting there should be no tight clothing no acute anxiety patient should say silent prior and during the procedure she should not have taken coffee or any anti histaminics before she comes to you or any nasal decondistance and we have to also remember that the bp should be measured by having the woman in sitting posture with the arm at the level of the heart and the cuff size of the bp apparatus has to be normal and this has to be the breadth of 1.5 times the circumference of the woman's arm if she has very fat arms or very thin arms then your cuff may not correctly measure the blood pressure and while you are measuring the karat cough sounds first systolic blood pressure is going to be called one that is going to be 5 for the diastolic blood pressure and if the diastolic blood pressure is persistently less than 40 mils of mercury then we can consider using muffling that is the fourth part of sounds because about 20 to 30 percent of women would have hyperdynamic circulation and therefore this would be important now help we talked about h e l p and this help is a very very important diagnosis and an entity and you have to be alert every woman who presents to you with vomiting in the second half of pregnancy please be suspicious she may be having liver stretch hemolysis and liver affection then if she and if you don't pay attention she can rapidly deteriorate after initial symptoms early diagnosis always will give you the best chance so whenever a patient comes to you with an abdominal pain during the pregnancy it's colicky or soreness a common symptom is present in most patients they'll say there's a pain in abdomen doctor i'm uncomfortable and you have to carefully see where this plane is if it is localized to the mid epigastric or the right upper quadrant or below the sternum you may consider it to be gastropolitis but yeah look for tenderness nausea vomiting generalizable eyes are signs suggest you of sometimes non-specific viral illness or viral hepatitis i have clinically diagnosed pancreatitis in women coming to with pregnancy polar cystitis and these things require attention and if you do their liver function test such as sgpt and ldh that means lactose dehydrogenase lot of reluctance is seen amongst clinicians to do these tests but this is a go-to test to identify hemolysis because you are not going to do peripheral blood smear so commonly in your you know clinics so if the ldhs are markedly evaluated that helps us in telling us that there is hemolysis which is settled less common symptoms include headache mutual changes jaundice and oscitis and this has to be known now coming to protein urea now protein urea if it is many times uristics may not be standardized but if you find them to be more than two plus that means you have to be on guard sometimes she may be having urinary attack infection or contamination from the vaginal secretion so ask her to catch the midstream urine now to be able to be correct in your protein era diagnosis the most standard of measurement of proteinuria is doing the 24 hour protein collection of the urine and then subjecting it to estimation and when you find it to be 0.3 grams per deciliter in a complete 24 urine sample then it is taken as significant proteinuria friends we must know that during pregnancy protein uri is always there there is definitely in a normal like you and me will have 150 milligrams per deciliter or maybe less than that pregnant women would have up to 300 because of increased j alpha but when it goes beyond 300 then it becomes significant so this has to be remembered while you are interpreting your patient and the other point of care spot test is doing and protein creatine ratio and if it is found to be more than or equal to 30 milligrams per millimole it represents significant protein urea in singleton pregnancy now you would ask me a question as to when do we do this test if the patient is already showing hypertension and two plus protein you don't have to do anything but now you may have that high risk mother who is putting on weight we're showing little body line bp rise 130 by 80 who is diabetic you may consider doing pre-emptoli a protein creatine ratio to be on guard to identify whether she is having microalbuminuria and this way you would be able to preemptively diagnose these patients earlier so my next question to you is going to be this what is significant routine area so in the answer box in your chat box you are going to write more than 150 200 or 300 milligrams per 24 hours so you write your number whatever field 150 200 300 so that was my question always always remember chronic hypertension converted to super imposed preeclampsia is quite common in fact communist pregnancy and gestational hypertension 40 to 50 percent can convert to preeclampsia now friends i said that with this protein you'd have at the outset i mentioned to you that protein urea is not actually taken as a cardinal sign why because severity of proteinuria is not strongly associated with adverse maternal and neurological outcomes that's one and preeclampsia can occur even in the absence of proteinuria up to 10 of women with preeclampsia and 20 percent of women with eclampsia have no proteinuria on their initial evaluation so don't get misguided and remember this in your mind so these are the reasons why we are seeing today that protein so now coming to the famous person that i always want i would be wanting to warn you about the help which always always is a laboratory diagnosis so whenever there is hemolysis which can be estimated by two things one doing a peripheral blood smear where you will see the schistocytes that are fragmented rbcs and cells if the serum bilirubin is more than 1.2 but that would occur very very late in the later part of the disease ldh more than two times the upper level of normal or you can just look at 600 international units as a good cutoff when it is more than 850 it is a sign of a severe disease severe anemia unrelated to blood loss she may be having hemolysis therefore becomes anemic and look at her pcv if the pcv is less than 30 then she is sucking premo concentration with anemia she must be having hemolysis elevated liver enzymes as geotin agp more than 75 and look at the trend of serum alkaline phosphates because serum alkaline phosphatase is known to increase in the later part of pregnancy because it gets manufactured by the placenta and therefore you may go wrong there so it's always better to depend on hdot and hgpp and lth and if the platelets are low less than 1.5 or less than one lakh be on guard this patient is probably getting immobilized within herself and then remember the differentials it can be acute fatty liver of pregnancy which can be in the later part of pregnancy i have seen as early as 28 weeks aflp setting in some women so these are three major disorders in differential diagnosis which you should keep at the back of your mind thrombotic thrombocytopenic purpura where especially when the disease is very severe and pregnancy related hypo hemolytic uremic syndrome there are certain specific tests which are done to identify these and we may require to have a multi-team approach with the nephrologist physician and so many other people on board and simple things like gastroenteritis hepatitis appendicitis gallbladder disease lupus flare applause syndrome pancreatitis non-alcoholic fatty liver disease can all affect pregnant women and we have to be an astute clinician to be able to identify these now how do we treat this disease one of the simplest way of going about is keep the blood pressure under control if you have identified it earlier and the first drug of choice apparently is the labitolol and this is a very very safe oral antihypertensive medication which can be used safely during pregnancy and is well tolerated in a dose of 200 to 400 milligrams given orally in two to three divided dosages up to two thousand milligrams per day can be considered it is well tolerated potential bronchoconstitutive effects are known and therefore it would be best avoided in patients with asthma and congestive heart failure nia philippine nicardium 30 to 120 milligrams daily use a slow release preparation so that you can keep or maintain a sustained blood pressure release and never ever use it sublingually because if it gets suddenly absorbed there can be sudden hypotension which can cause challenges to the phytoplasmal unit and even to the mother's perfusion methyl dopa is a very very long tested antihypertensive given in the dose of 0.5 to 3 grams per day orally in 2 to 3 divided dosages childhood safety data to 7 years of age is well established but it may not be as effective in controlling chronic severe hypertension that's one the second challenge is it is not very easily available the third challenge is that we have to remember that it may cause any change in the indirect course test may come positive in these patients so we have to be on guard and it cannot expect a not given postnatally and remember that whenever you have antihypertensive given to the mother sometimes there can be some changes in their ctg recordings thiazide diuretics are taken as second line agents and are best avoided no diuretics in a pregnant mother because she already has a hemo-concentrated by intravascular compartment you give her a diuretic that will again compromise her own perfusion and the baby's provision and ace inhibitors and arbs are absolutely contraindicated during pregnancy because it's not that they cause anomalies they were thought to be associated with animals but i'm going to in pregnancy and in the pre-conceptional period so my question to you friends in the chat box which i want you to write is what is the drug of choice in pregnancy with hypertension is it labitolol type l alpha methyl dopa hydrolyzine or knife phytipine so labitolol alpha methyl dopa hydrolyzing or life when we look at what do you do in high potency crisis we have been for a long period of time talking about hydrolyzing but unfortunately it is not available in our country not in all states in some states it's available but definitely in the state where i practice in guru maharashtra it's not available then what is our first step of choice in a hypertensive crisis we give labatolon labitol injectable can be given intravenously with a 20 milligram iv as bonus to start with so we would be looking at laboratory you all should be absolutely well-versed with giving this laboratory all because it can turn out to be a very very important life-saving medication and if you find that the patient is conscious and she is listening to your commands you can very well give her oral 200 milligrams of lavatory lol with a sip of water it has been shown through a very large indian study that 200 milligram oral labitalol is immediately effective you remember the contraindication however bradycardia and asthma if you have other medicine which is very safe and can be given orally in hypertensive crisis is knife very clean so first you 10 milligrams per orally to start with and repeat 10 milligrams in 30 minutes if needed and always better to use it as a oral formulation and never sublingual then sometimes in rare cases when they don't respond to anything we may have to consider using sodium nitrogen injection but remember they have a risk of causing fetal cyanide poisoning if used for more than four hours so another very important medicine that you will be definitely giving during the hypertensive crisis is magnesium sulfate you are not going to look at impending eclampsia or she is she throwing a convulsion any woman coming to you with severe hypertension of pregnancy give her magnesium sulfate so prophylactic magnesium sulfate is the new mantra and it can be given as a regular uh bonus dose that we give that is four grams of magnesium sulfate given in hundred ml of ns or maybe 20 ml of injection water for injection or rl infused over 20 minutes uh you can give it through a big syringe or you can give it to an iv line and you have to continue it for 24 hours till she delivers or till you have temporaries because you're giving it as an expected management patient may not deliver always she may get control so you would give it for 24 hours and many a times it's always smarter to give it through an iv injection rather than giving intra muscular injections now intramuscular pictures regimen is much stabilized by the who why because so many women are delivering in certain such facilities that they may not have an iv access but the question which always comes to my mind is then how do we give the iv bonus so when you can give the iv bowlers as the first program medicine you can very well continue giving her a 24 hour intravenous injection and furthermore if you have an access and i think we should now start having access in all our facilities is of an infusion pump you may deliver this magnesium sulphate as an administration of 5 grams in 500 ml of fingers like it delivered at the drop rate of 25 to 26 drops per minute is given to ensure so that she gets one gram of magnesium sulfate over one hour or this can also be administered by using infusion pump where the accurate dose is administered so magnesium sulfate always as a prophylaxis it was not going to only help her to have better stable brain function is going to improve the placenta perfusion and if it is an early onset pregnancy it is going to also award neuro protection to the baby and your chances of taking this pregnancy a little forward expectantly till the time that the mother is safe to deliver and the baby especially safe to deliver can be awarded and definitely it will prevent a seizure because we all know when a mother gets equilampsia her mobility and possibility of mortality increases phenomenally always always be ready with the magnesium sulphate box you must have a magnesium sulfate box which will have 10 amps of 50 of magnesium sulfate a normal cell line injection of 100 ml in drug cats sticking plaster syringe mouth gag alcohol swabs every fifth day of every month you must go and open your magnesium sulfate box and check whether everything is in place and keep it level ready wherever your pregnant mothers are moving around because you may have to give that life-saving loading prophylactic or abortive dose because it can be also be given as an abortion of a conversion do not go and fetch the isoparm give magnesium sulfate it's a very safe drug given in proper dilution and it doesn't require any levels to be monitored you have to just clinically monitor this condition the who has conducted huge trials and is telling about the effectivity of full regimens of magnesium sulfate which include the loading dose followed by 24 hours maintenance therapy and even in cases where you are considering transferring this patient to somewhere the woman to a higher level facility or a tertiary level center then still give her one labrador tablet and knife pin and give her the four grams of magnesium sulfate write it on a piece of paper and then only send the mother to a reference center so it's very important to look at this management of severe hypertension checklist which was proposed by the acog and which i find it very very wonderful so what is the trigger for initiating this checklist when the blood pressure is more than 160 by 110 in an indian setting and the gestures group believes that even at 1 1500 with any severe signs of the disease you must start and initiate this checklist contraindications would be pulmonary edema renal failure and myasthenia gravis and what should you give first initiate the magnesium sulfate for seizure prophylaxis as i described to you sometime back and give her anti-hypertensive medications which would be in the form of labity lol given injectable or oral hydrolysis which is not available with us but this is an acog guide guideline for us we'll give knife a dependency of that and repeat the blood pressure every 10 minutes now if the first line of management is not effective then ask for second opinions consultation specialist to be on board and then treat this patient in accordance so these are the things that one has to remember whenever we are talking about the hypertensive crisis and the management of it now there's something very interesting fact that i want to discuss with your friends here there has been a lot of understanding some time back when we identified the giving high energy hypertension medicines to the mother would reduce her blood pressure reduce the placental confusion and may cause fetal growth restriction and this was the concern that we had but then there was this particular study which was the metabolism of our cities of treatment versus no treatment of pregnant women with mild to moderate hypertension so long time back we used to only give antihypertensives to severe hypertension but today we are considering giving it even to the milder versions and this was the result of the study where they randomly assigned the mothers with hypertension to diastolic blood pressure treatment targets of 85 or 100 nissan mercury material treatment did not increase the risk of delivery of a small for gestational age in front of all excess fetal risks and in fact when this study was further analyzed in a post hoc analysis what was found women who had severe maternal hypertension where associated with low infant birth weight mobile deliveries preeclampsia and features of health but while mild to moderate patients who were treated with less controlled strategy they went on to develop severe hypertension had a higher rate of serious maternal morbidity and that caused a problem so therefore mild and moderate hypertension needs to be treated so even if your blood pressure is 140 by 90 start giving her antihypertensive medicines because that will prevent the severe hypertension from occurring and that will also protect the mother's health which is at risk of developing disorders as she goes by even after this pregnancy now the question which comes to our mind is are anti-hyper hypertensions safe now all of them are known to cross the placenta there is no rct to base a strong recommendation for use of one drug over the other and data regarding both comparative efficacy in improving pregnancy outcome and fetal safety are inadequate for almost all anti-hypertensive drugs now friends i want your attention this is something which i am going to tell you something more about this anti-hypertensive medicines and what is that that is women with chronic hypertension either treated or untreated are at increased risk of congenital malformations in offspring so it is not the antihypertensive medicines which cause cardiac malformations in these babies the mother's hypertension itself at the time of organogenesis and embryogenesis if it is abnormal and that itself acts as a teratogen to cause problems to the mother so if you find her blood pressure abnormal even in the first trimester and in fact before she comes to you for preconceptional guidance thank you guys i love you for that you have to control her blood pressure and the safest medication which you can give her is going to be levital although it is possible that hypertension increases the risk of chd in offsprings and that antihypertensive drugs further increase this risk it is also possible that hypertension and chd share similar risk factors so i think i gave you some wonderful insights today now how do you do the fetal surveillance one you have to do the initial assessment by biometry where you look at the fetal growth parameters amniotic fluid index and you tried artery doppler umbilical artery droplet and the middle cerebral artery doppler if the fetal growth restriction the doppler and the afi estimation are found to be abnormal and you would then want her to deliver umbilical artery reverse end diastolic flow mandates a weekly doctor now when would this be considered when the patient is very very remote from 34 weeks is very premature then you would want to give her some more time to be in neutral and to grow them and if there is absence in diastolic flow then you would do a surveillance twice in a week to see the baby's condition with redf more than 70 percent of the interviewer circulation is compromised and it is time to deliver by c-section do not takes do not say it's a total baby and then maybe it will be able it may not be able to take uterine contractions of course this will be a weird decision taken after discussing with the parents whether they are able to take care of the baby in the nicu whether they would want this to happen whether they'll be able to you know what is the survival rate at that particular gestational age so all this decision will be individualized because we have to also look at the other angle if you do a preterm delivery of a mother you are going to give her a scar in such a way that subsequent pregnancy she will again land up in a c-section that's one and secondly we all know that scissoring section especially the premature c-sections are associated with morbidly other and placentas in the subsequent pregnancies so all these weighted decisions have to be taken properly ductus venus or umbilical vein appearance absent flows is known to be associated with fetal acidemia and poor prognosis so your surveillance will stop when you are seeing the ductus you are going to deliver this patient magnesium sulfate is to be given for neural protection for babies who are less than 32 weeks i even extend it sometimes to 34 weeks and archery doppler significant for fetal prognosis before 32 weeks you can consider doing arterial droplets nowadays they are doing many of them and venus doppler can be done later and if the patient the cpr that is the cerebral plastical ratio is found to be more than one then it gives us some time to postpone the delivery so that you can then try to award the baby the advantage of being inside the youtube so role of doppler is quite profound in the decision making especially in the presence of heater growth restriction it plays a significant role in deciding the neonatal outcome and the timing of the delivery and you will be looking at that sequentially so you'll be looking at the growth lags the cerebral blood flows the umbilical rtpi look at the redistributions try to correlate it with the material condition and the abnormal ctgs and then also look at the amniotic fluid index and take a proper decision it was observed that whenever there is mca redistribution that is middle cerebral arterial distribution it confirms an 11 fold increased risk of adverse parental outcome when compared to fetuses with normal cpr that is cerebroplasty ratio and this may be useful to indicate delivery between 34 to 37 days now you have patients who are having hypertension you are trying to control them you are wondering now how long do i continue this pregnancy are there any markers yes there are certain biomarkers which can help you in segregating these patients where you may be guided whether you can continue the expectant management or you need to deliver one of these marker is the glycosylated fibronectin which is like a simple test used with a machine and which tells you the quantification of the glycosylated fibronectin if it is increased then that is an indicator that you need to deliver this patient so you have seen here that this is a bgog publication which has come from the indian study where it concluded that glycosylated hemoglobin can be a good point of care test which can be validated in low and middle income countries setting for preeclampsia diagnosis and may be useful adjective tool for early identification and appropriate triage likewise there are other biomarkers such as the plg of which can be done so they also can be decided if they are found to be more than 85 moms then that would be an indicator so what can be do how can you manage this patient always skip a context of the pathophysiology that we understood which is a two-stage pathophysiology do screening for all your patients as i told you a screening at the outset and then a continuous surveillance as she goes by the mother the moment you identify that the patient has these risk factors do a vigilant antenatal surveillance always look at their diets ensure that they are taking proper proteins it's been found that high fiber diet is known to reduce complications and occurrences and severity of preeclampsia and this is an rcp so if you are taking loads and loads of green leafy vegetables and salads and fruits it has been found to be a good protective mechanism giving them calcium supplements in the right quantity and also giving them low dose aspirin can help in mitigating this particular challenge what are the supportive therapies that you can give as i mentioned dietary advice adequate rest strict bed rest is not recommended it is harmful because hypercoagulable straight there can be chances of thromboembolism anemia correction extremely important because anemia means reduced oxygen carrying capacity means less oxygenation means less clearance of the immune complexes and calcium supplementation of 1.5 to 2 grams of calcium per day either in the form of a supplement or definitely taken from the diet is mandatory always educate women and her family about severe headache visual disturbances epigastric pain shortness of breath spotting and pain in abdomen as the six major warning signs of preeclampsia they have to come to you for regular follow-up we have to discuss the plan of delivery need for transport in case of emergency possible financial requirements especially when the new q and the hdu admissions would be in the under um play and vigilance for any serious presentations follow up every 7 to 10 days repeat appropriate laboratory and clinical evaluations repeat pre-eclampsia full evaluation within a week if one plus proteinary or dipstick no hypertension no symptoms consider reducing the interval for repeat evaluation if she has headache virtual disturbances reduced fetal movements or sga frequencies less than diastolic blood pressure 90 mr mercury and their trace or no protein then she can be considered to be home vp monitored and be on call but if she is having any of the severe signs she is better under her hospitalization so every 7 to 10 days correct her blood pressure correct blood pressure reading repeat the labs and the clinical evaluation and then look for proteinuria now once you've already diagnosed her for protein urine don't have to repeat it if the patient is just showing hypertension and no progeneria then you may have to do the protein test till the proteins come positive and then you may consider reducing her vigilance if she has any of these signs when do you deliver patients with stable mild gestational hypertension should be allowed to reach 37 weeks and beyond in the absence of any sudden indication or any adverse outcome if there is fetal growth restriction and all you are definitely going to deliver them earlier but otherwise if they are well stabilized at 37 weeks you may very well consider them 46 percent of mild gestational hypertension progress to preeclampsia and 10 percent who develop severe disease has to be remembered and gestational hypertension can be taken to term while mild preeclampsia should be delivered at 37 weeks to avoid consequences of preparation of disease now there have been certain studies which have shown that in conditions such as hdlp in eclampsia there is no expectant management the patient has to be stabilized you can pre-transfer her to the emergency department seizure prevention control anti-hypertensive medications transfusion therapy if necessary neurological assessment fluids to be given with caution steroid therapy if the baby is premature controversial but it's also been found like the same steroids that you are giving for antenatal steroids for prematurity the same steroids are also known to be of helpful in health syndrome and the steroid that we commonly use in our country recommended by our government is the pixar methods on given intramuscularly never given intravenously then ultrasound fetal well-being would be seen placental interface look for any residual um abruption or apoptosis liver imaging needs to be done to see for any hematomas and consider doing ct mri for the liver and as well as brain if the patient has thrown a conversion because p r e s that is posterior reverse encephalopathy is quite common this is a syndrome which is seen in these women doesn't have any diagnostic change because all patients of eclampsia would have this but that gives your guidance that this patient would require a proper care after delivery also if the fetal well-being 34 weeks or more can be considered you can consider to take it beyond but if the disease is severe you may consider delivering her between 24 to 34 weeks steroids and delivery and if the patient is less than 24 weeks and has protein severe disease there is no point in continuing this pregnancy in very very high risk mothers awarding up to 26 weeks gestation some of the nicu's are able to take these babies forwards so this would be an individualistic decision but studies by and large have shown that survivability is always better after 34 weeks of gestation between 24 to 34 weeks you have to tailor me your decision and delivery now timing of delivery in greek lumps and hypertension were studied through habitat 1 and city of women with just additional hypertension or mild preeclampsia with a significant pregnancy between 36 and 34 41 weeks of gestation primary outcome was a composite measure of material morbidity and mortality 756 patients were randomized to induction of labor and expecting management and about 31 women in the induction group developed poor maternal outcome and 44 women in the expectant group also so therefore it is recommended that if you have protein uric hypertension even if the woman is stable please deliver her at 37 weeks of gestation and do not postpone this pregnancy further hepatitis ii trial was an open label rct of women with non-severe hypertensive disorder of pregnancy between 34 and 37 weeks of gestation and immediate delivery induction of labor or c-section within 24 hours was performed expected management until 37 weeks or deterioration of mother of the fetus was taken in 351 and what was advocated was expected management with monitoring until the clinical situation deteriorates is what was proposed and this is a landsat 2015 publication so if you do an adverse immediate intervention adverse material outcome would be less while expectant uh it would be 11 while neonatal respiratory distress syndrome would be present in immediate management which will be more because you're not giving it time for the antenna steroids to act so it should be a balanced expectant decision stabilization of the mother and then deciding how we are going to deliver the patient so the happy type 2 trial 34 to 37 weeks late three pre-terms found that rds was six percent in the immediate delivery group compared to two percent in the expected group so induction of labor versus c-section versus expectant management in gestational hypertension and non-severe pre-prolonged check concluded that women with non-severe hypertensive disorders at 34 to 37 weeks immediate delivery might reduce the already small risk of adverse maternal outcomes however it significantly increases the risk of neonatal rgs therefore routine immediate delivery does not seem justified and a strategy of expected monitoring until the clinical situation deteriorates can be considered so immediate delivery did not significantly decrease the risk of adverse maternal outcomes it did significantly increase the risk of neonatal respiratory disease syndrome and that is what we have to remember what are the fetal indications of delivery for the mother we know severe disease non-controlled hypertension eclampsia hellp are the indications in the fetus fetal growth restriction lack of growth umbilical artery dopplers which are abnormal and abnormal dopplers and especially the crp that i told you which are the corticosteroids now you have to remember this dose pit and cut for lung naturality where the appropriate most commonly used regimen is the beta methods on 12 milligrams 12 to 24 hours two dosages but in our country we do not have the right salt so you will be using that's what the government of india recommends dexamethasone six milligrams six hourly four dosages each given intra muscularly how do you deliver induction of labor in absence of any matter of heat indeed a complication at 37 to 38 weeks even with low bishop score these women are known to progress well in labor may be because of the inflammation-induced prostaglandins prolonged induction of labor for more than 48 hours should be avoided scissoring section is done for obstetrical indications and low threshold for c-section should be followed now i have a question to ask you which are going to type in the chat box primey patient is there just remember there is a primary gravita who is 19 years of age she has come to you at 32 weeks in the emergency with the blood pressure of 165 by 110 proteinuria 2 plus i hope you are carefully listening to what i am saying complains of headaches and seems agitated and restless as clonus after oral habitual her blood pressure became 150 by 100 mr mercury what should i give her next should we give her steroids magnesium sulfate labs and should we deliver her so you are going to write if you think that you should give steroids magnesium sulfate labs and deliver please type steroids that is s m l and d for deliver if you think that you don't want to deliver her you need not type that so you can just write that stamen or you think that only m should be given so steroids s m for magnesium sulfate l for labs and d so consider this and let me see your answers at the end of this so intra pattern period yes i can see most of you okay sudanshi only wants to give steroids while yeah somebody wants to give only magnesium sample okay somebody wants to deliver okay that that means you didn't understand betta see we have to understand that we have to give steroids because it's a 32 week of baby so anthony steroids magnesium sulfate as prophylaxis it will act as a neuro protector as well as prevention of seizure and labs to identify whether she is having health syndrome and delivery can be considered after stabilizing the vision so that is the answer to that question okay so s m l illa you are right sml madhu you are also right so even a mild disease can deteriorate during labor so be very very closely monitoring the fetal and the material condition remember the mother is already fragile and the placenta is fragile so both these people can get affected close monitoring anti-hypertensives and medications and appropriate fluid management is very essential and we also have to be vigilant for eclampsia help and abduction i have seen women going into abruption while in labor so you have to be vigilant and sometimes i am very very grateful to my post graduates who have been able to identify so continuous electronic fetal monitor looking at the patient clinically definitely helps now what kind of anesthesia and energy cell would you give to this patient it's always a good practice to give them epidural analgesia if you have an axis because it is known to improve perfusion of the placenta and pain induced catecholamines and hypertensive response is much reduced in these patients and if you're planning a c-section delivery you can consider giving her a spinal anesthesia and it has been found to be quite safe general anesthesia would be given only and only when there will be severe thrombocytopenia and we have to remember that there is a contracted circulation if there is hypotension and if the woman is in our ideas or something maybe we may consider giving or she is having a seizure we may consider giving general anesthesia you have to remember that passing a laryngoscope and the tube even is not easy because these women may have laryngeal plus general anaesthetic medications are known to have challenges with the magnesium sulfate that we are using so it's always better to give a regional anesthesia to this patient and remember most of our patients are already on low dose aspirin if they have been gone through the testosterone analysis saw the color droplet assessment or the papi and all such kind of screening then this is not a contraindication to regional anesthesia because of course if it's a low molecular weight pattern which has been given to a woman who has thrombophilia then six hours of stopping that drugs is enough in the class study it was found that 1422 women on aspirin received epidurals without any bleeding complications in the intrapartum care if you have a non-severe hypertension mother blood pressure 140 by 90 and moderately not very beyond severe hypertension major bpa hourly the first stage patient should be confined to the bed epidural anaerobic jcr acidity control of blood pressure with antihypertensive to continue monitor her urinary output and continuous with heart rate monitoring in the second stage cut short the second stage of labor by either giving intravenous oxytocin or may be using a vacuum or a forceps depending on the maturity and the gestation of the baby because we all know for premature babies it will always be a forceps delivery third stage always always do active management of third stage do not use methyl argometry because even if little blood loss happens these women are going to go into shock they only have 3.5 liters of blood in an average weighted woman in the body in contrast to 6.5 to 6 liters in a normal weighted woman so even if little blood loss she will go into shock and be vigilant about blood loss monitor bp and sudden hypotension severe hypertension patient then it's always better to deliver here in an hvu kind of a setting this is something that we have to remember and wherein you would be giving her epidural analgesia will be confined to the sedatives control controller blood pressure prophylactic magnesium sulfate or injectable laboratory may be considered monitor input output charting maternal pulse oximetry is known to help it's always better to put her on a multipara monitor so that you are able to look at her properly but short the second stage of labor active management and no matter machine to be given has to be remembered now fluid management is very important post delivery only is obligatory don't get scared don't push fluids if you suddenly push fluids because you think that there is anuria she may go into pulmonary edema because whenever there was this confidential inquiry study done in these women it was found that they died of pulmonary edema because of bad fluid management anuria can be there because of a blocked catheter or obstructed or cut uraters until proved otherwise acute kidney injury does not kill but pulmonary edema does so please remember that be very careful with fluid management and preeclampsia two point three percent of pulmonary edema versus point fifty five percent dialysis is found to be required so you can definitely treat women who go into aka versus args fluid restriction is appropriate and necessary in the management of preeclampsia 85 mils per hour in the absence of hemorrhage and avoid any seeds in these mothers because anna says in now you want something for pain relief you may consider giving her tremendous now coming to the last two or three slides on postpartum testos which is very important and it has been found that we have to keep this mother under close vigilance after delivery for at least 12 to 24 hours under magnesium sulfite cover if they have and then especially the ones who have helped syndrome ones who are having free term deliveries we have to be very careful it's been also found that women who wear normal tension can turn hypertensive after delivery and therefore this concept of understanding the postpartum gestosis or postpartum greek lambshaft came into being even if you have delivered normally or to teach the woman that you are still at risk of developing this condition in post delivery and therefore we have to keep a close vigilance look for arf erbs pulmonary edema stroke i can tell you stories and stories of women coming back with these challenges and then losing their lives teach them about warning signs and then of course we have to be vigilant and very very conscious now what are the potential causes of this postpartum hypertension gestational hypertension pleat lumps which are pre-existing conditions women who have renal disease women with medications you know sometimes some medications may induce these challenges women with hyperthyroidism are at risk then so chronic hypertension there can be denominator hypertension suddenly occurring which can be like preeclampsia hlp syndrome there can be secondary hypertension to ttp hus sle cerebral venous thrombosis stroke cerebral angiopathy and adrenal tumors so we have to be looking at these women all women who have delivered carefully and educating them and as i always like to keep this slide at the end we are all committed to women's health because a woman who even shows a single transient hypertension during pregnancy or delivery is a woman who has to be educated for various things that she has to have maintain her good life and good health because she is still young she has a child which has to look after and they are at risk of coronary heart disease you can see the graphs down there under the pictures heart failure aortic stenosis and mitral regurgitation because hypertension definitely affects them their cardiac structure as well as functioning so always be on guard keep your checklist in place in your delivery rooms they should be well equipped with good oxygen maternal neonatal resuscitation facilities eclampsia kits and emergency trays ready protocols in place and proper documentation is essential and you may i also give you an invitation if you wish to be a part of this moment which is the wwe dot proxy slash ner dot in wherein you can become a national italian registry reporter where we keep on writing blogs information and we encourage people to report their patience of rapture and this is the website of www.discourses.com which refers to the entire spectrum of hypertensive disorders in pregnancy and i hope i have been able to deliver something i can actually keep on talking and talking and talking about this particular problem and thank you so much for the time and the attention thank you so much man for a lovely lovely session uh and very interactive and i was going through the comments to get some questions and there were many comments there so i've just i've written the questions aside i'm sorry i'm not able to take any names that have come with the question but there were many questions uh many doctors who asked similar questions so we've all put them together and um so the first one we'll start with is what is the role of injection ntg in in preeclampsia okay ntg would be given only only if she is not responding to the primary line of health and it's always better not to be given by you as an observation you would always consult a physician or a political care specialist before you give an input thank you i hope that answers all the questions that were asked regarding mvg uh moving on to uh what would be the ideal dose of aspirin uh would it be 75 milligrams or 150 ml now there is a challenge because rolling study which has come up after the spree and the aspirate study that are published we they have found a significant change in two things one is 150 milligrams of aspirin and two by giving aspirin at the night time so you should give it at the evening timing after eight to twelve hours of waking up of the woman and that has shown to effectively reduce the blood pressure related complications now having said that sometimes are very slight or sometimes they may be obese so then in such a situation such extreme situation you can move your clinical judgment and you may consider maybe using 75 grams or milligrams of aspirin or the testosterone group says that high risk factor one factor is there just give 100 milligrams that would be there or you can consider giving the 150. now availability is another challenge because if you look at the acog guidelines it mentions 81 milligrams or it says 162 milligrams because the us fda manufactures only 81 milligrams of fluorescence so they have to make a multiplication of that so the whole nines would say 75 or 150. what is important is give that aspect and forgiving aspirin identify the risk mothers earlier do not give it as a blanket therapy because it is not going to help us thank you what happens is they study you know this was in one hypertension journal where they studied all these three point times giving aspirin in the morning giving it in the afternoon and giving it in the evening and they found that the blood pressure control with the ice cream which was taken at night was better so that's why nice thank you ma'am uh there were a lot of questions asked on levitton infusion so what's the maximum dose that can be given and for how many hours can it be contained 20 milligrams and you can continue it up to 72 hours 220 milligrams in 20 products okay and what is the role of penetoine in uh eclampsia magnesium sulfate is your first go to medicine always always always if your patient is still convincing that means one you have not given magnesium sulfate properly that can be one of the reasons or she may be having something else she may be having some in an intracerebral event or something so always magnesium suffered in the right toes but if that doesn't work then you may consider giving felipe or even level circums or any other idea sometimes obstetricians what has been studied globally is there's a lot of reluctance in giving magnesium cells they will give something like a homeopathic dose you know two grams one so basically there is a challenge i'll tell you one is the moment we learn about magnesium sulfate we immediately start speaking about its anterior calcium glucose yeah so we have that fear you do magnesium something will happen no four grams of boneless dose given diluted doesn't cause any harm so rest assured given second challenge is we have those ampules which read fifty percent one ample is leading 25 percent and then we are confused 50 is equal to 1 gram fit it in your brain so if you are going to give a translate for 50 percent don't keep 25 percent in your labor room we don't want that aggression we only want 50 percent so once you remember that it is easy we are doing at the foxy level and at the gestures level we are doing a lot of advocacy to the government that please make give us miles give us those iv foods if bangladesh can have such iv fluids which are preemptively carrying one in a magnesium sulfate when you just start the those don't calculate but right now we'll have to calculate [Music] a little bit of work when you're in the labor room do a quick math calculations before giving and you're on the wall so that you don't have to use your brain so much you have to use your brain but then you know numbers can go wrong yeah exactly uh moving on to the next question we have is there any relationship between um is is there any relationship between antihypertensives uh in gestation period like what's the best type of antihypertensive that can be given in gestation uh period okay uh and you can consider giving hydrated but labitolol is the best way okay uh yeah and is there any relation between antidepressants and eclampsia yes not antidepressants depression closely disorders and schizophrenia have been found to be associated there's a five percent increased chance of these women developing i think it must be because of constantly they have very high levels of catecholamines so one of the things when you have patients at risk i think all pregnant women today have to be counseled for a proper mental attitude just too much of the moment they become pregnant they are scared first thing is fear there is no happiness there is fear there is anxiety and if they are suffering from any disease then all the more is still because they don't do googling to get assured you know they get willing to get scared doctor google is helpful for that uh yeah and okay these were the questions that i had noted down as the session was going on i think we've covered most of the questions that have come in thank you ma'am thank you so much for a lovely lovely please like the lecture give me a wave okay it was an amazing lecture ma'am i will give all hearts to it thank you so much thank you so much and we'll uh get in touch with you again to call you back on uh netflix for another session thank you so much ma'am for the lovely session and we hope to have you on metrics again thank you so much everyone for making this session amazing thank you mom good night and good night everyone

BEING ATTENDED BY

Dr. Anita Singla & 1046 others

SPEAKERS

dr. Girija Wagh

Dr. Girija Wagh

Consultant Gynaecologist and Laparoscopic Surgeon at her practice in Bharati Vidyapeeth University Medical College and Hospital Pune as Professor and Head of High risk Obstetrics and Perinatology Uni...

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dr. Rohan Desai

Dr. Rohan Desai

MBBS | MBA, IIM-A | Founder & CEO, PlexusMD

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dr. Girija Wagh

Dr. Girija Wagh

Consultant Gynaecologist and Laparoscopic Sur...

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dr. Rohan Desai

Dr. Rohan Desai

MBBS | MBA, IIM-A | Founder & CEO, PlexusMD

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