hypertension in pregnancy Flashcards
what advise is given to women who have HTN wanting to get pregnant
if they are taking ACE inhibitors or ARBs it can increase the risk of congenital abnormalities
same goes for thiazide or thiazide like diuretics
what should not be used to lower BP
nitric oxide donors
progesterone
diuretics
low molecular weight heparin.
magnesium folic acid antioxidants (vitamins C and E) fish oils or algal oils garlic.
which women at high risk of pre-eclampsia
- hypertensive disease during a previous pregnancy
- chronic kidney disease
- autoimmune disease such as systemic lupus erythematosus or antiphospholipid syndrome
- type 1 or type 2 diabetes
- chronic hypertension.
if women is at high risk of preclampsia what medication is given as precautionary and when
75-150 mg of aspirin1 daily from 12 weeks until the birth of the baby.
if they have one high risk factor
if they have more than one moderate risk factor
moderate risk of factors of pre-eclampsia
- first pregnancy
- age 40 years or older
- pregnancy interval of more than 10 years
- BMI of 35 kg/m2 or more at first visit
- family history of pre-eclampsia
multi-fetal pregnancy.
at what BP should one stop treatment
SBP <90
DBP <70
the woman has symptomatic hypotension.
target - 135/85mmHg
Mx for HTN in pregnant women
1ST LINE - LABETALOL
- oral or iV
SEs - bradycardia, confusion, depression, dry eye, heart failure
CI - bronchospasm
nifedipine
SEs - abdo pain, dizzy, flushing, headache, nausea, angioedema, gingivial hyperplasia
CI - diabetes, elderly, ischaemic pain
methyldopa - stop within 2 days of birth
SEs - abdo distension, amenorrhoea, angioedema
CI- depression, acute porphyria, phaeochromocytoma
also provide aspirin 75-150mg once daily from 12 weeks
what test can be done to rule out pre-eclampsia between 20 weeks and up to 35 weeks of pregnancy
PIGF placetnal growth factor
what lifestyle and diet advise can be given to the pregnant woman
weight management
exercise
healthy eating
lowering the amount of salt in their diet.
No of antenatal appointments if women has chronic HTN
weekly appointments if hypertension is poorly controlled
appointments every 2 to 4 weeks if hypertension is well-controlled.
what additional fetal monitoring is done in women with chronic HTN and when
ultrasound for fetal growth and amniotic fluid volume assessment, and umbilical artery doppler velocimetry at 28 weeks, 32 weeks and 36 weeks.
which women need additional fetal monitoring
- severe pre-eclampsia
- pre-eclampsia that resulted in birth before 34 weeks
- pre-eclampsia with a baby whose birth weight was less than the 10th centile
- intrauterine death
- placental abruption.
during labour when do you measure BP HTN women
hourly, in women with hypertension
every 15-30 minutes until blood pressure is less than 160/110 mmHg in women with severe hypertension.
when to measure BP after giving birth with HTN women
daily for the first 2 days after birth
at least once between day 3 and day 5 after birth
as clinically indicated if antihypertensive treatment is changed after birth.
what advise to give if women choses to breastfeed while taking antihypertensives
consider monitoring the blood pressure of babies, especially those born preterm, who have symptoms of low blood pressure for the first few weeks
when discharged home, advise women to monitor their babies for drowsiness, lethargy, pallor, cold peripheries or poor feeding.
Mx of HTN in postnatal period
enalapril - monitor of maternal renal function and maternal serum potassium.
africa or carribean
- nifedipine
amlodipine
protein:creatinine ratio quantity to diagnose pre-eclampsia
use 30 mg/mmol as a threshold for significant proteinuria
albumin:creatinine ration quantity to diagnose pre-eclampsia
use 8 mg/mmol as a diagnostic threshold
when will and what additional fetal monitoring done in gestational HTN
ultrasound for fetal growth and amniotic fluid volume assessment and umbilical artery doppler velocimetry at diagnosis and if normal repeat every 2 to 4 weeks, if clinically indicated.
when to carry out CGT cardiotocography
pre-eclampsia or severe gestational HTN
If conservative management of pre-eclampsia or severe gestational hypertension is planned, carry out all the following tests at diagnosis:
ultrasound for fetal growth and amniotic fluid volume assessment
umbilical artery doppler velocimetry.
when to repeat CTG
the woman reports a change in fetal movement
vaginal bleeding
abdominal pain
deterioration in maternal condition.
what is and features of symphysis pubis dysfunction
Ligament laxity increases in response to hormonal changes of pregnancy
Pain over the pubic symphysis with radiation to the groins and the medial aspects of the thighs. A waddling gait may be seen
uterine rupture features
Ruptures usually occur during labour but occur in third trimester
Risk factors: previous caesarean section
Presents with maternal shock, abdominal pain and vaginal bleeding to varying degree
Mx of pre-eclampsia
reduce BP >160/110
- Labetolol is first-line as an antihypertensive
- Nifedipine (modified-release) is commonly used second-line
- Methyldopa is used third-line (needs to be stopped within two days of birth)
EMERGENCY CONTROL OF SEVERE HTN IV
1. Labetalol
2. Intravenous hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia
IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures
- steroids for lung maturation if preterm
- deliver
- strict fluid balance
- HDU care
after switching
Enalapril (first-line)
Nifedipine or amlodipine (first-line in black African or Caribbean patients)
Labetolol or atenolol (third-line)
when to think about delivery before 37 weeks
cant control BP after use of 3 drugs sats <90 deterioration of organs eclampsia placental abruption
Ix of preeclampsia
high bP
protein
Maternal
- FBC- thrombocytopenia
- U&Es -> raised urea and creatinine
uric acid - elevated
-> LFTs - reduced albumin, deranged liver enzymes
Protienuria -> 24hr urinary protein - >0.5g in 24 hours, PCR
DIC (coagulation profile in severe cases or thrombocytopenia
Fetal:
- Growth velocity (fetal growth ultrasound)
- Fetal wellbeing (CTG, amniotic fluid volume, fetal Doppler)
Pre-eclampsia complications maternal
CNS
Eclampsia
Intracranial haemorrhage/Stroke
Cortical blindness
Renal
Renal tubular necrosis (Acute kidney injury)
Respiratory
Pulmonary oedema
Liver
HELLP Syndrome (Haemolysis, elevated liver enzymes, low platelets)
Liver capsule haemorrhage
Liver rupture
Haematological
DIC
VTE
Placenta
Placental abruption
FETUS
- stillbirth
- small for gestational age
- prematurity
Pathophysiology of pre-eclampsia
Failed trophoblastic invasion & adaptation of spiral arteries
Reduced placental perfusion and placental ‘ischaemia’ ® oxidative stress ® endothelial dysfunction
- High levels of circulating pro-inflammatory cytokines -> Endothelial dysfunction -> Increased capillary permeability -> Release of vasoconstrictive substances such as thromboxane A2 and endothelin
Decrease in prostacyclin synthesis
NOT NORMAL AS PROGESTRONE SHOULD RELAX NAD BP SHOULD BE LOW
Increased ECF volume secondary to endothelial damage raised filtration pressure (BP) low colloid oncotic pressure and capillary leakage No increase in COP or blood volume systemic vascular resistance
Symptoms of pre-eclampsia
Headache Visual disturbance Sudden increase in swelling Generally unwell Vomiting Reduced fetal movements Abdominal pain Bleeding
signs of pre-eclampsia
HypertensionProteinuria Non dependent oedema Hyperreflexia/clonus Fetal growth restriction Oligohydramnios Abnormal fetal Doppler
what factors determine if you van delay or deliver???
gestation -> >37w deliver
- severity of maternal disease
- speed of progression (fulminating pre-eclampsia)
- Presence of Complications (HELLP etc)
- Fetal wellbeing
define eclampsia
Seizuresoccurring in pregnancy or within 10 days of delivery and with at least two of the following features documented within 24 hours of the seizure:
- Hypertension
- Proteinuriaone “plus” or at least 0.3 g/24 h
- Thrombocytopenialess than 100 000/μl
- Raised transaminases
Mx of eclampsia
ABCDE
- IV Access
- Bolus of 4g Magnesium Sulphate
Continuous infusion of Magnesium Sulphate 1g/h over 24hrs - Control hypertension
- If antenatal- plan for delivery by most appropriate route
- Fluid balance
- HDU care
postnatal Mx
may require Mx for 6-12 weeks
increased risk of VTE, PET - bloods
contraception before discharge
BP targets
systolc <150
diastolic 80-100
