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3 Reproduction > Hypertension in Pregnancy > Flashcards

Hypertension in Pregnancy Flashcards

1
Q

what percentage of pregnant women get hypertension

A

10-15%

mild pre-eclampsia affects 10% of Primigravid women

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2
Q

what is the biggest cause of iatrogenic preterm birth

A

pre-eclampsia

only cure is delivery

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3
Q

what CVS changes are there in pregnancy

A

increase in:

  • plasma volume
  • cardiac output
  • stroke volume
  • heart read

peripheral vascular resistance decreases

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4
Q

definition of hypertension in pregnancy

A

> 140/90 on two occasions

> 160/110 once

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5
Q

what are the types of hypertension you get in pregnancy

A

pre-existing hypertension

pregnancy induced hypertension (PIH)

Pre-eclampsia (PET)

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6
Q

when do PIH and PET resolve

A

within 3 months after delivery

if not -could have been pre-existing hypertension

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7
Q

risks associated with pre-existing hypertension

A

PET (risk doubled)
Intrauterine growth restriction
Placental abruption

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8
Q

what is pregnancy induced hypertension

A

hypertension that occurs in pregnancy - usually in the second half of pregnancy

most commonly resolves within 6 weeks of birth

better outcomes than pre-eclampsia

15% progress to PET - depends on gestation (earlier diagnosed more likely to progress to PET)

recurrence is common in other pregnancies

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9
Q

what is pre-eclampsia

A

Hypertension

Proteinuria (>0.3g/l or >0.3g in 24 hours)

Oedema

Absence does not exclude the diagnosis

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10
Q

what causes pre-eclampsia

A

diffuse vascular endothelial dysfunction

widespread circulatory disturbance

affects all organs in the mother and can also affect the baby

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11
Q

what is early pre-eclampsia

A

pre-eclampsia <34 weeks

uncommon
associated with placental pathology
higher risk of adverse maternal and fetal outcomes

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12
Q

what is late pre-eclampsia >34 weeks

A

minimal placental disease

maternal factors more common cause (eg. previous hypertension, metabolic syndrome)

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13
Q

what is the pathogenesis behind pre-eclampsia

A

genetic/environmental predisposition

stage 1- abnormal placental perfusion - placental ischameia

stage 2 - maternal syndrome - an anti-angiogenic state associated with endothelial dysfunction

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14
Q

what systems are involved in pre-eclampsia

A 
CNS
Renal 
Hepatic 
Haematological 
Pulmonary 
Cardiovascular 
Placental
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15
Q

what liver disease is caused by pre-eclampsia

A

Epigastric/ RUQ pain
Abnormal liver enzymes
Hepatic capsule rupture

HELLP syndromes,e
Haemoloysis
Elevated liver enzymes
Low platelets

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16
Q

what does placental disease cause

A

Fetal growth restriction
Placental abruption
Intrauterine death

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17
Q

symptoms of pre-eclampsia

A 
headache 
visual disturbance 
epigastric/RUQ pain 
Nausea/vomiting 
Rapidly progressive oedema

considerable variation in timing, progression and order of symptoms

18
Q

Signs of pre-eclampsia

A 
Hypertension 
Proteinuria 
Oedema 
Abdominal tenderness
Disorientation 
Small for gestational age deus 
Intrauterine fetal death 
Hyper-reflexia/involuntary movements/clonus
19
Q

Investigations for pre-eclampsia

A 
Urea and electrolytes 
Serum urate (usually rises in PET) 
Liver function tests (look for HELLP)
Full blood count 
Coagulation screen 
Urine-protein creatinine ratio 
Cardiotocography 
Ultrasound for dental assessment
20
Q

management of hypertension in pregnancy

A 
Asses risk at booking 
If hypertension <20 weeks- look for secondary cause 
Antenatal screening - BP, urine 
Treat hypertension 
Maternal and fetal surveillance
Timing of delivery
21
Q

what are risk factors for pre-eclampsia

A 
age >40 
BMI >30 (doubles risk)
Family history 
Parity (first pregnancy 2-3x increased risk) 
Multiple pregnancy 
Previous Pre-eclampsia
Birth interval >10 years (doubles risk) 
Molar pregnancy/triploidy 
Multiparous women develop more severe disease
22
Q

medical risk factors for pre-eclampsia

A 
pre-existing renal disease 
pre-existing hypertension 
diabetes
connective tissue disease 
thrombophilias (congenital or acquired (antiphospholipid syndrome))
23
Q

how do you minimise the risk of risk factors for the mother

A

Low Dose Aspirin

-inhibits cyclo-ocygenase on the prostaglandin pathway and prevents TCA2 synthesis

therefore prevents thrombosis in the placenta

15% reduction in risk of pre-eclampsia and prevents most severe forms of disease

24
Q

what dose of aspirin do you give mothers at increased risk

A

150mg dose

25
Q

what change happens in the uterine artery vessels in pregnancy

A

they change from high resistance vessels to low resistance vessels

monitored by Maternal Uterine Artery Doppler

26
Q

what is a normal maternal uterine artery doppler

A

very low resistance

if high resistance wave form (notch) it implies high resistance in the placenta and the vessels haven’t changed in the way you would expect

highly increases risk of pre-eclampsia - need to increase monitoring

27
Q

what is the criteria to determine when do refer someone to the daycare unit for investigations

A

BP >140/90
++ proteinuria
Increased oedema
symptoms - esp persistent headache

28
Q

criteria to admit the mother

A

BP >170/110 or >140/90 with ++ proteinuria

significant symptoms

abnormal biochemistry

significant proteinuria >300mg/24h

need for antihypertensive therapy

signs of fetal compromise

29
Q

how are the women managed as an in patient with pre-eclampsia

A

4 hourly blood pressure

urinalysis - daily

input/output fluid balance chart

urine PCR - if proteinuria on urinalysis

Bloods - FBS, U&Es, Urate, LFTs - minimum X2 per week

30
Q

how do you treat hypertension if patient is an inpatient

A

need to lower to 140-150/90-100, significant drop can harm the baby

Methyldopa - alpha agonist

Labetolol - alpha and beta agonist

31
Q

when would you use doxazocin

A

if women resistant to other forms of antihypertensive treatment

only one not safe to use in breast feeding

32
Q

how do you survey the health of the fetus if the mother has hypertension

A

Reduced fetal movements

CTG - daily if inpatient

Ultrasound - look for placental disease

  • look at size
  • amniotic fluid index (marker of fetal renal function)
  • umbilical artery doppler (look at resistance in the placenta on the baby side not the maternal)
33
Q

what do you see on a umbilical artery doppler

A

resistance of umbilical artery

normal

AEDF - absence of end diastolic volume

REDF - reversal of end diastolic volume (blood starts going back towards baby because resistance is so high)

34
Q

how soon after diagnosis do most mothers with pre-eclampsia give birth

A

2 weeks

need to give steroids if preterm - up to 36 weeks

35
Q

what are crises in eclampsia - also a reason for delivery

A 
eclampsia 
HELLP syndrome 
Pulmonary oedema 
Placental abruption 
Cerebral haemorrhage 
Cortical blindness 
DIC 
Acute renal failure 
Hepatic rupture
36
Q

what is Eclampsia

A

Tonic-clonic seizure occurring with features of pre-eclampsia

endothelial dysfunction in the cerebral circulation

most common in teenagers

37
Q

how do you manage eclampsia

A

control BP
Stop/prevent seizures
Fluid balance
Delivery

38
Q

what hypertensives are used in life threatening eclampsia

A

IV labetolol
IV hydralazine

be careful not to cause hypotension because it causes fetal distress

39
Q

how do you treat seizures in eclampsia

A

Magnesium Sulphage

4gIV over 5 mins loading dose

1g/ hour IV infusion maintancence dose

if another seizure - give 2g

if persistent seizures consider diazepam 10mg IV

40
Q

how do you manage eclampsia in birth

A 
aim for vaginal delivery 
control BP 
epidural 
continuous electronic fetal monitoring 
avoid ergometrine 
caution with IV fluids
41
Q

how do you manage hypertension postpartum

A 
breast feeding 
contraception 
BP management 
counselling 
manage future risk 
consider long term CVS risk

3 Reproduction (49 decks)

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