HYPERTENSION/PET Flashcards

Question

How many women with GH will get PET?

Answer 1

Treatment goals - 110-140/85 ( cease or reduce if diastolic < 80) IHSSP Monitoring - growth monitoring particularly if uric acid high ( IHSSP) - UA 1-2 x week, - weekly PET bloods, - USS growth at time of dx and 2 weekly from 24/40 if IUGR or 26/40 normally grown ( IHSSP) - AFI/dopplers weekly or more if increased UA resistance (IHSSP) Delivery (IHSSP) - no later than 34/40 if absent EDF - 30/40 if reversed EDF < 30/40 ( + admit, 3 x weekly AFI/dopplers, daily CTG) - CS if REDF, AEDF or very preterm - immediately if severe HT > 3 agents, worsening PLT/LFTs, euro symptoms, REDF, pulm oedema, non- reassuring petal status (not proteinuria) intra/post partum ( IHSSP) - MgS04 severe HT, severe HA, per persistent/repeat visual change, - Fluid restrict 60-80mL.hr - BP 4-6 hourly for 3 days - avoid NSAID - Repeat abn. PET bloods - Taper meds after 3-6 days - RV with GP in one week. 3m RV to ensure resolved - IX for ongoing symptoms

Answer 2

1. No set of tests reliably predict women who will get PET 2. A combination of markers can be used; - UA dopplers - angiogenic factors ( best for early onset but only comprises 10% of HTN) esp sFLT1 ( placental hypoxia releases into circ. These mop up VEGF and PlGF (these factors cause angiogenesis) --> antiangiogenesis (^ ASPRE trial for prevention PTB used these 2 factors to predict and prevent PTB with aspirin 150mg nocte) - PAPPA, homocysteine, uric acid PP13, lepton, urinary albumin, calcium) BUT NOT WIDELY ESTABLISHED

Answer 3

Major - Prior PET - Chronic HT - pre existing TIIDM - BMI > 30 - APLS - ART Minor x 2 - AMA - fam hx PET - short duration of sexual relationship - primiparity - primipaternity - connective tissue disorder ( no assoc. with thrombophilias, FVL may be a RF) * Use below <160/40 ideally but definitely < 20/40

Answer 4

Predicts likelihood of composite severe maternal adverse outcomes using information gathered infers 48h of admission a. GA b. Chest pain c. O2 sat d. PLT count e. Creat f. ALT

Answer 5

Poorly understood Primarily placental disorder ( resolved when placenta delivered) Theories 1. Abnormal placental endovascular invasion Phase 1: impaired trophoblastic invasion into spiral arterioles 20/40 = poorly perfused placenta + Phase 2: placenta has inflammation response and releases factors into maternal circulation --> endothelial dysfunction 2. widespread endothelial dysfunction. Predominance of vasoconstrictive substances ( endothelia, TXAa2) over vasodilators ( prostacyclin). = Increased vasc. permeability --> oedema = Injury --> increased fibronectin--> increased PLT agg --> depressed ATIII levels -->HELLP, coagulopathy =Cerebral vasospasm --> oedema, disruption of BBB = Glomerular endotheliosis (structural changes in glomerulus) - Swelling of endothelial cells, subendothelial fibrinoid deposition, mesangial cell interposition--> reduced GFR-> renal insufficiency 3. imbalanced maternal conc. angiogenic v antiangiogenic factors 5.Immunological factors • Evidence: prior exposure to paternal/fetal antigens appears to protect against preeclampsia (higher rates in nulliparous, long inter-pregnancy interval, use of barrier contraception, new partner) 6. Genetic predisposition • Evidence: P0 women with a family history of preeclampsia have a 2-5x higher risk • Both maternal and paternal contributions to fetal genes may have a role • Candidate genes - Genes for sFlt-2 and Flt-1 on chromosome 13; trisomy 13 → higher risk of pre-eclampsia - Locus at 12q → ? linked to HELLP; alterations in non-coding RNA at 12q23 – regulates a large set of genes that may be important for extravillous trophoblast migration 7. Increased sensitivity to antiogensin II

Answer 6

Aim: To determine if IOL in women with PIH or Mild PET reduced severe maternal morbidity Study: Multi-centre RCT 750 women 36-41 weeks Interventions – IOL Vs Expectant Primary: Composite of poor maternal outcome. Mortality + sequele of PET Secondary: MOD and neonatal Results ITT analysis – Reduced maternal morbidity, NNT 8 – 31 vs 44%, RR 0.7, 13/1000 fewer outcomes – Reduced CS (not statistically different). No difference in neonatal outcomes – Results more pronounced with unfavorable cervix Criticism – Neonatal outcome was only for short term. Worsening PET defined by single BP not two 6 hours apart CONCLUSION: IOL SHOULD BE ADVISED FOR WOMEN WITH GEST HTN OR MILD PET > 37 WEEKS GESTATION ? what is mild defined by

Answer 7

Aim: To assess the safety effect of low dose aspirin on fetal and neonatal morbidity in pts at high risk of PET and IUGR Study: Multi centre (213) RCT 9300 women, 12-32 weeks, Interventions – Low dose Aspirin 60mg or placebo for – Prophylaxis (74%) / treatment (12%) PET – Prophylaxis (12%) / treatment (3%) IUGR Primary: Proteinuric PET, Duration of pregnancy, Birth weight/IUGR FDIU/SB. Results – No-sig reduction in PET by 12%. Significant trend toward reduced proteinuric PET with more preterm delivery – Reduced in preterm delivery 22 vs 19 2.5 /1000 women – No increased harm – bleeding, for maternal/placental/fetal Criticism – PET defined as 1+ proteinuria, started after 12 weeks, small numbers in each group - Aspirin dose too low (60mg vs. 100-150mg) - Aspirin not started early 2nd trimester (<16 weeks) – started 12-32 weeks which may be too late (60% AT 12-20 weeks, 27% at 20-28 weeks, 11% >28 weeks!) Some women receiving treatment already had symptoms/signs PET/IUGR so started too late CONCLUSION: LOW DOSE ASPIRIN USE MAY PREVENT EARLY ONSET PET IN WOMEN AT RISK OF SEVERE PET WITH PTB. FINDINGS DOE NOT SUPPORT PROPHYLACTIC OR THERAPEUTIC USE FOR ALL WOMAN AT RISK OFIUGR/PET

Answer 8

Aim: To determine if MgSO4 prevents eclampsia Study: RCT Multicentre (33 countries) 10 000 antenatal women or < 24 hrs postpartum, BP >140/90 + 1+ proteinuria, Interventions – MgSO4 vs placebo Primary: Eclampsia Results ITT analysis – MgSO4 58% lower risk of eclampsia, 11/ 1000 fewer, NNT 63 with severe PET, or 109 for mild PET – Maternal mortality lower for MgSO4 RR 0.55 (non sig) – Reduced riks of placental abruption RR 0.67 – Greater SE profile in Mg group Criticism – No threshold established for treatment – clinical unsure for benefit – Clinical applicability – high NNT in lower PNM countries – CONCLUSION: MgS04 HALVES THE RISK OF ECLAMPSIA AND PROBABLY REDUCED RISK FO MORTALTIY

Answer 9

Early exposure may lead to cardiovascular and CNS malformations Later exposure leads crosses placenta --> interference with renal fetal haemodynamics ( fall in GFR can cause decreased fetal urine production Can also lead to limb contracture, craniofacial changes, pulmonary hypoplasia