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Hypertension in Pregnancy Flashcards

1
Q

How common is hypertension in pregnancy?

A

Affects 10-15% of all pregnancies = 14% of maternal deaths due to hypertension

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2
Q

What is the most common cause of iatrogenic prematurity?

A

Pre-eclampsia

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3
Q

What are some CVS changes that occur during 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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4
Q

What is needed to make a diagnosis of hypertension?

A

BP >= 140/90 mmHg on two occasions

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5
Q

What are some reasons for hypertension during pregnancy?

A

Pre-existing hypertension, pregnancy induced hypertension or pre-eclampsia

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6
Q

When is pre-existing hypertension likely?

A

If hypertension occurs in early pregnancy

May be retrospective diagnosis if BP hasn’t returned to normal after 3 months post-delivery

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7
Q

What are the risks associated with pre-existing hypertension?

A

Pre-eclampsia (x2), IUGR, abruption

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8
Q

When does pregnancy-induced hypertension usually present?

A

In second half of pregnancy = resolves within 6 weeks of delivery

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9
Q

What are the features of pregnancy-induced hypertension?

A

No proteinuria or other features of pre-eclampsia
15% progress to pre-eclampsia
High rate of recurrence

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10
Q

What are the symptoms of pre-eclampsia?

A

Hypertension, proteinuria (>=0.3 g/L), oedema

May be asymptomatic at time of first presentation

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11
Q

What occurs in pre-eclampsia?

A

Diffuse vascular endothelial dysfunction with widespread circulatory disturbance due to placental ischaemia

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12
Q

What are the two types of pre-eclampsia?

A 
Early = <34 weeks gestation
Late = >=34 weeks gestation
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13
Q

What are some features of early pre-eclampsia?

A

Uncommon = 12% of all pre-eclampsia
Associated with extensive villous and placental lesions
Higher rat of complications than late type

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14
Q

What are some features of late pre-eclampsia?

A 
Majority of pre-eclampsia = 88%
Minimal placental lesions
Maternal factors (e.g hypertension) have important role
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15
Q

How does having a first degree relative affected by pre-eclampsia increase risk?

A

3x higher risk if mother or sister has pre-eclampsia

20-25% higher if mother, up to 40% if sister

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16
Q

How do genetic and environmental factors lead to pre-eclampsia?

A

Create conditions leading to defective deep placentation

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17
Q

What are the stages of pre-eclampsia?

A 
1 = abnormal placental perfusion causing placental ischaemia 
2 = maternal syndrome, anti-angiogenic state associated with endothelial dysfunction
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18
Q

What causes failure of normal vascular remodelling in pre-eclampsia?

A

Abnormal placentation and trophoblast invasion = spiral arteries fail to adapt to become high capitance-low resistance vessels

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19
Q

What does endothelial activation cause in pre-eclampsia?

A

Increased capillary permeability, expression of CAM, prothrombotic factors and platelet aggregation

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20
Q

What do VEGF and TGF-beta1 do in a normal pregnancy?

A

They maintain endothelial health

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21
Q

What do sFlt1 and sEng do?

A

Antagonise VEGF and TGF-beta1 = secreted in excess in PE, cause imbalance between angiogenic and anti-antiangiogenic factors

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22
Q

What systems are affected by pre-eclampsia?

A

CNS, renal, hepatic, pulmonary, placental, CV and haematological

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23
Q

How can pre-eclampsia affect the hepatic system?

A

Epigastic/RUG pain, abnormal liver enzymes, hepatic capsule rupture, HELLP syndrome

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24
Q

What are the features of HELLP syndrome?

A

Haemolysis, elevated liver enzymes, low platelets

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25
Q

What are some feature of placental disease cause by pre-eclampsia?

A

Foetal growth restriction, placental abruption, intrauterine death

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26
Q

What are the symptoms of pre-eclampsia?

A

Headache, visual disturbance, epigastic/RUQ pain, nausea and vomiting, rapidly progressive oedema

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27
Q

What are the signs of pre-eclampsia?

A

Hypertension, proteinuria, oedema, abdominal tenderness, disorientation, small for gestational age foetus, intrauterine foetal death, hyper-reflexia

28
Q

What investigations are done for pre-eclampsia?

A

Us & Es, serum urate, LFTs, FBC, coagulation screen, urine protein:creatine ratio, cardiotocography, US for foetal assessment

29
Q

What is the basic management for pre-eclampsia?

A

Treat hypertension

Maternal and foetal surveillance

30
Q

What are the risk factors for pre-eclampsia?

A

Maternal age >45 or BMI >30
Family history, first pregnancy or multiple pregnancy
Previous PE or birth interval >10 years
Molar pregnancy/triploidy
Pre-existing renal disease or hypertension
Diabetes = pre-existing or gestational
Connective tissue disease or thrombophilias

31
Q

What is the mechanism of aspirin?

A

Inhibits COX which prevents TXA2 synthesis

32
Q

Which women is pre-eclampsia more severe in?

A

Multiparous women

33
Q

How is aspirin used to treat pre-eclampsia?

A

150mg dose commenced before 16 weeks gestation
15% reduction in pre-eclampsia
May be more beneficial in preventing severe early onset pre-eclampsia

34
Q

What women at considered at moderate risk from pre-eclampsia?

A

First pregnancy, age >=40, pregnancy interval >10 years, BMI >=35, family history, multiple pregnancy

35
Q

What women are considered at high risk from pre-eclampsia?

A

Hypertensive disease during previous pregnancy, CKD, diabetes, autoimmune disease, chronic hypertension

36
Q

What is done at antenatal screening to detect pre-eclampsia?

A

BP and urine analysis

MUAD = maternal uterine artery doppler = done at 20-24 weeks

37
Q

When would you refer a patient to AN DCU?

A

BP >= 140/90 mmHg, (++) proteinuria, oedema, symptoms (especially persistent headache)

38
Q

When would you admit a patient?

A

BP >170/110 OR >140/90 with (++) proteinuria
Significant symptoms = headache, visual disturbance
Significant proteinuria >300 mg/24h
Abnormal biochemistry or signs of foetal compromise
Need for antihypertensive therapy

39
Q

What is the inpatient assessment for someone with pre-eclampsia?

A

BP every 4hrs and daily urinalysis
Input/output fluid balance chart
Urine PCR if proteinuria present
Bloods at least 2x week = FBC, Us & Es, LFTs

40
Q

What does a MAP >= 150 mmHg carry significant risk of?

A

Cerebral haemorrhage

41
Q

When would you treat a patient with high BP?

A

If >=150/100 mmHg = aim for 140-150/90-100 mmHg

Control of BP doesn’t lower risk of pre-eclampsia

42
Q

What are the first line agents for treating hypertension in pregnancy?

A

Methyldopa, labetolol, nifedipine SR

43
Q

What are the features of methyldopa?

A

Alpha agonist = 250mg twice daily starting dose, contraindicated in depression

44
Q

What are the features of labetolol?

A

Alpha and beta antagonist = 100mg twice daily starting dose, contraindicated in asthma

45
Q

What is nifedipine SR?

A

Calcium channel blocker = 100mg twice daily starting dose

46
Q

What are the second line treatments for hypertension in pregnancy?

A

Hydralazine and doxazocin = avoid use with diuretics and ACE inhibitors

47
Q

What is hydralazine?

A

Vasodilator = 25mg three times daily starting dose

48
Q

What are the features of doxazocin?

A

Alpha antagonist = 1mg once daily starting dose, not suitable if breastfeeding

49
Q

What are some methods of foetal surveillance?

A

Foetal movements and daily CTG

US = biometry, amniotic fluid index, umbilical artery doppler

50
Q

What is the only cure for pre-eclampsia?

A

Birth of baby = mother must be stabilised before birth, may use steroids

51
Q

How soon does birth of the baby follow after pre-eclampsia diagnosis?

A

Most women deliver within two weeks of diagnosis

52
Q

What are the indications for delivering the baby?

A

Term gestation, inability to control BP, rapidly deteriorating biochemistry/haematology, eclampsia or other crisis, foetal compromise (abnormal US/CTG)

53
Q

What are some crises that occur in pre-eclampsia?

A

Eclampsia, HELLP syndrome, pulmonary oedema, placental abruption, cerebral haemorrhage, cortical blindness, DIC, acute renal failure, hepatic rupture

54
Q

What is eclampsia?

A

Tonic-clonic (grand mal) seizures occurring with features of pre-eclampsia

55
Q

What is usually the first symptom of eclampsia?

A

> 1/3 will have seizures before onset of hypertension or proteinuria

56
Q

When does eclampsia occur?

A

38% antepartum, 16% intrapartum, 44% postpartum

More common in teenagers

57
Q

What is eclampsia associated with?

A

Ischaemia or vasospasm

58
Q

What is the management of eclampsia?

A

Control BP and stop seizures, fluid balance, delivery of baby

59
Q

What antihypertensives can be used to treat eclampsia?

A

IV labetolol or hydralazine

60
Q

How are the seizures of eclampsia treated?

A

Magnesium sulphate = loading dose is 4g IV over 5mins upped to maintenance dose of 1g/hr IV infusion

61
Q

What should be given if seizures persist after magnesium sulphate is given?

A

Administer further 2g magnesium sulphate

Consider 10mg IV diazepam if persistent

62
Q

How common is oliguria in eclampsia?

A

Occurs in 30% = doesn’t require intervention

63
Q

How is labour managed in women with hypertension?

A

Aim for vaginal birth if possible
Control BP and give epidural anaesthetic
Continuous electronic foetal monitoring

64
Q

What should be avoided during labour in pregnant women?

A

Ergometrine and use caution with IV fluids

65
Q

What are the postpartum considerations in women who had hypertension during pregnancy?

A

Breast feeding and contraception
BP management
Consider longterm CV risk

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