Hypertension in pregnancy Flashcards
Definition of cHTN
Before 20 weeks EGA or > 12 weeks PP:
SBP > 140 mm Hg, DBP > 90
2x at least 4 hrs apart
Def’n of gHTN
HTN > 20 weeks, normal BP at 12 weeks PP
Def’n pre-eclampsia
gHTN + proteinuria
Proteinuria:
- > 300 mg on 24 hr urine
- UPC 0.3+
- random urine > 30 mg/dL (dipstick reading of 2+)
proteinuria on dipstick and correlation
\+ = 30 mg/dL \++ = 100 mg/dL \+++ = 300 mg/dL \++++ = > 2000 mg/dL
Fatty liver of disease findings
- low glucose
- liver dysfunction
- prolonged PTT
- high maternal and fetal mortality
how do you assess in first trimster for risk of pre-eclampsia?
medical history:
- personal/fam hx of pre-x
- multifetal gestation
- cHTN, CKD, or both
- DM I and II
No commercial tests; low PPV
what can you do to prevent pre-eclampsia
LDASA (81 mg)- high risk for PX and women with 1+ moderate RF
- start week 12-28 (ideally before 16 wks)
- continue until 36 weeks/delivery?
HR:
- hx px
- cHTN
- DM I or II
- CKD
- multifetal gestation
- autoimmune conditions: APAS or lupus
Mod risk:
- age > 35 yrs
- nullip
- obesity
- african american
- low socioeconomic status
- pos fam hx (mom or sister)
- prior adverse preg including low BW or SGA
- > 10 yr interval between pregnancy
how many ecclamptic sz’s happen in absence of HTN, proteinuria?
15-20%
ddx for eclamptic sz:
- stroke
- aneurysm
- AVM
- sz disorder
ddx for pre-x like sx before 20 weeks:
TTP-HUS, molar pregnancy, renal disease, autoimmune disease
percentage of women with gHTN who go on to have pre-x?
50%, more common if dx before 32 weeks
when do you deliver gestational hypertension?
37 weeks
when do you deliver gestational hypertension with severe features/pre-x with SF?
34 weeks, no delay for steroids
with pre-x what are indications for delivery irrespective of gestational age?
- first must stabilize mom
- maternal indications: persistent neuro sx, stroke, MI, pulmonary edema, renal dysfunction (1.1 or 2x normal), suspicion of abruption, severe uncontrollable HTN, persistent epigastric pain, HELLP, eclampsia
- fetal: no suspicion of fetal survival (ie lethal anomaly), fetal death, persistent reversed end diastolic flow, abnormal fetal testing
maternal and fetal monitoring for outpatient management of gHTN and pre-x w/o SF?
- maternal: weekly HELLP labs, weekly proteinuria eval, at least 1 x in clinic BP, constant sx surveillance
- fetal: weekly MVP/AFI evaluation, twice weekly testing, q3-4 growth scan
NNT to prevent eclampsia in asx PX with SF? sx?
asx: 1 in 129
sx: 1 in 36
what are contraindications to magnesium sulfate?
- myasthenia gravis
- moderate to severe kidney disease
- myocarditis
- heart block
- myocardial ischemia
- hypocalcemia
what medications for eclampsia ppx and tx can you use if magnesium contraindicated?
- dilantin/phenytoin
- valium (need to be able to intubate)
- amobarbital
dosing of mag sulfate for eclampsia?
IV: 4-6 g loading dose, 2 g/hr
additional 2-4 g bolus can be given for recurrent seizure
IM: 10 g IM (5 mg in each buttock), then 5 g q4hr
what are serum concentrations associated with ttx dosing of mag sulfate, and toxicities? how to manage toxicity?
5-9 mg/dL -> ttx
> 9 -> loss of patellar reflex
> 12 -> respiratory paralysis
>30 -> cardiac arrest
stop infusion; check mag levels q2hr
if impending respiratory distress: 10% calcium gluconate in 10 mL inflused over 3 minutes; consider lasix
discussion of mode of delivery
with gHTN and PX w/o SF -> vaginal
with PX and gHTN with SF -> individualized
at 28 wks -> likelihood of CD = 97%
at 32 wks -> likelihood of CD = 65%
IOL not harmful to low birth weight fetuses
management of eclamptic seizure:
1st: basic supportive measures:
- calling for help
- prevention of maternal injury
- placement in lateral decubitus position
- prevention of aspiration
- administration of oxygen,
- monitoring vital signs with SpO2
Ddx cHTN
- Essential HTN
- Renal disease
- Renal artery stenosis
- Coarctation of aorta
- OSA
- Cushing syndrome
- Pheochromocytoma
- Primary hyperaldosteronism
- Methamphetamine or cocaine use
% of women with cHTN go develop pre-x? cHTN wiht end organ dysfunction?
up to 50%. up to 75%
