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REPRO > Hypertension in Pregn. > Flashcards

Hypertension in Pregn. Flashcards

1
Q

How common is hypertension in pregnancy?

A

10-15% of all pregnancies

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2
Q

How common is severe pre-eclampsia?

A
  • only affects 1% of primigravid women

- whilst mild pre-eclampsia affects 10% of primigravid women

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3
Q

What is the biggest cause of iatrogenic pre-term birth?

A
  • Pre-eclampsia
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4
Q

How does the maternal CVS system adapt to pregnancy?

A
  • increase in plasma volume (50%)
  • incr. in CO, SV, HR
  • decr. in peripheral vascular resistance (15-20%)
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5
Q

Trends in BP and HR in Normal Pregnancies?

A
  • mild dip in BP in Mid-trimester of the pregnancy

- progressive rise in HR by 7 bpm (not sudden!)

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6
Q

What is hypertension define as?

A
  • > 140/90mmhg on 2 occassions

- >160/110 mmHg once

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7
Q

How to dx pre-existing H/T?

A
  • if H/T does not resolve within 3 months of delivery
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8
Q

Risks of pre-existing htn?

A
  • PET (pre-eclampsia) x2
  • IUGR
  • placental abruption
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9
Q

What are fts of pregnancy induced htn?

A
  • no proteinuria/ other PET fts
  • better outcomes than PET
  • but 15% progresses into pre-eclampsia
  • recurrence is high
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10
Q

How does pre-eclampsia present as?

A
  • htn
  • proteinuria
  • edema
  • —-absence of ONE of these 3 fts does NOT exclude PET dx
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11
Q

How does PET affect blood vessels?

A
  • d/t endothelial dysfxn in whatever system is affected (renal/ hepatic/cvs/hematology/cns/placenta)
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12
Q

How diff. is early pre-eclampsia vs late pre-eclampsia?

A
  • EARLY (<34wks) : HIGHER risk of maternal and FETAL complications/ uncommon/ a.w extensive villous and vascular lesions of the placenta

——LATE : majority/ minimal placental lesions/ maternal factors important (metabolic syndrome) /most caseECLAMPSIA AND MATERNAL DEATH!

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13
Q

How does pre-eclampsia come about?

A
  • insufficient blood flow to the placenta secondary to INADEQUATE remodelling of spiral arteries of the uteroplacental vascular bed
  • trophoblasts normally cause a change in the endothelium by invading the musculoelastic walls; to allow blood for the fetus to be well recieved
  • in pre-eclampsia: d.t failure of normal vascular remodelling, Spiral arteries fail to adapt to become high capacitance, low resistance vessels
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14
Q

What liver conditions does pre-eclampsia cause?

A

epigastric/ RUQ pain
- hepatic capsule rupture

Hemolysis
Elevated Liver ENzymes
Low Plates

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15
Q

How does placental abruption present as?

A
  • painful ante-partum hemorrhage
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16
Q

What placental disease may arise from hypertension?

A

FGR
Placental abruption
- Intra-uterine death

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17
Q

Symptoms of pre-eclampsia?

A
  • Headache
  • Visual disturbance
  • Epigastric / RUQ pain
  • Nausea / vomiting
  • Rapidly progressive oedema (can’t fit rings in)
  • loss of vision!
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18
Q

What are the signs of pre-eclampsia?

A 
Hypertension
Proteinuria
Oedema
Abdominal tenderness
Disorientation
Small for Gestational Age (SGA) Fetus
Intra uterine fetal death
Hyper-reflexia / involuntary movements / clonus
----painless ante-partum hemorrhage= low-lying placenta
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19
Q

Ivx for pre-eclampsia?

A 
Urea &amp; Electrolytes
Serum Urate
Liver Function Tests (HELLP $) 
Full Blood Count (hemolysis and thrombocytopenia) 
Coagulation Screen
Urine - Protein Creatinine Ratio (PCR) (>30 )
Cardiotocography
Ultrasound - fetal assessment
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20
Q

How to manage pre-eclampsia?

A

Assess risk at booking - identify risk factors

  • if Hypertension < 20 weeks - look for secondary cause (renal disease, echo-cardiac scans)
  • Antenatal screening - BP, urine, MUAD
  • Treat hypertension
  • Maternal & fetal surveillance
  • Timing of Delivery
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21
Q

Risk factors of pre-eclampsia?

A 
>40y.o
BMI >30 
Family hx (up to 40% if sis is affected/ 25% if mum) 
- parity (1st pregn: 2-3x) 
multiple preg. (twins 2x) 
previous pre-eclampsia (7x)
BIRTH interval >10 years
Molar preg./ triploidy 
- multiparous women
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22
Q

Medical risk factors for pre-eclampsia?

A 
Pre-existing renal disease
Pre-existing hypertension
Diabetes (pre-existing/gestational)
Connective tissue disease
Thrombophilias (congenital / acquired- lupus anti-coagulant)
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23
Q

How does aspirin help in pre-eclampsia?

A
  • inhibits Cyclo-oxygenase; prevents TXA2

- —-prevents thrombosis in placental blood vessels; saves perfusion of placenta

24
Q

What is the dose of aspirin given, to whom and for how long ?

A
  • used on HIGH risk women (renal disease, DM, aPS/SLE, multiple risk factors)
  • 150mg dose
  • commence before 16 wks
25
Q

Why does peripheral resistance reduce in pregnancy?

A

High resistance low capacity > low resistance high capacity blood vessels

26
Q

When can pre-eclampsia be dx on the Maternal Uterine artery doppler?

A

20-24 weeks

—–HOW DOES it appear: as a notch

27
Q

When to refer to antenatal Day care unit?

A
  • proteinuria ++
  • ^^edema
  • persistent headache
    BP >140/90
28
Q

When to admit to ward?

A
  • BP >170/110 OR >140/90 w. proteinuria
  • Significant symptoms - headache / visual disturbance / abdominal pain

Abnormal biochemistry

Significant proteinuria - >300mg / 24h

Need for antihypertensive therapy

Signs of fetal compromise

29
Q

Inpatient assessment involves what investigations?

A

Blood Pressure - 4 hourly

Urinalysis - daily

Input / output fluid balance chart

Urine PCR - if proteinuria on urinalysis

Bloods - FBC, U&Es, Urate, LFTs. Minimum X2 per week

30
Q

What is recommended when treating hypertension?

A

Aim to bring the BP down slowLY, d.t risk of hypoperfusion to fetus (aim for 140-150/90-100)

31
Q

Hypertensive medication c.i in pregnant ladies?

A
  • diuretics and ACE-Is
32
Q

How is the fetus assessed?

A
  • fetal movements
  • CTG
  • USG (biometry/ AFI/ umbilical artery doppler)
33
Q

What to check for on the umbilical artery doppler?

A
  • in 3rd trimester pregnancy

- —-with incr. reisstance; - loss of flow during disatole and reversal of blood flow

34
Q

When to deliver the baby?

A
  • mother to be stabilised
  • 2 DOSES OF DEXAMETHASONE (if pre-term)
  • —most should be delivered in 2weeks of dx
35
Q

Indications for birth?

A

Term gestation
Inability to control BP
Rapidly deteriorating biochemistry / haematology
Eclampsia
Other Crisis
Fetal Compromise - abnormal Ultrasound or CTG

36
Q

Rx of eclampsia ?

A
  • IV LABETOLOL
  • IV HYDRALAZINE

—–continuous perfusion; beware of hypotension

37
Q

Fluid balance is a MAIN cause of maternal death and fluid challenges are potentially dangerous….
What is done to manage fluid overload?

A
  • run the pt dry : 80ml/h
38
Q

What is involved with the management of Pre-eclampsia?

A
  • contorl BP
  • prevent seizures
  • fluid balance
  • delivery
39
Q

Cause of 14% of maternal deaths?

A

hypertension

40
Q

Secondary causes of pre-existing hypertension?

A
  • renal
  • cardiac
  • Cushing’s
  • Conn’s
  • Phaeochromocytoma
41
Q

Local vasospasm d/t pro-inflammatory release from the placenta results in various multisystemic symptoms. What are they?

A
  • kindeys: oligouria, proteinuria
  • Retina: scotoma, flashing lights, blurred vision
  • Liver: injury and swelling, elevated liver enzymes, capsule stretching (RUQ pain)
42
Q

How does hemolysis come about in pre-eclampsia?

A
  • numerous thrombi form d.t to the dysfunctional endothelium
  • cause break down of RBCs
  • —-thrombi may also use up the platelets!
43
Q

Why does generalized edema arise in pre-eclampsia? How does it present as?

A
  • endothelial dysfxn causes vascular permeability
  • with reduced oncotic pressure; MORE FLUID loss in to the tissues
  • seen in legs, face and hands
  • —PULMONARY edema: cough, sob
  • —-cerebral edema: headache, confusion and seizures
44
Q

What pro-inflammatory factors are released by the placenta when hypoperfused?

A
  • VEGF
  • sEng
  • Flt1
  • PIGF
45
Q

How effective is ASPIRIN?

A
  • 15 % reduction of PET

- more beneficial in preventing SEVER early onset of pre-eclampsia

46
Q

WHat is the 1st line rx of hypertension?

A
  • Methyldopa (c.i in Depression)
  • LABETOLOL
  • Nifedipine (SR)
47
Q

What hypertensive drug should be avoided in an asthmatic pt?

A

Labetolol- beta blocker

48
Q

Which hypertensive drug should be avoided in a depressed pt?

A
  • Methyldopa
49
Q

Name 2nd line hypertensive rx?

A
  1. Hydralazine (vasodilator)

2. Doxazocin (alpha-blocker)

50
Q

Which drug should be avoided when breastfeeding?

51
Q

What complications may arise in Pre-eclampsia?

A
  • eclampsia
  • HELLP $
  • Pulm. Edema
  • Placental abruption
  • cerebral hemorrhage
  • Cortical blindness
  • DIC
  • Acute renal failure
  • hepatic failure
52
Q

WHat is eclampsia?

A

Pre-eclampsia with seizures

  • –tonic-clonic (grand mal) seizure
  • —>1/3 will have seizure BEFORE HTN onset/proteinuria
53
Q

In whom is eclampsia commonly seen in?

And what is eclampsia commonly a.w?

A
  • seen in Teenagers

- a.w vasospasm

54
Q

Why is fluid balance important in pre-eclamptic management?

A
  • pulm. edema is the main cause of death
55
Q

How is labour and birth any diff. in a case of eclampsia?

A
  • aim for vaginal birth
  • control BP
  • epidural anaesthesia
  • continous fetal monitoring!
  • AVOID ergometrine
  • caution with IV fluids
56
Q

What management is provided post-partum?

A 
Breast feeding
Contraception
BP management
Counselling  / debrief
Future risk
----gestation dependent 
Consider long term CVS risk

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