hypertension in pregnancy Flashcards
hypertension in pregnancy is defined as what?
> 140/90mmHg on 2 occasions or
160/110mmHg
3 types of hypertension?
- pre-existing/chronic hypertension
- gestational hypertension
- pre-eclampsia
if women comes into booking appointment with hypertension what is she considered to have?
- chronic hypertension
what secondary causes can you consider in hypertension presenting for the first time?
- renal/cardiac
- cushing’s
- conn’s
- phaeochromocytoma
risks of hypertension in pregnancy?
- PET 2x
- fetal growth restriction
- abruption
what cardiac medications are women recommended to avoid while trying to get pregnant?
- ACE
- ARB
- thiazide diuretics
> teratogenics
what is gestational hypertension?
- hypertension seen in second half of pregnancy and resolves 6/52 of delivery
how many women w gestational hypertension can progress on to pre-eclampsia
- 15%
- depends on gestation
Mx for chronic/GH
- timing of birth dependent on clinical condition
- aim to deliver women > 37 weeks
- monitor BP daily after birth
- aim to keep BP < 130/80
- continue antihypertensives - review 2 weeks post natal by GP
- further review 6-8 weeks post natal
- stop methyl dopa within 2 days
what is pre-eclampsia?
- pregnancy specific multi system disorder
- may be asymptomatic at time of first presentation
- diffuse vascular endothelial dysfunction widespread circulatory disturbance
- renal/hepatic/CV/haem/CNS/placenta
pre-eclampsia clinical signs
- hypertension
- proteinuria (UPCR >30mg/mmol)
- oedema
- absence does not exclude diagnosis
early pre-eclampsia is before when?
< 34 weeks
late pre-eclampsia is when?
> 34 weeks
- 9/10 women present with late pre-eclampsia vs early pre-eclampsia
does pre-eclampsia have genetic or environmental predisposition?
- yes - if in family more likely to get it
- risk inc 3x if mother of sister has PET
what are 2 stages in pathogenesis of pre-eclampsia?
- abnormal placental perfusion
placental ischaemia - stage 2 - maternal syndrome
anti-angiogenic state assoc w endothelial dysfunction
describe process of trophoblast invasion during pregnancy
- trophoblast invasion from placenta into spiral artery
- loss of muscle layer of spiral artery
- more blood flow/nutrition/blood going to baby
> failure of trophoblast invasion - endothelial damage - platelet aggregation - placental ischaemia and infarction - causing hypertension
HELLP syndrome stands for what?
- haemolysis
- elevated liver enzymes
- low platelets
has a high morbidity/mortality
how does liver disease related to pre-eclampsia present?
epigastric/RUQ pain
abnormal liver enzymes
hepatic capsule rupture
symptoms of pre-eclampsia?
- headache
- visual disturbance
- epigastric/RUQ pain
- nausea/vomiting
- rapidly progressive oedema
- lack of fetal movement
signs of pre-eclampsia
- hypertension
- proteinuria
- oedema
- abdominal tenderness
- disorientation
- small for gestational age fetus
- intrauterine fetal death
- hyper-reflexia/involuntary movements/clonus (check CNS)
investigations for pre-eclampsia?
- U+Es
- serum urate
- liver function tests
- FBC
- coagulation screen -> DIC
- urine protein creatinine ratio (UPCR)
- carditocography
- US - fetal assessment
women at high risk of PET are?
- hypertensive during px pregnancy
- CKD
- AI - SLE or APS
- type 1 or 2 DM
- chronic hypertension
> recommend 75-100mg aspirin daily from 12 weeks until birth of baby
moderate risk factors of pre-eclampsia
- nulliparity
- > 40
- interval between pregnancies of more than 10 years
- BMI of 35 or more at first visit
- FH of pre-eclampsia
- 1 or more also given aspirin
in tayside how much low dose aspirin is given to women with high risk/ 1 or more mod risk factors for pre-eclampsia?
- 150mg dose from 12 weeks
how can you predict pre-eclamspia?
- using maternal uterine artery doppler
- done at 20-24 weeks
treatment of hypertension?
- continue antihypertensives unless SBP <110 or DBP < 70
- offer tx to women not on tx if SBP >140 or DBP >90
- target BP = 135/85
- risk of cerebral haemorrhage if MAP >150
- BP >170/110 requires immediate tx
what medications can you give women in tx of hypertension
- methyldopa (a-agonist) 250mg/bd
- labetolol (a and B agonist) 100mg/bd
- nifedipine (Ca channel antagonist) SR 10mg/bd
2nd line
- hydralazine
- doxazocin
CI to methyldopa?
- depression
CI to labetolol?
- asthma
which anti-hypertensives not safe to take while breast feeding?
- doxazocin
fetal surveillance in mother with hypertension/pre-eclampsia risk
- fetal movements
- CTG - daily
- US - biometry, amniotic fluid index, umbilical artery doppler (AEDF, REDF)
when to admit to hospital?
- SBP > 160mmHg or high
- creatinine >90
- ALT > 70
- platelet count < 150
- signs of impending eclampsia
- signs of impending pulmonary oedema
- other signs of severe pre-eclampsia
- suspected fetal compromise
when to deliver baby?
- only cure for pre-eclampsia is birth
- mother must be stabilised first
- consider expectant mx if pre-term
- steroids/mag sulphate
- mode dependent on gestation, parity, maternal/fetal condition
indications for birth
- term gestation - deliver within 24-48 hrs
- inability to control BP
- rapidly deteriorating biochemistry/haematology (pulse oximetry less than 90%)
- eclampsia
- pulmonary oedema
- placental abruption
- fetal compromise - abnormal US or CTG
- still birth
crises in pre eclampsia
what is eclampsia?
- tonic clonic (grand mal) seizure occuring w features of pre-eclampsia
- can occur ante-partum/intra-partum/post partum
- more common in teenagers
- assoc w ischaemia/vasospasm
mx of severe PET/eclampsia?
- control BP
- stop/prevent seizures
- fluid balance
- delivery
- IV labetolol
- IV hydralazine (2nd line)
> beware hypotension - fetoplacental unit
seizure tx/prophylaxis
magnesium sulphate
loading dose: 4g IV over 5-15 mins
maintenance dose: IV infusion 1g/h
further seizures give: 2-4g Mg SO4
administer for 24 hrs
labour and birth
- aim for vaginal birth if possible
- control BP
- epidural anaesthesia
- continuous electronic fetal monitoring
- avoid erogemtrine
- caution with IV fluids - restrict input to 80ml/hr
post-partum mx
- BP monitoring
- antihypertensives
- bloods
- breast feeding
- contraception
- urinalysis 6-8 weeks
- counselling/debrief - recurrence
- consider long term CV risk
