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Reproductive & Sexual Health > Hypertension in pregnancy > Flashcards

Hypertension in pregnancy Flashcards

1
Q

What is the most common cause of iatrogenic prematurity?

A

Pre-eclampsia

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2
Q

What are the CVS system changes in pregnancy?

A
  • Plasma volume increases by 45%
  • Cardiac output increases by 30-50%
  • Stroke volume increases by 25%
  • Heart rate increases by 15-25%
  • Peripheral vascular resistance decreases by 15-20%
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3
Q

What is the definition of hypertension?

A

>140/90mmHg on 2 occasions

>160/mmHg once

(ACOG >30/15mmHg compared to first trimester BP)

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4
Q

What are the three variations of hypertension in pregnancy?

A
  • pre-existing hypertension
  • pregnancy induced hypertension (PIH)
  • pre-eclampsia
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5
Q

When is pre-existing hypertension likely

A

When hypertension discovered early in pregnancy

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6
Q

When is pre-existing hypertension a retrospective diagnosis?

A

If BP has not returned to nromal within 3 months of delivery

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7
Q

What could be the secondary causes of pre-existing hypertension?

A
  • renal/cardiac
  • cushings
  • conn’s
  • phaeochromocytoma
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8
Q

What are the risks of pre-existing hypertension?

A

PET (x2)

IUGR
Abruption

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9
Q

What is PIH?

A

Pregnancy induced hypertension

  • happens in second half of pregnancy and resolves within 6/52 of delivery
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10
Q

In PIH there is no ______ or other features of ___-_____, however __% progress to pre-eclampsia

A

In PIH there is no proteinuria or other features of pre-eclampsia, however __% progress to pre-eclampsia

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11
Q

What is pre-eclampsia?

A
  • hypertension
  • proteinuria (>0.3g/l or >0.3g/24hr)
  • oedema

Pregnancy multi-system disorder with unpredictable, widespread manifestations.

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12
Q

Describe the presentation of pre-eclampsia

A

May be asymptomatic at first presentation

Then diffuse vascular and endothelial dysfunction, widespread circulatory disturbance

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13
Q

When is pre-eclapmsia classed as early or late?

A

> 34 weeks

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14
Q

What is the pathogenesis of pre-eclampsia?

A
  • genetic/environmental predisposition
  • stage 1- abnormal placental perfusion
    • placental ischaemia
  • stage 2- maternal syndrome
    • an anti-angiogenic state associated with endothelial dysfunction
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15
Q

What are genetic and environmental factors though to do that cause pre-eclampsia?

A

Create conditions leading to defective deep placentation; the injured placenta then releases factors into the maternal circulation that induce pre-eclapmsia

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16
Q

Describe the pathogenesis of abnormal placentation?

A
  • Abnormal placentation and trophoblast invasion -> failure of normal vascular remodelling
  • Spiral arteries fail to adapt to become high capacitance, low resistance vessels
  • Placental ischaemia and widespread endothelial damage and dysfunction
  • Mechanism unclear (??oxidative stress / PGI2: TXA2 imbalance / NO)
  • Endothelial Activation causes;
    • increased Capillary Permeability
    • increased Expression of CAM
    • increased Prothrombotic Factors
    • increased Platelet aggregration
    • Vasoconstriction
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17
Q

What maintains endothelial health in normal pregnancy?

A

VEGF and TGF-B1

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18
Q

What is excreted in excess in pre-eclampsia?

A

sFIt1 and sEng

  • they antagonise VEGF and TGF-B1*
  • sFit1 also antagonises PIGF*
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19
Q

What systems does pre-eclampsia affect?

A
  • CNS
  • Renal
  • hepatic
  • haematological
  • pulmonary
  • cardiovascular
  • placental
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20
Q

Describe liver disease in pregnancy?

A

HELLP syndrome

Haemolysis, Elevated Liver Enzymes, Low Platelets

21
Q

How might liver disease in pregnancy present?

A
  • Epigastric/RUQ pain
  • abnormal liver
  • hepatic capsule rupture
22
Q

Placental disease can cause;

f___ _____ r_____

_________ a________
and intrauterine _____

A

Placental disease can cause;

foetal growth restriction

placental abruption
and intrauterine death

23
Q

What are the symptoms of pre-eclampsia?

A
  • headache
  • visual disturbance
  • epigastric/RUQ pain
  • nausea/volitting
  • rapidly progressive oedema
24
Q

What are the signs of pre-eclampsia?

A
  • hypertension
  • proteinuria
  • oedema
  • abdominal tenderness
  • disortientation
  • small for gestational age (SGA) fetus
  • intrauterine fetal death
  • hyper-reflexia/involuntary movements/clonus
25
Q

What are the investigations for pre-eclapmsia?

A
  • urea and electrolytes
  • serum urate
  • liver function tests
  • full blood count
  • coagulation screen
  • urine- protein creatinine ratio
  • cardiotocography
  • ultrasound- foetal assessment
26
Q

Describe the management of hypertension in pregnancy?

A
  • assess risk at booking- identify risk factors
  • hypertension <20 weeks- look for secondary cause
  • antenatal screening- BP, urine, MUAD
  • treat hypertension
  • maternal & foetal surveillance
  • timing of delivery
27
Q

What are the risk factors for hypertension in pregnancy?

A
  • maternal age (>40 years ->2x)
  • maternal BMI (>30 -> 2x)
  • family history
  • parity (first pregnancy 2-3x)
  • multiple pregnancy (twins 2x)
  • previous PE (7x)
  • birht interval >10 years (2x)
  • molar pregnancy/triploidy
  • multiparous women might develop more severe disease
28
Q

What are the medical risk factors for hypertension?

A
  • pre-existing renal disease
  • pre-existing hypertension
  • diabetes (pre-existing/gestational)
  • connective tissue disease
  • thrombophilias (congenital acquired)
29
Q

How does aspirin work?

A

Inhibits cyclooxygenase -> prevents TXA2 synthesis

30
Q

When is LDA used?

A

High risk women- renal, DM, aPS, multiple risk factors, previous PET

31
Q

When should LDA be commenced and what dose?

A

Before 16 weeks

150mg

32
Q

When should a hypertensive pregnant lady be admitted?

A
  1. BP >170/110 OR >140/90 with (++ proteinuria)
  2. Significant symptoms- headache/visual disturbance/abdominal pain
  3. abnormal biochemistry
  4. significant proteinuria >300mg/24hr
  5. need for antihypertensive therapy
  6. signs of fetal compromise
33
Q

Describe inpatient assesement of hypertension

A
  • blood pressure- 4 hourly
  • urinalysis- daily
  • input/output fluid balance chart
  • urine PCR - proteinuria on urinalysis
  • bloods- FBC, U&Es, Urate, LFTs, minimum X2 week
34
Q

What is there significant risk of in MAP >150mmHg

A

Cerebral haemorrhage

35
Q

What BP requires immediate Rx

A

>170/110mmHg

36
Q

What should be the aim of treatment

A

Achieve BP for 140-150/90-100mmHg

37
Q

Control of BP ______ reduced the risk of developing pre-eclampsia?

A

Control of BP doesn’t reduced the risk of developing pre-eclampsia

38
Q

Describe treatment of hypertension

A

First line;

  • methyldopa- centrally acting a agonist, start on 250mg bd, maximum 1g tds, contraindications : depression, safe for breastfeeding
  • labetolol- a and b antagonist, start on 100mg bd, maximum 600mg qid, containdications : asthma, safe for breastfeeding
  • nifedipine SR- Ca channel antagonist, start on 10mg bd, maximum 40mg bd, safe for breastfeeding

Second line

  • hydralazine- vasodilator, start on 25mg tds, maximum 75mg qid, safe for breastfeeding
  • doxazocin- a antagoinst, 1mg od, max 8mg bd, not safe in breastfeeding
39
Q

What is done in foetal surveillance?

A
  • fetal movements
  • CTG-daily
  • ultrasound
    • biometry
    • amniotic fluid index
    • umbilical artery doppler
40
Q

What are the indications for birth in maternal hypertension?

A
  • term gestation
  • inability to control BP
  • rapidly deteriorating biochemistry/haematology
  • eclampsia
  • other crisis
  • fetal compromise- abnormal US or CTG
41
Q

What are the crises in pre-eclampsia

A
  • eclampsia
  • HELLP
  • pulmonary oedema
  • placental abruption
  • cerebral haemorrhage
  • cortical blindness
  • DIC
  • acute renal failure
  • hepatic rupture
42
Q

Describe eclampsia

A
  • tonic-clonic (grand mal) seizure occuring with features of pre-eclampsia
43
Q

What is the management of severe PET/eclampsia

A
  • control BP
  • stop/prevent seizures
  • fluid balance
  • delivery
44
Q

What antihypertensives should be given in severe PET/eclampsia

A

IV labetolol

IV hydralazine

45
Q

What is the seizure treatment/prophylaxis?

A

Magnesium sulphate

  • Loading dose 4g IV over 5 minutes*
  • Maintenance dose- IV infusion 1g/hr*

If further seizures administer 2g Mg SO4

If persistent seizures consider diazepam 10mg IV

46
Q

What is the main cause of maternal death?

A

Pulmonary Oedema

47
Q

What causes pulmonary oedema in mums?

A

Capillary Leak

Fluid overload

Cardiac Failure

48
Q

What should be done if there is any doubts about renal function?

A

Urine osmolality

Reproductive & Sexual Health (54 decks)

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