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Maternal Medicine > Hypertension And PET > Flashcards

Hypertension And PET Flashcards

1
Q

What is the primary change in the circulation during pregnancy?

A

Vasodilation

Fall in the systemic vascular resistance

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2
Q

When is the nadir of BP in pregnancy?

A

22-24/40

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3
Q

What should be taken as the diastolic reading?

A

Phase V (Disappearance)rather than phase IV (muffling) or Korotkoff sounds

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4
Q

How should BP be taken in pregnancy?

A

Sitting or lying on side with 30 degree tilt

If taken supine, it will be falsely low due to decreased venous return

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5
Q

If you use a normal size cuff to measure BP on a larger women, what error will occur?

A

Over-estimate of BP

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6
Q

What is the prevalence of Gest HTN?

A

10-15%

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7
Q

What is the prevalence of PET?

A

3-5%

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8
Q

What is the commonest cause of iatrogenic prematurity?

A

PET

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9
Q

What are secondary causes of hypertension?

How do you investigate for them?

A

Renal artery stenosis - listening for renal bruits, USS
Underlying renal disease - urinalysis, ? Proteinuria, haematuria, serum Creat
Aortic coarctation - radiofemoral delay, CT
Conn’s - hypokalaemia
Cushing’s
Phaechromocytoma - urinary catecholamines
Hyper parathyroid is - serum Ca

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10
Q

What are women with pre-existing HTN at risk of in pregnancy?

A

PET (25%)
PTB (28%)
LBW (17%)

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11
Q

How does PET affect the kidney?

A 
Decreased GFR
Proteinuria
Rise in serum creat
Rise in rate
Oliguria
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12
Q

What is the cause of hyperuricaemia in PET?

A

Placental ischaemia

Accelerating trophoblast turnover and production of purines (substrate for xanthine oxidase)

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13
Q

What is the cause of hyponatraemia in PET?

What is the treatment?

A

Fluid overload
With an element of SIADH?

Rx: fluid restriction

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14
Q

What are crises / complications in pre-eclampsia?

A 
HELLP
Pulmonary oedema
Renal failure 
Hepatic rupture
DIC
Placental abruption
Cerebral haemorrhage
Cortical blindness (linked to PRES)
Transient LV dysfunction
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15
Q

What are the two stages in the pathogenesis of PET?

A
  1. Abnormal placentation
    - spiral arteries do not undergo normal vascular remodelling, failing to become high capacitance, low resistance vessels
    - invading placenta unable to optimise its blood supply
    - uteroplacental ischaemia
  2. Maternal response
    - metabolic disturbance
    - exaggerates inflammatory response
    - higher levels of pro-inflammatory cytokines associated with endothelial dysfunction, which leads to platelet activation and vasoconstriction
    - cause widespread micro vascular damage and dysfunction
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16
Q

What is the role of VEGF and TCF-beta1 in a normal pregnancy?

A

Maintain endothelial health

By interacting with endogenous endothelial receptors

17
Q

What factors are secreted by the placenta in excess in PET?

A

Soluble Flt1 (sFlt1) and soluble endoglin (sEng)

  • anti-angiogenic factors
  • antagonise VEGF and TGF-B1 (transforming growth factor) signalling, and PIGF (placental growth factor)
  • therefore producing systemic endothelial dysfunction

sFlt1 and sEng and increased and PIGF is decreased in the maternal circulation weeks before the onset of PET

18
Q

What is notching in the uterine artery at 20-24/40 predictive of?

A

PET
FGR
Placental abruption

19
Q

When is there a risk of cerebral auto regulation in PET?

A

MAP > 150

Mother at risk of cerebral haemorrhage

20
Q

How do you calculate MAP?

A

D + 1/3 (S-D)

21
Q

Women with PET should be encouraged to use what in labour?

A

Regional analgesia / anaesthesia

22
Q

How should postpartum oliguria in PET be managed?

A

Safer to err not he side of volume depletion and mild AKI than to treat immediate postpartum oliguria with aggressive volume replacement and risk pulmonary oedema

23
Q

What are the risks for future health, in women who have had PET?

A

Hypertension (3-4x)
IHD (2x)
Cerebrovascular disease

24
Q

What is the risk of recurrent PET?

A

15%

Increases with earlier gestation

25
Q

Perinatal mortality rises with DBP > ______

A

90mmHg

26
Q

What proportion of Gest HTN progresses to PET?

A

25%

More so when HTN presents <32/40

27
Q

Aspirin to prevent PET
What is the NNT
(Cochrane 2019)

A

Reduces risk of PET by 18%
NNT = 61
Benefit most marked at doses >75mg and when commenced <20 weeks

Also reduces:

  • risk of SGA babies
  • preterm birth <37 weeks
  • fetal and neonatal death

BUT
- slightly more women lost >500mL
- tends to more higher risk of abruption, but wide CI
THUS overall deemed safe and benefit outweighs risk

28
Q

With HELLP, what is the maternal mortality rate of expectant management?

A

6.3%

SOMANZ

29
Q

What was the conclusion of the CHIPS study?

A

The development of severe HTN (independent of PET) increases the risk of
- stroke
OTHER adverse perinatal and maternal outcomes including
- serious maternal complications

Antihypertensive therapy to normal maternal BP: tight BP control arm aimed for DBP <85

30
Q

What were the findings of the Cochrane Review looking at Calcium supplementation to prevent HTN / PET?

2018

A

Calcium supplementation
Less likely to
- Die
- Have serious problems related to PET

31
Q

For a women who has had previous PET, what is the RR of recurrent PET?

A

7

32
Q

What was the conclusion of the PHOENIX Trial?

A

Late preterm PET 34-36+6/40
- Randomised to immediate delivery or expectant management

Planned delivery reduces maternal morbidity and severe HTN compared with expectant management
With MORE neonatal unit admissions related to prematurity but no indicators of greater neonatal morbidity.

This trade-off should be discussed with women with later preterm PET to allow shared decision making on timing of delivery

33
Q

What were the findings of the CLASP trial 1994?

Why may its findings differ from other studies?

A
  • Multicentre RCT
  • Included women from 12-32 weeks gestation if risk factors for PET OR developing signs and symptoms of PET
  • Treatment = 60mg aspirin

Findings:
- Risk reduction proteinic PET by 12% but not statistically significant

WHY??

  • Low dose of aspirin - cochrane 2019 suggests benefit more clear when >75mg used, unclear benefit at doses <75mg
  • Including later gestations - cochrane 2019 suggests significant benefit if commenced prior to 20 weeks, vs unclear benefit if commenced after 20 weeks gestation

Maternal Medicine (18 decks)

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