My own view of this socio economic –medical problem: Imagine a poor woman has been admitted with BP of 170/ 120 at 28
weeks of gestation in a small hospital. Advices are :-- Not to allow her go
home. 2) To consult physician of the small
hospital (where I am working voluntarily-Honorary assignment after retirement from Govt service) 3) BP chart three times a day –to keep a chart 4) Salt
restricted diet 5) mild sedatives if warranted if sleep disturbances out of
anxiety related to husband family members Repeated Lab & imaging studies including Urinary
proteins, Uric acid, Doppler , 5) It is reported from previous san that there
is already growth lag of 3 wks, In my view it is hogh time that I should increase
the dose of Gravidol or supplement
1) But one concern is can the -combination of Nicardia & Gravidol potentiating
adverse effects of / actions of Mag Sulphatase in case she develops Imminent
ECL/ Fits.
What is the back of mind of
Dr S K Pal??? Ans: Let me disclose my
view to this case. In any case whatever the Doppler /AFI/MVP /CTG -, I have a
strong feeling that our small team will try to deliver her at 34-35 Weeks after proper
counseling.
First tip in selecting anti hypertensive’s in early
preg-say first trimester:-To avoid beta blocker, ARB(angiotensisin
Receptor Blockers--namely Losartan -marketed as Repace. Losar Losagard etc) and
ACE (Angiotensin converting Enzyme blockers- Enalaprils,Lisinopril,Ramipril, )
. May opt for amlodepine to which we are all very much acquainted. May change
the hypertensive if she was n such agent prior to preg with an intimation to
primary care doctor who prescribed ARB,ACE inhibitors /Propanol(except
BISOPROPOL) etc Renin inhibitors, and thiazides are also risky. Safest option
in early preg is Ca channel blockers.,
Second Trip in treating PIH(of mild nature) :-There have been many debates as to when one should initiate anti
hypertensives in peg. Till now ,as far as I know , no consensus. However, I
usually initiate anti-HTN Ry when BP reaches 150/90 or above after extra rest
and salt restricted diets. I usually start with nicardia (Nifedipine Retard )
10 mg Tab (not Cap)-on BD schedule or Amlodepine like stamlo- 2.5 mg on OD dose
---> to monitor every other day at domiciliary settings -to maintain a BP
chart..Most cases (mild PIH) will remain stable in such dose, Rarely we have to
increase the dose of former drug at 20 mg Tab BD or in case of amlodepine to 5
mg. Whenever BP remains uncontrolled with such a agent,I shall prefer to
combine Labetolol with total 40 mg Nicardia OD . Amlodepine 5 mg OD. If still
remains uncontrolled one can increase the dose in a titrating fashion if U
proteins, LFT, Coagulation profitless, & lastly Doppler study are
reassuring-and therefore one intends to prolong the preg. say highest dose of
such anti hypertensive , as I believe are for NIcardia max 60 mg/OF; Alpha-Dopa
2-Gm per Day and for Labetolo max dose per day as admissible is 1200-mg OD.
The third tip in controlling BP : In pregancy period??
Tip-3: Few clinical informations on
Nifedipine :-Tablets are available both plain and Retard formulation. For
emergency situations better to initiate Tab(not Retard ) -one can initiate with
20 mg stat on admission-->to check BP-->on hourly basis and g
Tip:-4: TheFourth tip in controlling BP : In pregancy period?? Tip-4-Clinical
informations Pertaining to LABETOLOL_A COMBINED alpha and beta blockers
(sympathetic) . Max total DAILY dose is 1200 mg in divided dose.(by contrast in
case of alpha Dopa--> Max 4000 mg) However most mild cases do well with 200
mg BD schedule,initially COMMENCING WITH 100 MG bd.: should NOT BE USED IN
asthma(-Broncho-spastic Diseases) OR copd/ Almost all Lung diseases and Hear
failure)) !!! iN EMERGENCY SITUATION (UNBOOKED-UNDIAGNOSED htn)-AT emergency
ROOM ONE CAN SAFELY ADMINISTER iIn lABETOLOL 20 MG SLOWLY(EACH AMP CONTAINS 5
MG IN 2 ml ).--> to watch response it will be safe to rpt another 20 mg
after only 30 minutes as bolus again , though some clinicians are of opinion if
BP is 200/130 first bolus can be 50 mg-no apprehension about sudden fall.
Meanwhile Blood for LFT(AST, LDH in particular), Alk Pho,other hepatic
parameters, Compl haemogagm, Group typing, Coagulation profile, Uric acid,
Creatinine, & Physician consultation if available. Intake output chart,
When fully recovers from crisis than hepatic & Obstetric, Renal sonogram...
Multistix Urine Exam method for detection of albuminuria is limited to only in
emergency situations.To add blood tests like TSH(interpret with caution in all
acute diseases), Serum electrolytes, and most importantly patelate count.tests
for collagen diseases(if Hospital Fund permits-keeping in mind we loose
hundreds of mother annually in hypertensive crisis), Thee are other clinically
established agents for acute Hypertensive crisis in emergency settings like-Sod
nitroprusides,(at a dose of 5 mcg /mt microdrip with RMO /ICU person stting by
te side- Nitroglycerine, To continue antihypertascesin post partum period with
close vigilance. May avoid OCPlater,
Nicardia 20mg TID
Mgso4 to b given
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