(a) (i) Classify hypertensive disorders in pregnancy. (ii) Enumerate the types and complications of eclampsia. (iii) Discuss the…

(a)(i) Classification

Hypertensive disorders in pregnancy are classified per ISSHP/ACOG by timing, proteinuria and end-organ injury. Chronic hypertension is BP ≥140/90 mmHg before pregnancy or before 20 weeks, or new hypertension after 20 weeks that persists beyond 12 weeks postpartum. Gestational hypertension is new BP ≥140/90 after 20 weeks without proteinuria or other preeclampsia features, resolving by 12 weeks postpartum. Preeclampsia is new hypertension after 20 weeks with proteinuria (≥300 mg/24 h or protein/creatinine ratio ≥0.3) or end-organ dysfunction; severe features include BP ≥160/110, renal/hepatic impairment, cerebral/visual symptoms, pulmonary edema, HELLP. Eclampsia is preeclampsia with generalized tonic-clonic seizures. Superimposed preeclampsia occurs when chronic hypertension develops new proteinuria/end-organ disease after 20 weeks or sudden worsening.

(a)(ii) Types and complications of eclampsia

Eclampsia is classified as antepartum, intrapartum and postpartum; postpartum may be immediate (within 48 h) or late. Maternal complications include cerebral haemorrhage/infarction, cerebral oedema, DIC, acute renal failure, hepatic rupture/HELLP, pulmonary oedema, ARDS and death. Fetal complications include IUGR, placental abruption, preterm birth, stillbirth and neonatal death.

(a)(iii) Management of antepartum eclampsia at 32 weeks

In a 25-year-old primigravida with antepartum eclampsia at 32 weeks, management is in a tertiary unit using ABCDE: left lateral position, airway, oxygen, suction, seizure control. MgSO4 is first-line: Pritchard regimen 4 g IV over 15–20 min plus 10 g IM (5 g each buttock), then 5 g IM every 4 h; or Zuspan 4 g IV loading then 1 g/h infusion (Sibai: 6 g then 2 g/h). Before each dose check that the patellar reflex is present, respiratory rate ≥16/min and urine output ≥30 mL/h (≥100 mL in 4 h); the therapeutic serum level is 4–7 mEq/L (reflexes are lost around 10 and respiratory paralysis occurs around 15 mEq/L); toxicity suggests absent patellar reflex, RR <12, oliguria; keep calcium gluconate 10% 10 mL IV ready as antidote. Recurrent seizures are treated with a further 2 g IV MgSO4. MgSO4 is continued for at least 24 h after delivery or last seizure. Severe hypertension (≥160/110) is treated within 30–60 minutes with IV labetalol, IV hydralazine or oral nifedipine to a target of about 140–150/90–100 mmHg to prevent stroke, avoiding abrupt falls that compromise placental perfusion. Delivery is the definitive treatment: eclampsia is an indication for delivery at any gestation once the mother is stabilised (seizures controlled, BP controlled, oxygenation adequate), usually within 6–12 hours. At 32 weeks, antenatal corticosteroids (betamethasone 12 mg IM) are started for fetal lung maturity, but delivery is not postponed to complete the course. The mode is by obstetric indications: induction with prostaglandin or oxytocin if the cervix is favourable and the fetus is stable, and caesarean section for an unfavourable cervix with a prolonged induction expected, fetal distress, abruption or other obstetric reasons, preferably under regional anaesthesia if platelets are adequate. A paediatrician and NICU should be ready for the preterm baby. ICU monitoring, fetal surveillance, correction of coagulopathy and fluid restriction complete care.

(b)(i) Ulcerative colitis

Ulcerative colitis presents with bloody diarrhoea, urgency, tenesmus, abdominal pain, fever, weight loss and anaemia; extraintestinal features include uveitis, arthritis, erythema nodosum and primary sclerosing cholangitis. It involves the rectum and extends continuously proximally, is mucosal/submucosal, and shows crypt abscesses and pseudopolyps. Severity is graded by the Truelove–Witts criteria: acute severe UC is ≥6 bloody stools a day with at least one of pulse >90/min, temperature >37.8 °C, haemoglobin <10.5 g/dL or ESR >30 mm/h. Diagnosis is by colonoscopy with biopsy, stool tests and faecal calprotectin. Management is severity-based: hydration, exclude C. difficile, 5-ASA for mild-moderate disease, corticosteroids for acute flares (IV hydrocortisone 100 mg 6-hourly or methylprednisolone in acute severe UC, with rescue infliximab or ciclosporin if there is no response by day 3–5) and thromboprophylaxis, immunomodulators such as azathioprine and biologics (anti-TNF, vedolizumab, ustekinumab) or JAK inhibitors (tofacitinib) for moderate-severe/refractory disease. Colonoscopic surveillance for dysplasia starts 8 years after onset of extensive colitis. Maintenance therapy aims to prevent relapse and preserve quality of life. Toxic megacolon or perforation requires emergency subtotal colectomy with end ileostomy; IPAA is an elective reconstructive option after recovery, not an emergency operation. Surgery is also indicated for dysplasia/cancer or medically refractory disease.

(b)(ii) Differences from Crohn's disease

UC has continuous rectal involvement, mucosal inflammation, bloody diarrhoea, no granulomas, no fistulae and no rectal sparing; Crohn’s has skip lesions, transmural inflammation, non-caseating granulomas, strictures/fistulae/perianal disease, rectal sparing and small-bowel involvement.

(c) Home-based Newborn Care (HBNC)

Launched in 2011 under NHM, HBNC aims to reduce neonatal and infant mortality, detect danger signs early, promote exclusive breastfeeding, ensure thermal care, cord care, immunization and timely referral. Under the National Health Mission, it strengthens the last-mile link between facility and family. ASHA is responsible for six scheduled visits after an institutional delivery (days 3, 7, 14, 21, 28 and 42) and seven after a home delivery (an additional visit on day 1), with extra visits for low-birth-weight or preterm babies,using the HBNC kit (weighing scale, digital thermometer, watch) to assess weight, temperature, feeding, cord and immunization status; promoting early initiation of breastfeeding within one hour, exclusive breastfeeding, skin-to-skin (Kangaroo Mother) care and dry cord care; checking the mother for postpartum haemorrhage, fever and breast problems; identifying danger signs (poor feeding, fast breathing, chest indrawing, hypothermia or fever, convulsions, jaundice) and referring to the nearest facility or SNCU; giving first-level care such as oral amoxicillin or cotrimoxazole for suspected sepsis where referral is not possible, as per programme guidelines; tracking LBW and sick babies; promoting birth registration and immunization; maintaining the HBNC format; and linking families with the ANM. Visits continue under Home-Based Care for Young Children (HBYC, 2018) at 3, 6, 9, 12 and 15 months, and ASHA receives a performance-based incentive after completing the visits.