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Hypertension in pregnancy Flashcards

1
Q

Describe the changes in blood pressure in pregnancy

A

¥ Blood pressure (BP) proportional to systemic vascular resistance and cardiac output
¥ Pregnancy Vasodilatation
¥ BP falls in early pregnancy
¥ Nadir reached at 22-24 weeks (lowest point)
¥ Steady rise until Term
¥ BP falls after delivery but subsequently rises and peaks at day 3-4 P/N

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2
Q

what is the classification of hypertension in pregnancy?

A

¥ ≥140/90 mmHg on 2 occasions
¥ Diastolic BP >110 mmHg
¥ ACOG - >30/15 mmHg compared to booking BP

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3
Q

What 3 different ways can hypertension present in pregnancy?

A
  • pre-existing hypertension
  • pregnancy induced hypertension
  • Pre-eclampsia
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4
Q

Pre-existing hypertension:

  • what is this?
  • what is important to consider?
  • what does this increase the risk of?
A

This is:

  • HTN at booking or <20wks
  • HTN >3mths of delivery

Consider:
-secondary causes e.g. renal/cardiac, cushing’s, conn’s, phaeochromocytoma

Risks:

  • PET
  • IUGR
  • Abruption
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5
Q

What is pregnancy induced hypertension?

A

New hypertension > 20wks without signif. Proteinuria and resolves within 6months of delivery

¥ No proteinuria or other features of pre-eclampsia
¥ Better outcomes than pre-eclampsia
¥ 15% progression to pre-eclampsia - depends on gestation
¥ Rate of recurrence is high

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6
Q

What is pre-eclampsia? what are the three criteria?

A

This is a pregnancy-specific multi-system disorder with unpredictabl, variable and widespread manifestations

  1. Hypertension
  2. Proteinuria (≥0.3g/l or ≥0.3g/24h)
  3. Oedema
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7
Q

what is the pathogenesis of pre-eclampsia?

A

¥ Genetic predisposition
¥ Stage 1 - abnormal placental perfusion
¥ Stage 2 - maternal syndrome

¥ Abnormal placentation and trophoblast invasion failure of normal vascular remodelling
¥ Spiral arteries fail to adapt to become high capacitance, low resistance vessels
¥ Placental ischaemia widespread endothelial damage and dysfunction
¥ Mechanism unclear (??oxidative stress / PGI2 : TXA2 imbalance / NO)
¥ inc. Endothelial Activation
¥ inc. Capillary Permeability
¥ inc. Expression of CAM
¥ inc. Prothrombotic Factors
¥ inc. Platelet aggregration

VASOCONSTRICTION

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8
Q

How does Pre eclampsia effects the CNS? 6

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

How does Pre eclampsia affect the renal system?

A

¥ GFR

¥ Proteinuria

¥ serum uric acid (also placental ischaemia)

¥ creatinine / potassium / urea

¥ Oliguria /anuria

¥ Acute renal failure

  • acute tubular necrosis
  • renal cortical necrosis
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10
Q

How does Pre eclampsia affect the liver?

A

¥ Epigastric/ RUQ pain

¥ Abnormal liver enzymes

¥ Hepatic capsule rupture

¥ HELLP Syndrome
Haemolysis, Elevated Liver Enzymes, Low Platelets
(microvascular endothelial activation and cell injury)

¥ high morbidity/ mortality

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11
Q

How does Pre eclampsia affect the haematological system?

A 
¥	decreased `Plasma Volume
¥	Haemo-concentration
¥	Thrombocytopenia
¥	Haemolysis
Disseminated Intravascular Coagulation
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12
Q

How does Pre eclampsia cause cardi/pulmonary disease?

A 
¥	Pulmonary oedema leads to ARDS
¥	iatrogenic
¥	disorder related
¥	Pulmonary Embolus
High mortality
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13
Q

What can the placental disease of Pre eclampsia lead to?

A
  • Intrauterine growth restriction
  • Placental abruption
  • Intrauterine death
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14
Q

What are the symptoms of pre-eclampsia? 6

A 
¥	Headache 
¥	Visual disturbance
¥	Epigastric / RUQ pain
¥	Nausea / vomiting
¥	Rapidly progressive oedema
¥	Considerable variation in timing, progression and order of symptoms
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15
Q

What are the signs seen in pre-eclampsia? 8

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

What investigations are carried out for Pre eclampsia ? 10

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

What are the risk factors for Pre eclampsia ?

A 
¥	Maternal Age (>40 years 2X)
¥	Maternal BMI (>30 2X) 
¥	Family History (20-25% if mother affected, up to 40% if sister)
¥	Parity (first pregnancy 2-3X)
¥	Multiple pregnancy (Twins 2X)
¥	Previous PET (7X)
¥	Molar Pregnancy / Triploidy
¥	medical risk factors
(Multiparous women develop more severe disease)
18
Q

What are the medical risk factors for Pre eclampsia ? 5

A 
¥	Pre-existing renal disease
¥	Pre-existing hypertension
¥	Diabetes Mellitus
¥	Connective Tissue Disease
¥	Thrombophilias (congenital / acquired)
19
Q

How is Pre eclampsia screened for/assessed at the booking appointment?

A

¥ Assess risk at booking – risk factors for pre-eclampsia = aspirin
¥ Then surveillance (scans/BP monitoring/urine testing)
¥ Hypertension < 20 weeks - look for secondary cause
Antenatal screening – BP/urine

20
Q

How is Pre eclampsia managed antenatally?

A

¥ Treat hypertension

¥ Follow ups in MDAU PIH can be managed as o/p in day care unit

21
Q

How is Pre eclampsia managed in labour?

A

¥ Maternal & fetal surveillance
¥ Timing of Delivery – most deliver at 37 weeks vaginally if pre-eclampsia
¥ Stabilize, treat hypertensions, prevent convulsions, deliver

22
Q

When is a woman with pre-eclampsia referred to the antenatal day care unit? 4

A
  • BP 140/90 or more
  • (++)proteinuria
  • oedema
  • symptoms - esp persistent headache
23
Q

When is a woman admitted for Pre eclampsia ? 6

A
  1. BP >170/110 OR >140/90 with (++) proteinuria
  2. Significant symptoms - headache / visual disturbance / abdominal pain
  3. Abnormal biochemistry
  4. Significant proteinuria - UPCR >30mg/mmol
  5. Need for antihypertensive therapy
  6. Signs of fetal compromise
24
Q

What is involved with inpatient assessment of Pre eclampsia ?

A 
¥	Blood Pressure - 4 hourly
¥	Urinalysis - daily
¥	Input / output fluid balance chart
¥	UPCR - if proteinuria on urinalysis
¥	Bloods - FBC, U&amp;Es, Urate, LFTs. Minimum X2 per week
25
Q

What is involved with fetal surveillance in Pre eclampsia ?

A 
¥	Fetal Movements
¥	CTG - daily
¥	Ultrasound
-Biometry
-Amniotic Fluid Index
-Umbilical Artery Doppler
26
Q

When is hypertension treated in pregnancy?

A

Treat regardless of aetiology

With MAP ≥150 mmHg there is significant risk of cerebral haemorrhage:
¥ Most treat if BP ≥150/100 mmHg (aim for <150/80-100 BP)
¥ If target organ damage aim for BP <140/90
¥ If less than 140/90 or 130/90 – reduce dose
¥ BP ≥ 170/110 mmHg requires immediate Rx

(Control of blood pressure does not reduce the risk of developing pre-eclampsia)

27
Q

What does every woman with pre-eclampsia recieve?

A

magnesium sulphate to prevent siezures

28
Q

What 4 drugs are used for hypertension in pregnancy?

A
  • Methyldopa
  • labetalol
  • nifedipine SR
  • Hydralazine
29
Q

Methyldopa:

  • mode of action
  • starting dose
  • max. dose
  • contraindication
  • breast feed?
A

mode of action:
-centrally acting alpha agonist

Starting dose:
-250mg BD

max. dose:
- 1gram TDS

Contraindication:
-depression

breast feed?
-YES

30
Q

Labetalol oral or IV:

  • mode of action
  • starting dose
  • max. dose
  • contraindication
  • breast feed?
A

Mode action:
-alpha and beta blocker

Starting dose:
-100mg BD

Max dose:
-600mg qid

contraindications:
-asthma

Breastfeed:
yes

31
Q

Nifedipine SR oral :

  • mode of action
  • starting dose
  • max. dose
  • contraindication
  • breast feed?
A

mode of action:
-Ca channel blocker

  • starting dose:
  • 10mg BD
  • max. dose:
  • 40mg BD
  • contraindication:
  • none

-breast feed?
yes

32
Q

Hydralazine IV:

  • mode of action
  • starting dose
  • max. dose
  • contraindication
  • breast feed?
A

Action:
-vasodilator

Starting dose:
-25mg tds

Max dose:
-75mg QID

Contrai. - none

Breast feed:
-yes

33
Q

What anti-HTN drugs are avoided in pregnancy?

A

Diuretics/ACE-I

34
Q

When is the baby delivered in pre-eclampsia?

A

¥ The only cure for pre-eclampsia is delivery
¥ Mother must be stabilised before delivery
¥ Consider expectant management if pre-term
¥ Most women delivered within 2 weeks of diagnosis

35
Q

What are 6 indications for delivery?

A 
¥	Term gestation
¥	Inability to control BP
¥	Rapidly deteriorating biochemistry / haematology
¥	Eclampsia
¥	Other Crisis
¥	Fetal Compromise - REDF, abnormal CTG
36
Q

What crisis exists in pre-eclampsia? 9

A 
¥	Eclampsia
¥	HELLP syndrome
¥	Pulmonary Oedema
¥	Placental Abruption
¥	Cerebral Haemorrhage
¥	Cortical Blindness
¥	DIC
¥	Acute Renal Failure
¥	Hepatic Rupture
37
Q

What is eclampsia?

A

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

¥ >1/3 will have seizure before onset of hypertension / proteinuria
¥ Ante-partum (38%) / Intra-partum (16%) / post-partum (44%)
¥ More common in teenagers
¥ Associated with ischaemia / vasospasm

38
Q

What is the management of severe PET or eclampsia?

A

¥ Control BP: IV labetalol/IV hydralazine
¥ Stop / Prevent Seizures
¥ Fluid Balance
¥ Delivery

39
Q

Describe the prevention of siezures in PET?

A

Magnesium sulfate:

Loading dose: 4g IV over 5 minutes

Maintenance dose:IV infusion 1g/h

If further seizures administer 2g Mg SO4

If persistent seizures consider diazepam 10mg IV

40
Q

Describe fluid balance in PET?

A

¥ Main cause of death = pulmonary oedema
(Capillary leak / fluid overload / cardiac failure)

¥ Oliguria in 30%. Does not require intervention

¥ Any doubts about renal function urine osmolality

¥ Fluid challenges are potentially dangerous

¥ Safer to run a patient “dry” - 80 ml/

41
Q

Delivery in PET:

  • aim for what delivery?
  • what is used for anaesthesia
  • what is used to monitor baby?
  • what is avoided and cautioned?
A 
¥	Aim for vaginal delivery if possible
¥	Control BP
¥	Epidural anaesthesia
¥	Continuous electronic fetal monitoring
¥	Avoid ergometrine
¥	Caution with iv fluids
42
Q

When is low dose aspirin used in the prevention of PET?

A

¥ Aspirin - inhibits cyclo-oxygenase prevents TXA2 synthesis
¥ 75mg Aspirin 15% reduction in PET (NNT=90)
¥ May be more beneficial in preventing severe early onset pre-eclampsia (MRC CLASP Trial)
¥ Safe
¥ Used for high risk women - Renal, DM, APS, Multiple risk factors, previous PET
¥ Commence before 12 weeks (NICE Aug 2010)

Reproduction (34 decks)

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