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Obstetrics > Hypertension In Pregnancy > Flashcards

Hypertension In Pregnancy Flashcards

1
Q

What was the outcome of the CHIPS trial?

A

There was increased incidence of severe HTN in the patients randomized to “less-tight” DBP control (<100 mmHg) compared to the “tight” (DBP < 85 mmHg) control. In a post-hoc analysis, those with severe HTN had increased risk of pregnancy loss, need for high-level neonatal care > 48 hours and pre-term delivery.

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2
Q

What is pre-existing HTN in pregnancy defined as?

A

Dx prior to 20 weeks gestation.

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3
Q

What is the definition of gestational HTN?

A

Diagnosis of HTN > 20 weeks gestation.

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4
Q

What is the definition of severe HTN in pregnancy?

A

SBP > or = 160 mmHg

OR

DBP > or = 110 mmHg

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5
Q

What is the BP cutoffs for diagnosis of non-severe HTN in pregnancy?

A

Average of 2 measurements, 15 minutes apart.

Office:
SBP ≥ 140 or DBP ≥ 90mmHg

Ambulatory BP Monitoring:
SBP ≥ 135 or DBP ≥ 85mmHg

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6
Q

What are the first line therapies in hypertension during pregnancy?

A

Labetalol
Methyldopa
Long-acting oral nifedipine
Some B-Blockers (metoprolol, propranolol)

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7
Q

Which beta-blocker do you need to avoid during pregnancy and breast feeding? Why?

A

Atenolol

Associated with IUGR in pregnancy.
Associated with fetal bradycardia in breast feeding.

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8
Q

Which ACEi are safe during lactation?

A

Enalapril
Captopril
Quinapril

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9
Q

What are the consequences of ACEi/ARBS in pregnancy?

A

Fetal renal agenesis
Oligohydramnios
Pulmonary aplasia

** especially in the 2nd & 3rd trimester

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10
Q

What are some second line options for HTN tx in pregnancy?

A

Hydralazine
Clonidine
Thiazides (but associated with fetal renal toxicity)

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11
Q

What are your starting doses of some commonly used anti-hypertensives in pregnancy?

A

Labetalol 100 mg BID to TID
Methyldopa 250 mg BID
Nifedipine XL 30 mg daily

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12
Q

What are the maximum doses of your typical anti-hypertensives in pregnancy? (3)

A

Labetalol 300 mg QID (1200 mg daily total)
Methyldopa 500 mg QID (2g daily max)
Nifedipine XL 60 mg BID (120 mg daily max)

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13
Q

What are 3 options to treat severe HTN during pregnancy?

A
  1. Labetalol 10-20 mg IV Q30 min
  2. Hydralazine 5-10 mg IV Q30 min
  3. Nifedipine IR 5-10 mg PO (chew) Q30 min
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14
Q

What are the fetal risk factors for pre-eclampsia during pregnancy? (3)

A

Multiple gestation
Hydrops fetalis
Molar pregnancy

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15
Q

What are the maternal risk factors for pre-eclampsia in pregnancy? (6)

A 
Previous pre-eclampsia
Chronic HTN
Renal Disease
Diabetes
Auto-immune Disorders (SLE, APLA)
Obesity
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16
Q

What are the epidemiological risk factors for pre-eclampsia in pregnancy? (5)

A 
First pregnancy
New partner
IVF
Family Hx
Age < 20 or > 35
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17
Q

What is the definition of pre-eclampsia?

A

Hypertension (either BP >140/90 x 2 or >160/110 x 1) PLUS one of:

1) New or worsening proteinuria.
2) One or more adverse conditions, including maternal symptoms, lab abnormalities, or fetal complications.
3) One more severe complications.

18
Q

What are the CNS symptoms considered to be an adverse condition in pre-eclampsia?

A

Headache

Visual symptoms/changes

19
Q

What are the CNS features considered to be severe complications in pre-eclampsia (other than eclampsia itself)? (4)

A

PRES
Cortical Blindness
GCS < 13
Stroke, TIA or reversible ischemic neurological deficit

20
Q

What are the the cardio respiratory features considered to be adverse conditions in pre-eclampsia? (3)

A

Chest pain
Dyspnea
SpO2 < 97%

21
Q

What are the cardio respiratory features considered to be severe complications of pre-eclampsia? (5)

A 
Uncontrolled HTN (>160/110 over 12h despite 3 antihypertensives)
O2 <90%
Need for >50% O2 for 1 hr
Intubation
Pulmonary Edema
22
Q

What are the hematologist abnormalities considered to represent adverse conditions of pre-eclampsia?

A

Elevated WBC
Elevated INR or aPTT
Low Plt < 100

23
Q

What are the hematologic features that are considered to be a severe complication of pre-eclampsia?

A

Plt < 50

Transfusion of any blood product

24
Q

What are the renal features that are considered to represent adverse conditions of pre-eclampsia? (2)

A

Elevated serum creatinine

Elevated serum uric acid

25
Q

What are the severe renal complications of pre-eclampsia?

A

AKI (Cr >150 no prior renal disease) New indication for dialysis

26
Q

What are the hepatic abnormalities considered to represent adverse conditions of pre-eclampsia?

A 
N/V
RUQ or epigastric pain
Elevated AST, ALT, LDH
Elevated bilirubin
Low alb* (than expected based on dilution effects of pregnancy)
27
Q

What are the severe hepatic complications of pre-eclampsia?

A 
Liver dysfunction (INR>2 without DIC or warfarin) 
Hepatic hematoma or rupture
28
Q

What are fetal-placental abnormalities represent adverse conditions of pre-eclampsia?

A

AbN FHR
IUGR
Oligohydramnios
Absent or reversed End diastolic flow

29
Q

What are the severe fetal-placental complications of pre-eclampsia?

A

Abruption

Reverse ductus venosus A wave Stillbirth

30
Q

When should antenatal steroids be considered for women with pre-eclampsia?

A

Should be considered for all women who present with pre-eclampsia at < or = 34 + 6 weeks gestation

31
Q

What is the first line treatment for seizures in pregnancy related to eclampsia?

A

Magnesium sulfate 4 gram loading dose then 1-2 grams per hour x 24 hours.

32
Q

What are the toxic effects of eclampsia TREATMENT?

A

Magnesium Toxicity:

Symptoms: Respiratory suppression, bradycardia, hypotension and reduced LOC.

33
Q

How do you monitor for magnesium toxicity in eclampsia?

A

NOT Mg levels

Need to monitor urine O/P (everyone needs a Foley) and reflexes (decreased)

34
Q

How do you treat Mg toxicity?

A

Stop Mg
Give calcium gluconate
Dialysis

35
Q

What are the indications for delivery in pre-eclampsia?

A
  1. Immediate delivery if severe pre-eclampsia
  2. Refractory maternal symptoms: resistant HTN, persistent Sx, end-organ damage
  3. Fetal complications: IUGR, Doppler abnormalities, fetal distress
  4. ALL women at term: > 37 weeks gestation
36
Q

What does pre-eclampsia put women at risk for in the post-partum period?

A

4x increased risk of chronic HTN

2x increased risk of heart disease, stroke, VTE and diabetes

37
Q

Which medications do you give patients for pre-eclampsia prevention?

A

ASA 81-162 mg daily

Calcium 1000 mg daily if low dietary intake

38
Q

What are the indications for ASA in pregnancy? (8)

A
  1. Previous pre-eclampsia
  2. Chronic HTN
  3. Type 1 or 2 Diabetes
  4. CKD
  5. SLE
  6. APLA syndrome
  7. Multiple Gestation
  8. Two or more minor factors (ex. nulliparous or new partner, IVF, Age >35, BMI>30, first degree family history of pre-eclampsia)
39
Q

What are the minor factors that puts a women at risk for pre-eclampsia? (6)

A 
Nulliparous
New partner
IVF
Age >35,B
MI>30
First degree family history of pre-eclampsia
40
Q

What is the BP target in pregnancy?

A

DBP < 85

41
Q

What are the complications of ACEi/ARB use in pregnancy (3)?

A

(1) Fetal Renal Agenesis
(2) Oligohydramnios
(3) Pulmonary Aplasia

Especially in T2/T3

42
Q

Which trial showed the benefit of ASA in prevention of pre-eclampsia?

A

ASPREE

Obstetrics (9 decks)

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