Case: PIH

Questions

a) Differential diagnosis

b) Management

c) Drugs (SE&MOA)

d) Drugs contraindicated in PIH

Definition

BP more than or equal to 140/90 mmHg in previously normotensive patient, @ A rise in systolic BP of > 30 mmHg or diastolic BP > 15 mmHg compared with pre-conception or first trimester value in two recording of at least 4H apart

Differential diagnosis

- Chronic hypertension (long or before 20w)

- Pre eclampsia (>20W+new onset proteinuria)

- PE with superimposed chronic HPT

New onset or A) acutely worsen proteinuria, B) sudden increase in BP, C) thrombocytopenia or D) elevated liver enzymes after 20 week gestation in women with pre existing HPT

- Gestational HPT (after 20w without proteinuria)

Management

1) if detected <20w,>

2) If pre existing HPT during Booking, should be managed by obs+internist

3) Every other day BP check at local clinic if BP is first high during any ante natal check up.

4) Investigation for PE profile (platelet count, uric acid, serum creatinine level, AST, urine albumin). If PE is diagnosed, then it should be repeated once a week

5) If BP sustained at >100mg/ >25 increament mmHg or clinical suspicious of IUGR, poor maternal-feternal well being, abnormal surveilance basic blood test (BP and urine dipstick at least 3X per week, weekly PE profile and CTG.)

6) Starts anti hypertensive when diastolic BP > 90 mmHg

a) T. Methyldopa 250 mg tds to max dose of 3g/day or

b) T. labetolol 100 mg tds to max 300 mg tds

7) IM dexamethasone 12 MG 12 hourly for two doses for expectant prem delivery.

In case of severe PE

1) Manage in hospitals

2) Close monitor BP 4Hly, reflex, clonus

3) Check fundus

4) Twice weekly(or more based on severity) PE, CTG, biophysical profile and doppler

5) Anti-hypertensive but aim for 20-25 reduction only and not normal by using hydrallazine or labetolol

In labour

1) BP stabilization

2) Watch for fluid overload (monitor UO)

3) Seizure prophylaxis in severe PE

4) Epidural analgesic is the best

5) Oxytoxin only to augment labour.

6) Never allow woman with severe PE to push excessively. If BP high, consider instrumental delivery.

7) c/I of ergometrine/syntometrine in third stage due to hypertensive effect.

Drugs contraindicated for PIH includes ACE inhibitor and ARB as it can cause renal dysgenesis of the baby.