Hypertension in pregnancy Flashcards
are there any changes to the ECG in pregnancy that are considered normal?
there are many
T wave inversion V1 - 3 can be normal.
small Q wave in lead III
what happens to the following during pregnancy:
- CO
- SVR
- circ blood volume
- incr. CO
- dec. SVR
- circ blood volume inc
What is the thing you listen to when checking someone’s BP? Which of the Korotkoff sounds?
systolic is I
diastolic is V, but if that’s silent, use IV
what BP is considered hypertension in pregnancy?
what is considered SEVERE for urgent treatment?
> 140 / > 90
> 170/ >110
if patient k < 20, and found to have HTN in the clinic, what is a good next test?
It seems that white coat hypertension is particularly common in k < 20 (where 1/3 will have normal ambulatory measurements)
therefore, consider amb BP in all k < 20
what is the classification of gestational HTN, chronic HTN and PET?
gest is >140/90 after k 20
PET is gest plus organ involvement
chronic is >140/90 before k 20
what is the definition of preeclampsia
hypertension after k 20
PLUS ONE OF:
proteinuria and renal insufficiency (PCR > 30; Cr > 90; oliguria)
liver disease (elevated AST ALT)
neuro problems (convulsions, hyperreflexia with sustained clonus, persistent headaches, visual abnor, stroke)
haematological disturbances (Plt < 100, DIC, haemolysis)
foetal growth restriction
what are some factors that determine how severe a case of PET is?
if BP control is difficult HELLP impending eclampsia worsening thrombocytopenia worsening IUGR
the level of proteinuria is actually less important
what is the underlying pathophys with PET?
for some reason there is less of the NKs and lymphocytes in the placenta. This means less cytokines being secreted.
Unfortunately there are less of these chemicals to stimulate the necessary changes in the spiral arteries. This means that these spiral arteries never become low-resistance enough for the placenta.
this leads to ischaemia
the ischaemic placenta also secretes a heap of factors:
sFLT-1 (soluble FMS like tyrosine kinase 1) - this mops up the PIGF, which leads to more procoagulant and vasoconstriction happening
syncytiotrophoblast microparticles (STMP) - inc. in PET, harmful to maternal endothelium
finally, there is endothelial cell dysfunction - this is from inc response to vasoactive substances like angiotensin II and reduced prostacyclin, NO
There is also systemic inflammatory response, with activation of neutrophils, monocytes, LLs with inc TNF, IL6, IL8
risk factors for PET
Preconception Risk Factors
Partner related
Nulliparity; primipaternity
Limited sperm exposure
Previous PET pregnancy in partner
Maternal
Previous PET- 7X risk
FH PET- mother ~25% risk: sister 40% Increased age- > 40years – double risk Increased interval between pregnancies – 2-3 X if 10 years
Assisted reproduction
Underlying disorders HT Renal disease Obesity – BMI > 30 double risk Diabetes mellitus Antiphospholipid syndrome CT diseases
Pregnancy associated risk factors
Multiple pregnancies – 2-3X risk with twins Congenital anomalies Hydrops fetalis Chromosomal anomalies Hydatidiform mole
what are the strongest RF for preeclampsia?
antiphospholipid
previous hx of PET
pre-existing DM
next three are equal:
- nulliparity
- multiple pregnancy
- fam hx of PET
then obesity (BMI > 30)
what is the Tx of PET?
treat htn
monitor fluid balance
mag SO4 is useful for Tx of eclampsia and prophylaxis
give betamethasone for foetal lung maturation if gestation t deliver for 24 - 48 hours)
what are the anti-HTN to use in pregnancy
commence anti HTN if systolic > 160 or diastolic >110
treatment options include
- labetalol IV 20 up to 80
- nifedipine oral 10 up to 40
- hydralazine IV 10 mg up to 30
- diazoxide 15 mg IV up to 45 mg
why do we use magnesium in eclampsia?
the “collaborative eclampsia trial” published in Lancet in 1995 compared phenytoin, diaze, Mg in prevention of recurrent seizures and showed that mag was superior
in a patient with pre-eclampsia, if you are proceeding to delivery, and the baby is significantly pre-term, are there any additional medications that are useful?
what role do those drugs have?
antenatal corticosteroids if
