CARDIOVASCULAR DISEASES (based on Williams) Flashcards
What are the three hypertensive disorders that complicate pregnancies?
“Preeclampsia. gestational hypertension. and chronic hypertension.”
What percentage of pregnancies are complicated by hypertensive disorders?
“Up to 10 percent.”
Which member of the deadly triad contributes greatly to maternal morbidity?
“Hypertensive disorders alongside hemorrhage and infection.”
What percentage of pregnancy-related maternal deaths in the US from 2011-2015 were caused by preeclampsia or eclampsia?
“7 percent.”
What are the four types of hypertensive disorders of pregnancy described by ACOG?
“Preeclampsia and eclampsia syndrome. chronic hypertension of any etiology. preeclampsia superimposed on chronic hypertension and gestational hypertension.”
What systolic and diastolic blood pressure levels define hypertension empirically?
“Systolic ≥140 mm Hg and diastolic ≥90 mm Hg.”
What is Korotkoff phase V used for in diagnosing hypertensive disorders?
“To define diastolic pressure.”
What term describes a sudden rise in blood pressure within the normal range during pregnancy?
“Delta hypertension.”
What is gestational hypertension?
“Blood pressure ≥140/90 mm Hg for the first time after midpregnancy without proteinuria.”
How is preeclampsia classified based on onset?
“Early onset (<34 weeks)”
“Late onset (>34 weeks)”
What are the diagnostic criteria for preeclampsia?
“Hypertension plus one or more: proteinuria. thrombocytopenia. renal insufficiency
What distinguishes severe preeclampsia from nonsevere?
“Severe preeclampsia includes symptoms like headaches. visual disturbances. epigastric pain. thrombocytopenia. elevated serum creatinine or marked serum transaminase elevation.”
What is superimposed preeclampsia?
“Preeclampsia developing in a woman with pre-existing chronic hypertension.”
What are the risk factors for preeclampsia?
“Nulliparity -older age-obesity-diabetes-chronic hypertension-history of preeclampsia and genetic predisposition.”
What racial and ethnic groups have higher preeclampsia incidence?
“Hispanic and African American women.”
What are the major risks for preeclampsia identified by Bartsch et al.?
“Older age-nulliparity-obesity-diabetes-chronic hypertension and history of HELLP syndrome.”
What is the incidence of eclampsia in countries with adequate healthcare resources?
“1 case in 2000 to 3000 deliveries.”
How does smoking during pregnancy affect hypertension risk?
“It lowers the risk for hypertension during pregnancy.”
What are some markers of severe preeclampsia?
“Headaches- visual disturbances-upper abdominal pain-oliguria-convulsions-elevated creatinine-thrombocytopenia and pulmonary edema.”
Which laboratory finding reflects worsening preeclampsia?
“Thrombocytopenia (<100 000/μL).”
What is the defining characteristic of delta hypertension?
“A relatively acute rise in blood pressure within the normal range.”
How is gestational hypertension reclassified if preeclampsia does not develop?
“As transient hypertension if blood pressure normalizes by 12 weeks postpartum.”
What proportion of eclamptic seizures develop before proteinuria is detectable?
“10 percent.”
What is the recommended diagnostic marker for proteinuria in preeclampsia?
“Protein ≥300 mg/24h protein:creatinine ratio ≥0.3 or persistent dipstick 1+.”
What factors distinguish severe gestational hypertension from nonsevere?
“Systolic BP ≥160 mm Hg . diastolic BP ≥110 mm Hg and symptoms like headaches or visual disturbances.”
What are the characteristics that make gestational hypertensive disorders more likely to develop?
- Exposure to chorionic villi for the first time;
- Exposure to a superabundance of chorionic villi (e.g., twins or hydatidiform mole);
- Preexisting conditions associated with endothelial cell activation or inflammation;
- Genetic predisposition to hypertension during pregnancy.
What is the incidence of eclampsia per 10,000 births at Parkland Hospital in 2018?
4.8
Is a fetus required for preeclampsia to develop?
No, a fetus is not required. Chorionic villi are essential but can be extrauterine. as in advanced abdominal pregnancy.
What does the ‘two-stage disorder’ theory of preeclampsia suggest?
Stage I (Placental Syndrome): Faulty endovascular trophoblastic remodeling;
Stage II (Maternal Syndrome): Systemic vascular endothelial damage, inflammation, and maternal conditions like hypertension or diabetes exacerbate the condition.
What are some primary suggested mechanisms causing preeclampsia?
- Abnormal trophoblastic invasion of uterine vessels;
- Dysfunctional maternal-paternal-fetal immunological tolerance;
- Maternal maladaptation to cardiovascular or inflammatory changes;
- Genetic factors.
What is the effect of defective trophoblastic invasion in preeclampsia?
Incomplete invasion of spiral arterioles leads to smaller-caliber vessels with high resistance, impairing placental blood flow and creating a hypoxic environment.
What histological feature is associated with early-onset preeclampsia?
Placental vascular atherosis. characterized by endothelial damage. lipid-laden macrophages and myointimal cell proliferation.
What genetic factors are associated with preeclampsia?
- Multifactorial polygenic inheritance; 2. Higher risk in daughters and sisters of preeclamptic women; 3. Interaction of inherited genes and environmental factors; 4. Ethnoracial predispositions.
What is endothelial cell activation, and how does it relate to preeclampsia?
Endothelial cell activation is systemic injury caused by placental ischemia or inflammatory mediators. leading to oxidative stress. vasospasm. proteinuriaand thrombocytopenia.
What role does nitric oxide play in preeclampsia?
Nitric oxide is a vasodilator that maintains low vascular resistance. Its reduced synthesis in preeclampsia contributes to vasospasm and hypertension.
What is the angiogenic imbalance observed in preeclampsia?
Excessive production of antiangiogenic factors like sFlt-1 and sEng inhibits VEGF and TGF-ß signaling leading to endothelial dysfunction and reduced placental perfusion.
When do maternal serum levels of sFlt-1 and sEng start to rise in preeclampsia?
Months before clinical symptoms develop especially in early-onset disease.
What is the relationship between preeclampsia and the soluble form of endoglin (sEng)?
sEng inhibits TGF-ß signaling. reducing endothelial nitric oxide production and causing vasodilation dysfunction.
Disturbances in the cardiovascular system in preeclampsia syndrome are related to which factors?
Greater cardiac afterload. reduced cardiac preload. endothelial activation leading to fluid leakage.
What factors influence cardiovascular changes in pregnancy-related hypertensive disorders?
Preeclampsia severity. degree of hypertension. underlying chronic disease and the clinical point studied.
What happens to cardiac output during preeclampsia?
Cardiac output declines due to greater peripheral resistance.
What is diastolic dysfunction in preeclampsia, and how long can it persist?
Diastolic dysfunction where ventricles don’t relax and fill properly. can persist up to 4 years after delivery.
What causes diastolic dysfunction in preeclampsia?
Ventricular remodeling due to increased afterload and high antiangiogenic protein levels.
What may happen to women with preeclampsia and underlying ventricular dysfunction?
Further diastolic dysfunction may lead to cardiogenic pulmonary edema.
How do high-sensitivity cardiac troponin levels change in women with preeclampsia?
They are slightly elevated in some preeclamptic women.
What happens to amino-terminal pro-brain natriuretic peptide (NT-pro-BNP) levels in severe preeclampsia?
NT-pro-BNP levels are increased.
How does aggressive hydration affect ventricular function in preeclamptic women?
It results in hyperdynamic ventricular function and elevated pulmonary capillary wedge pressures, which may lead to pulmonary edema.
What does hemoconcentration in eclampsia result from?
Generalized vasospasm followed by endothelial activation and plasma leakage into the interstitial space.
What effect does severe hemoconcentration have on blood loss at delivery?
Women with severe hemoconcentration are unduly sensitive to blood loss at delivery.
How does blood volume change in eclamptic women compared to normotensive women?
Blood volume expansion is severely curtailed in eclamptic women.
What are the typical platelet changes in women with preeclampsia?
Thrombocytopenia and platelet activation with increased platelet clearance and reduced platelet aggregation.
What is the typical recovery pattern of platelet counts after delivery in preeclamptic women?
Platelet counts generally rise to normal levels within 3 to 5 days after delivery.
What is the relationship between thrombocytopenia and fetal health in preeclampsia?
Severe maternal thrombocytopenia does not indicate fetal need for cesarean delivery.
What is the effect of severe preeclampsia on hemolysis?
Elevated serum lactate dehydrogenase levels. reduced haptoglobin and microangiopathic hemolysis.
What is the relationship between erythrocyte morphology and preeclampsia?
Erythrocyte morphological changes are partially caused by serum lipid alterations. including decreased long-chain fatty acid content.
What is HELLP syndrome?
A combination of hemolysis. elevated liver transaminase levels and low platelet count associated with severe preeclampsia.
What coagulation changes are commonly seen in preeclampsia and eclampsia?
Elevated factor VIII. increased fibrinopeptides A and B. increased D-dimers and reduced antithrombin III. protein C and protein S.
Do coagulation aberrations in preeclampsia typically have clinical significance?
Coagulation changes are generally mild and seldom clinically significant.
Are routine laboratory assessments of coagulation necessary for managing pregnancy-associated hypertensive disorders?
No. routine assessments like PT. aPTT and plasma fibrinogen levels are not required unless placental abruption is present.
What plasma levels are augmented during normal pregnancy?
Plasma levels of renin - angiotensin II- aldosterone - deoxycorticosterone and ANP are augmented.
What triggers the release of ANP during pregnancy?
ANP is released during atrial wall stretching from blood volume expansion and in response to cardiac contractility.
What happens to ANP levels in preeclampsia?
ANP levels are elevated in preeclampsia and its secretion is further enhanced.
How are vasopressin levels in preeclamptic women compared to normal pregnant women?
Vasopressin levels are similar in both nonpregnant- normally pregnant and preeclamptic women- though its metabolic clearance is higher in the latter two.
What causes pathological fluid retention in severe preeclampsia?
Endothelial injury and extravasation of intravascular fluid lead to pathological fluid retention.
What change in plasma oncotic pressure is seen in severe preeclampsia?
There is reduced plasma oncotic pressure in severe preeclampsia.
What is the mechanism behind lower serum pH and bicarbonate concentration in eclampsia?
Lactic acidosis and compensatory respiratory loss of carbon dioxide lead to a lowered serum pH and bicarbonate concentration.
How does renal blood flow and GFR change during normal pregnancy?
Renal blood flow and GFR rise appreciably during normal pregnancy.
What happens to GFR in preeclampsia?
GFR is slightly reduced in preeclampsia due to increased afferent arteriolar resistance.
How does glomerular endotheliosis affect filtration in preeclampsia?
Glomerular endotheliosis blocks filtration-causing serum creatinine levels to rise.
What causes elevated plasma uric acid concentration in preeclampsia?
The elevation exceeds that due to reduced GFR and is likely caused by enhanced tubular reabsorption.
How is calcium excretion affected in preeclampsia?
Urinary excretion of calcium is diminished in preeclampsia likely due to greater tubular reabsorption.
How is proteinuria defined in preeclampsia?
Proteinuria is defined by 24-hour urinary excretion exceeding 300 mg- a protein:creatinine ratio ≥0.3 or persistent protein values of 30 mg/dL in random urine samples.
What urinary protein:creatinine ratio suggests a low likelihood of proteinuria exceeding 300 mg/d?
A urinary protein:creatinine ratio of <130-150 mg/g indicates a low likelihood of proteinuria exceeding 300 mg/d.
What should be done if a midrange protein:creatinine ratio is observed?
If a midrange ratio is observed, it should be repeated and if persistent- a 24-hour urine collection for protein measurement should be considered.
What impact does urine concentration have on dipstick assessment of proteinuria?
Urine concentration affects dipstick assessment- potentially leading to false-positive or -negative results.
What percentage of women with HELLP syndrome do not have proteinuria at presentation?
10-15% of women with HELLP syndrome do not have proteinuria at presentation.
What morphological changes occur in the kidneys of eclamptic women?
Kidneys in eclamptic women show enlarged glomeruli- glomerular capillary endotheliosis and subendothelial protein and fibrin deposits.
How is endothelial swelling in preeclampsia linked to angiogenic protein withdrawal?
Endothelial swelling results from the complexing of free angiogenic proteins with antiangiogenic protein receptors- leading to podocyte dysfunction.
What anatomical changes occur in the liver of women with severe preeclampsia?
Hepatic lesions include periportal hemorrhages and infarction and serum hepatic transaminase levels are elevated.
What is the characteristic feature of acute fatty liver of pregnancy?
The hallmark of acute fatty liver of pregnancy is marked liver dysfunction- unlike the normal liver function seen in HELLP syndrome.
What is the main clinical difference between HELLP syndrome and acute fatty liver of pregnancy?
Acute fatty liver of pregnancy is marked by severe liver dysfunction whereas liver function is usually normal in HELLP syndrome.
What is HELLP syndrome?
HELLP syndrome stands for hemolysis- elevated liver enzyme levels and low platelet count.
What complications are common in women with HELLP syndrome?
Complications include eclampsia- placental abruption- acute kidney injury- pulmonary edema-stroke-hepatic hematoma-coagulopathy and sepsis.
How does preeclampsia-related liver involvement present clinically?
Liver involvement may present with moderate to severe right upper quadrant or midepigastric pain and tenderness often accompanied by elevated serum AST or ALT levels.
What is the usual management for hepatic hematomas in preeclampsia?
Management of unruptured hepatic hematomas is typically observation, with surgical intervention or angiographic embolization if bleeding persists.
What is the maternal mortality rate for women with ruptured hepatic hematomas?
The maternal mortality rate for women with ruptured hepatic hematomas is 22%.
What clinical differences exist between HELLP syndrome and preeclampsia?
Women with HELLP syndrome have worse outcomes- including higher rates of eclampsia-preterm birth and perinatal mortality compared to those with preeclampsia.
How is brain involvement described in severe preeclampsia?
Brain involvement is common and includes headaches- visual symptoms and convulsions with imaging studies revealing anatomical changes.
What is the primary cause of death in eclamptic women?
“Most deaths in eclamptic women are from pulmonary edema
What is the typical pathology seen in the brains of women with eclampsia?
“Cortical and subcortical petechial hemorrhages-fibrinoid necrosis of the arterial wall-perivascular microinfarcts and hemorrhages-softening areas and white matter hemorrhages.”
What is the first theory explaining cerebrovascular abnormalities in eclampsia?
“The first theory suggests that severe hypertension causes cerebrovascular overregulation- leading to vasospasm and eventual tissue infarction.”
What is the second theory explaining cerebral abnormalities in eclampsia?
“The second theory suggests that sudden elevations in systemic blood pressure exceed cerebrovascular autoregulatory capacity - leading to vasodilation- vasoconstriction and edema.”
How is posterior reversible encephalopathy syndrome (PRES) related to eclampsia?
“PRES lesions predominantly involve the occipital and parietal cortices and are commonly seen in women with eclampsia due to vascular changes.”
What is autoregulation in the context of cerebral blood flow?
“Autoregulation is the mechanism by which cerebral blood flow remains constant despite changes in cerebral perfusion pressure.”
What happens to cerebral blood flow during pregnancy?
“During the first two trimesters- cerebral blood flow in pregnant women is similar to nonpregnant values. In the third trimester- cerebral blood flow drops by 20% with higher flow in women with severe preeclampsia.”
What role does endothelial cell dysfunction play in eclampsia?
“Endothelial cell dysfunction likely contributes to vascular abnormalities such as the interendothelial cell leak which leads to edema and possibly eclampsia.”
What are the common neurological manifestations of preeclampsia?
“Headache-scotomata-convulsions-cognitive decline and in some cases blindness or cerebral edema.”
How is convulsion related to eclampsia?
“Convulsions in eclampsia are caused by abnormal neural activity and are considered diagnostic for the condition.”
How does CT imaging appear in women with eclampsia?
“CT scans often show hypodense lesions at the gray and white matter junction - primarily in the parietooccipital lobes- which correspond to petechial hemorrhages and edema.”
What do MR imaging findings in eclampsia indicate?
“MR imaging shows hyperintense T2 lesions in subcortical and cortical regions of the parietal and occipital lobes- indicative of PRES.”
What is the most common cause of blindness in eclampsia?
“Blindness in eclampsia is most often due to occipital lobe edema- although retinal artery occlusion may also cause permanent visual impairment.”
How is cerebral edema associated with eclampsia?
“Cerebral edema in eclampsia can lead to confusion- lethargy- and coma- and is a sign of worsening disease- potentially resulting in transtentorial herniation.”
What is the role of uteroplacental perfusion in preeclampsia?
“Compromised uteroplacental perfusion contributes to increased perinatal morbidity and mortality in preeclampsia- with abnormal blood flow being a significant factor.”
What is the significance of uterine artery Doppler in preeclampsia?
“Uterine artery Doppler measurements can predict abnormal placental perfusion and are linked to preeclampsia and fetal growth restriction.”
What is fetal-growth restriction in the context of preeclampsia?
“Fetal-growth restriction in preeclampsia typically correlates with maternal hemodynamic abnormalities- such as higher blood pressure and elevated uterine artery pulsatility index.”
What are the challenges with predicting preeclampsia?
“Currently- no screening tests for preeclampsia are reliably predictive-valid or economical. Efforts have resulted in strategies with poor sensitivity and poor positive predictive values.”
What is the role of multivariable screening algorithms in predicting preeclampsia?
“Multivariable screening algorithms- such as those using serum sFlt-1 levels or midpregnancy tests- may be superior to single predictors but have not been adequately verified for widespread use.”
What is the role of vascular resistance testing in predicting preeclampsia?
“Tests like the roll-over test-isometric exercise test and angiotensin II infusion test assess blood pressure responses but have sensitivities between 55-70% and specificities around 85%.”
What does uterine artery Doppler velocimetry reflect in preeclampsia prediction?
“It is posited to reflect faulty trophoblastic invasion of the spiral arteries but has poor predictive value for preeclampsia.”
What is the predictive value of serum uric acid levels for preeclampsia?
“Sensitivity ranges from 0 to 55%
How effective is microalbuminuria as a predictive test for preeclampsia?
“Microalbuminuria has sensitivities ranging from 7 to 90% and specificities from 29 to 97%.”
What role do fibronectins play in predicting preeclampsia?
“Fibronectins- which are elevated following endothelial injury- were found not to be clinically useful for predicting preeclampsia.”
How does platelet volume relate to preeclampsia?
“Increased platelet volume- due to platelet immaturity- has been described as an early predictor of preeclampsia.”
What is the role of oxidative stress markers in preeclampsia?
“Higher levels of lipid peroxides and decreased antioxidant activity are seen in preeclampsia but none of the oxidative stress markers have sufficient predictive value.”
What is the significance of angiogenic and antiangiogenic factor imbalance in preeclampsia?
“An imbalance- where VEGF and PIGF drop and sFlt-1 and sEng rise- is convincingly linked to preeclampsia and can be used for early prediction and diagnostic adjuncts.”
What is the role of cell-free DNA (fDNA) in predicting preeclampsia?
“fDNA- thought to be released due to accelerated apoptosis in preeclampsia- showed no correlation with preeclampsia prediction in studies.”
How effective is a low-salt diet in preventing preeclampsia?
“A low-salt diet has been researched but shown to be ineffective in preventing preeclampsia.”
How does regular exercise impact the risk of preeclampsia?
“Regular exercise during pregnancy is linked to a lower risk of developing preeclampsia.”
How does calcium supplementation affect preeclampsia prevention?
“Calcium supplementation has generally shown no benefit in preventing preeclampsia- unless the woman is calcium deficient.”
Does iodine sufficiency prevent preeclampsia?
“A meta-analysis found no association between iodine sufficiency and preeclampsia risk.”
How effective is fish oil supplementation in preventing preeclampsia?
“Studies on fish oil supplementation have shown no significant benefits for preventing preeclampsia.”
What is the role of antihypertensive drugs in preventing preeclampsia?
“Although diuretics and antihypertensive drugs were popular- trials have failed to show significant benefits in preventing preeclampsia.”
What is the role of antioxidants in preventing preeclampsia?
“Studies on antioxidants like vitamins C and E have not shown a reduction in preeclampsia rates despite supplementation.”
What is the potential role of statins in preventing preeclampsia?
“Statins may prevent preeclampsia through stimulating heme oxygenase-1 expression but need more clinical studies.”
How does metformin impact the prevention of preeclampsia?
“Metformin has shown potential in reducing severe preeclampsia in pre-diabetic women- though more clinical studies are needed.”
How do antithrombotic agents like low-molecular-weight heparin prevent preeclampsia?
“Low-molecular-weight heparin has been studied for preventing preeclampsia but has not significantly reduced the risk in randomized trials.”
What is the efficacy of low-dose aspirin in preventing preeclampsia?
“Low-dose aspirin has been shown to reduce preeclampsia rates by about 60% if given before 16 weeks’ gestation in high-risk women.”
How does low-dose aspirin work to prevent preeclampsia?
“Low-dose aspirin inhibits platelet thromboxane A biosynthesis- with minimal effects on vascular prostacyclin production.”
What are the recommendations for low-dose aspirin use in preeclampsia prevention?
“The U.S. Preventive Services Task Force and ACOG recommend low-dose aspirin between 12 and 28 weeks’ gestation for high-risk women.”
What is the effect of aspirin and heparin combination therapy in preventing preeclampsia?
“In women with a history of early-onset preeclampsia- outcomes were similar whether given aspirin alone or aspirin plus enoxaparin.”
