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Phase 3a Obstetrics > Hypertension in pregnancy > Flashcards

Hypertension in pregnancy Flashcards

1
Q

What forms can hypertension in pregnancy take?

A

Gestational hypertension (can develop into pre-eclampsia)
Chronic hypertension
Pre-eclampsia
Eclampsia
Pre-eclampsia superimposed on chronic hypertension or renal disease

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2
Q

What are the risk factors for hypertension in pregnancy?

A 
young mother 
black people  
1st baby, then more than 5 babies (primigravida and grand multipara)
multifetal pregnancy 
pre-existing hypertension 
diabetes 
renal disease 
collages vascular disease - lupus, scleroderma, RA
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3
Q

What are the features that point towards chronic hypertension?

A
  • before pregnancy
  • Before the 20th week of gestation
  • During pregnancy and not resolved postpartum
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4
Q

How do you diagnose gestational hypertension?

A

New HT after 20 wks gestation
Systolic >140; Diastolic>90
No or little proteinuria

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5
Q

How do you diagnose pre-eclampsia?

A

New HT after 20th week
Increased BP with proteinuria
(sometimes get oedema, but not part of definition)

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6
Q

Define pre-eclampsia

A

New HT after 20th week with proteinuria

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7
Q

Define eclampsia

A

New HT after 20th week with proteinuria AND generalised tonic clonic seizures

(pre-eclampsia plus seizures)

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8
Q

What clinical parameters would you use to diagnose pre-eclampsia and what are their abnormal ranges?

A

Gestational hypertension
Systolic >140; Diastolic>90

Proteinuria
≥ 0.3g protein /24hr
≥ +2 on urine dip specimen

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9
Q

How do you accurately measure BP in pregnancy?

A 
Sitting position (NOT supine as get IVC compression)
Sit quietly for 10-15 minutes
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10
Q

What are the classifications of pre-eclampsia-eclampsia?

A

Mild pre-eclampsia
Severe pre-eclampsia
Eclampsia

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11
Q

What are the clinical criteria for severe pre-eclampsia?

A

ONE OR MORE OF:
BP: >160 systolic, >110 diastolic

Proteinuria: >5gm in 24 hrs, over 3+ urine dip

Oliguria: < 400ml in 24 hrs

CNS: Visual changes, headache, scotomata, mental status change (confusion/drowsiness)

Fundoscopy: retinal oedema and vasospasm

Pulmonary Edema

Epigastric or RUQ Pain (due to liver enlargement and swelling)

Weight gain due to peripheral oedema

Effect on baby:
Intrauterine Growth Restriction on USS

Oligohydramnios on USS

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12
Q

What are the lab criteria for severe pre-eclampsia?

A

Impaired LFTs - high AST and ALT

Thrombocytopenia: <100,000 (normal 150,000 to 350,000) - this is the first step of DIC

Raised uric acid

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13
Q

How do you identify Preeclampsia Superimposed Upon Chronic Hypertension

A

Basically chronic hypertension pts will have hypertension <20 weeks. Pre-eclampsia can be identified in these individuals by:

New-onset proteinuria after 20 weeks

OR if they had HT and proteinuria anyway <20 weeks, they will now get:

Sudden increase in proteinuria
Sudden increase in BP when HT was well controlled
Thrombocytopenia (<100,000)
Abnormal ALT/AST
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14
Q

What are the spiral arteries and what two structures do they join together?

A

They are arteries that grow from the placenta and join the mothers arteries (arcuate arteries) in the myometrium

They allow oxygenated blood to flow from mother to baby

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15
Q

Describe the pathophysiology of pre-eclampsia

A
  1. Normally the spiral arteries lose their torsuosity and dilate significantly
  2. In pre-eclampsia, the spiral arteries do not lose their toruosity as much and are not as dilated, so there is reduced blood flow from the mother to the fetus
  3. leads to placental ischaemia
  4. placenta produces thromboplastins which catalyse the conversion of prothrombin to thrombin
  5. renin is produced which causes vasoconstriction (think of it as there is placental ischaemia so the body is trying to increase blood flow by increasing BP)
  6. vasconstriction results in
    - poor renal perfusion
    - hypertension
    - proteinuria
    - oedema

Overall

  1. poor placentation
  2. ischaemia
  3. activation of the coagulation system
  4. deranged control of blood volume and pressure
  5. oxidative stress and inflammation
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16
Q

How does pre-eclampsia affect the kidney?

A 
Reduced GFR 
Increased uric acid 
Proteinuria 
Hypocalciuria - hormone dysregulation 
Impaired Na+ excretion due to renin - so will retain water
17
Q

How does pre-eclampsia affect the coagulation system?

A

Thrombocytopenia - due to consumption of platelets
low antithrombin III - low levels promote clotting
higher fibronectin (causes blood clots to form)

18
Q

How does pre-eclampsia affect the liver system?

A

HELLP syndrome
Haemolysis
Elevated Liver enzymes - ALT and AST
Low platelets

19
Q

How does pre-eclampsia affect the CNS system?

A 
If severe: 
Headache 
Visual symptoms 
Scotoma 
Cortical blindness - blindness in a normal appearing eye as the pathology is in the occipital cortex
20
Q

What examination findings are there with pre-eclampsia?

A

Hypertension >140/90
Fundoscopy - retinal vasospasm and oedema
Peripheral oedema
Auscultation of lungs - late sign is basal crackles
Increased reflexes
Ankle clonus

21
Q

What investigations would you do for pre-eclampsia?

A

FBC - platelets, low Hb due to haemolysis, haemoconcentration with high haematocrit

LFTs - high AST and ALT

U+Es - high uric acid, late low GFR

Urine dip - proteinuria

Urine PCR - Protein creatinine ratio

Measure urine input and output (input-output chart)- oliguria <400ml/24 hrs

DO USS for foetal growth

22
Q

What are the complications of pre-eclampsia?

A

Maternal

  • eclampsia
  • HELLP syndrome
  • DIC and haematuria
  • stroke
  • reduced GFR and then renal failure

Foetal

  • IUGR
  • IUD
  • premature delivery and complications related to this - ARDS
  • abruptio placentae
23
Q

How would you manage pre-eclampsia?

A

Ambulatory management at home or day-care unit for mild pre-eclampsia

Hospitalisation for severe pre-elampsia

Restrict activity

Deliver under certain criteria

24
Q

What are the maternal indications for delivery in pre-eclampsia?

A

Gestational age 38 wks

Platelet count < 100,000 cells/mm3

Progressive deterioration in liver and renal function

Suspected abruptio placentae (ie bleeding and pain)

Persistent severe headaches, visual changes, nausea, epigastric pain, or vomiting

25
Q

What are the fetal indications for delivery in pre-eclampsia?

A
  1. Severe fetal growth restriction - definition is growth <10th centile (USS)
  2. Nonreassuring fetal testing results (umbilical artery doppler - absent EDF or reversed flow, and suspicious or pathological CTG)
  3. Oligohydramnios (amniotic fluid index < 5cm on USS)
26
Q

When would you deliver in mild pre-eclampsia?

A 
If mother >37 weeks 
Favourable cervix 
Fetal jeopardy
Visual disturbance 
Persistant headaches 
Ie pt is symptomatic
27
Q

Does everyone with pre-eclampsia have to have a C section?

A

No - vaginal delivery is preferable

28
Q

How would you treat severe pre-eclampsia?

A
  1. Induction of labour within 24 hours
  2. Antihypertensives - Labetalol or Hydralazine
  3. Anticonvulsant therapy - IV magnesium sulphate
29
Q

What are the CIs for labetalol and what would you use instead?

A

Asthma
CHF

Hydralazine

And if Hydralazine is ineffective then use nifedipine

30
Q

How is pre-eclampsia prevented for future pregnancies?

A

Aspirin 75 mg daily from the beginning of the next pregnancy

Reduces risk of HTN and it’s severity if it does happen again

Phase 3a Obstetrics (11 decks)

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