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Hypertension in Pregnancy Flashcards

1
Q

What is the incidence of HT in pregnancy?

A

10-15%

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2
Q

What is the commonest cause of iatrogenic prematurity?

A

Pre-eclampsia

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3
Q

Describe BP throughout pregnancy

A

Falls in early pregnancy
Nadir reached at 22-24wks
Steady rise until term
Falls after delivery but rises and peaks at day 3-4 P/N

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4
Q

What are the risks associated with pre-existing HT?

A

PET x2
IUGR
Abruption

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5
Q

When will PIH occur and resolve?

A

Second half of pregnancy

Resolves within 6/52 PN

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6
Q

What are they key features of pre-eclampsia?

A

HT
Proteinuria (>=0.3g/l or >=0.3g/24hrs)
Oedema

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7
Q

What are some of the pathophysiological causes of pre-eclampsia?

A

Abnormal placentation and trophoblast invasion, leading to failure of normal vascular remodelling
Spiral arteries fail adapt to become high capacitance, low resistance vessels
Placental ischaemia, leading to widespread endothelial damage and dysfunction
Endothelial activation leading to increased capillary permeability, expression of CAM, prothrombotic factors, platelet aggregation and vasoconstriction

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8
Q

What are the CNS components of pre-eclampsia?

A 
Eclampsia
Hypertensive encephalopathy
Intracranial haemorrhage
Cerebral Oedema
Cortical Blindness
Cranial Nerve Palsy
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9
Q

What are the renal components of pre-eclampsia?

A

Decreased GFR
Proteinuria
Increased serum uric acid (also placental ischaemia) and creatinine/potassium/urea
Oliguria /anuria
Acute renal failure- acute tubular necrosis, renal cortical necrosis

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10
Q

What are the hepatic components of pre-eclampsia?

A

Epigastric/RUQ pain
Abnormal liver enzymes
Hepatic capsule rupture
HELLP syndrome: Haemolysis, Elevated Liver Enzymes, Low Platelets-high morbidity/mortality

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11
Q

What are the haematological components of pre-eclampsia?

A 
Decreased PV
Haemo-concentration
Thrombocytopenia
Haemolysis
Disseminated Intravascular Coagulation
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12
Q

What are the cardiopulmonary components of pre-eclampsia?

A

Pulmonary oedema leading to ARDS- iatrogenic, disorder related
PE
High mortality

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13
Q

What are the placental components of pre-eclampsia?

A

IUGR
Placental abruption
IUD

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14
Q

What are the symptoms of pre-eclampsia?

A 
Headache
Visual disturbance
Epigastric/RUQ pain
Nausea/vomiting
Rapidly progressive oedema
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15
Q

What are the signs of pre-eclampsia?

A 
Hypertension
Proteinuria
Oedema
Abdominal tenderness
Disorientation
SGA
IUD
Hyper-reflexia / involuntary movements / clonus
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16
Q

What Ix are required in pre-eclampsia?

A 
Urea & Electrolytes
Serum Urate
Liver Function Tests
Full Blood Count
Coagulation Screen
UPCR
CTG
Ultrasound - biometry, AFI, Doppler
17
Q

How is pre-eclampsia managed?

A 
Assess risk at booking
HT at <20wks-look for 2' cause
Antenatal screening- BP, urine, MUAD
Treat HT
Maternal &amp; fetal surveillance
Timing of delivery
PIH can be managed as OP in Day Care Unit
18
Q

What are the RFs for pre-eclampsia?

A 
Maternal age (>40y: 2x)
Maternal BMI (>30: 3x)
FHx (20-25% if mother affected, up to 40% if sister)
Parity (1st pregnancy 2-3x)
Multiple pregnancy (Twins 2x)
Previous PET (7x)
Molar pregnancy/triploidy
19
Q

What are the medical RFs for pre-eclampsia?

A 
Pre-existing renal disease
Pre-existing HT
DM
CTD
Thrombophilias (congenital/acquired)
20
Q

When should you refer to AN DCU?

A

BP >=140/90
Proteinuria ++
Oedema ++
Symptoms: esp persistent headache

21
Q

When should you admit women with pre-eclampsia?

A

BP >170/110 OR >140/90 with (++) proteinuria
Significant symptoms - headache / visual disturbance / abdominal pain
Abnormal biochemistry
Significant proteinuria - UPCR >30mg/mmol
Need for antihypertensive therapy
Signs of fetal compromise

22
Q

How should HT be treated in pregnancy?

A

Treat regardless of cause
With MAP of >=150mmHg significant risk of cerebral haemorrhage
BP >=170/110 requires immediate Rx
Aim for 140-150/90-100

23
Q

When is methyl dopa contraindicated in HT treatment?

A

Depression

24
Q

When is labetolol contraindicated in HT treatment?

A

Asthma

25
Q

Are methyl dopa, labetolol, nifedipine SR and hydralazine safe in pregnancy?

A

Yes

26
Q

When are most deliveries carried out after a pre-eclampsia diagnosis?

A

Within 2 wks of diagnosis

27
Q

What are the indications for delivery in pregnancy with HT?

A 
Term gestation
Inability to control BP
Rapidly deteriorating biochemistry / haematology
Eclampsia
Other Crisis
Fetal Compromise - REDF, abnormal CTG
28
Q

What are some crises in pre-eclampsia?

A 
Eclampsia
HELLP syndrome
Pulmonary Oedema
Placental Abruption
Cerebral Haemorrhage
Cortical Blindness
DIC
Acute Renal Failure
Hepatic Rupture
29
Q

What is eclampsia?

A

Tonic-clonic (grand mal) seizure occurring with features of pre-eclampsia

30
Q

How many women will have eclampsia seizure before onset of proteinuria/HT?

A

> 1/3

31
Q

In what age group is eclampsia more common?

A

Teenagers

32
Q

What antihypertensives are used in eclampsia?

A

IV Labetolol
IV Hydralazine
(beware hypotension-fetoplacental unit)

33
Q

What is the treatment and prophylaxis for eclampsia seizure?

A 
Magnesium Sulphate:
Loading dose 4g IV over 5mins
Maintenance IV infusion 1g/h
If further seizurs 2g MgSO4
If persistent consider diazepam 10mg IV
34
Q

What is the main cause of death in eclampsia?

A

Pulmonary oedema

35
Q

What is the safe option in fluid administration in eclampsic patients?

A

Run patient dry- 80ml/hr

Fluid challenges can be dangerous

36
Q

What should be checked when there is any doubt about renal function in an eclampsic patient?

A

Urine osmolality

37
Q

Does oliguria require intervention in eclampsia?

A

No- occurs in 30%

38
Q

Describe labour and delivery in eclampsia

A 
Aim for vaginal delivery if possible
Control BP
Epidural anaesthesia
Continuous electronic fetal monitoring
Avoid ergometrine
Caution with iv fluids
39
Q

When is aspirin used in pre-eclampsia?

A

High risk women- renal, DM, APS, multiple RFs, previous PET

Commence before 12 weeks (75mg)

Reproduction (40 decks)

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