PIH / HELLP😍

Smoking protective for

• PIH

• UC

String Sign:

• TB

• CHPS

• Crohns Disease

Indications of Aspirin:

• APLA

• Past h/o PIH/chronic Hytn

• Multifetal pregnancy

• Overt DM

• CKD

PIH:

Definitions

• BP ≥140/90 mmHg
• On 2 occasions, 4 hours apart

• If BP ≥160/110 mmHg, recheck after 15 mins

Assessment Criteria

Proteinuria

• Protein:Creatinine ratio ≥0.3

• Screening: Urine dipstick
• Dipstick ≥1+

• Gold Standard:
• 24-hour urine sampling
• Excretion ≥300 mg protein in 24 hours

Signs of End-Organ Damage

• Any:
• Platelet count <1 lakh
• Liver enzymes ≥2 times ULN
• S. Creatinine ≥1.1
• Pulmonary edema
• Cerebral edema / Visual disturbances / Severe headache

Preeclampsia Severity

Eclampsia

• Definition: Generalized tonic-clonic seizures in severe preeclampsia

• Types:
• Antepartum: Most common, worst prognosis
• Intrapartum: During labor
• Post-partum: Within 48 hours of delivery

• MRI: Subcortical white matter edema

• M/c/c of death: IC Bleed

• Outcome depends on duration rather than severity of HN

Risk Factors & Prevention

Risk Factors

• Female exposed to placenta for first time:
• Primigravida
• New paternity
• Long interpregnancy interval

• Increased placental tissue:
• Twin pregnancy
• Diabetic patient
• Rh negative pregnancy
• Molar pregnancy

• Autoimmune disease:
• APLA syndrome

• Patient details:
• Age <18 or ≥40 years
• Obesity
• Calcium deficiency

• Previous History:
• In vitro fertilization
• Chronic HTN
• PIH

• Note: Smoking is protective

Prevention

• Prophylactic Aspirin (Low Dose):
• Start: 12 weeks (not later than 16 weeks)
• End: 36 weeks
• Dose: 75-100 mg/day

• ACOG Recommendation for Aspirin:
• APLA syndrome
• Chronic HTN
• Twins
• Kidney disease
• Diabetes
• Mnemonic: All Hypertensive Mothers Kan Die

Other Measures:

Pathophysiology & Predictors

 

Extravillous Cytotrophoblast (Endovascular Part)

• Functions
• Replaces spiral artery lining
• Converts from high-resistance to low-resistance vessels
• Maintains uteroplacental circulation
• Known as trophoblastic invasion / vascular remodelling

• Phases
• 1st Phase (up to 12 weeks):
• Replaces decidual segment lining
• 2nd Phase (16–20 weeks):
• Replaces myometrial segment lining

• Immune Role
• Maternal NK cells help in remodelling

Predictors for PIH

Effects of Vasoconstriction

Clinical Manifestation: PIH (after 20 weeks)

• Vasoconstriction → ↑ BP

• Virchow Triad Present
• ↑ Thrombosis risk
• End organ damage

Mechanism for Eclampsia

• Leaky capillaries →
• Cerebral edema
• Hypoxia
• Excitatory neurotransmitters →
• Eclampsia / Convulsions

• Loss of autoregulation →
• Cerebral hyperperfusion
• Symptoms:
• Throbbing/severe headache
• Visual disturbances (occipital lobe)

HPE finding:

• Glomeruloendotheliosis

Management

All PIH Patients

• Admit

• Preliminary:
• History
• Fundal examination
• Lab work (LFT, S. Creatinine, Platelets)

• Check for:
• BP ≥160/110 mmHg
• Signs of end-organ damage

Mild Preeclampsia

• OPD-based:
• BP monitoring: Twice daily
• No role: Anti-hypertensives, MgSO4

• Definitive:
• TOP ≥37 weeks

• Note: No role for aspirin, salt restriction, bed rest

• Aspirin is given to prevent preeclampsia → once preeclampsia already occured → no role

Severe Preeclampsia

In-patient:

• 1st line: MgSO4 (prevent seizures)

• 2nd-3rd line: IV antihypertensives

• 28-34 weeks POG: 1st dose corticosteroids

• No role of conservative management in
• Impending Eclampsia
• Eclampsia

Definitive:

• Termination of Pregnancy (TOP)
• If No Severe Risk Factors:
• TOP ≥34 weeks
• If Severe Risk Factors (+):
• Action: Immediate TOP
• Abruption
• Fetal distress
• DIC
• Pulmonary edema
• Impending eclampsia
• HELLP syndrome
• Complete course of corticosteroids and TOP if
• Mnemonic: PROM
• PROM
• Umbilical artery doppler:
• Absent/reversed end diastolic flow
• Renal dysfunction
• Oligohydramnios

Eclampsia (Magpie Trial)

Patient with Convulsions:

• Step 1: Raise bed rails / Airway management → O2 to child and mother

• Step 2: MgSO4 (treat convulsions)
• Seizure control → MgSO₄ (drug of choice).
• Other options → Thiopentone > Phenobarbitone.
• Avoid diazepam → causes thrombophlebitis, respiratory depression.

• Step 3: Anti-HTN (IV)

• Correct maternal acidosis if present.

Definitive:

• TOP (irrespective of gestational age)
• In PIH
• Vaginal delivery (Neuraxial > Epidural)
• In Eclampsia
• General anaesthesia → CS

Antihypertensives in Pregnancy

Indications

• BP ≥160/110 mmHg (single occasion)

• NICE guidelines: BP persistently ≥150/100 mmHg

Types

• Severe Preeclampsia:
• Labetalol IV (DOC)
• Alpha+ Beta blocker
• max. dose
• Oral → 2400 mg
• IV → 300 mg
• C/I: Asthma, Heart Failure
• Hydralazine IV
• Oral Nifedipine

• Chronic Hypertension:
• α-methyldopa (Oral)
• Oral Labetalol
• Oral Nifedipine
• Note: Hydralazine not used because it is given as IV

• Refractory Hypertension:
• Nitroprusside (S/E: Cyanide poisoning)

• Contraindicated:
• ACE inhibitors
• ARBs (e.g., Losartan)
• Diazoxide
• Beta blocker
• Diuretics:
• Not absolutely contraindicated
• C/I in PE
• Can be used in chronic HTN (not 1st line, but can be used before 20 wks)

Magnesium Sulphate (MgSO4)

• DOC for: Seizure prevention/treatment in hypertensive pregnant female

• MOA:
• Centrally acting (not antihypertensive)
• Bind to NMDA receptor in Brain

• Therapeutic Range: 4 to 7 mEq/L

Pritchard Regime:

• 1 ampule = 2mL = 1g MgSO4 = 50% solun

• Loading Dose:
• IM: 10g of 50% MgSO4 (5g each buttock, 10 ampoules) AND
• IV: 4g of 20% MgSO4 (4 ampoules)
• IV prep: 4 ampoules (4g/8ml) + 12 mL NS = 20 mL (20% concentration)
• Note: Renal function not checked for loading dose, monitor maternal HR

• Maintenance Dose:
• IM: 5g 50% solution every 4 hours in alternate buttocks
• Continue: 24 hours after delivery OR last convulsion

• Before dose, check:
• Deep tendon reflex/Knee jerk (+) → 1st sign
• Respiratory rate ≤ 12/min
• Urine output
• ≥ 100 mL/4 hours
• > 30 mL/ hr

• Note: MgSO4 can ↓ variability on CTG

• S. Mg not routinely measured

Toxicity Signs:

Antidote

• 10 mL of 10% calcium gluconate IV slowly (over 10 min)

Role of Doppler in PIH

• Assesses
• Umbilical Artery,
• Uterine Artery,
• Middle Cerebral Artery.

• Performed in 3rd trimester (32 weeks).

Umbilical Artery Doppler:

Uterine Artery Doppler

• Uses
• Predicts PIH
• Diagnosis of IUGR

• Done: 22-24 weeks POG

• Normal:
• Low resistance
• high diastolic flow.

• ↑ Risk of PIH:
• PI > Diastolic notch
• Increased Pulsatility Index
• 11-13 weeks
• Higher PI → Higher resistance.
• Persistence of diastolic notch
• Suggestive of high resistance.
• Normal upto 22 weeks
• After 22 weeks → suggest Preeclampsia
• Indicates high risk of
• Preeclampsia
• Uteroplacental insufficiency,
• IUGR
• PIH.

• Diagnoses early onset preeclampsia

• Indications: PIH, uteroplacental insufficiency, IUGR

Pulsatility Index (PI)

• For diagnosis of
• IUGR
• Early PIH

• PI = Peak Systolic Velocity – End Diastolic Velocity
  Mean Velocity

• Higher PI → Higher resistance.

• Normal Values
• Middle cerebral artery (MCA): increases with gestational age.
• Umbilical artery: decreases with gestational age.
• Uterine artery: normally decreases as pregnancy advances.

PI Value	Meaning	Example / Significance
Low PI, MCA	↓ Resistance in brain	fetal hypoxia → brain-sparing effect
High PI, Uterine A (> 95th percentile)	↑ Resistance	IUGR, preeclampsia, placental insufficiency

Abnormal MCA Doppler – Implications

• Brain-sparing effect
• Compensation for fetal hypoxemia
• ↑ Diastolic flow
• ↓ Pulsatility Index (PI)

• ↑ PI
• Indicates worsening oxygen deficit
• May suggest cerebral edema

• Reversal of MCA flow
• Severe abnormality
• Suggests cerebral edema / impending fetal demise

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SD Ratio

• S/D Ratio = Peak Systolic Velocity / End Diastolic Velocity

• Reflects resistance to blood flow in a vessel.

• With advancing gestation → S/D ratio decreases
• (because placental resistance falls as more villi develop).

• Normal: <3

• In Uteroplacental insufficiency
• Increases
• ≥ 3 → ≥ 28 weeks
• Mild PIH → TOP ≥37 weeks

Findings	Meaning	Clinical Significance
MCA S/D ratio ↓	Fetal hypoxia	Brain-sparing effect
PI ↑↑(>95th percentile)	↑ Vascular resistance	Placental insufficiency, IUGR, Preeclampsia
Absent end-diastolic flow (AEDF)	Severe placental disease	Terminate > 34 weeks
Reversed end-diastolic flow (REDF)	Impending fetal death	Terminate > 32 weeks
Late decelerations / Loss of beat to beat variability	ㅤ	Immediate TOP

Abnormal Waveforms:

• Absent End Diastolic Flow (AEDF)

• Reverse End Diastolic Flow (REDF)

Management for POG <33 Weeks (Severe PE / IUGR)

• Admit

• Corticosteroids

• NST: Daily/twice daily

• UA Doppler: 2-3 times/week

• USG for fetal growth

IUGR (Intrauterine Growth Restriction)

Criteria

Umbilical / Uterine artery Doppler

• ↑↑ PI

Oligohydramnios:

• Can be present (+/-)

Condition	Estimated Fetal Weight (EFW)	Timing of Delivery (TOP)
Small for Gestational Age	3-9%	38-39 weeks
Very Small for Gestational Age	<3%	37 weeks
Oligohydramnios	Not specified	36-37 weeks

Morphological IUGR

• Definition: Babies with clinical features of malnutrition.

• Birth weight: Between 10th–25th percentile for gestational age.

• Classification:
• Considered as IUGR
• Not SGA

• IUGR: Clinical diagnosis → based on growth pattern and clinical features.

SGA:

• Birth weight <10th percentile for gestational age.

• Asymmetrical IUGR, Symmetrical IUGR

HELLP Syndrome

• Diagnosis (All 3):
• Hemolysis (Microangiopathic)
• Elevated Liver enzymes
• Low Platelet count

• Symptom: Pain abdomen in T3

Tennessee Criteria:

1. Hemolysis (Any 2):
• P/S: Schistocytes
• ↑ LDH levels
• ↑ S. Bilirubin ≥1.2 mg/dL
• ↓ Haptoglobin levels
• Severe anemia unrelated to blood loss

2. Elevated Liver Enzymes: SGOT/SGPT 2 times normal (30-35 IU)

3. Low Platelet Count: <1 lakh/mm³

Notes:

• PIH: Common in primigravida

• HELLP: Common in multigravida

• BP not a criterion

Management:

• Initial: MgSO4 (prevent seizures) + antihypertensives

• Definitive:
• 1st dose corticosteroid (<34 wks POG),
• Immediate TOP

Acute Fatty Liver of Pregnancy (AFLP)

Buzzwords

• Rare

• Fulminant liver failure signs
• ↑↑ OT/PT
• Hypoglycemia
• ↑↑ Ammonia
• ↑↑ Maternal mortality rate

• Other complications
• Pancreatitis
• Hepato Renal failure
• Encephalopathy
• Coagulation failure

• Mortality: High (10%)

• Diagnosis criteria: Swansea criteria

Pathophysiology

• Enzyme involved:
• Long Chain 3-hydroxyacyl CoA Dehydrogenase (LCHAD)
• In child

Disease Seen In

• Fetus:
• Homozygous LCHAD deficiency
• Defect in FA oxidation
• Intermediate FA products accumulate in fetal circulation

• Mother:
• Heterozygous LCHAD deficiency
• Fetal metabolites enter maternal circulation
• Limited maternal oxidation capacity
• FA accumulation in liver → Free radical formation

Features

• m/c cause of liver failure in females: AFLP

• Timing: 3rd trimester (30–36 weeks)

• m/c symptoms at presentation:
• Nausea
• Vomiting
• Right upper quadrant pain

Risk Factors

• Previous H/O AFLP

• Twin pregnancy

• Pre-eclampsia

• Male fetus

• Primi gravida

Management

• Stabilize mother

• TOP irrespective of POG

• Liver function usually normalizes within 1 week after delivery

Terminology for pregnant women with itching of normal skin

Gestational pruritus

• Itching and peak bile acid concentrations < 19 micromol/L

Intrahepatic cholestasis of pregnancy (ICP)

• Itching and raised peak bile acid concentrations ≥19 micromol/L

Intrahepatic Cholestasis of Pregnancy

Buzzword

• ↑↑ Bile Acid

• No pain

• Pruritis

Features

• Seen in:
• Genetically predisposed females
• Third trimester

• Predisposing factors:
• Genetic susceptibility
• Increased estrogen
• Increased progesterone

Pathophysiology

Bile Acid in Amniotic Fluid

• Fetus swallows bile salt:
• Preterm Labor
• Irritates fetal bowel
• Meconium in amniotic fluid
• Meconium aspiration syndrome
• Accumulates in fetal heart
• Cardiac arrest
• Stillbirth

• Bile acids:
• Incompletely cleared → accumulate in plasma

• Unique to pregnancy

• High-risk condition

• Reversible and recurrent

Accumulation of Bile Acids & Salts in Plasma

• First symptom: Pruritis
• Appears 4 weeks before jaundice
• Predilection for palms & soles
• Worse at night

• Prematurity

• ↓ Vitamin K absorption
• → ↑ PPH, ↑ APH

• Irritates uterus
• → Preterm labour
• Risk of respiratory distress syndrome

Risk Factors

• Previous H/O AFLP

• Twin pregnancy

• Estrogen

Diagnosis

• Serum bile acids >10 μmol/L
• First/Best investigation

• ↑ SGOT/SGPT (<2× normal)

• ↑ Bilirubin (<5 mg/dL)

Management

• Mother:
• Ursodeoxycholic acid
• Inj. Vitamin K

• Intrapartum fetal monitoring (start at 32 weeks):
• NST – weekly
• BPS – weekly
• USG for fetal growth – every 3 weeks

• Termination of pregnancy:
• At 37> 38 weeks (induction)

• Newborn:
• Inj. Vitamin K

Notes

• OCPs contraindicated

• ↑ Risk of gallstones