Hypertension in pregnancy Flashcards
hypertension affects how many pregnancies
10-15%
what happens to blood pressure in early pregnancy
falls
what happens after the fall in BP
slowly rises until term after 22-23 weeks
what happens to BP after delivery
falls after
rises and peaks at day 3-4
can rise again till day 10 and then will usually return to pre pregnancy levels
hypertension values
> =140/90 on two occasions
DBP>110
pre existing hypertension when is it likely
if hypertension during early pregnancy as blood pressure should fall during this period
when will it be pre existing hypertension after delivery
if still present 3 months after delivery
what secondary causes should be considered when hypertension is present
renal - do renal US cardiac - echo cushings conns phaemochromocytoma TFTs
PIH when dx when does it resolve signs progression recurrence
second half of the preg 6 weeks of delivery no proteinuria or other signs of PET 15% progress to PET esp in early gestation rate of recurrence is high
three common signs in PET
htn
proteinuria >=0.3/l or >= 0.3/24hours
oedema
what is PET
pregnancy specific multi system disorder with unpredictable variable end widespread manifestations
what are the different systems PET can affect
renal hepatic cardiovascular haem CNS placenta pulmonary
causes for PET
genetic usually
stages of PET
STAGE 1 abnormal placental perfusion in early pregnancy
STAGE 2 maternal syndrome
what is the pathogenesis for placentation
takes place in the first 20 weeks pf pregnancy
trophpblast invasion on the walls of the spinal artery which takes away the muscle layer around the artery going towards the decidua
this causes the spinal arteries to dilate and increases the blood flow to the placenta
what happens in PET associate with placentation
failure of trophoblastic invasion leading to low capacity high resistant circulation of blood
less blood goes to the placenta so the mother increases her blood pressure to try and compensate
this leads to endometrial damage leading to placental infarction causing further endometrial damage - in the second half of pregnancy this is manifested as PET
CNS disease in PET
eclampsia hypertensive encephalopathy - confusion intracranial haemorrhage cerebral oedema corticol blindeness - occipital ischemia cranial nerve palsy in extreme forms can lead to a seizure
renal disease in PET
decrease GFR proteinuria increased serum acid (also can be due to placental iscaemia) increased creatinine/k/urea oliguria/anuria acute renal failure
urate level above what is always abnormal for a pregnancy woman
0.4
liver disease in PET
epigastric/RUQ pain
abnormal liver enzymes
hepatic capsule rupture
what is HELLP syndrome
what does it have
variant of eclampsia
haemolysis
elevated liver enzymes
low
platelets
high morbidity/mortality
haematological disease in PET
decrease in plasma volume ahem concentration thrombocytopenia haemolysis disseminated intravascular coagulation
cardiac/pulmonary disease in PET
pulmonary oedema leads to ARDS which is usually iatrogenic due to fluid intake
PE - leading cause of maternal mortality
placental disease in PET
IUGR
placental abruption
both can potentially lead to intra uterine death
symptoms in PET
headache - CNS visual disturbance - CNS epigastric/RUQ pain - liver N/V - liver rapidly progressing oedema
signs in PET
htn proteinuria oedema abdominal tenderness/uterine tenderness disorientation due to encephalopathy SGA intra uterine death hyper flexia/involuntary movements/clonus
investigations in PET
U&Es serum urate LFTs FBC coag screen urinary protein creat ratio CTG US - biometry, AFI, doppler
management of PET
assess risk at booking
if htn present <20 weeks look for secondary cause
at antenatal screening - BP, urine, maternal uterine artery doppler
treat hypertension
maternal and fetal surveillance
risk factors for PET
maternal age >40 doubles risk maternal BMI >30 doubles risk FH 20-25% if mum affected 40% if sister first preg 2-3x risk multiple pregnancy 2x risk previous PET 7x risk molar pregnancy/triploidy
when is PET worse
when it is in the consecutive pregnancies and the first preg was fine - tends to be more severe
medical risk factors for PET
renal disease hypertension DM CTD - esp anti phospho synd thrombophillia
maternal uterine artery doppler when is it done
what does it assess and abnormalities
20-24 weeks with the fetal anomaly scan
normal result is high resistance vessels going to low resistance vessels
abnormal - high resistance - notch present
when should a px be referred to antenatal day care unit
how many of these women will be admitted
BP >=140-90
proteinuria ++
oedema present
symptoms such as persistent headache
for 1000 20
when should a px be admitted
BP >170/110 or >140/90 with proteinuria ++
significant symptoms - headache, visual disturbance, abdominal pain
abnormal biochem
significant proteinuria UPCR >30
need for anti hypertensives
signs of fetal compromise
inpatient assessment - what is done
blood pressure - 4 hourly urinalysis - daily input/output fluid chart UPCR if proteinuria on urinalysis bloods - FBC, UandEs, LFTs min twice weekly
fetal surveillance
fetal movements
CTG done daily
US if no result on CTG - amniotic, biometry, umbilical artery doppler
umbilical artery doppler
can be used for someone who already has PET or IUGR
blood sent to the mum from the baby
treatment of hypertension when
> =150/100
BP >=170/110 requires immediate treatment
wat can happen with MAP >=150
significant risk of cerebral haemorrhage
aim in BP
140-150/90-100
1st line in treatment of ht
2nd line
3rd line
labetalol
nifedipine
hydrazine IV for women with asthma who can’t tolerate nifedipine
what should be given before delivering the baby
steroids - 12mg of dexa IM given at 4 or 12 hour intervals
indications for delivery
term gestations inability to control BP rapidly deteriorating biochem/haemo PET other crisis fetal crisis - REDF, abnormal CTG
crises in PET
eclampsia HELLP pulmonary oedema placental abruption cerebral haemorrhage corticol blindeness DIC acute renal failure hepatic failure
what do steroids do
promote fetal lung surfactant production
decrease neonatal respiratory distress syndrome by up to 50% if administered 24-48 hours before delivery
eclampsia seizure
tonic clonic occurs before features of PET
>1/3 will have one before the onset of htn/proteinuria
most common in teenagers
assoc with ischaemia/cerebral vasopasm
when do most seizures occur
in labour or after
management of severe PET/ecmlapsia
control BP - IV labetalol, IV hydralazine
stop/prevent seizures
fluid balance
delivery
seizure management/prophylaxis
Mg sulphate 4g IV over 5 mins
maintenance dose IV infusion 1g/h
if further seizures then 2mg mg sulphate
if persistent then diazepam 10mg IV
how much fluid an hour
80ml
treatment of oliguria following delivery
does not require intervention
common
happens to 30% of women
what should be avoided in labour
ergometrine as it causes maternal hypertension - just use syntocin
dose of aspirin given and why and to who
75mg
prevents PET
given to anyone with risk factors for PET
