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TN Obstetrics > 8. Hypertensive Disorders of Pregnancy > Flashcards

8. Hypertensive Disorders of Pregnancy Flashcards

1
Q

Hypertensive disorders of pregnancy are classified how? (2)

A
  • either pre-existing or gestational HTN.
  • Pre- eclampsia and eclampsia are included in the spectrum of hypertensive disorders of pregnancy
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2
Q

Define: Pre-existing hypertension (2)

A
  • BP ≥140/90 prior to 20 wk GA; BP should be elevated on ≥2 occasions at least 15 minutes apart
  • essential HTN is associated with an increased risk of gestational HTN, abruptio placentae, intrauterine growth restriction (IUGR), and intrauterine fetal death (IUFD)
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3
Q

Define gestational HTN (1)

A
  • sBP ≥140 or dBP ≥90 after 20 wk GA without proteinuria in a woman known to be normotensive before pregnancy
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4
Q

Define: Preeclampsia (1)

A

pre-existing or gestational HTN with new onset proteinuria or adverse conditions (end organ dysfunction)

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5
Q

Define: Eclampsia (1)

A
  • the occurrence of ≥1 generalized convulsions and/or coma in the setting of preeclampsia and in the absence of other neurologic conditions
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6
Q

Name: Ominous Symptoms of HTN in Pregnancy (3)

A
  • RUQ pain
  • headache
  • visual disturbances
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7
Q

Eclampsia prior to 20 wk of gestation is common or rare? (1)

A

is rare and should raise the possibility of an underlying molar pregnancy or antiphospholipid syndrome

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8
Q

Name: Clinical Manifestation of Eclampsia (5)

A
  • eclampsia is a clinical diagnosis
  • typically tonic-clonic and lasting 60-75 s
  • symptoms that may occur before the seizure include
    • persistent frontal or occipital headache
    • blurred vision
    • photophobia
    • right upper quadrant or epigastric pain
    • altered mental status
  • in up to one third of cases, there is no proteinuria or blood pressure >140/90 mmHg prior to the seizure
  • in general, women with typical eclamptic seizures who do not have focal neurologic deficits or prolonged coma do not require diagnostic evaluation including imaging
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9
Q

Name MATERNAL Risk Factors for Hypertensive Disorders in Pregnancy (7)

A
  • primigravida (80-90% of gestational HTN), first conception with a new partner, Past medical history PMHx or FHx of gestational HTN, or preeclampsia/eclampsia
  • DM, chronic HTN, or renal insufficiency
  • obesity
  • antiphospholipid syndrome or inherited thrombophilia
  • extremes of maternal age (<18 or >35 yr)
  • previous stillbirth or intrauterine fetal death IUFD
  • vascular or connective tissue disease
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10
Q

Name FETAL Risk Factors for Hypertensive Disorders in Pregnancy (5)

A
  • intrauterine growth restriction IUGR or oligohydramnios
  • gestational trophoblastic neoplasia (GTN)
  • multiple gestation
  • fetal hydrops “mirror syndrome”
  • abruptio placentae
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11
Q

Name adverse maternal conditions that cause hypertension in pregnancy (5)

A
  • HELLP (life-threatening liver disorder thought to be a type of severe pre-eclampsia)
  • Cerebral hemorrhage
  • Renal dysfunction: oliguria <500 mL/d
  • Left ventricular failure, pulmonary edema
  • Placental abruption, disseminated intravascular coagulation (DIC)
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12
Q

Name symptoms of Hypertension in Pregnancy (4)

A
  • Abdominal pain, N/V
  • Headaches, visual problems
  • Shortness of breath (SOB), chest pain
  • Eclampsia: convulsions
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13
Q

Name adverse fetal conditions that cause hypertension in pregnancy (4)

A
  • intrauterine growth restriction (IUGR)
  • Oligohydramnios
  • Absent/reversed umbilical artery end diastolic flow
  • Can result in:
    • Fetal disability and/or death
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14
Q

Describe: Clinical Evaluation of mother of Hypertensive Disorders in Pregnancy (10)

A
  • body weight
  • central nervous system
    • presence and severity of headache
    • visual disturbances – blurring, scotomata
    • tremulousness, irritability,and somnolence
  • hematologic: bleeding, petechiae
  • hepatic:
    • RUQ or epigastric pain
    • severe N/V
  • renal: urine output and colour
  • evaluation of fetus: fetal movement
  • fetal heart rate tracing – NST
  • U/S for growth
  • BPP
  • Doppler flow studies
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15
Q

Describe: Laboratory Evaluation of Hypertensive Disorders in Pregnancy (6)

A
  • CBC
  • PTT, INR, fibrinogen – if abnormal LFTs or bleeding
  • ALT, AST
  • creatinine, uric acid
  • 24 h urine collection for protein or albumin:creatinine ratio
  • may consider placental growth factor (PlGF) testing as an early screening test for suspected preeclampsia
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16
Q

Name MATERNAL Complications of Hypertensive Disorders in Pregnancy (7)

A
  • liver and renal dysfunction
  • seizure - “eclampsia”
  • abruptio placentae
  • left ventricular failure/pulmonary edema
  • DIC (release of placental thromboplastin consumptive coagulopathy)
  • HELLP syndrome
  • hemorrhagic stroke (50% of deaths)
17
Q

Name FETAL Complications of Hypertensive Disorders in Pregnancy (4)

A

2° to placental insufficiency

  • intrauterine growth restriction (IUGR)
  • prematurity
  • abruptio placenta
  • intrauterine fetal death (IUFD)
18
Q

For non-severe HTN (149-159/90-105), target what BP? (2)

A
  • without comorbidities: 130-155/80-105
  • with comorbidities: <140/90
19
Q

For both pre-existing and gestational HTN, name medication to manage HTN (3)

A
  • labetalol 100-400 mg PO bid-tid
  • nifedipine XL preparation 20-60 mg PO od
  • α-methyldopa 250-500 mg PO bid-qid
20
Q

For severe HTN (BP>160/110), how to treat? (2)

A
  • labetalol 20 mg IV then 20-80 mg IV q30min (max 300 mg) (then switch to oral)
  • nifedipine 5-10 mg capsule q30min
    • hydralazine 5 mg IV, repeat 5-10 mg IV q30min or 0.5 to 10 mg/h IV, to a maximum of 20 mg IV (or 30 mg IM)
21
Q

Describe the management of preeclampsia if stable and no adverse factors?

A
  • if stable and no adverse factors (GA 24-33+6 wk), expectant management, ± delivery as approaching 34-36 wk (must weigh risks of fetal prematurity vs. risks of developing severe preeclampsia/eclampsia)
  • antenatal corticosteroids should be considered if GA ≤ 34 wk
22
Q

Describe the management of preeclampsia if >37wk (1)

A

if >37 wk, immediate delivery is recommended

23
Q

Describe the management of severe preeclampsia (1)

A

for severe preeclampsia, stabilize and deliver, regardless of GA

24
Q

Describe monitoring of severe preeclampsia during labour. (4)

A

increase maternal monitoring:

  • hourly input and output
  • urine dip q12h
  • hourly neurological vitals
  • increase fetal monitoring (continuous FHR monitoring)
25
Q

Describe antihypertensive therapy of preeclampsia (2)

A
  • labetalol 20 mg IV, then 20-80 mg IV q30min (max 300 mg) (then switch to oral)
  • nifedipine 5-10 mg capsule q30min
    • hydralazine 5 mg IV, repeat 5-10 mg IV q30min or 0.5-10 mg/h IV, to a maximum of 20 mg IV (or 30 mg IM)
26
Q

For preeclampsia prevention among increased risk women, what is recommended? (1)

A

low-dose ASA (75-100 mg/d) is recommended until delivery.

27
Q

____ Doppler velocimetry should be part of the antenatal fetal surveillance in preeclampsia.

A

Umbilical artery Doppler velocimetry should be part of the antenatal fetal surveillance in preeclampsia.

28
Q

Initial antihypertensive therapy for severe HTN (sBP >160 or dBP ≥110) should be with what? (3)

A
  • labetalol
  • nifedipine
  • hydralazine.
29
Q

Initial antihypertensive therapy for non-severe HTN (BP 140-159/90-109 mmHg) should be with what? (3)

A
  • methyldopa
  • β-blockers
  • calcium channel blockers.
30
Q

For fetal lung maturation, what should be considered for all women with preeclampsia before 34 wk gestation? (1)

A

Antenatal corticosteroids

31
Q

In a planned vaginal delivery with an unfavourable cervix, what should be used? (1)

A

cervical ripening should be used.

32
Q

___ should be used as part of the management of HTN during the third stage of labour, particularly in the presence of thrombocytopenia or coagulopathy.

A

Oxytocin 5 units IV or 10 units IM

33
Q

___ is the recommended first-line treatment for eclampsia.

A

Magnesium sulfate is the recommended first-line treatment for eclampsia.

34
Q

___ is the recommended eclampsia prophylaxis in severe preeclampsia.

A

Magnesium sulfate is the recommended eclampsia prophylaxis in severe preeclampsia.

35
Q

Name: Preeclampsia Investigations (6)

A
  • CBC
  • AST, ALT
  • INR and aPTT (if abn LFTs or bleeding)
  • Cr
  • Urine (24 h protein collection or albumin/ creatinine ratio)
  • Uric acid
36
Q

Describe seizure prevent in preeclampsia (6)

A
  • magnesium sulfate: 4 g IV loading dose, followed by 1g/h
  • postpartum management
  • risk of seizure highest in first 24 h postpartum – continue MgSO4 for 12-24 h after delivery
  • vitals q1h
  • consider HELLP syndrome
  • most return to normotensive BP within 2 wk
37
Q

Describe HELLP Syndrome (3)

A
  • Hemolysis
  • Elevated Liver Enzymes
  • Low Platelets
38
Q

Describe: Management of Eclampsia (8)

A
  • ABCs
  • roll patient into left lateral decubitus position LLDP
  • supplemental O2 via face mask to treat hypoxemia due to hypoventilation during convulsive episode
  • aggressive antihypertensive therapy for sustained dBP ≥105 mmHg or sBP ≥160 mmHg with hydralazine or labetalol
  • prevention of recurrent convulsions: to prevent further seizures and the possible complications of repeated seizure activity (e.g. rhabdomyolysis, metabolic acidosis, aspiration pneumonitis, etc.)
  • MgSO4 is now the drug of choice
  • the definitive treatment of eclampsia is DELIVERY, irrespective of gestational age, to reduce the risk of maternal morbidity and mortality from complications of the disease
  • mode of delivery is dependent on clinical situation and fetal-maternal condition

TN Obstetrics (16 decks)

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