8. Hypertensive Disorders of Pregnancy Flashcards
Hypertensive disorders of pregnancy are classified how? (2)
- either pre-existing or gestational HTN.
- Pre- eclampsia and eclampsia are included in the spectrum of hypertensive disorders of pregnancy
Define: Pre-existing hypertension (2)
- 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)
Define gestational HTN (1)
- sBP ≥140 or dBP ≥90 after 20 wk GA without proteinuria in a woman known to be normotensive before pregnancy
Define: Preeclampsia (1)
pre-existing or gestational HTN with new onset proteinuria or adverse conditions (end organ dysfunction)
Define: Eclampsia (1)
- the occurrence of ≥1 generalized convulsions and/or coma in the setting of preeclampsia and in the absence of other neurologic conditions
Name: Ominous Symptoms of HTN in Pregnancy (3)
- RUQ pain
- headache
- visual disturbances
Eclampsia prior to 20 wk of gestation is common or rare? (1)
is rare and should raise the possibility of an underlying molar pregnancy or antiphospholipid syndrome
Name: Clinical Manifestation of Eclampsia (5)
- 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
Name MATERNAL Risk Factors for Hypertensive Disorders in Pregnancy (7)
- 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
Name FETAL Risk Factors for Hypertensive Disorders in Pregnancy (5)
- intrauterine growth restriction IUGR or oligohydramnios
- gestational trophoblastic neoplasia (GTN)
- multiple gestation
- fetal hydrops “mirror syndrome”
- abruptio placentae
Name adverse maternal conditions that cause hypertension in pregnancy (5)
- 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)
Name symptoms of Hypertension in Pregnancy (4)
- Abdominal pain, N/V
- Headaches, visual problems
- Shortness of breath (SOB), chest pain
- Eclampsia: convulsions
Name adverse fetal conditions that cause hypertension in pregnancy (4)
- intrauterine growth restriction (IUGR)
- Oligohydramnios
- Absent/reversed umbilical artery end diastolic flow
- Can result in:
- Fetal disability and/or death
Describe: Clinical Evaluation of mother of Hypertensive Disorders in Pregnancy (10)
- 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
Describe: Laboratory Evaluation of Hypertensive Disorders in Pregnancy (6)
- 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
Name MATERNAL Complications of Hypertensive Disorders in Pregnancy (7)
- 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)
Name FETAL Complications of Hypertensive Disorders in Pregnancy (4)
2° to placental insufficiency
- intrauterine growth restriction (IUGR)
- prematurity
- abruptio placenta
- intrauterine fetal death (IUFD)
For non-severe HTN (149-159/90-105), target what BP? (2)
- without comorbidities: 130-155/80-105
- with comorbidities: <140/90
For both pre-existing and gestational HTN, name medication to manage HTN (3)
- labetalol 100-400 mg PO bid-tid
- nifedipine XL preparation 20-60 mg PO od
- α-methyldopa 250-500 mg PO bid-qid
For severe HTN (BP>160/110), how to treat? (2)
- 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)
Describe the management of preeclampsia if stable and no adverse factors?
- 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
Describe the management of preeclampsia if >37wk (1)
if >37 wk, immediate delivery is recommended
Describe the management of severe preeclampsia (1)
for severe preeclampsia, stabilize and deliver, regardless of GA
Describe monitoring of severe preeclampsia during labour. (4)
increase maternal monitoring:
- hourly input and output
- urine dip q12h
- hourly neurological vitals
- increase fetal monitoring (continuous FHR monitoring)
Describe antihypertensive therapy of preeclampsia (2)
- 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)
For preeclampsia prevention among increased risk women, what is recommended? (1)
low-dose ASA (75-100 mg/d) is recommended until delivery.
____ Doppler velocimetry should be part of the antenatal fetal surveillance in preeclampsia.
Umbilical artery Doppler velocimetry should be part of the antenatal fetal surveillance in preeclampsia.
Initial antihypertensive therapy for severe HTN (sBP >160 or dBP ≥110) should be with what? (3)
- labetalol
- nifedipine
- hydralazine.
Initial antihypertensive therapy for non-severe HTN (BP 140-159/90-109 mmHg) should be with what? (3)
- methyldopa
- β-blockers
- calcium channel blockers.
For fetal lung maturation, what should be considered for all women with preeclampsia before 34 wk gestation? (1)
Antenatal corticosteroids
In a planned vaginal delivery with an unfavourable cervix, what should be used? (1)
cervical ripening should be used.
___ should be used as part of the management of HTN during the third stage of labour, particularly in the presence of thrombocytopenia or coagulopathy.
Oxytocin 5 units IV or 10 units IM
___ is the recommended first-line treatment for eclampsia.
Magnesium sulfate is the recommended first-line treatment for eclampsia.
___ is the recommended eclampsia prophylaxis in severe preeclampsia.
Magnesium sulfate is the recommended eclampsia prophylaxis in severe preeclampsia.
Name: Preeclampsia Investigations (6)
- CBC
- AST, ALT
- INR and aPTT (if abn LFTs or bleeding)
- Cr
- Urine (24 h protein collection or albumin/ creatinine ratio)
- Uric acid
Describe seizure prevent in preeclampsia (6)
- 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
Describe HELLP Syndrome (3)
- Hemolysis
- Elevated Liver Enzymes
- Low Platelets
Describe: Management of Eclampsia (8)
- 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
