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Women's Health Theory > Hypertension in pregnancy > Flashcards

Hypertension in pregnancy Flashcards

1
Q

Definition: chronic hypertension during pregnancy

A

BP >140/90 within first 20 weeks of pregnancy OR persisting >12 weeks postpartum

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2
Q

Definition: Gestational HTN

A
  • New onset HTN > 20 wks without proteinuria or other signs of preeclampsia: 50% will develop preeclampsia by the end of pregnancy
  • RESOLVES in the PP period: If lasts > 12 weeks pp = CHRONIC htn
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3
Q

Definition: Eclampsia

A

o New onset generalized seizures in a women with preeclampsia

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4
Q

When is preeclampsia diagnosed?

A

o Dx > 20 weeks OR PP

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5
Q

What is the BP rage for preeclampsia and what else is required?

A

> 140/90 AND +proteinuria OR end organ dysfunction

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6
Q

How many elevated BP readings are required to diagnose?

A

 2 readings of BP > 140/90 at least 4 hrs apart after 20 weeks
 1 reading BP > 160/110

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7
Q

What are the proteinuria/protein/creatinine ratio cut offs?

A
  • > = 0.3 grams in protein/creatinine ratio OR 300 mg in 24 hours urine specimen
    Think rule of 3’s: 0.3 or 300
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8
Q

How often does eclamptic seizures occur during the PP period?

A

1/3 eclamptic seizures

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9
Q

What is the typical period of time that PP eclamptic seizures will occur?

A

up to 4 weeks

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10
Q

Definition: HELLP Syndrome

A

o Hemolysis (on blood smear, or indirect hyperbilirubinemia, low
serum haptoglobin, or markedly elevated lactate dehydrogenase)
o Elevated Liver enzymes (AST/ALT twice the upper limit of normal)
o Low Platelet (thrombocytopenia – platelet count <100,000/mm)

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11
Q

How often does preeclampsia complicate pregnancies?

A

2-8 %

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12
Q

What is the greatest risk for women with chronic hypertension?

A

superimposed preeclampsia

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13
Q

High risk factors: preeclampsia

A
  • Hx preeclampsia with previous pregnancy
  • Multifetal gestation
  • Chronic HTN
  • Pregestational diabetes
  • Renal disease
  • Autoimmune disease
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14
Q

Moderate risk factors: preeclampsia

A
  • > = 35 y/o
  • BMI >= 30
  • Fhx mother or sister
  • Nulliparity
  • Personal hx risk factors (low birth weight, SGA, over 10 year pregnancy interval)
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15
Q

What causes complications in preeclampsia?

A

Vasoconstriction

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16
Q

What must be present for preeclampsia to occur? What does not have to present?

A

-Placenta must be present
-Do not need a fetus –> can happen in molar pregnancy

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17
Q

What is the issue with the placenta in preeclampsia?

A

Failed remodeling of the spiral arteries to accommodate increased blood flow

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18
Q

What is the maternal response to the initial abnormal placentation and subsequent placental hypoxemia?

A

release or cytokines that leads to systemic inflammation, vascular endothelial dysfunction throughout the vascular system and prothrombotic condition

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19
Q

Fetal risks preeclampsia

A

-miscarriage
-abruptions
-SGA
-preterm birth
-perinatal death

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20
Q

What is the increased risk of stillbirth?

A

2-3x

21
Q

List fetal complications related to reduced uteroplacental perfusion (vasoconstriction)

A
  • Fetal growth restriction
  • Oligohydramnios
  • Placental abruption - can lead to DIC/hemorrhage  maternal/fetal death
22
Q

Maternal complications preeclampsia

A

 CNS complications: encephalopathy d/t under perfusion of brain (causing your seizure), cortical blindness, hemorrhagic stroke, permanent visual impairment
 Thrombocytopenia
* Excessive bleeding
* Postpartum hemorrhage
* Not able to get anesthetic
* Worry about DIC!

23
Q

Signs/symptoms of preeclampsia

A

 CNS: visual changes, HA
 Pulmonary edema
 Thrombocytopenia (rapidly dropping platelets)
 Renal insufficiency
 Livery dysfunction

24
Q

Key questions to ask a patient when thinking about the risks of preeclampsia?

A

-FHX
-Hx Htn?
-Hx CAD?

25
Q

Baseline labs you draw at the beginning of pregnancy when there is known chronic htn:

A

-serum creatinine
-urine protein
-EKG

26
Q

Labs that you monitor for preeclampsia complications:

A

-CBC
-Platelet count
-ALT/AST
-Uric acid
-LDH
-Cr
-24 hr urine or protein/creatinine ratio

27
Q

What are ways you can prevent preeclampsia?

A

-Low Ca patients – supplement!
-Low dose aspirin (81 mg) initiated during 1st trimester: can initiate at 12 weeks when performing nuchal translucency US

NOT recommended for low risk patients
should have 1 severe risk factor or 2 or more low/moderate risk factors

28
Q

Additional monitoring for preeclamptic patients:

A

-Addition growth US in addition to the 20 anatomical US
-see patients monthly

29
Q

Maternal monitoring preeclampsia without severe features:

A

o 1-2x weekly blood pressure
o Weekly lab: CBC, platelet count, ALT, AST< uric acid, LDH, Cr, 24 hr urine or protein/creatinine ratio urine

30
Q

Fetal monitoring

A

o 1-2x weekly testing: NST, AFI, BPP
o Growth US q 3-4 weeks

31
Q

When do you deliver uncomplicated gestational hypertension patients?

A
  • 38/39 weeks
  • ACOG says delivery if >= 37 weeks and sooner if 160/110
32
Q

When do you deliver preeclampsia without severe features?

A

37 weeks 0 days

33
Q

What do you want to use for a preterm delivery?

A

antenatal corticosteroids to promote fetal lung growth

34
Q

What are the requirements for antenatal corticosteroids administration?

A

o Between 24-34 weeks gestation
o At risk to deliver within 7 days
* Also recommended for patients between 34w0d-36w6d at risk for delivery within 7 days and no prior course of corticosteroids

35
Q

How are antenatal corticosteroids administered?

A
  • 1 course of Betamethasone IM injection –> 2 doses over 24 hours
36
Q

When do initiate anti-hypertensive therapy?

A

BP >= 160/110

37
Q

What is your first line anti-hypertensive and why? What is a contraindication?

A
  • First line = labetalol (non selective alpha and beta adrenergic blocker)
    o Preserves the uteroplacental flow
    o More rapid onset
    o Avoid in patients with CHF and asthma
38
Q

Second line medication for hypertension:

A
  • Second line = nifedipine (CCB)
    o Immediate release is reserved for emergency situations
39
Q

What treatment is used in emergency situations?

A
  • Hydralazine ** IV emergency use only**
40
Q

Which treatments are absolutely contraindicated?

A

o Thiazide diuretics
o Clonidine
o ACE/ARB
o Mineral corticosteroid antagonists (spironolactone, eplerenone)
o No NSAIDS – they can increase blood pressure!

41
Q

When do you treat post partum preeclampsia? (BP)

A

> 150/>100

42
Q

How do you monitor PP preeclampsia?

A

-monitor BP Q72 hrs post delivery and at 7-10 days PP
-bring back 2-3 days post delivery then watch weekly for downtrend

43
Q

When do you administer magnesium sulfate?

A

-Preeclamptic patients
-IV mag continues 24 hours PP to cause vasodilation

44
Q

Once they have preeclampsia - what are the additional CV risks that the patient now faces?

A
  1. HTN
  2. Ischemic heart attack
  3. Cerebrovascular disease
  4. Diabetes
  5. Renal disease
  6. Thromboembolism
45
Q

How do you manage Gestational Hypertension?

A
  • Preeclampsia must be ruled out
  • Monitor blood pressure at home
  • Mother is seen 1-2x weekly
  • Fetal monitoring: fetal movement counts and weekly fetal surveillance testing
  • Induction of labor at 37-38 weeks gestation
46
Q

How do you manage preeclampsia?
-medication?
-BP monitor?
-fetal surveillance?
-labs?

A
  • No antihypertensive medication until severe features
  • Weekly blood pressure measurements
  • Daily fetal movement counts
  • Assessment maternal symptoms
  • Monitor platelet counts, liver enzyme levels
47
Q

How to manage chronic hypertension - prenatal care:
-assessments
-baseline labs

A

 PE
 Assessment of current medications
 Baseline testing renal function
 Labs: serum creatinine, electrolytes, uric acid, liver enzymes, platelet count and
quantitative measure of urine protein

48
Q

How to manage chronic hypertension during pregnancy:
-Mild elevation
-dieting
-when do you begin antenatal fetal testing?

A

 Mild elevations (140-150/90-100) and no other comorbid conditions - Can monitor
without the use of medication
 Remember there is the physiologic response that occurs –> decline in blood
pressure during the first half of the pregnancy
 Salt restricted and weight loss are not recommended during pregnancy
 Weekly or biweekly antenatal fetal testing and amniotic fluid assessment can be
recommended starting in the early third trimester

Women's Health Theory (7 decks)

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