Hypertension in Pregnancy Flashcards by Joanna Mitchell

How many pregnancies will hypertension affect?

10-15%

How well did you know this?

Not at all

Perfectly

Who is PET most likely to affect?

Primigravida

How well did you know this?

Not at all

Perfectly

What is the commonest cause of iatrogenic prematurity?

PET

How well did you know this?

Not at all

Perfectly

Describe the CV changes in pregnancy

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

How well did you know this?

Not at all

Perfectly

How will BP change in pregnancy?

Mid pregnancy dip in 2nd trim

Progressive risk in HR

How well did you know this?

Not at all

Perfectly

Definition of hypertension in pregnancy?

> 140/90 on 2 occasions

>160/110 once

How well did you know this?

Not at all

Perfectly

What are the different forms of hypertension in pregnancy?

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

How well did you know this?

Not at all

Perfectly

What is pre-existing hypertension?

Diagnosis prior to pregnancy

If hypertx before 20 weeks; nothing to do with baby

How well did you know this?

Not at all

Perfectly

What are the secondary causes of PEH?

Renal/ cardiac anomalies
Cushing’s
Conn’s
Phaeo

How well did you know this?

Not at all

Perfectly

What are the risks to PEH in pregnancy?

Double the risk of developing PET
IUGR
Abruption

How well did you know this?

Not at all

Perfectly

When will PIH resolve?

Within 6/52 of delivery

How well did you know this?

Not at all

Perfectly

What differentiates PIH from PET?

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

How well did you know this?

Not at all

Perfectly

Cardinal signs of pre-eclampsia?

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

How well did you know this?

Not at all

Perfectly

What causes pre-eclampsia?

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

How well did you know this?

Not at all

Perfectly

Describe early pre-eclampsia?

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

How well did you know this?

Not at all

Perfectly

Deswcribe late PET

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

How well did you know this?

Not at all

Perfectly

What is stage 1 of the pathogenesis of PET?

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

How well did you know this?

Not at all

Perfectly

What is stage 2 of the pathogenesis of PET?

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

How well did you know this?

Not at all

Perfectly

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

Imbalance of angiogenic and antiangiogenic factors

Endothelial dysfunction

How well did you know this?

Not at all

Perfectly

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

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

How well did you know this?

Not at all

Perfectly

Si and Sy of HELLP?

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

How well did you know this?

Not at all

Perfectly

What does HELLP stand for?

Haemolysis
Elevated Liver enzymes
Low Platelets

How well did you know this?

Not at all

Perfectly

What can placental disease result in?

FGR
Placental abruption
Stillbirth - IUD

How well did you know this?

Not at all

Perfectly

Symptoms of PET?

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

How well did you know this?

Not at all

Perfectly

Signs of PET

``` Hypertx Proteinuria Oedema Abdominal tenderness Disorientation SGA IUD Hyperreflexia/ involuntary movements/ clonus ```

Describe a praevia vs abruption?

Praevia; painless antepartum haemorrhage | Abruption; painful antepartum haemorrhage

Ix for PET?

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

Management of PET?

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

Risk factors for development of PET?

``` 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 ```

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

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

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

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

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

Inhibits cyclooxygenase and prevents TXA2 synthesis | Prevents thrombosis in placenta

When should LDA be started?

``` Before 16 weeks 150 mg (NICE is 75 mg) ```

Via what scanning method can pre-eclampsia be predicted?

Maternal uterine artery doppler at 20-24 weeks

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

Notch | High resistance waveform with very little flow in diastole

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

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

When should women be admitted with pre-eclampsia?

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

What is the inpatient assessment of pre-eclampsia?

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

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

No; can still develop severe PET

What is the target for BP?

135/85 mmHg

Mode of action of methyldopa?

Centrally acting alpha agonist

CI to methyldopa?

Depression

Can antihypertensives be taken whilst breastfeeding?

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

Mode of action of labetalol?

Alpha and beta antagonist

CI to labetalol?

Asthma

Mode of action of nifedipine?

Ca channel antagonist

Mode of action of hydralazine?

Vasodilator

Mode of action of doxazosin?

Alpha antagonist

What antihypertensives are CI in pregnancy and breastfeeding?

Diuretics | ACEi

How can the foetus be surveyed in PET?

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

What abdominal circumference suggests FGR?

<10th centile

What is the amniotic fluid index a marker of?

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

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

Uterine artery; 20 weeks. Marker of PET | Umbilical artery doppler; 3rd trim investigation. Identified resistance in the placenta

What is a really worrying sign in umbilical artery doppler?

Reverse flow in diastole

What is the only cure for pre-eclampsia?

Birth

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

Steroids; beta/dexamethasone | Decreases risk of NEC, intraventricular haemorrhage and increases production of pulmonary surfactant

Indications for birth in pre-eclampsia?

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

What are crises in pre-eclampsia?

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

What is eclampsia?

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

Management of severe PET/ eclampsia?

Control BP Stop/ prevent seizures Fluid balance Delivery

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

IV labetolol | IV hydralazine

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

YES; if you drop it too low can cause foetal compromise | Due to diseased placenta; a high blood pressure is required for adequate flow

What is used for seizure treatment/ prophylaxis in eclampsia?

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

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

Pulmonary oedema; be careful with fluid balance | Run 80ml/hr

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

``` Aim for vaginal Control BP Epidural CTG Avoid ergometrine Caution with IV fluids ```

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

Will result in hypotension

Why should ergometrine be avoided in pre-eclamptic women?

It is a hypertensive agent | In active 3rd stage of labour; give synticonon