Hypertension Flashcards
1
Q
Chronic Hypertension
(Criteria)
A
- BP > 140/90 before pregnancy or 20 weeks gestation
OR
- Persistent HTN 12 weeks postpartum
- 5% pregnant people
- Mild chronic HTN > 140>90
- Severe chronic HTN > 180/110
2
Q
Chronic Hypertension
(Management)
A
- Baseline 24 hour urine protein, creatinine
- EKG
- Ophthamology exam
- Growth scans at 28, 32, 36 weeks
- Twice weekly NSTs starting at 32 weeks
- Delivery by EDC
3
Q
Chronic Hypertension
(Medication Guidlines)
A
- Do not treat if B/P <160/105 and no evidence of end-organ damage
- If using anti-HTN agent, maintain BP 120-160/80-105
- Recommended initial medications:
- Labetolol (B-blocker)
- Nefidipine, Norvasc (Ca-channel blockers)
- Methyldopa
- Avoid: ACE inhibitors
4
Q
Gestational HTN and Mild PEC w/o severe features
(Eval/Management)
A
Expectant management until 37 weeks
- Daily patient assessment of patient symptoms and fetal movement (by the patient)
- BP measurements and antenatal testing (NST/AFI) 2x’s/wk
- Weekly office visits and laboratory assessment (Cr, LFTs, CBC/Platelets)
- Growth U/S q 3-4 weeks (depending on setting and severity of disease can be at 20, 28, 32, 36 wks)
- No meds needed if only GHTN
- If BP increase to point of tx, then consider dx of PEC with or w/o severe features
- No magnesium sulfate for the prevention of eclampsia in women with “mild disease”
5
Q
Gestational Hypertension
(Criteria)
A
- Systolic BP ≥140 or diastolic BP ≥90 on at least two occasions at least 4 hours apart for the first time during pregnancy after 20 weeks’ gestation
- But < 160/110
- NO proteinuria, Plt > 100,000, normal liver enzymes
- BP returns to normal at 12 weeks postpartum (final dx made post partum)
- Up to 25% will develop preeclampsia (PEC)
6
Q
Preeclampsia (PEC)
(Criteria and define severe features)
A
- 75% present in 3rd tri or at term
- Often asymptommatic
- BP ≥140/90 on two occasions ≥4 hours apart in a previously normotensive patient AND proteinuria
- Mild PEC (w/o severe features)
- Proteinuria (only 1 needed)
- 24 hour urine has ≥ 300mg of protein
- Proteinuria/creatinine ratio ≥ 0.3
- Dipstick reading 1+ (only if other methods not available)
- Proteinuria (only 1 needed)
- Severe PEC (with severe features)
- ≥160/110 within minutes (DO NOT NEED TO WAIT FOUR TO SIX HOURS)
- If no proteinuria, signs of end organ damage
- Platelets < 100,000
- Impaired liver function (2x normal)
- New renal insufficiency (creatinine > 1.1 or 2x baseline, or oliguria < 500 cc urine/day)
- Pulmonary edema
- New-onset cerebral or visual disturbances
7
Q
Preeclampsia with severe features
(Management)
A
- Expectant management until safe delivery – in setting with ICU/NICU.
- Delivery after 34 weeks
- Can wait as long as no evidence of problems with pregnant person and baby
- Goals of management include seizure prevention and B/P control
- Magnesium sulfate
- IV Labetalol or Hydralazine for BP
- 2 doses of Betamethasone 24 hours apart before delivery
- Daily observation and testing
- Daily labs (CBC, CMP, Electrolytes, etc.). frequency may change based on pt stability.
- Urine output q8 hours
- BPs ≥ q8 hours
- Symptom assessment every 8 hours
- Daily NST and twice weekly fluid checks
- Serial growth scans
8
Q
Eclampsia
(Criteria)
A
- New onset seizures with HTN and/or proteinuria in second ½ of pregnancy not attributable to other causes
- not r/t degree of proteinuria
- 50% during labor, 25% before and 25% after
- Most occur in 48 hrs. If seizure farther than 72 hrs out look for another cause
- 1% of patients with PEC
- Can lead to cerebral hemorrhage, aspiration pneumonia, hypoxic encephalopathy, thromboembolic events
- Seizures < 20 weeks → generally associated with molar or hydropic degeneration of the placenta with or without a coexistent fetus
9
Q
HELLP Syndrome
(Criteria)
A
-
Hemolytic Anemia
- Schisocytes/burr cells on peripheral smear
- Elevated LDH (2x ULN)
- Elevated total bilirubin (>1.2mg/dL)
-
Elevated Liver Enzymes
- Increase in ALT and AST (2x ULN)
-
Low Platelets
- Thrombocytopenia (< 100,000 mm3)
- Lab diagnosis, do not need elevated BP
- 20% of severe PEC will develop HELLP
- Most present preterm 27-37 wks (PEC usually at term)
- Malaise, fatigue, and nonspecific physical symptoms in 90% of women with HELLP syndrome shortly before seeking medical attention
- Also nausea and vomiting, right upper quadrant pain, and other signs and symptoms of preeclampsia (including high BP)
10
Q
Superimposed Preeclampsia
(Criteria and tx)
A
- One or more:
- New onset proteinuria ≥300 mg in a 24-hour urine in person with chronic HTN after 20 weeks’ gestation or a sudden increase in preexisting proteinuria (before pregnancy)
- Sudden increase in BP
- Thrombocytopenia (Plt < 100,000)
- Superimposed PEC with severe features
- BP > 160/110 despite therapy escalation
- Persistent cerebral symptoms (HA, vision sx)
- Elevated LFTs (2x) or Plt < 100,000
- New onset or worsening renal insufficiency
- If B/P trending upwards (measured q visit) → 24-hour urine
- Compare to baseline 24-hr urine (if taken at the beginning of pregnancy)
- 1/3 patients with CHTN develop superimposed PEC
- Hard to distinguish from worsening CHTN
- Treat as PEC appropriate to features (severe/not severe)
11
Q
Pathophysiology of HTN disorders of pregnancy
A
- Not well understood, esp PEC
- Systemic inflammatory response
- Increased thromboxane:prostacyclin ratio → vasoconstriction/spasm → reduced uterine/placental blood flow → leaky blood vessels → serum leaks out vasculature → local tissue hypoxia → hemolysis, necrosis, end organ damage → lab abnormalities
- Abnormal placentation
- Abnormal spiral artery invation → hypertrophy of smooth muscle surrounding spiral arteries → constriction → decreased blood flow
- Immune mediated
- “Rejection” of pregnancy, like pregnancy is a new organ
- Antigen immune complexes
- Sperm? (new paternity is a risk factor)
- “Rejection” of pregnancy, like pregnancy is a new organ
12
Q
RIsk factors for HTN disorders
A
- Chronic HTN
- Chronic Renal disease
- Pregestational DM
- Preexisting vascular disease
- Antiphospholipid syndrome
- African American race
- Extremes of age
- Nulliparous
- Prior PEC
- Multiple gestation
- Abnormal placentation
- New paternity
- IVF
- Family hx
- Obesity
13
Q
USPSTF recommendations on ASA during pregnancy
A
- 81mg aspirin after 12 week if at high risk
- Reduces PEC, preterm delivery due to PEC, IUGR, abruption
- No harmful effects to pregnancy, bleeding risk at delivery or problems with epidural
- High risk:
- History of PEC, esp if bad outcome
- Multiple gestation
- Chronic HTN
- Type 1 or 2 diabetes
- Renal disease
- Autoimmune disease
- Grade B
14
Q
Identify the risks of hypertensive disorders to the fetus
A
- 15% preterm deliveries due to pregnancy related HTN or IUGR (often concurrent with HTN issues)
- Placental infarction or abruption
- Intrapartum fetal distress or stillbirth
- Growth restriction
- Oligohydramnios
15
Q
Summary of HTN disorders
(slide from HTN lecture)
A
