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Repro and Sexual Health > Hypertension in Pregnancy > Flashcards

Hypertension in Pregnancy Flashcards

1
Q

How many pregnancies will hypertension affect?

A

10-15%

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2
Q

Who is PET most likely to affect?

A

Primigravida

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3
Q

What is the commonest cause of iatrogenic prematurity?

A

PET

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4
Q

Describe the CV changes in pregnancy

A 
Plasma vol increased by 45% 
CO increased by 30-50% 
SV increased by 25%
HR increased by 15-25% 
PVR increased by 15-20%
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5
Q

How will BP change in pregnancy?

A

Mid pregnancy dip in 2nd trim

Progressive risk in HR

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6
Q

Definition of hypertension in pregnancy?

A

> 140/90 on 2 occasions

>160/110 once

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7
Q

What are the different forms of hypertension in pregnancy?

A

Pre-existing hypertension (PEH)
Pregnancy induced hypertension (PIH)
Pre-eclampsia (PET)

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8
Q

What is pre-existing hypertension?

A

Diagnosis prior to pregnancy

If hypertx before 20 weeks; nothing to do with baby

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9
Q

What are the secondary causes of PEH?

A

Renal/ cardiac anomalies
Cushing’s
Conn’s
Phaeo

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10
Q

What are the risks to PEH in pregnancy?

A

Double the risk of developing PET
IUGR
Abruption

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11
Q

When will PIH resolve?

A

Within 6/52 of delivery

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12
Q

What differentiates PIH from PET?

A

Hypertension with no other features such as proteinuria or pre-eclampsia

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13
Q

Cardinal signs of pre-eclampsia?

A

Hypertension
Proteinuria (>0.3 g/l or >300 mcg/24hr)
Oedema

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14
Q

What causes pre-eclampsia?

A

Diffuse vascular endothelial dysfunction with widespread circulatory disturbance
Can affect; renal/ hepatic/ CV/ haematology/ CNS/ placenta

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15
Q

Describe early pre-eclampsia?

A

<34 weeks
Assoc with extensive villous and vascular lesions of placenta
Higher risk of maternal and foetal complications that late PET

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16
Q

Deswcribe late PET

A

> 34 weeks
Minimal placental lesions
Maternal factors (metabolic syndrome and hypertx)

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17
Q

What is stage 1 of the pathogenesis of PET?

A

Abnormal placental perfusion resulting in placental ischaemia
Failure of placentation and trophoblast invasion and thinning of spiral arteries resulting in a high resistance, low flow placenta

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18
Q

What is stage 2 of the pathogenesis of PET?

A

Widespread endothelial damage and dysfunction
Endothelial activation resulting in increased capillary permeability, increased expression of CAM, increased prothrombotic factors, increased platelet aggregation, increased vasoconstriction

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19
Q

What is one of the central pathogenic mechanisms in pre-eclampsia?

A

Imbalance of angiogenic and antiangiogenic factors

Endothelial dysfunction

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20
Q

What symptoms can PET present with (as a multisystem disorder)?

A 
CNS; seizures
Renal; AKI 
Hepatic; HELLP
Haematological; HELLP, DIC
Pulmonary oedema
CV; hypertx, cardiomyopathy
Placental; insufficiency and infarction (IUGR, abruption, stillbirth)
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21
Q

Si and Sy of HELLP?

A

Epigastric/ RUQ pain
Hepatic capsule rupture -> intra-abdominal haemorrhage
Abnormal liver enzymes

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22
Q

What does HELLP stand for?

A

Haemolysis
Elevated Liver enzymes
Low Platelets

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23
Q

What can placental disease result in?

A

FGR
Placental abruption
Stillbirth - IUD

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24
Q

Symptoms of PET?

A 
Headache
Visual disturbance 
Epigastric/ RUQ pain 
N+V 
Rapidly progressive oedema
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25
Q

Signs of PET

A 
Hypertx
Proteinuria
Oedema
Abdominal tenderness
Disorientation 
SGA
IUD
Hyperreflexia/ involuntary movements/ clonus
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26
Q

Describe a praevia vs abruption?

A

Praevia; painless antepartum haemorrhage

Abruption; painful antepartum haemorrhage

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27
Q

Ix for PET?

A 
U+Es
Serum urate = first thing to go off 
LFTs
FBC
Coag screen 
Protein:Creatinine ratio 
CTG
USS; foetal assessment
28
Q

Management of PET?

A

Assess risk at booking
Hypertension <20 weeks; look for secondary cause
Antenatal screening; BP, urine, maternal uterine artery doppler
Treat hypertension
Maternal and foetal surveillance
Timing of delivery

29
Q

Risk factors for development of PET?

A 
Maternal age over 40 
Maternal BMI over 30 
Family history 
Primi 
Multiple 
Previous PET 
Birth interval >10 yrs 
Molar/ triploidy 
Multiparous women will develop more severe disease
30
Q

How can PET point to a diagnosis of a molar pregnancy?

A

If pre-eclamptic before 12 weeks; high chance of it being a molar pregnancy - esp partial (has potential to be missed on USS)

31
Q

What are the medical risk factors that predispose to the development of pre-eclampsia?

A 
Pre-existing renal disease
Pre-existing hypertension 
Diabetes (pre or gestational) 
Connective tissue; SLE
Thrombophilias; APS
32
Q

What is the mechanism of low dose aspirin in pre-eclampsia prevention?

A

Inhibits cyclooxygenase and prevents TXA2 synthesis

Prevents thrombosis in placenta

33
Q

When should LDA be started?

A 
Before 16 weeks 
150 mg (NICE is 75 mg)
34
Q

Via what scanning method can pre-eclampsia be predicted?

A

Maternal uterine artery doppler at 20-24 weeks

35
Q

What will be seen that can point towards pre-eclampsia on maternal uterine artery doppler?

A

Notch

High resistance waveform with very little flow in diastole

36
Q

When should women be referred to the antenatal day care unit?

A

BP >140/90
++ proteinuria
++ oedema
Symptoms esp persistent headache

37
Q

When should women be admitted with pre-eclampsia?

A

BP >170/110 or >140/90 with ++ proteinuria
Significant symptoms; headache, visual disturbance, abdo pain
Abnormal biochemistry
Significant proteinuria >300 mg/ 24 hrs
Need for antihypertensive therapy
Signs of foetal compromise; abnormal scan or CTG

38
Q

What is the inpatient assessment of pre-eclampsia?

A 
BP 4 hrly 
Urinalysis daily 
Input/ output fluid balance chart
Urine PCR 
Bloods; FBC, U+Es, urate, LFTS minimum 2x weekly
39
Q

Will treatment of hypertension alter the course of pre-eclampsia?

A

No; can still develop severe PET

40
Q

What is the target for BP?

A

135/85 mmHg

41
Q

Mode of action of methyldopa?

A

Centrally acting alpha agonist

42
Q

CI to methyldopa?

A

Depression

43
Q

Can antihypertensives be taken whilst breastfeeding?

A

Yes; all prescribed during pregnancy can be used whilst breastfeeding EXCEPT doxazosin

44
Q

Mode of action of labetalol?

A

Alpha and beta antagonist

45
Q

CI to labetalol?

A

Asthma

46
Q

Mode of action of nifedipine?

A

Ca channel antagonist

47
Q

Mode of action of hydralazine?

A

Vasodilator

48
Q

Mode of action of doxazosin?

A

Alpha antagonist

49
Q

What antihypertensives are CI in pregnancy and breastfeeding?

A

Diuretics

ACEi

50
Q

How can the foetus be surveyed in PET?

A

Foetal movements
CTG daily
USS; biometry, amniotic fluid index, umbilical artery doppler

51
Q

What abdominal circumference suggests FGR?

A

<10th centile

52
Q

What is the amniotic fluid index a marker of?

A

Foetal renal function; will be reduced if the baby is sick

53
Q

What is the difference between the umbilical artery doppler and uterine artery doppler?

A

Uterine artery; 20 weeks. Marker of PET

Umbilical artery doppler; 3rd trim investigation. Identified resistance in the placenta

54
Q

What is a really worrying sign in umbilical artery doppler?

A

Reverse flow in diastole

55
Q

What is the only cure for pre-eclampsia?

A

Birth

56
Q

What should be given to women if they are having a preterm delivery?

A

Steroids; beta/dexamethasone

Decreases risk of NEC, intraventricular haemorrhage and increases production of pulmonary surfactant

57
Q

Indications for birth in pre-eclampsia?

A 
Term gestation 
Inability to control BP 
Rapidly deteriorating biochem/ haematology
Eclampsia
Other crisis
Foetal compromise; USS or CTG
58
Q

What are crises in pre-eclampsia?

A 
Eclampsia
HELLP
Pulmonary oedema
Placental abruption 
Cerebral haemorrhage
Cortical blindness
DIC
Acute renal failure
Hepatic rupture
59
Q

What is eclampsia?

A

Tonic-clonic seizure occurring with features of pre-eclampsia
Most common in intra-post partum period
More common in teenagers

60
Q

Management of severe PET/ eclampsia?

A

Control BP
Stop/ prevent seizures
Fluid balance
Delivery

61
Q

What antihypertensives can be used in management of severe pre-eclampsia/ eclampsia?

A

IV labetolol

IV hydralazine

62
Q

Do you need to be careful when treating BP in eclamptic mothers?

A

YES; if you drop it too low can cause foetal compromise

Due to diseased placenta; a high blood pressure is required for adequate flow

63
Q

What is used for seizure treatment/ prophylaxis in eclampsia?

A 
Magnesium sulphate
Loading dose; 4g IV over 5 mins 
Maintenance; IV infusion 1g/hr 
If further seizures; 2g 
If persistent; diazepam 10mg IV
64
Q

What is the most common complication leading to death in pre-eclampsia?

A

Pulmonary oedema; be careful with fluid balance

Run 80ml/hr

65
Q

How should labour and birth be managed in pre-eclampsia?

A 
Aim for vaginal
Control BP 
Epidural 
CTG
Avoid ergometrine 
Caution with IV fluids
66
Q

Why is an epidural helpful in pre-eclamptic women in birth?

A

Will result in hypotension

67
Q

Why should ergometrine be avoided in pre-eclamptic women?

A

It is a hypertensive agent

In active 3rd stage of labour; give synticonon

Repro and Sexual Health (77 decks)

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