Hypertension and Pre-Eclampsia Flashcards
Define the following: pre-gestational hypertension?
BP of greater than 140/90mm/hg before 20 weeks gestation
Define the following: gestational hypertension?
BP persistently greater than 140/90 which develops after 20 weeks gestation.
Or an increase of 30/20 from booking BP
Describe the different stages of gestational hypertension?
Mild: 140/90
Moderate: 150/100
Severe: 160/110
What BP should be aimed for in pregnancy?
120/80
What are the risks due to pre-gestational HTN in pregnancy?
Increased risk of:
- Pre-eclampsia
- IUGR
- Placental abruption
- Still birth
How should pre-gestational HTN be managed?
DO NOT USE:
ACE inhibitor or Diuretics
Treat with:
-Labetalol (beta blocker)
OR
-Nifedipine (Ca antagonist)
Treat with low dose aspirin to reduce pre-eclampsia risk
Monitor BP and urine dip more frequently screen with uterine aa doppler
What is pre-eclampsia?
A placental disease characterised by suboptimal uteroplacental perfusion associated with a maternal inflammatory response and maternal vascular endothelial dysfunction.
What are the diagnostic criteria for pre-eclampsia?
Hypertension of greater than 140 systolic OR 90 diastolic and proteinuria in the second half of pregnancy.
With or without oedema.
Who is at risk of developing pre-eclampsia?
Current pregnancy, past pregnancy, PMH, FH
Nulliparous
PMH of pre-eclampsia
Afro-carribean
FH of pre-eclampsia
Chronic HTN Chronic renal disease Antiphospolipid syndrome Collegen vascular disease Diabetes
Pregnancy in young or old (less than 15 older than 35)
Multiple pregnancy
What is the proposed pathophysiology of pre-eclampsia?
Incomplete invasion of spiral aa into the trophoblasts (this usually leads to vasodilation).
This leads to reduced uteroplacental blood flow.
This causes the placenta to become ischaemic which may cause an exagerated maternal inflammatory response causing widespread endothelial damage.
This causes vasoconstriction, increased vascular permeability (oedema) and clotting dysfunction.
What are the symptoms of pre-eclampsia?
Usually asymptomatic.
Note presence of symptoms suggests severe pre-eclampsia
Symptoms can include:
- Headache
- Visual disturbances (blurred/scotomas)
- Drowsiness
- Nausea and vomiting (late stage complication)
- Epigastric pain
- Breathlessness secondary to pulmonary oedema
What are the maternal complications of pre-eclampasia in pregnancy?
- Eclampsia (treat with MgSO4)
- Cerebrovascular haemorrhage
- HELLP syndrome
- Renal failure
- Pulmonary oedema (O2, furosemide and fluid restriction to treat)
What is HELLP syndrome?
It is a complication of severe pre-eclampsia characterised by:
Haemolysis
Elevated Liver enzymes (ALT*)
Low Platelets
Can cause DIC, needs many blood products + give MgSO4 to prevent eclampsia
*Note ALP is produced by the placenta and therefore is always raised in pregnancy
What are the fetal complications of pre-eclampsia?
Increased mortality
IUGR (pre-term delivery is often required)
Placental abruption (risk of mortality)
How should you manage a patient that is at risk of pre-eclampsia?
More frequent BP and urine monitoring.
Prophylactic aspirin 75mg from 12 weeks
What tests should be done when confirming pre-eclampsia?
BP
MSU and urine protein measurement
What are the criteria for mild, moderate and severe pre-eclampsia?
Mild:
Proteinuria and mild-moderate HTN (150/100)
Moderate:
Proteinuria and severe HTN (160/110)
Severe:
Proteinuria and HTN before 34 weeks Or any maternal complications
How should you monitor a pre-eclamptic patient in hospital?
If pre-eclampsia patient needs admission.
4hrly BP
Catheterise and daily urinalysis
Daily CTG
Regular bloods: FBC and LFTs
How and when should you manage blood pressure in hypertension or pre-eclampsia?
When BP reaches 150/100
Treat with labetalol and nifedipine
IV labetalol can be given in severe hypertension/pre-eclampsia.
Hydralasine can be used as an alternative
What is magnesium sulphate used for?
Used in treatment of eclampsia and in prevention in severe pre-eclampsia.
Note: toxicity is severe including respiratory depression, hypotension and loss of deep tendon reflexes (check for these)
What is the definitive treatment of pre-eclampsia?
Delivery of the foetus
When should you aim for delivery in mild, moderate and severe pre-eclampsia?
Mild deliver by 37 weeks
Moderate-severe deliver between 34-36 weeks
If maternal complications deliver at any point if necessary
When are steroids indicated in pre-eclampsia?
Before 34 weeks in moderate/severe pre-eclampsia as helps lung maturation if pre-term delivery is indicated
What is the post natal care protocol for a pre-eclamptic mother?
Keep in hospital for ~5days
Monitor BP, UO
Bloods: FBC, LFTs, U&E’s
Important as may still fit post natally
In magnesium sulphate toxicity what is the treatment?
Calcium glutamate
