Hypertension in pregnancy - Busy SpR + NICE Flashcards
What’s the most common cause of death in women with PET/eclampsia?
Cerecrovascular events - ICH
What % of women with PET delivery before
- 34 weeks
- 37 weeks
- 10% before 34 weeks
- 50% before 37 weeks
What is the recurrence risk of PIH/PET if had any previous hypertension?
1 in 5
If previous any HTN in this or previous pregnancy
- Risk gestation HTN
- Risk PET
- Gestational 9% (1/11)
- PET 14% (1/7)
If previoud PET, risk of
- Gestational HTN
- PET
- Chronic HTN
- 6-12% 1/8
- 16% 1/6 (if 28-34 33%1/3)
- 2% 1 in 50
If PET <34/40 risk of PET in this pregnancy?
1/3
Risk greater if >10 year interval
If previous gestational HTN
- Risk gestation HTN
- PET
- Chronic HTN
11-15% 1/7
PET: 7% 1/14
Chronic 3% 1/34
Risk chronic HTN if previous
- PET
- PIH
- PET 1 in 50 2%
- PIH 1 in 34 3%
According to NICE which high risk women should take 150mg aspirin from 12 well?
hypertensive disease during a previous pregnancy
chronic kidney disease
autoimmune disease such as SLE or antiphospholipid syndrome
type 1 or type 2 diabetes
chronic hypertension
According to NICE what are the moderate risk factors for PET, if more than one should take aspirin
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
multiple pregnancy
What BP os considered severe HTN?
> 160/110 - these women should be admitted to hospital
According to NICE how to manage someone with BP >160/110.
-Target BP
- Frequency observations
- Fetal assessment
-Frequency bloods/urine dip
- admit to hospital
- Give antihypertensives aiming 135/85
- Every 15-30 mins until BP below 160/110
- Daily urine dip and bloods as inpatient
- PLGF on 1 occasion
- Fetal auscultation at every visit, USS 2 weekly, CTG as Dx
According to NICE how to manage 140/90-159/109
- How often urine/bloods
- PLGF ration
- Fetal assessment
Treat if BP remains >140/90 aiming 135/85
BP and urine 1-2 weekly
Bloods at presentation then weekly
PLGF ratio x 1
Fetal USS 2-4 weekly, fetal auscultation at every AN
When to reduce anti-hypertensives
<130/80
For women with PIH postpartum, when should their BP be measured?
Day 2 after birth
1 x between day 3-5
As clinically indicated if antihypertnesices change
What medication should be offered 1st line to treat BP in postnatal period (non black women)?
Enalapril - monitor renal function and K
What medication should be offered 1st line to treat BP in postnatal period for black women?
Nifedipine or
amlodipine if used before
If not controlled use combination
When does NICE say need to admit for PET?
Creatinine >90
ALT >70 x upper limit
Fall in platelets
Signs eclampsia/pulmonary oedema
Suspected Fetal compromise
What is the dose of magnesium sulphate given to women to previous eclamptic seizure?
IV 4g loading 5-15 mins, 1g/hour for 24 hours (continue 24 hours after last seizure)
Recurrent first, further 2-4g IV
If PET and is only passing 5-10ml/hour of urine, what should the fluid input be?
80ml/hr
What feature may mean you need to deliver <37 weeks in PET?
inability to control BP despite using 3 or more classes of antihypertensives in appropriate doses
SPO2 less than 90%
progressive deterioration in liver function, renal function, haemolysis, or platelet count
ongoing neurological features, such as severe intractable headache, repeated visual scotomata, or eclampsia
placental abruption
reversed end-diastolic flow in the umbilical artery doppler, a non-reassuring CTG, or stillbirth.
Postpartum, PET and no antihypertensives
when should be BP be measured?
4 x day as inpatient
1 x Day 3-5
Alt dats until normal, if abnormal day 3-5
Commence antihypertensives if BP >150/100 on 2 occasions
Postpartum, PET on antihypertensives:
4 x day inpatient
1-2 days for 2 weeks until off treatment
Consider reducing if <140/90, reduce if <130/80
If patient on methyldopa for PET when should it be chanced
Within 2 days
If PET when should see GP
2 and 6 weeks
What class of receptors does labetolol block?
Selective, competitive alpha-1-adrenergic
Non-selective, competitive, beta-adrenergic
What effect dose labetolol have on the cardiovascular system?
Dose-related fall in BP without reflex tachycardia, no sig reduction in HR
Elavated renin
Half life of IV and PO labetolol
IV 5.5 hrs
PO 6-8hrs
Is the half life of labetolol effected by decreased liver or renal function?
no
How is labetolol metabolised?
Conjugated with glucuronides which are exerted in urine and bile
Does labetolol cross the placenta?
Yes
In PET what happed to sFLT-1 levels
They rise
In PET what happed to PIGF levels
Lower
In normal pregnancy when does the PIGF level peak?
26-30 weeks, then decreases
What is the sFLT/PIGF ratio used for?
To help rule out pre-eclampsia
Cut of values for sFlt-1/PIGF ratio 20-33+6 weeks
Rule out <33
Rule in >85
Cut of values for sFlt-1/PIGF weeks 34 weeks - delivery
Rule out <33
Rule in >110
If PET and BP >160/110. How to manage:
- frequency BP
- Urine dip
- PET bloods
- Fetal assessment
Admit
Treat BP aiming 135/85
BP every 15-30 mins until >160/110, then 4 x day as inpatient
Only repeat urine dip if clinically indicated
PET bloods 3 x week
USS 2 x weekly, FH each ANC
PET and BP 140/90-159/109
Admit if clinical concerns mother/baby, high score on full PIERS PREP-S
Tx if BP remains >140/90, aim 135/85
BP every 48 hrs, unless admitted
PET bloods 2 x weekly
USS 2 weekly, FH at each ANC
When to consider delivery <37/40 for PET>
Inability to contol BP 3+ antihypertensives
Pulse Oximeter 90%
Progressive deterioration in bloods
Ongoing neurological - headache
Abruption
Reversed end diastolic flow in UAD, non reassuring CTG, still with
Senior decision
PET no antihypertensives, when to offer PN BP measurement
BP 4 x a day as inpatient
1x Day 3-5 (if abnormal alt days_
Tx if >150/100
PET on antihypertensives, when to offer PN BP measurement
BP 4 x a day as inpatient
Every 1-2 days for up to 2 weeks
Reduce if <130/80
2 week GP and 6-8 weeks
In PET if ongoing proteinuria at 6-8 week GP check
Review again with GP or specialist in 3 months
When to consider MgSU
Severe PET and birth within 24hrs
Consider 1+
- Worsening severe headache
- Visual scotomata
- N+V
- Epigastric pain
- Oliguria + severe HTN
- Progressively worsening bloods
Dose of MgSu
4g 5-15mins
1g/hr in 24 hours
How much fluid restriction
80ml/hr unless ongoing losses (haemorrhage)
