Hypertension

Question 1

Level of proteinuria that is diagnostic of Preeclampsia?

Answer 1

P/Cr ratio >/= 0.3

> /= 300 mg/24 hrs

Question 2

Pre E Severe Features

Answer 2

BP >/= 160/110
Chest pain, Dyspnea, pulm edema
Cr > 1.1 or double baseline
New HA/Visual disturbances
Plts < 100 k
AST/ALT > 2 x baseline
Persistent RUQ pain/epigastric pain w/out other other causes

Question 3

How do you screen for preeclampsia risk?

Answer 3

Based on Hx
Personal or Fm Hx of Pre E
Multiple gestation
Chronic HTN
Type 1/2 DM
Autoimmune disease

Get Baseline UPC/HELLP labs

Start ASA 81 mg QD for any hx of hypertensive disease

Question 4

Who gets ASA in pregnancy?

Answer 4

1 high risk criteria:
- Hx of Pre E
- Chronic HTN
- Renal Disease
- Twins
- Pre gestational DM
- Autoimmune disease (APLS, Lupus)

OR 1 or more moderate risk factors
- AMA
- Nulliparity
- Obesity
- African American
- Low socioeconomic status
- Fm Hx of Pre E
- Previous SGA, low birth weight
- > 10 years since previous pregnancy
- IVF

Question 5

When should you start ASA?

Answer 5

Between 12-28 weeks

MOST EFFECTIVE IF STARTING PRIOR TO 16 WEEKS

Question 6

Therapeutic range of Mg?

Answer 6

4.8-5.9 mg/dL

Question 7

Physical Exam findings of Mag Toxicity?

Answer 7

Loss or reflexes > 9 mg/dL
Respiratory arrest > 12 mg/dL
Cardiac arrest > 30 mg/dL

Question 8

Antidote of Mag Toxicity?

Answer 8

STOP INFUSION

Calcium gluconate 1 gm (10 cc) IV over 3 minutes

Question 9

Max dose of IV labetalol?

Answer 9

Total 300 mg

Give 20, 40, ,80 mg Q10 mins

Question 10

Max dose of Hydralazine?

Answer 10

Total 30 mg

Give 5, 10 mg Q20 mins

Question 11

Nifedipine dosing?

Answer 11

PO 10, 20, 20 Q20 mins

Question 12

Preeclampsia w/ Myasthenia Gravis?

Answer 12

CAN’T GET MAG! (risk of respiratory arrest)

Phenytoin (monitor with EKG)
Diazepam (be able to intubate)

Question 13

Secondary causes of hypertension?

Answer 13

Illicit drug use (meth or cocaine)
Renal artery stenosis/ Renal disease
Sleep Apnea

Question 14

What to do if no IV and need to start Mag?

Answer 14

Can give IM 10 g

Give 5 g in each butt cheek

Question 15

Management of Eclamptic Seizure

Answer 15

Call for help
Position in lateral decubitus
Prevention of aspiration
Oxygen, check vitals
Eclamptic seizures are self limiting!!!

Give 2-4 g IV Mag over 5 minutes (prevents next seizure)

Question 16

What is refractory eclamptic seizure?

What should you do?

Answer 16

Still seizing 20 mins after bolus
OR
More than 2 occurrences

Question 17

Does Eclampsia require a C/S?

Answer 17

Women should be delivered in a timely fashion

Eclampsia by itself is NOT an indication for CS

After stabilization consider other factors: GA, presentation, cervix

*High rate of induction failure if < 30 weeks

Question 18

What can you expect FHT to do during seizure?

Indication for CS?

Answer 18

During Seizure:
Prolonged decelerations
Fetal Bradycardia
Increase in uterine contractility

After Seizure:
Recurrent decelerations
Tachycardia
Minimal variability

***Maternal resuscitation is usually followed by normalization of FHT

Question 19

Additional agents for recurrent eclamptic seizures?

Answer 19

Diazepam 5-10 mg IV every 5-10 minutes

MAX DOSE 30 mg

Question 20

When should you start meds prenatally for a chronic HTN? What is the goal pressures?

Answer 20

Start if persistently > 140/90
Titrate to < 140/90 during pregnancy

Question 21

Maternal risks of cHTN in pregnancy?

Answer 21

Increased risk of Pre E
CVA/MI/Pulmonary edema
Worsening renal function
GDM
C/S and PPH
Placental abruption

Question 22

Fetal risks of cHTN in pregnancy?

Answer 22

FGR
IUFD
Preterm Birth

Question 23

Delivery timing for hypertensive disorders?

Answer 23

CHTN, uncomplicated, no meds 38 - 39w6d
CHTN, uncomplicated, on meds 37 -39w6d
Pre E w/out SF or GHTN @ 37 wks
Pre E w/ SF @ 34 wks

Question 24

How does ASA reduce risk of Pre E?

Answer 24

Reduces thromboxane production by platelets
Thrombozane promotes vasocontriction and platelet aggregation

*decreases vascoconstriction and platelet aggregation

Start 12-28 weeks, best time to start is < 16 wks

Daily low dose 81 mg/day ASA has not been associated with signficant maternal or fetal complications!!!!