8: HTN Flashcards
Preeclampsia is the presence of ? and ?
hypertension >140/90 mm Hg (2x 6hrs apart) and proteinuria > 300 mg/24 hours or or >1 to 2> on dipstick (+/- nondependent edema)
-most common in nulliparous in her 3rd trimester
Preeclampsia is characterized by generalized multiorgan vasospasm that can lead to ?
seizure, stroke, renal failure, liver damage, pulmonary edema, DIC/thrombocytopenia, or fetal demise.
Risk factors for preeclampsia include ?
nulliparity, multiple gestation, and chronic hypertension.
patients present with eclamptic seizures occurring ?
before labor (25%), during labor (50%), or after delivery (25%).
Chronic hypertension is defined as hypertension occurring when?
before conception, before 20 weeks’ gestation, or persisting more than 6 weeks postpartum
- leads to superimposed preeclampsia in one-third of patients.
- tx with nifedipine or labetalol (NOT methyldopa)
what tests for suspected preeclampsia
A baseline ECG and 24-hour urine collection for protein and creatinine should be performed.
severe preeclampsia is defined as ? and ?
BP>160/110, protein >5g/24hrs (3-4+ on dipstick) and s/s of severe preeclampsia (detailed later)
When hypertension is seen early in the second trimester (14 to 20 weeks), consider ?
hydatidiform mole or previously undiagnosed chronic hypertension
Unlike other preeclamptic patients, the patient with HELLP is more likely to be less than ? weeks at time of presentation
36 weeks
HELLP typically presents with
RUQ pain, epigastric pain, or N/V in the 3rd trimester
HTN states of pregnancy
GH (or pregnancy-induced hypertension) Preeclampsia Severe preeclampsia Chronic hypertension Chronic hypertension w/superimposed preeclampsia HELLP syndrome AFLP
fetal complications of preeclampsia
*Complications related to prematurity (if early delivery is necessary) Acute uteroplacental insufficiency Placental infarct and/or abruption Intrapartum fetal distress Stillbirth (in severe cases) Chronic uteroplacental insufficiency Asymmetric and symmetric SGA fetuses IUGR Oligohydramnios
obstetric complications of preeclampsia
Uteroplacental insufficiency
Placental abruption
Increased premature deliveries
Increased cesarean section deliveries
disease-related risk factors for preeclampsia
Chronic hypertension Chronic renal disease Collagen vascular disease (e.g., SLE) Pregestational diabetes African American Maternal age (35)
immunogenic-related and fam hx risk factors for preeclampsia
Nulliparity Previous preeclampsia Multiple gestation Abnormal placentation New paternity Female relatives of parturient Mother-in-law Cohabitation
If a diagnosis of preeclampsia is being made in the acute setting, what urine dip can be diagnostic?
proteinuria of 1+ or greater on a clean catch urine dipstick on two occasions has also been used to diagnose proteinuria.
if 2+, 24 hr urine typically >300mg
is a negative/trace urine dip reassuring if pt is hypertensive?
No, more than 2/3 of patients with elevated BPs and negative or trace on urine dip had >300 mg/ 24 hr and all patients with 3+ and 4+ protein on urine dip had significant proteinuria on a 24 hour urine protein
-a better predictor than dip is PCR ratio
A spot urine P/C ratio of ? is concerning for preeclampsia and should prompt further evaluation, including ?
0.2 to 0.3
a 24 hour urine protein collection.
severe preeclampsia by systems
Neuro: severe headache (not relieved by acetaminophen)
Visual changes; scotomata
Cardiovascular: SBP >160 mm Hg or DBP >110 mm Hg
Pulmonary: Pulmonary edema
Renal: Acute renal failure with rising creatinine
Oliguria 3+ on dipstick
GI: RUQ pain
Elevation of transaminases, AST and ALT
Heme: hemolytic anemia
Thrombocytopenia:
many clinical symptoms of preeclampsia are explained by ?
-vasospasm (and intravascular depletion secondary to a generalized transudative edema) leading to ischemia, necrosis and hemorrhage of organs.
diagnose of HELLP
hemolytic anemia: Schistocytes on PBS, Elevated LDH, Elevated total bilirubin
Elevated liver enzymes: increase in AST and ALT
Low platelets: thrombocytopenia (less than 100,000)
a number of AFLP patients will have fetuses with deficiency of ?
long-chain hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency
To differentiate AFLP from HELLP
AFLP (liver failure): elevated ammonia level, blood glucose
Mg sulfate dosage for mild preE seizure ppx during L/D (and 12-24 hrs after delivery)
4 g load and 1 g/hour maintenance, or 4 or 6 g load and 2 g/hour maintenance regimen.
severe preE management
Mg sulfate, hydralazine (a direct arteriolar dilator) or labetalol (beta and alpha blockade)
-Beyond 32 wga or in a severe preeclamptic patient with signs of renal failure, pulmonary edema, hepatic injury, HELLP syndrome, or DIC, delivery should ensue immediately.
severe preE treatment after delivery
- may worsen due to ^Ag exposure, Mg ppx 24 hrs after
- if BP chronically elevated: nifedipine and labetalol
- if HELLP with worsening thrombocytopenia: corticosteroids
theorized tx to prevent preE in subsequent pregnancies
ASA and Ca2+
eclampsia complications
(+seizures: tonic-clonic/grand mal) cerebral hemorrhage, aspiration pneumonia, hypoxic encephalopathy, and thromboembolic events.
when is MgSO4 initiated in eclampsia?
at the time of diagnosis and continued for 12 to 24 hours after delivery
In the case of MgSO4 overdose, rapidly administered ?
10 mL 10% calcium chloride or calcium gluconate IV for cardiac protection.
Clinical Response to Serum MgSO4 Concentrations
4.8–8.4: Therapeutic seizure prophylaxis
8: CNS depression
10: Loss of DTRs
15: Respiratory depression/paralysis
17: Coma
20–25: Cardiac arrest
delivery should be initiated in eclamptic pt only after ?
patient has been stabilized and convulsions have been controlled
- stabilize the mother by establishing adequate maternal oxygenation and cardiac output
- may see prolonged FHR decels
An increase in the SBP/DBP of ? over pre pregnancy BP is indicative of superimposed preeclampsia
SBP >30 mm Hg or in the DBP >15 mm Hg
in a patient with renal disease, an elevated ? is sometimes used to differentiate preeclampsia from exacerbation of HTN
uric acid above 6.0 to 6.5
chronic HTN leads to superimposed preE in ? of patients
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