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EndoRepro 2 Exam 1 > Clin: Hypertensive Disorders in Pregnancy - Wootton > Flashcards

Clin: Hypertensive Disorders in Pregnancy - Wootton Flashcards

1
Q

what is considered elevated BP?

A

systolic between 120-129, diastolic less than 80

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2
Q

what is considered stage 1 HTN?

A

systolic between 130-139 or diastolic between 80-90

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3
Q

what is considered stage 2 HTN?

A

systolic at least 140 or diastolic at least 90

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4
Q

what is considered a hypertensive crisis?

A

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

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5
Q

hypertension present before or recognized during first half of pregnancy

A

chronic

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6
Q

HTN recognized after 20 weeks gestation

A

gestational

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7
Q

HTN after 20 weeks gestation that coexists with proteinuria

A

preeclampsia

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8
Q

new onset seizure activity associated with preeclampsia

A

eclampsia

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9
Q

transposed onto chronic HTN

A

superimposed preeclampsia/eclampsia

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10
Q

how do you take a BP?

A

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

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11
Q

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

A
  • CBC
  • glucose
  • CMP
  • 24 hr urine collection for total protein
  • EKG
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12
Q

how do you assess for fetal wellbeing in chronic HTN?

A
  • initial US for accurate dating
  • screening US
  • growth US monthly after 28 weeks
  • antepartum fetal testing to begin between 32-34 weeks gestation
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13
Q
  • 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
A

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

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14
Q

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)
A

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
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15
Q

what should be avoided in treatment of severe chronic HTN?

A
  • *ace inhibitors and angiotensin receptor blockers**

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

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16
Q

HTN WITHOUT any features of preeclampsia

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

gestational HTN

- true dx made in retrospect

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17
Q

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
A

preeclampsia

18
Q

what are the risk factors for preeclampsia?

A

age (<20 and >35)

  • primigravid
  • multiple gestation
  • hydatiform mole
  • diabetes
  • prepregnancy BMI >30
  • chronic HTN
  • renal dz
  • SLE (collagen vascular dz)
19
Q

what happens in the brain during preeclampsia?

A

cerebral edema

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

20
Q

what happens in the heart during preeclampsia?

A

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

21
Q

what happens in the lungs during preeclampsia?

A

noncardiogenic pulmonary edema

  • changes in colloid osmotic pressure
  • capillary endothelial integrity and intravascular hydrostatic vessels (leaking vessels)
22
Q

what happens in the liver during preeclampsia?

A

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
23
Q

what happens in the kidneys during preeclampsia?

A

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

24
Q

what happens in the eyes during preeclampsia?

A

retinal vasospasm

- retinal edema

25
Q

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

A

proposed etiology of preeclampsia

26
Q

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
A

mild preeclampsia (without severe features)

27
Q

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
A

severe preeclampsia (with severe features)

28
Q

what exam findings would you expect in pt with preeclampsia?

A
  • brisk reflexes
  • clonus
  • edema
29
Q

what lab findings would you expect in pt with preeclampsia?

A

increased:

  • hematocrit
  • LDH
  • AST, ALT
  • uric acid

thrombocytopenia (low platelets)

30
Q

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

A
  • once (BPP) or twice (NST) weekly antepartum testing
  • fetal growth US every 3-4 weeks
  • office visits and lab eval
  • possible hospitalization
31
Q

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

A
  • if favorable cervix -> induction

- if unfavorable -> use cervical ripening agent to begin induction

32
Q

how do you manage a pt with severe preeclampsia?

A
  • immediate hospitalization
  • delivery if greater than 34 weeks
  • management of blood pressure with anti-hypertensives: hydralizine, labetalol (drug of choice), nifedipine
33
Q

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

A

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

34
Q

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

A

magnesium sulfate

35
Q

what is the preferred delivery method for women with preeclampsia?

A

vaginal delivery

- use cervical ripening agents and pitocin as necessary

36
Q

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

A

if she is thrombocytopenic

37
Q

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

A

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

38
Q

what is the therapeutic value of magnesium sulfate?

A 
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

39
Q

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

A

protect the airway

  • magnesium sulfate first tx
  • may need lorazepam if persistent
  • fetus may need some in-utero resuscitation time
40
Q

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
A

HELLP syndrome

- indicates immediate delivery

EndoRepro 2 Exam 1 (25 decks)

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