Clin: Hypertensive Disorders in Pregnancy - Wootton

Question 1

what is considered elevated BP?

Answer 1

systolic between 120-129, diastolic less than 80

Question 2

what is considered stage 1 HTN?

Answer 2

systolic between 130-139 or diastolic between 80-90

Question 3

what is considered stage 2 HTN?

Answer 3

systolic at least 140 or diastolic at least 90

Question 4

what is considered a hypertensive crisis?

Answer 4

systolic over 180 and/or diastolic over 120, with pt needing prompt changes in medication if there are no other indications of problems

Question 5

hypertension present before or recognized during first half of pregnancy

Answer 5

chronic

Question 6

HTN recognized after 20 weeks gestation

Answer 6

gestational

Question 7

HTN after 20 weeks gestation that coexists with proteinuria

Answer 7

preeclampsia

Question 8

new onset seizure activity associated with preeclampsia

Answer 8

eclampsia

Question 9

transposed onto chronic HTN

Answer 9

superimposed preeclampsia/eclampsia

Question 10

how do you take a BP?

Answer 10

after pt has rested for at least 10 minutes, seated with legs uncrossed and back supported
- appropriate sized cuff = length 1.5 times the upper arm circumfrence

Question 11

what labs need to be drawn to assess for maternal end-organ damage in chronic HTN?

Answer 11

• CBC
• glucose
• CMP
• 24 hr urine collection for total protein
• EKG

Question 12

how do you assess for fetal wellbeing in chronic HTN?

Answer 12

• initial US for accurate dating
• screening US
• growth US monthly after 28 weeks
• antepartum fetal testing to begin between 32-34 weeks gestation

Question 13

• begin aspirin therapy 81 mg daily at 12 weeks til delivery
• initiate antihypertensive if reach threshold value
• prenatal visits every 2-4 weeks until 34-36 weeks, then weekly
• antepartum fetal monitoring
• delivery between 39-40 weeks

Answer 13

management of MILD chronic HTN (less than 160/110)

Question 14

antihypertensive therapy:

• methyldopa (sedation, dizziness, depression)
• labetalol (avoid in women w/asthma, previous myocardial dz)
• nifedipine (reserved for control of severe acutely elevated BP in hospitalized pts)

Answer 14

management of SEVERE chronic HTN

• observe for signs of developing superimposed preeclampsia
• antepartum fetal surveillance (growth US every 3-4 weeks, NST or biophysical profiles)
• delivery after 38 weeks

Question 15

what should be avoided in treatment of severe chronic HTN?

Answer 15

• *ace inhibitors and angiotensin receptor blockers**

- increased risk of malformations (renal dysgenesis, calvarial hypoplasia and fetal growth restrictions)

Question 16

HTN WITHOUT any features of preeclampsia

• occurs after 20 wks
• or within 48-72 hrs after delivery
• resolves by 12 weeks postpartum

Answer 16

gestational HTN

- true dx made in retrospect

Question 17

complicates 2-8% pregnancies, 20-50% of patients with chronic HTN develop superimposed preeclampsia

• HTN
• proteinuria
• edema
• scotoma (black dot in vision)
• blurred vision
• epigastric/RUQ pain
• HA

Answer 17

preeclampsia

Question 18

what are the risk factors for preeclampsia?

Answer 18

age (<20 and >35)

• primigravid
• multiple gestation
• hydatiform mole
• diabetes
• prepregnancy BMI >30
• chronic HTN
• renal dz
• SLE (collagen vascular dz)

Question 19

what happens in the brain during preeclampsia?

Answer 19

cerebral edema

- possible fibrinoid necrosis, thrombosis, micro-infarcts and petechial hemorrha

Question 20

what happens in the heart during preeclampsia?

Answer 20

absence of normal intravascular volume expansion (third spacing)
- reduction in circulating blood volume

Question 21

what happens in the lungs during preeclampsia?

Answer 21

noncardiogenic pulmonary edema

• changes in colloid osmotic pressure
• capillary endothelial integrity and intravascular hydrostatic vessels (leaking vessels)

Question 22

what happens in the liver during preeclampsia?

Answer 22

sinusoidal fibrin deposition in the periportal areas with surrounding hemorrhage and portal capillary thrombi

• subscapular hematoma -> liver rupture
• stretching of glisson’s capsule (CT surrounding liver) results in RUQ pain

Question 23

what happens in the kidneys during preeclampsia?

Answer 23

swelling and enlargement of glomerular capillary endothelial cells
- narrowing of the capillary lumen

Question 24

what happens in the eyes during preeclampsia?

Answer 24

retinal vasospasm

- retinal edema

Question 25

chronic uteroplacental ischemia, immune maladaption, VLDL toxicity, increased trophoblast apoptosis or necrosis, exaggerated maternal inflammatory rxn to trophoblast

Answer 25

proposed etiology of preeclampsia

Question 26

BP > 140/90 but < 160/110 - PROTEINURIA > 300mg/24hr urine, but < 5gm/24hr - or single specimen urine protein:creat ratio of 0.3mg/dL - asymptomatic

Answer 26

mild preeclampsia (without severe features)

Question 27

BP systolic > 160 or diastolic > 110 (2 occasions, 4 hrs apart) - proteinuria > 5gm/24hr of 3+ protein on 2 random urine dips at least 4 hrs apart - oliguria < 500ml/24 hrs - liver enzymes twice the upper limit of normal, or epigastric pain refractory to treatment - thrombocytopenia - pulmonary edema - new onset headache - cerebral/visual disturbances

Answer 27

severe preeclampsia (with severe features)

Question 28

what exam findings would you expect in pt with preeclampsia?

Answer 28

- brisk reflexes - clonus - edema

Question 29

what lab findings would you expect in pt with preeclampsia?

Answer 29

increased: - hematocrit - LDH - AST, ALT - uric acid thrombocytopenia (low platelets)

Question 30

how do you manage a pt with mild preeclampsia (no severe features) if less than 37 weeks?

Answer 30

- once (BPP) or twice (NST) weekly antepartum testing - fetal growth US every 3-4 weeks - office visits and lab eval - possible hospitalization

Question 31

how do you manage a pt with mild preeclampsia (no severe features) if between 37-40 weeks?

Answer 31

- if favorable cervix -> induction | - if unfavorable -> use cervical ripening agent to begin induction

Question 32

how do you manage a pt with severe preeclampsia?

Answer 32

- immediate hospitalization - delivery if greater than 34 weeks - management of blood pressure with anti-hypertensives: hydralizine, labetalol (drug of choice), nifedipine

Question 33

how do you manage a pt with severe preeclampsia if less than 37 weeks?

Answer 33

administer corticosteroids and work towards delivery as long as pt as fetus are stable

Question 34

what can you give a woman with preeclampsia as seizure prophylaxis?

Answer 34

magnesium sulfate

Question 35

what is the preferred delivery method for women with preeclampsia?

Answer 35

vaginal delivery | - use cervical ripening agents and pitocin as necessary

Question 36

when would a woman with preeclampsia not be able to receive an epidural?

Answer 36

if she is thrombocytopenic

Question 37

what are the loading and maintenance doses of magnesium sulfate in preeclampsia?

Answer 37

loading: 4gm bolus maintenance: 2 gm/hr - continue for approx 24 hours after delivery - fluid restriction to prevent overload: 100mL/hr

Question 38

what is the therapeutic value of magnesium sulfate?

Answer 38

``` 5-9 mg/dL - shouldn't get above 7-8mg/dL > 9: loss of patellar reflexes > 12: respiratory paralysis > 30: cardiac arrest ``` can overload and result in respiratory compromise and cardiac arrest

Question 39

what is the first thing to do during an eclampsia seizure?

Answer 39

protect the airway - magnesium sulfate first tx - may need lorazepam if persistent - fetus may need some in-utero resuscitation time

Question 40

variant of preeclampsia - hemolysis, elevated liver enzymes, low platelets - RUQ pain, epigastric pain, NV are common - LDH > 600 IU/L, AST/ALT elevated TWICE the upper limit, platelets < 100,000 - HTN and proteinuria

Answer 40

HELLP syndrome | - indicates immediate delivery