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Hypertensive Disorders in Pregnancy, Ectopic Pregnancy (Early Pregnancy…
Hypertensive Disorders in Pregnancy
Chronic Hypertension
Definition
Present before pregnancy OR
Diagnosed <20 weeks OR
Persists >12 weeks postpartum
Types
Essential (no underlying cause)
Secondary (secondary to other disease)
Management
Target BP until 160/100, focus on diastolic 90–100
Labetalol (first line)
Nifedipine (second line, avoid if possible due to side effects)
Methyldopa (third line)
Hydralazine IV (emergency severe cases)
Avoid ACE inhibitors and ARBs
Low-dose aspirin 50–100 mg for high-risk, start <16 weeks
Fetal surveillance and growth scans
Delivery: 38–39 weeks if uncomplicated
Gestational Hypertension
Definition
Onset ≥20 weeks
No maternal organ dysfunction
Resolves ≤12 weeks postpartum
Management
Monitor BP and urine protein
Antihypertensives if BP elevated
Fetal surveillance
Deliver 37–38 weeks if stable
Manage as pre-eclampsia if deterioration occurs
Red flags for escalation
BP >160/100
Visual disturbance
Symptoms of HELLP
Platelets <100
Pre-eclampsia
Definition
HTN ≥140/90 after 20 weeks
PLUS maternal organ dysfunction or proteinuria
Diagnosis
Proteinuria ≥300 mg/24h OR PCR ≥30 OR albumin:creatinine ratio
Edema (particularly facial/spitting edema)
Other maternal organ dysfunction
Severe Pre-eclampsia Criteria
BP ≥160/110
Severe headache
Visual disturbance
Epigastric or right upper quadrant pain (due to liver distension)
Platelets <100
Elevated liver enzymes (ALT, AST)
Renal impairment (↑ creatinine)
Pulmonary edema
IUGR
Management (Non-severe)
Admit or monitor closely
Antihypertensives (Labetalol, Nifedipine, Methyldopa)
Labs: FBC, LFTs, U&E
Fetal surveillance
Delivery at 37 weeks if stable
Management (Severe)
Admit (HD/ICU)
BP control (Labetalol, Hydralazine, Nifedipine)
Magnesium sulfate prophylaxis
Loading 4 g IV
Maintenance 1 g/hour
Fluid restriction
Continuous maternal & fetal monitoring
<34 weeks: corticosteroids if stable
Delivery ≥34 weeks or earlier if unstable
HELLP Syndrome
Definition
Hemolysis
Elevated liver enzymes
Low platelets
Management
Treat as severe pre-eclampsia
Magnesium sulfate
BP control
Correct coagulopathy
Urgent delivery
Eclampsia
Definition
Pre-eclampsia + new onset grand mal seizures
Can occur antenatal, intrapartum, postpartum
Management
Immediate stabilisation
ABC
Left lateral position
Oxygen
Protect airway
Seizure control
Magnesium sulfate
Loading 4 g IV
Maintenance 1 g/hour
If seizure recurs
Additional magnesium sulfate
Benzodiazepine (e.g., diazepam) if refractory
BP control
Treat if ≥160/110
Delivery after maternal stabilisation
Mode based on obstetric indications
Postpartum eclampsia
Continue magnesium maintenance
Magnesium Sulfate Monitoring
Monitor
Respiratory rate ≥12/min
Urine output ≥25 mL/hour
Deep tendon reflexes present
Toxicity signs
Loss of deep tendon reflexes
Respiratory depression
Coma
Management of toxicity
Stop magnesium infusion
IV calcium gluconate 10 mL of 10%
Dose adjustment
Urine output <100 mL/4h → reduce maintenance dose by half
Aspirin Prophylaxis
Dose 50–100 mg/day
Start before 16 weeks in high-risk women
Reduces risk of pre-eclampsia
Delivery Timing Summary
Gestational HTN → 37–38 weeks
Pre-eclampsia → 37 weeks
Severe PE → ≥34 weeks or earlier if unstable
Eclampsia → after stabilisation
AMC Exam Rule
Classify → Assess severity → Magnesium if severe → Control BP → Deliver
Ectopic Pregnancy (Early Pregnancy Bleeding ≤20 weeks)
Definition
Implantation of a fertilized ovum outside the uterine cavity
Most common site: ampulla of the fallopian tube
Other possible sites: ovary, cervix, abdomen
Epidemiology
Occurs in ~1–2% of pregnancies
Major cause of first-trimester maternal mortality
Recurrence risk: 10–15%
Risk Factors
Previous ectopic pregnancy
Pelvic inflammatory disease (PID) – most common underlying cause
Tubal surgery or adhesions
Assisted reproduction (IVF)
Endometriosis
Smoking
Clinical Features
Classic triad: amenorrhea + abdominal/pelvic pain + vaginal bleeding
Abdominal/pelvic tenderness on examination
Cervical motion tenderness
Shoulder tip pain → indicates rupture with hemoperitoneum (referred diaphragmatic irritation)
Syncope, pallor, hypotension if ruptured
Differential Diagnosis
Miscarriage / abortion (threatened, incomplete, complete)
Early intrauterine pregnancy
Corpus luteum cyst
Investigations
Pregnancy test: urine or serum hCG
Negative → consider PID or other non-pregnancy causes
Transvaginal ultrasound (TVUS)
Normal intrauterine pregnancy → viable fetus
Empty uterus ± adnexal mass → suspect ectopic, early miscarriage, or corpus luteum
Free fluid in pouch of Douglas → suggests rupture
Serial quantitative beta-hCG
Normal early intrauterine pregnancy: doubles ~48 hours
Abnormal rise / plateau → suspect ectopic or abnormal pregnancy
Blood tests
Hemoglobin / hematocrit
Blood group & Rh typing → give anti-D if Rh-negative
Management
Hemodynamically stable, unruptured ectopic
Medical: Methotrexate (if small, no fetal heartbeat, meets criteria)
Single dose: 50 mg/m² IM
Monitor beta-hCG on days 4 and 7 (expect ≥15% drop)
Surgical: Laparoscopic salpingostomy or salpingectomy if methotrexate not suitable or fails
Hemodynamically unstable or ruptured ectopic
Emergency surgery: laparoscopy or laparotomy
Salpingectomy or salpingostomy depending on damage
Resuscitation: IV fluids, blood transfusion if required
Supportive care: pain relief, emotional support
AMC Exam Key Points
Always assess
hemodynamic stability first
Suspect ectopic in
any first-trimester bleeding + abdominal pain
Shoulder tip pain = red flag for rupture
Investigations: urine/serum hCG, TVUS, serial quantitative beta-hCG
Management depends on
stability and rupture
: methotrexate if stable, surgery if unstable
Anti-D prophylaxis for Rh-negative women