hypertension in pregnancy Flashcards
Classification of HTN
mild 140/149 90/99
moderate 150/159 -100/109
severe >160 >110
What are the three types of hypertension in pregnancy
gestational hypertension (non-proteinuric)
chronic hypertension
pre-eclampsia
what is gestational HTN
new HTN that arises after 20 weeks
non-proteinuric
chronic HTN
women who have confirmed HTN in first half of pregnancy - can put you at risk of pre-eclampsia
What is pre-eclampsia
Hypertension recorded on 2 separate occasions 4 hour apart
w/ 3OOmg protein in 24 hour urine collection
that commences after 20 weeks and resolves 6 weeks post-partum
what renal lesion is seen in P-E
glomeruloendotheliosis (leads to selective protein loss - albumin and transferrin)
What is HELLP
Haemolytic anaemia (fibrin deposition) Elevated liver enzymes (fibrin messes up liver) Low PLatelets (deposition of PLT due to vascular damage)
What is eclampsia
tonic-clonic seizures in woman with P-E
Classical symptoms of P-E
frontal headache
Visual disturbance
Epigastric pain
non-specific flu-type stuff
Tx for P-E
Have to reduce BP or they will get intracerebral bleed Give labetalol (alpha-blocker) Give MgSO4 if woman has features of P-E and birth planned in next 24 hours
What medication is contraindicated in P-E
ERGOMETRINE (it can raise BP)
Birth advice for people with P-E?
Especially when to deliver
If severe HTN get to 34 weeks and deliver
If mild 34-37
If moderate and after 37 weeks deliver within 24-48 hours
Adivce:
deliver on labour ward
Epidural is good to control BP
NO ERGOMETRINE
Mx for P-E mild HTN (140/149)
Admit, don’t treat, monitor 4x a day (check kidneys, electorlytes, FBC)
Mx for P-E moderate HTN (150/59)
Admit, give oral labetalol to keep SBP <150 and DBP 80-100, monitor 4x a day and check kidneys, electrolytes, FBC
Mx for P-E severe HTN (160/69)
Admit, give oral labetalol aim for SBP <150, DBP 80-100, monitor more than 4x a day check kidney electrolytes, FBC
When would you give anticonvulsants for P-E
if in intensive care with previous fit or severe HTN
If they’re symptomatic (liver, visual disturbance, headache)
If they have severe HTN w/ proteinuria
Which antihypertensives are teratogenic
ARB
ACEi
atenolol
Mx mild (<150/100) chronic HTN
No treatment needed
Monitor growth w/ serial growth scan between 28-36 weeks
low dose aspirin from week 12
Mx if BP >150/100 chronic HTN
Do not admit
Antihypertensive to maintain BP <150/100-80
Measure BP twice a week
Blood tests not essential
Causes of FGR
Foetal -
chromosomal abnormalities (aneuploidy)
structural abnormalities (renal agenesis)
intrauterine infection (CMV)
Maternal - Undernutrition (malnutrition
hypoxia
drugs (fags, alcohol, coke)
PLacental
reduced utero-placental perfusion (inadequate trophoblast invasion, sickle cell)
reduced foetoplacental transfusion (TTTTS, single umbilical artery)
Two types of FGR
symmetrical (implies a problem in something directly impacting foetal growth)
asymmetrical (uteroplacental insufficiency - head gets all the blood so develops normally while the liver and kidneys don’t - associated w/ oligohydramnios)
how to asses gestational age
CRL <13+6
Head circumference 13+6-20
Who are at high risk of P-E?
Hypertensive disease during previous pregnancy CKD DM Autoimmune conditions chronic HTN
what do you give for P-E prophylaxis
prophylactic aspirin from 12 weeks daily
antenatal medical mx for gestational HTN
Antihypertensives: 1st line: labetalol 2nd line: nifedipine 3rd line: methyldopa aim for 135/85
Postnatal mx of gestational HTN
Monitor BP daily for first 2 days, then once between days 3-5
Continue taking antihypertensive (but change methyldopa to something else postpartum)
Hypertension should resolve within 6 weeks
Postnatal mx of P-E
keep under observation for at least 24 hours
monitor BP 4x a day while inpatient, then 1-2 days a week til no HTN
F/U w/ GP after 2 weeks if still on antihypertensive
F/U at 6 weeks to ensure HTN has resolved
mx of eclampsia
ABCDE MgSO4 4g loading dose then 1g/hour Complications: resp depression and arrhythmias Give 10ml 10% calcium glauconate antihypertensives expedite delivery
Intrapartum and postpartum management in pre-existing chronic HTN
if <160/110 don’t offer induction at 37 week
postpartum measure BP for 2 days, then once between day 3-5 and GP follow up at 2 weeks
What are high risk factors for P-E
HTN in previous disease
pre-existing maternal disease (chronic HTN, renal disease, DM, AI disease)
What are moderate risk factors for P-E
First pregnancy Age >40 BMI >35 Pregnancy interval >10 multiple pregnancy FH of P-E
Who do you give P-E prophylaxis to?
1 major risk factor
2 minor
What is P-E prophylaxis
75mg aspirin daily from 12 weeks
What are the indications for admission to antenatal ward with pre eclampsia
Severe HTN >160
Headaches or other signs of late stage disease
Biochemical abnormalities (elevated liver enzymes, deranged U+E)
Low platelets
SIGNS OF FOETAL COMPROMISE
What is antenatal monitoring for woman with P-E?
BP every 2 days
Bloods 2x a week (FBC, LFT, U+E)
Serial growth scans every 2 weeks
what do you look for on serial growth scan
UA doppler flow, growth, liquor
antenatal monitoring for gestational HTN
Lifestyle modification (reduce salt)
Monitor BP weekly if poorly controlled and every 2 weeks if well controlled
Serial growth scans every 4 weeks from 28-36 weeks
