Clin: Hypertensive Disorders in Pregnancy - Wootton Flashcards
what is considered elevated BP?
systolic between 120-129, diastolic less than 80
what is considered stage 1 HTN?
systolic between 130-139 or diastolic between 80-90
what is considered stage 2 HTN?
systolic at least 140 or diastolic at least 90
what is considered a hypertensive crisis?
systolic over 180 and/or diastolic over 120, with pt needing prompt changes in medication if there are no other indications of problems
hypertension present before or recognized during first half of pregnancy
chronic
HTN recognized after 20 weeks gestation
gestational
HTN after 20 weeks gestation that coexists with proteinuria
preeclampsia
new onset seizure activity associated with preeclampsia
eclampsia
transposed onto chronic HTN
superimposed preeclampsia/eclampsia
how do you take a BP?
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
what labs need to be drawn to assess for maternal end-organ damage in chronic HTN?
- CBC
- glucose
- CMP
- 24 hr urine collection for total protein
- EKG
how do you assess for fetal wellbeing in chronic HTN?
- initial US for accurate dating
- screening US
- growth US monthly after 28 weeks
- antepartum fetal testing to begin between 32-34 weeks gestation
- 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
management of MILD chronic HTN (less than 160/110)
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)
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
what should be avoided in treatment of severe chronic HTN?
- *ace inhibitors and angiotensin receptor blockers**
- increased risk of malformations (renal dysgenesis, calvarial hypoplasia and fetal growth restrictions)
HTN WITHOUT any features of preeclampsia
- occurs after 20 wks
- or within 48-72 hrs after delivery
- resolves by 12 weeks postpartum
gestational HTN
- true dx made in retrospect
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
preeclampsia
what are the risk factors for preeclampsia?
age (<20 and >35)
- primigravid
- multiple gestation
- hydatiform mole
- diabetes
- prepregnancy BMI >30
- chronic HTN
- renal dz
- SLE (collagen vascular dz)
what happens in the brain during preeclampsia?
cerebral edema
- possible fibrinoid necrosis, thrombosis, micro-infarcts and petechial hemorrha
what happens in the heart during preeclampsia?
absence of normal intravascular volume expansion (third spacing)
- reduction in circulating blood volume
what happens in the lungs during preeclampsia?
noncardiogenic pulmonary edema
- changes in colloid osmotic pressure
- capillary endothelial integrity and intravascular hydrostatic vessels (leaking vessels)
what happens in the liver during preeclampsia?
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
what happens in the kidneys during preeclampsia?
swelling and enlargement of glomerular capillary endothelial cells
- narrowing of the capillary lumen
what happens in the eyes during preeclampsia?
retinal vasospasm
- retinal edema
chronic uteroplacental ischemia, immune maladaption, VLDL toxicity, increased trophoblast apoptosis or necrosis, exaggerated maternal inflammatory rxn to trophoblast
proposed etiology of preeclampsia
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
mild preeclampsia (without severe features)
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
severe preeclampsia (with severe features)
what exam findings would you expect in pt with preeclampsia?
- brisk reflexes
- clonus
- edema
what lab findings would you expect in pt with preeclampsia?
increased:
- hematocrit
- LDH
- AST, ALT
- uric acid
thrombocytopenia (low platelets)
how do you manage a pt with mild preeclampsia (no severe features) if less than 37 weeks?
- once (BPP) or twice (NST) weekly antepartum testing
- fetal growth US every 3-4 weeks
- office visits and lab eval
- possible hospitalization
how do you manage a pt with mild preeclampsia (no severe features) if between 37-40 weeks?
- if favorable cervix -> induction
- if unfavorable -> use cervical ripening agent to begin induction
how do you manage a pt with severe preeclampsia?
- immediate hospitalization
- delivery if greater than 34 weeks
- management of blood pressure with anti-hypertensives: hydralizine, labetalol (drug of choice), nifedipine
how do you manage a pt with severe preeclampsia if less than 37 weeks?
administer corticosteroids and work towards delivery as long as pt as fetus are stable
what can you give a woman with preeclampsia as seizure prophylaxis?
magnesium sulfate
what is the preferred delivery method for women with preeclampsia?
vaginal delivery
- use cervical ripening agents and pitocin as necessary
when would a woman with preeclampsia not be able to receive an epidural?
if she is thrombocytopenic
what are the loading and maintenance doses of magnesium sulfate in preeclampsia?
loading: 4gm bolus
maintenance: 2 gm/hr
- continue for approx 24 hours after delivery
- fluid restriction to prevent overload: 100mL/hr
what is the therapeutic value of magnesium sulfate?
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
what is the first thing to do during an eclampsia seizure?
protect the airway
- magnesium sulfate first tx
- may need lorazepam if persistent
- fetus may need some in-utero resuscitation time
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
HELLP syndrome
- indicates immediate delivery
