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Year 3 Clinical > Hypertension in Pregnancy > Flashcards

Hypertension in Pregnancy Flashcards

1
Q

Occurrence of hypertension in pregnancy?

A

Affects 10-15% of all pregnancies

Mild pre-eclampsia affects 10% of primigravid women and severe pre-eclampsia affects 1% of primigravid women

Eclampsia is less common

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2
Q

What is the most common cause of iatrogenic prematurity?

A

Pre-eclampsia

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3
Q

CVS changes that occur in pregnancy?

A 
Increase in the following:
• Blood volume
• Plasma volume
• Cardiac output
• Stroke volume
• Heart rate

Decreased peripheral vascular resistance

Unchanged CVP

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4
Q

When do these CVS changes occur during pregnancy?

A

Occur in the 1st trimester, with the most CVS changes occurring in the first 12 weeks of pregnancy

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5
Q

Changes in BP that occur during and after pregnancy?

A

BP FALLS in early pregnancy, due to the vasodilatation that occurs during pregnancy, with nadir being reached at 22-24 weeks

This is followed by a steady BP rise until term, with pre-pregnancy BP being reached at ~34 weeks

Following delivery, BP falls but subsequently rises to peak at 3-4 days post-natal

NOTE - if a women has a normal BP at her booking appointment (in the 1st trimester), she may have had pre-existing hypertension

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6
Q

Definitions of hypertension?

A

≥140/90 mmHg on 2 occasions

OR

> 160/110 mmHg once

NOTE - in the US, hypertension is >30/15 mmHg, compared to the 1st trimester BP

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7
Q

3 categories of hypertension in pregnancy?

A
  1. Pre-existing hypertension
  2. Pregnancy-Induced Hypertension (PIH)
  3. Pre-eclampsia (PET)

NOTE:
• If the hypertension presents occurs in early pregnancy, it is likely pre-existing hypertension
• If it presents late in the pregnancy, likely to be PIH or PET
• If it occur mid-pregnancy, there is a degree of uncertainty

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8
Q

What is pre-existing hypertension?

A

Diagnosis prior to pregnancy

OR

Likely to be the case if the hypertension presents in early pregnancy

OR

May be a retrospective diagnosis if the BP has not returned to normal within 3 months of delivery

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9
Q

Potential secondary causes of pre-existing hypertension?

A

Renal / cardiac causes

Cushing’s

Conn’s

Phaeochromocytoma

etc

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10
Q

Risks assoc. with pre-existing hypertension?

A

PET

IUGR

Placental abruption

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11
Q

What is Pregnancy-Induced Hypertension (PIH)?

A

Hypertension occurring in the second half of pregnancy and resolving within 6/52 of delivery

There is no proteinuria or other features of PET

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12
Q

Risks assoc. with PIH?

A

15% of patients progress to PET (depends on the gestation)

High recurrence rate in subsequent pregnancies

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13
Q

Features of pre-eclampsia?

A

Classic triad of:
• Hypertension
• Proteinuria (≥0.3 g/l or ≥0.3 g/24h)
• Oedema

NOTE - a diagnosis of PET does not require the presence of all 3 features, e.g: patients can have 2 of the features and still have PET

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14
Q

What is pre-eclampsia?

A

Pregnancy-specific multi-system disorder with unpredictable, variable and widespread manifestations

There is diffuse vascular endothelial dysfunction and widespread circulatory disturbance

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15
Q

Stages of pre-eclampsia?

A

Stage 1 - abnormal placental perfusion leads to placental ischaemia

Stage 2 - development of the maternal syndrome, which is an anti-angiogenic state assoc. with endothelial dysfunction

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16
Q

Explain normal placentation

A

During a normal pregnancy, trophoblast infiltration leads to loss of the smooth muscle surrounding spinal arteries; this reduces resistance and increases blood flow, i.e: the spiral arteries adapt to become high capacitance, low resistance vessels

Result is normal perfusion of the placenta

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17
Q

Pathogenesis of pre-eclampsia?

A

There is a genetic / environmental predisposition

There is abnormal placentation and a failure of trophoblast infiltration, so the smooth muscle around the spiral arteries remains

The maternal response is to increase blood flow by increasing BP; this leads to widespread endothelial damage and dysfunction

Endothelial activation:
• Increased capillary permeability
• Increased CAM expression
• Increase in pro-thrombotic factors
• Increased platelet aggregation
• Vasoconstriction

Result is end-organ damage

NOTE - in pre-eclampsia, there is an imbalance between angiogenic and anti-angiogenic factors

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18
Q

End-organ damage that can occur with pre-eclampsia?

A

CNS, renal, hepatic, haematological, pulmonary, CV

Placental

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19
Q

Classifications of pre-eclampsia and the occurrence of each?

A

Early pre-eclampsia (<34 weeks) is uncommon

Late pre-eclampsia (≥34 weeks) comprises the majority of cases

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20
Q

Risks assoc. with early pre-eclampsia?

A

Assoc. with extensive villous and vascular lesions of the placenta

There is a higher risk of maternal and foetal COMPLICATIONS than with late pre-eclampsia

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21
Q

Risks assoc. wit late pre-eclampsia?

A

Minimal placental lesions

Most cases of ECLAMPSIA and MATERNAL DEATH occur in late disease

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22
Q

CNS disease that can occur in pre-eclampsia?

A

Eclampsia

Hypertensive encephalopathy

Intracranial haemorrhage

Cerebral oedema

Cortical blindness (due to cortical ischaemia)

Cranial nerve palsy

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23
Q

Signs of renal disease in pre-eclampsia?

A

Oliguria / anuria

Reduced GFR

Proteinuria

Increased serum urate / uric acid (occurs due to maternal renal disease and also due to placental ischaemia)

Increased creatinine, K+ and urea

Acute renal failure:
• Acute tubular necrosis
• Renal cortical necrosis

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24
Q

Liver disease assoc. with pre-eclampsia?

A

HELLP Syndrome:
• Haemolysis
• Elevated Liver enzymes
• Low Platelets

It can lead to hepatic capsule rupture

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25
Q

Presentation of HELLP syndrome?

A

Early symptoms of epigastric / RUQ pain

NOTE - all women with suspected pre-eclampsia must be asked about this

26
Q

Haemtological disease manifestations in pre-eclampsia?

A

Reduced PV

Haemo-concentration

Thrombocytopaenia

Haemolysis

Disseminated Intravascular Coagulation (DIC) - PET can trigger the coagulation pathway

27
Q

Cardiac / pulmonary disease that can occur in pre-eclampsia?

A

Pulmonary oedema, either iatrogenic or disorder-related, can lead to ARDS

PE

These are assoc. with a high mortality

NOTE - generally, women are limited to 80 mls/hour fluid intake, if they have PET, to avoid fluid overloading them

28
Q

Placental disease that can occur in pre-eclampsia?

A

Foetal growth restriction (FGR)

Placental abruption

Intrauterine death

29
Q

Presentation of pre-eclampsia?

A

May be asymptomatic at the time of presentation; at every antenatal check, BP is urine is checked

Headache

Visual disturbance

Epigastric / RUQ pain

N&V

Rapidly progressive oedema

NOTE - these symptoms are non-specific and some of them often occur in normal pregnancies

30
Q

Signs of pre-eclampsia?

A

Hypertension, proteinuria and oedema

Abdominal tenderness

Disorientation (confusion may be a sign of CNS damage)

Small for gestational age (SGA) - if <10th centile

Intra-uterine death (IUD)

Hyper-reflexia / involuntary movements / clonus

31
Q

Ix for pre-eclampsia?

A

U&Es, serum urate (often the 1st reading to increase, due to maternal renal disease and also placental ischaemia), LFTs, FBC and coagulation screen

Urine PCR

CTG

USS:
• Foetal biometry
• Amniotic Fluid Index (AFI)
• Doppler

32
Q

General screening rules for pre-eclampsia?

A

Assess patient risk at booking appointment

If hypertension is present <20 weeks, look for a secondary cause

Antenatal screening involves:
• BP
• Urine
• Maternal Uterine Artery Doppler (MUAD) - used to check for normal changes in the spiral arteries

33
Q

Risk factors for pre-eclampsia?

A

Maternal age (>40 years)

Maternal BMI (>30)

FH:
• 20-25% if mother affected
• Up to 40% if sister affected

Parity (increased risk with 1st pregnancy)

Multiple pregnancy (increased risk with twins)

Previous pre-eclampsia

Birth interval >10 years, i.e: since last pregnancy

Molar Pregnancy / triploidy (abnormal trophoblast infiltration) - tends to cause early-onset PET

Multiparous women develop more severe disease, i.e: if the PET occurs in the 2nd pregnancy rather than the 1st, it tends to be more severe

34
Q

Medical risk factors for PET?

A

Pre-existing renal disease

Pre-existing hypertension

Diabetes (pre-existing OR gestational)

CTD, e.g: lupus (may be difficult to differentiate a lupus flare from pre-eclampsia)

Thrombophilias (congenital OR acquired)

35
Q

Prevention of pre-eclampsia?

A 
Low-dose (75mg) aspirin for high-risk women, e.g:
• Renal disease
• DM
• Anti-phospholipid syndrome
• Multiple risk factors
• Previous PET

It should be commenced before 12 weeks (as placentation occurs between 8 and 20 weeks)

36
Q

Ix to predict pre-eclampsia?

A

MUAD at 20-24 weeks

A normal MUAD shows a low resistance waveform, signalling good blood flow in both systole and diastole

A notch waveform indicates that spiral artery transformation has not yet occurred, so there is an increased risk of PET; monitor this woman and repeat at 28 weeks

37
Q

When should patients be referred with suspected pre-eclampsia?

A

BP ≥140/90 mmHg

(++) proteinuria

Oedema

Symptoms, esp. persistent headache

38
Q

When should patients be admitted?

A
  1. BP >170/110 mmHg
    OR
    >140/90 with (++) proteinuria
  2. Significant symptoms, e.g:
    • Headache
    • Visual disturbance
    • Abdominal pain
  3. Abnormal biochemistry
  4. Significant proteinuria (>300 mg/24hrs)
  5. Need for anti-hypertensive therapy
  6. Signs of foetal compromise
39
Q

Inpatient assessment of a woman with pre-eclampsia?

A

BP (4 hourly)

Daily urinalysis

Input / output fluid balance chart

Urine PCR (if proteinuria on urinalysis)

Bloods (minimum twice per week): 
• FBC
• U&amp;Es
• Urate
• LFTs
40
Q

Management of pre-eclampsia?

A

Treatment of hypertension

Maternal and foetal surveillance

Plan the timing of delivery (maternal risks must be balanced against the risks of prematurity)

NOTE - PIH can be managed as an outpatient

41
Q

When is hypertension in pregnancy treated?

A

It is treated regardless of the aetiology

Most patient are treated once their BP ≥150/100 mmHg

BP ≥170/110 mmHg required immediate treatment

42
Q

Target BP if treating hypertension in pregnancy?

A

Aim for 140-150 / 90-100 mmHg

NOTE - control of the BP does not reduce the risk of PET

43
Q

Drugs used to treat hypertension in pregnancy?

A

Labetalol (α + β antagonist)

Nifedipine (Ca2+ channel antagonist)

Methyldopa (centrally acting α-agonist)

2nd line:
• Hydralazine (vasodilator)
• Doxazocin (α-antagonist)

NOTE - avoid diuretics / ACEIs

44
Q

Contraindications of the drugs?

A

Methyldopa - contraindicated in depression

Labetalol - contraindicated in asthma

45
Q

Which of these drugs can be used while breastfeeding?

A

All except Doxazosin

46
Q

Methods of foetal surveillance?

A

Checking foetal movements

Daily CTG

USS:
• Biometry
• AFI
• Umbilical artery doppler

47
Q

Interpreting an umbilical artery doppler?

A

Normal

Absence of umbilical arterial end-diastolic flow (AEDF)

Reversal of umbilical arterial end-diastolic flow (REDF)

48
Q

Only cure for pre-eclampsia?

A

Delivery of the baby; mother must be stabilised beforehand

NOTE - most women deliver within 2 weeks of diagnosis

If preterm, consider expectant Mx

NOTE - do not forget steroids, for foetal lung maturation

49
Q

Indications for birth?

A

Term gestation

Inability to control BP

Rapidly deteriorating biochemistry / haematology

Eclampsia

Other crisies

Foetal compromise, e.g:
• REDF
• Abnormal CTG

50
Q

Crises in pre-eclampsia (require immediate delivery)?

A

Eclampsia

HELLP syndrome

Pulmonary oedema

Placental abruption

Cerebral haemorrhage

Cortical blindness

DIC

Acute renal failure

Hepatic rupture

51
Q

What is eclampsia?

A

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

NOTE - 1/3rd of patients will have the seizure prior to onset of hypertension or proteinuria

It is assoc. with ischaemia / vasospasm

52
Q

When do the seizures occur?

A

Ante-partum
Intra-partum
Post-partum

NOTE - most occur either during labour or after labour

53
Q

Occurrence of eclampsia?

A

More common in teenagers

54
Q

Mx of severe PET / eclampsia?

A

Control BP

Fluid balance

Stop / prevent seizures

Delivery (both require immediate delivery)

55
Q

Anti-hypertensives used for severe PET / eclampsia?

A

IV labetalol

IV hydralazine

NOTE - beware hypotension, which can reduce placental perfusion and cause foetal compromise

56
Q

Treatment / prophylaxis of seizures?

A

MAGNESIUM SULPHATE:
• Loading dose - 4g IV over 5 minutes
• Maintenance dose - IV infusion of 1g/hr

If the patient has further seizures, administer 2g magnesium sulphate

If the patient has persistent seizures, consider diazepam 10mg IV

57
Q

Why is fluid balance so important, esp. in the hypertensive pregnancy woman?

A

Main cause of maternal death is pulmonary oedema

Oliguria occurs in 30% of these patients but it does not require intervention

It is safer to run a patient ‘dry’, i.e: limit them to 80 mls/hr

58
Q

Ix for fluid balance?

A

Check renal function, if there are doubts, by checking the urine osmolality

59
Q

Mx of labour and birth with the hypertensive pregnancy?

A

If possible, aim for a vaginal birth; requires continous electronic foetal monitoring

Control BP and be cautious with IV fluids

Epidural anaesthesia can be used

NOTE - avoid ergometrine, as it has hypertensive effects

60
Q

Post-partum Mx of a the hypertensive woman?

A

Encourage breastfeeding and contraception (to allow recovery time)

Control BP (continue anti-hypertensives; may need to increase the dose during the first 3-4 days post-natal)

Counselling and advise on future risk and long-term CVD risk

Year 3 Clinical (100 decks)

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