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MD3: Women's > HTN in pregnancy > Flashcards

HTN in pregnancy Flashcards

1
Q

What is the Rx for pre-existing HTN in pregnancy?

A

Cease ACEI/ARB and diuretics (teratorgenic)

Monitor closely and if still require medication for control can use labetalol, nifedipine, methyldopa
Induce delivery at 38-40W

Management of HTN does not improve risks to foetus (IUGR, congenital malformations) but reduces the risk of stroke for mother

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2
Q

What are the DDx for HTN in first trimester/2nd trimester?

A

Chronic hypertension

Gestational hypertension (pregnancy induced HTN with no systemic features) - generally >20W but can occur at any gestation

White coat HTN

*Unless have pre-pregnancy readings/know they have HTN prior to pregnancy, cannot distinguish chronic fro gestation until ~6/52 post-partum

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3
Q

What is the assessment for women presenting with HTN in 1st & 2nd trimester?

A

Repeat measurements to ensure not white coat HTN

If 150-160/90-95 commence anti-hypertensives (labetolol, nifedipine)

Monitor more closely throughout pregnancy (BP, foetal wellbeing, urine, uric acid, reflexes, symptoms of pre-eclampsia) - at risk of pre-eclampsia, IUGR and placental abruption

Discuss likelihood of preterm induction/delivery due to associated risks (despite good control don’t prevent foetal issues, only risk of stroke)

Aspirin and calcium from at least 14W (or earlier)

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4
Q

When does pre-eclampsia occur?

A

Disorder of 3rd trimester

Uncommonly presents prior to 24W

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5
Q

What are the risk factors for pre-eclampsia?

A

Extremes of maternal age
PHx or FHx pre-eclampsia - 3-4x risk
First pregnancy
New paternity, cohabitation <6mths - related to

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6
Q

What are the clinical features of pre-eclampsia?

A

HTN

Hepatic - RUQ (capsule haemorrphage/swelling), elevated LFTs, coagulopathy

Renal - proteinuria, oliguria, renal failure (decreased perfusion), increased uric acid

Neuro - hyper-reflexia, clonus, headache, blurry vision, fundoscopy (papiloedema, haemorrphage, exudate), stroke, convulsions (eclampsia)

Placental - IUGR, abruption

Cardiorespiratory - 3rd space losses (pulmonary oedema, generalised oedema esp. face and hands)

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7
Q

What are features suggestive of severe disease in pre-eclampsia?

A 
Headache, blurry vision
Decreased urine output 
Raised LFTs, RUQ
Oedema
Papiloedema
Pulmonary HTN, Severe HTN (>170)
Hyper-reflexia, clonus 
Foetal compromise
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8
Q

What is the clinical course of pre-eclampsia?

A

Some can be slowly progressive and some can rapidly deteriorate - very careful monitoring and management

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9
Q

What is the approach to assessment for a women presenting with HTN in the 3rd trimester?

A
  1. Question for symptoms of pre-eclampsia and risk factors
  2. Examination
    - neurological signs
    - RUQ tenderness
    - Fundoscopy
  3. Day assessment monitoring and Ix
    - 4 hours - BP, CTG
    - U/S -foetal size, biophysical profile, dopplers
    - Urine protein:creatine
    - Uric acid
    - LFTs, coagulation profile
    - FBE
    - Renal function

4.Determine further Rx based on clinical work-up & presence of systemic features

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10
Q

What are the DDx for HTN in 3rd trimester?

A

White coat HTN

Gestational HTN

Chronic HTN

Pre-eclampsia

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11
Q

3rd trimester HTN management scenarios:

Persistent HTN (>150-60/90) with NO systemic features?

A

DDx - gestational HTN or chronic/essential HTN

Treat HTN that is >150-160/>90 - labetolol or nifedipine

Consider model of care - higher risk pregnancy

  • Closer monitoring (increased risk of pre-eclampsia, abruption and IUGR)
  • discuss likelihood of preterm delivery
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12
Q

3rd trimester HTN management scenarios:

Persistent HTN with MILD systemic features?

A

DDx - Pre-eclampsia

If Mild-moderate HTN with some/mild systemic features can go home but with close monitoring (? might admit in public system)

Anti-hypertensives

Monitoring

  • Every 2 days - BP, worsening symptoms, foetal wellbeing (CTG, biophysical profile)
  • Fortnightly dopplers (unless IUGR and then dopplers also every 2 days)

Delivery

  • If become severe/feotal compromise/rapidly progressive disease deliver regardless of gestation
  • Otherwise aim for delivery at >=38W
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13
Q

3rd trimester HTN management scenarios:

Severe pre-eclampsia (Severe HTN and systemic features)?

A

Admit/transfer

Antihypertensives
-IV labetolol to rapidly reduce BP - want to control at least 30mins prior to delivery to reduce risk of stroke

Stabilise and plan for C-section

  • Convulsion prophylaxis = MgSO4 - monitor reflexes for toxicity, antidote = CaCl
  • Fluids - caution with pulmonary oedema
  • Transfusion FFP/platelets if necessary
  • Corticosteroids if <37W
  • Continuous CTG monitoring and regular (4hrly FBE, renal and liver function tests)

If stabile can try to push through 24-48hrs to allow time for steroids but if unstable/rapidly progressive don’t

Delivery

  • Generally vaginal over c-section unless other risk factors
  • Stabilise before delivery
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14
Q

What is the value of proteinuria considered for pre-eclampsia?

A

> 300mg/24hours

Increased production to normal with pregnancy but particularly elevated in pre-eclampsia

Spot protein:creatinine ratio better - fast result, more practical, accurate

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15
Q

What are the features of uric acid when assessing pre-eclampsia?

A

Rising uric acid = early sign
Very specific and sensitive - excellent for assessment and monitoring
Rule of thumb - value should be less than gestation

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16
Q

Immediate post-partum care in women with pre-eclampsia?

A

Risk of eclampsia and stroke maintained for 3-4 days post partum

Especially increased in first 24 hours and may have worsening disease

Continue anti-hypertensives, MgSO4 and regular monitoring during this time

Once voiding normally can stop Rx/reduce monitoring - diuresis and functioning kidneys sign that they are improving/recovered

17
Q

6-week follow-up for women with pre-eclampsia?

A

Investigate for underlying cause
- thrombophilia (esp. anti-phospholipid syndrome), SLE, chronic HTN and causes of this

Counsel on risk factors - obesity, new partners, first pregnancy etc

Reassure some prevention strategies and close monitoring for 2nd pregnancy

  • Aspirin from at least 14W (usually from start) until ~36W (Low dose and more effective when taken at night)
  • Calcium and folate supplements
18
Q

What are the features of imminent eclampsia?

A

Aura
Confusion, drowsiness
Irritability, jiteriness, restlessness
Headache, visual changes

19
Q

What are the maternal consequences/risks associated with pre-eclampsia/eclampsia?

A

Stroke - generally occipital lobe

Convulsion - cerebral oedema and hypoxia

Liver rupture (due to capsule stretch with haemorrphage & oedema)

DIC and haemorrphage

Acute renal failure

Pulmonary oedema and heart failure

20
Q

What is considered HTN in pregnancy?

A

> 140/90

Or >30/15 above baseline

Typically treat from ~150-160/90-95 but mandatory to treat when >170/110

21
Q

What are the consequences of pre-eclampsia on the foetus/placenta?

A

Congenital abnormalities

IUGR

Abruption - hypoxia, stillbirth

Foetal distress syndrome

22
Q

What is HELLP syndrome?

A

Variant of severe pre-eclampsia

Haemolysis
Elevated LFTs
Thrombocytopenia

DDx - HUS, thrombotic thrombocytopenic purpura

MD3: Women's (19 decks)

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