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Repro > Complicated Pregnancy 3 > Flashcards

Complicated Pregnancy 3 Flashcards

Chronic HT Pre-eclampsia Gestational HT

1
Q

Thresholds for mild, moderate and severe HTN

A 
Mild = 140/90 up to 149/99
Moderate = 150/100 up 159/109
Severe = DBP >110 or SBP >160
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2
Q

How do you know if a patient’s hypertension is Chronic and not gestational?

A

Chronic if it was discovered pre-pregnancy or within the first 20 wks

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3
Q

Anti-hypertensive medication first line options [3]

What anti-hypertensive drugs should be avoided in pregnancy? [2]

A

Prescribe:

  • labetolol (combined alpha & BB) CI in asthma
  • nifedipine CCB
  • methyldopa

Avoid:
- ACEIs and ARBs

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4
Q

Define Gestational Hypertension?

What antenatal care should be given? [3]

A

Hypertension developing >20wks
Antenatal care:
- Routine bloods: FBC, LFT, U&E, Cr at presentation and weekly
- Urinalysis regularly
- USS at presentation and then 2-4w growth scans

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5
Q

What criteria are required for a diagnosis of pre-eclampsia?

in terms of blood pressure measurements

A

New hypertension >20 wks (either Mild HT twice more 4 hours apart or Moderate/Severe HT on one reading)

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6
Q

Describe 3 methods of testing for proteinuria during pregnancy. What are the results that would be classed as significant proteinuria?

A

Urine Dipstick - >1+
Spot Urinary protein: creatinine ratio > 30mg/mmol
24 hour urine protein collection >300mg

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7
Q

What are the risk factors for Pre-eclampsia?
High risk [5]
Moderate risk [5]

A

High risk:

  • Previous severe/early onset PE
  • Pre-existing HTN, gestational HTN
  • T1DM, T2DM
  • Autoimmune disease
  • CKD

Moderate risk:

  • Primiparous
  • Multiples
  • Low PAPP-A
  • Uterine artery notching on Doppler at 22-24w
  • FMHX
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8
Q

What are the major complications of Pre-eclampsia? [6]

A
  • Seizures (eclampsia)
  • Haemorrhage and Stroke
  • HELLP, DIC
  • Renal Failure
  • Pulm Oedema and HF
  • Impaired placental perfusion > placental abruption
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9
Q

What is HELLP? [3]

A

A potential consequence of pre-eclampsia where you get:

  • Haemolysis
  • Elevated Liver enzymes
  • Low Platelets
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10
Q

Pre-eclampsia can cause impaired placental perfusion, what are the consequences of this? [4]

Risk factor fetal for PET [2]

A
  • IUGR
  • Foetal Distress
  • Prematurity
  • Mortality

Risk factor:

  • Hyatidiform mole
  • hydrops fetalis
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11
Q

Many cases are asymptomatic and picked up on antenatal assessment.
Signs of deteriorating condition or progression to severe PE Toxaemia (PET) [4]

A
  • Headaches and blurred vision
  • Vomiting and convulsions
  • Swelling of the hands, face and legs
  • Epigastric Pain
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12
Q

What pre-eclamptic signs can be picked up on examination? [5]

A
  • Epigastric tenderness
  • Clonus and brisk reflexes
  • Crackles at lung bases
  • Papilloedema on fundoscopy
  • Reduced urinary output
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13
Q

Why do pre-eclampsia sufferers get epigastric pain?

A

Liver congestion from the high BP

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14
Q

What blood tests are relevant to PE and why? [6]

A

LFTs - Raised liver enzymes (congestion)
Bilirubin - HELLP
Urea and creatinine + Urate - renal damage

FBC
- low haemoglobin (HELLP)

Coagulation Tests

  • INR, D-dimer (DIC)
  • Low platelets and low fibrinogen (DIC)
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15
Q

How do we monitor the foetus’s condition in pre-eclampsia? [1]

A

Cardiotocography (CTG)

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16
Q

How long should we continue monitoring the mother’s BP, urine protein and symptoms?

A

Through the peurperium as PE risk remains for the first 6 wks after delivery

17
Q

Treatment of pre-eclampsia
3 stages
What is the only true ‘cure’ for PET?

A
  • Conservative management aiming for delivery
  • Seizure management
  • Post-delivery management

The only cure for PET is delivery of the baby and placenta
Consider induction of labour or c-section if maternal or fetal condition deteriorates, irrespective of GA

18
Q

How can we speed up the maturation of the foetus so we can deliver sooner?

A

Steroids

19
Q

How do we manage the (impending) eclampsia/seizures? [3]

A
  • Magnesium sulphate bolus 5g over 5-10 mins + IV infusion of 2g/h to control the convulsions
  • IV Labetolol, Hydralazine if the BP is >160/110
  • Controlled fluids to avoid overload (aim for 80mls/hr intake)
20
Q

What can we give a mother as prophylaxis if she has 1 high RF or 2 moderate RF? [1]

A

75mg aspirin from 12 weeks until delivery

21
Q

PE - conservative management [5]

A 
Monitoring - BP, examination
Blood investigations
CTG
Anti-hypertensives (Rx)
Steroids for fetal lung maturity if GA <36 weeks
22
Q

Pre-existing HTN
Antenatal care
Labour & delivery mx [3]
Post-natal mx [3]

A

Antenatal care: lower dietary sodium intake

L&D:

  • if <160/110 at 37w, offer IOL
  • and hourly BP monitoring if <159/109 or continuous if >160/110
  • continue anti-hypertensive mx during labour
  • Give oxytocin in third stage of labour
Post-natal:
- Check BP on day 1-5
 > Check at 2w
- Come off methyldopa
- Avoid diuretics if breastfeeding
23
Q

Why is ergometrine contraindicated in pre-existing HTN?

Why do we switch mothers off methyldopa post-natal?

A

DO NOT use ergometrine as causes severe HTN leading to stroke

SE: postnatal depression

24
Q

Management of anti-hypertensives in pregnancy induced HTN:
Target BP?
Moderate HTN [2]
Severe HTN [5]

A

Target BP 135/85

Moderate HTN:

  • Labetalol
  • 1-2w urine, BP check

Severe HTN:

  • Admit
  • CTG
  • Labetalol
  • BP every 15-30 mins
  • Daily urine check
25
Q

Management of anti-hypertensives in pregnancy induced HTN:
Labour & delivery [1]
Post-natal [3]

A

Labour & delivery:
- Aim for delivery at 37w

Post-natal

  • Same as for HTN
  • Target BP 130/80
  • Rv 2w, 6-8w
26
Q

Indications for magnesium sulphate [6]
Antidote?
Indications to stop Magnesium [3]
When do we stop it post-natal?

A
  • Ongoing/recurring severe headaches
  • Visual scotomata
  • Nausea and vomiting
  • Epigastric pain
  • Oliguria
  • Severe HTN

Antidote: calcium gluconate

Stop if RR<12, loss of tendon reflex, UO <20ml/h

Stop 24h after last seizure - postnatal

27
Q

In labour and delivery of PET, what are indications of LSCS [7]

A
  • Inability to control maternal HTN despite >3 classes of anti-hypertensive
  • maternal SpO2 <90%
  • progressive deterioration in bloods (HELLP)
  • ongoing severe intractable headache, repeated visual scotomata, eclampsia
  • placental abruption
  • reversed end diastolic flow on umbilical artery Doppler
  • non-reassuring CTG, stillbirth
28
Q

Management of pre-eclampsia and tonic clonic seizure
Immediate [6]
Subsequent [4]

A

Immediate management:

  • ABCDE approach
  • IV access
  • Senior help
  • CTG
  • Maternal BP
  • sPO2 monitoring

Subsequent management:

  • Fluid restriction
  • Seizure medication
  • Monitor UO, reflexes, RR, SPO2
  • LSCS once more stable

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