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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?

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
Baseline labs you draw at the beginning of pregnancy when there is known chronic htn:
-serum creatinine -urine protein -EKG
26
Labs that you monitor for preeclampsia complications:
-CBC -Platelet count -ALT/AST -Uric acid -LDH -Cr -24 hr urine or protein/creatinine ratio
27
What are ways you can prevent preeclampsia?
-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
Additional monitoring for preeclamptic patients:
-Addition growth US in addition to the 20 anatomical US -see patients monthly
29
Maternal monitoring preeclampsia without severe features:
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
Fetal monitoring
o 1-2x weekly testing: NST, AFI, BPP o Growth US q 3-4 weeks
31
When do you deliver uncomplicated gestational hypertension patients?
- 38/39 weeks - ACOG says delivery if >= 37 weeks and sooner if 160/110
32
When do you deliver preeclampsia without severe features?
37 weeks 0 days
33
What do you want to use for a preterm delivery?
antenatal corticosteroids to promote fetal lung growth
34
What are the requirements for antenatal corticosteroids administration?
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
How are antenatal corticosteroids administered?
* 1 course of Betamethasone IM injection --> 2 doses over 24 hours
36
When do initiate anti-hypertensive therapy?
BP >= 160/110
37
What is your first line anti-hypertensive and why? What is a contraindication?
* 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
Second line medication for hypertension:
* Second line = nifedipine (CCB) o Immediate release is reserved for emergency situations
39
What treatment is used in emergency situations?
* Hydralazine ** IV emergency use only**
40
Which treatments are absolutely contraindicated?
o Thiazide diuretics o Clonidine o ACE/ARB o Mineral corticosteroid antagonists (spironolactone, eplerenone) o No NSAIDS – they can increase blood pressure!
41
When do you treat post partum preeclampsia? (BP)
>150/>100
42
How do you monitor PP preeclampsia?
-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
When do you administer magnesium sulfate?
-Preeclamptic patients -IV mag continues 24 hours PP to cause vasodilation
44
Once they have preeclampsia - what are the additional CV risks that the patient now faces?
1. HTN 2. Ischemic heart attack 3. Cerebrovascular disease 4. Diabetes 5. Renal disease 6. Thromboembolism
45
How do you manage Gestational Hypertension?
- 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
How do you manage preeclampsia? -medication? -BP monitor? -fetal surveillance? -labs?
- No antihypertensive medication until severe features - Weekly blood pressure measurements - Daily fetal movement counts - Assessment maternal symptoms - Monitor platelet counts, liver enzyme levels
47
How to manage chronic hypertension - prenatal care: -assessments -baseline labs
 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
How to manage chronic hypertension during pregnancy: -Mild elevation -dieting -when do you begin antenatal fetal testing?
 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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