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Obstetrics and gynaecology > Hypertensive conditions - Essential HTN, Pre-eclampsia and eclampsia > Flashcards

Hypertensive conditions - Essential HTN, Pre-eclampsia and eclampsia Flashcards

1
Q

Describe the normal BP physiological changes in pregnancy

A

BP initially falls
Stabilises in 2nd trimester - usually 15mmHg lower than pre-pregnancy
Rises in third trimester
Reaches pre-pregnancy levels at term

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2
Q

Define pre-eclampsia

A

New hypertension presenting after 20 weeks (on more than 2 occasions >4hrs apart) AND significant proteinuria

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3
Q

What percentage of pregnancies are complicated by hypertension?

A

10-15%

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4
Q

What percentage of pregnancies are complicated by pre-eclampsia?

A

3-5%

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5
Q

How many UK pregnancies are complicated by eclampsia?

A

1 in 3000

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6
Q

Describe what happens in pre-eclampsia

A

Abnormal trophoblast invasion and differentiation in the 1st trimester

Failure of trophoblast cells to destroy the muscularis layer of the spiral arteries - Underdeveloped spiral arteries

Failure to transform into low resistance vessels

Reduction of blood flow to the intervillous space

Uteroplacental ischaemia - poorly perfused placenta

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7
Q

What happens as a result of the defective placenta?

A

Toxic factors release
Influence of ischaemia leads to endothelial damage, redistribution of fluid, protein leakage through kidneys, vasoconstriction, activation of the coagulation system

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8
Q

List some risk factors for pre-eclampsia

A 
Obesity
Age >40 
Genetic predisposition - sister greater risk than mother 
Multiple pregnancy 
Primip 
Long birth interval 
Hydrops with large placenta
Hydatidiform mole
Triploidy 
Pre-existing HTN
CKD
DM
Antiphospholipid antibodies
Connective tissue disease
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9
Q

List some clinical features of pre-eclampsia

A 
HTN
Proteinuria
Oedema
Headaches
Visual disturbances
Epigastric pain 
Clonus
Rib pain 
Vomiting
IUGR
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10
Q

What are some complications of pre-eclampsia

A

Maternal:

  • Eclampsia (seizures)
  • Cerebral haemorrhage
  • Pulmonary oedema
  • Pulmonary embolism
  • Renal failure (AKI)
  • HELLP syndrome, liver haemorrhage and rupture
  • Disseminated intravascular coagulopathy

Foetal:

  • Placental abruption
  • Oligohydramnios
  • Foetal growth restriction
  • Increased risk of HTN
  • Increased risk of stroke
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11
Q

What clinical picture is seen in HELLP syndrome

A

Haemolysis
Elevated liver enzymes
Low platelets

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12
Q

What is eclampsia

A

One or more tonic clonic seizure in association with features of pre-eclampsia and not attributable to any other cerebral pathology

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13
Q

What percentage of woman with eclampsia have symptoms of pre-eclampsia?

A

1/3

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14
Q

Describe the management of pre-eclampsia

A

Monitoring
VTE prevention - LMWH
Antihypertensive - labetalol
Delivery , nifedipine, methyldopa

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15
Q

Describe post natal care of pre-eclampsia

A

Usually resolves following delivery of placenta, however monitor mother for at least 24hrs post partum

Blood pressure monitored daily for first 2 days and then at least once 3-5day post partum and the need for antihypertensive should be assessed

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16
Q

What class of drug is labetalol?

A

Beta blocker

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17
Q

List the side effects of labetalol

A 
Postural hypotension
Fatigue
Headache
Nausea
Vomiting
Epigastric pain
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18
Q

What class of drug is nifedipine?

A

Calcium channel blocker

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19
Q

List the side effects of nifidipine

A 
Peripheral oedema
Dizziness
Flushing
Headache
Constipation
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20
Q

What drug class is methyldopa

A

Alpha agonist

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21
Q

List the side effects of methyldopa

A 
Drowsiness
Headache
Oedema
GI disturbance
Dry mouth 
Postural hypotension 
Bradycardia
Hepatotoxicity
22
Q

Which drug group of antihypertensive are contraindicated in pregnancy and why?

A

ACE inhibitors

Association of congenital abnormalities

23
Q

What investigations should be done in pre-eclampsia

A 
BP monitoring
Urine dipstick 
24hr urinary collection 
FBC - decreased Hb and platelets 
U&Es - increased urea, creatinine, urate and decreased urine output
LFTs - increased ALT and AST
24
Q

Which investigations should be done in eclampsia

A 
FBC
U&Es
LFTs
Clotting studies
Blood glucose 
Neurological examination - clonus
25
Q

Describe the immediate management of eclampsia

A

ABCDE assessment
Left lateral position
Secure airway and high flow O2 in non-rebreathe mask

2 large bore cannula

BP monitoring

Magnesium sulphate to stop seizures and also maintenance after as prophylaxis (4g in 100ml0.9% NaCl)

Control BP - labetalol and hydralazine (target MAP of <120mmHg)

Continuous CTG monitoring

Prompt delivery of baby and placenta if needed - caesearean section/vaginal delivery

Monitoring - fluid balance, BP

26
Q

Describe the inpatient management of eclampsia

A

Regular symptoms review - headaches and epigastric pain

Bloods 72hr post partum - FBC, LFT, creatinine

Pre-conceptual counselling

Step down care to community when BP target reached and asymptomatic

27
Q

Describe the community care after eclampsia

A

CT head if neurology
BP checked daily for 2 weeks post partum
Follow up at 6 weeks - BP, proteinuria, creatinine, FBC, FSTs and creatinine

28
Q

What is hypertension

A

> 140/90 on two separate occasions

29
Q

What is considered significant proteinuria?

A

Urine protein: creatinine ratio >30

24hr urinary protein >300mg

30
Q

What is a hypertensive woman <20 weeks gestation considered to have and why?

A

Pre-existing/essential hypertension as BP usually falls in first trimester

31
Q

Above what mean arterial pressure is maternal and foetal morbidity and mortality increased?

A

90

32
Q

List some risks related to pre-existing/essential hypertension in pregnancy

A 
Superimposed pre-eclampsia
Placental abruption 
Foetal growth restriction 
Intracerebral haemorrhage 
Maternal cardiac failure 
Intracranial haemorrhage 
Maternal death
33
Q

Describe pregnancy induced hypertension

A

BP >140/90 on two separate occasions
>20/40 gestation
No significant proteinuria

34
Q

What are the different severities of pre-eclampsia?

A

Mild - BP 140/90 - 150/100
Moderate - BP 150/100 - 160/110
Severe - BP >160/110 or BP<160/110 but >2 signs/symptoms of severe pre-eclampsia

35
Q

Describe the blood tests in pre-eclampsia and possible results

A 
FBC - decreased Hb and platelets - <100
U&Es - creatinine >100 
Uric acid - raised
LFT - ALT>50 
Clotting
36
Q

Does the presence of hypertension and proteinuria always signify pre-eclampsia?

A

No - could be essential hypertension or renal disease - consider the gestation and onset

37
Q

Is the presence of oedema a useful diagnostic sign?

A

No as can be normal in normal pregnancy

More specific if facial oedema however

38
Q

Describe what happens to the liver in pre-eclampsia

A

Vasoconstriction in hepatic bed
Periportal fibrin deposits, haemorrhage and hepatocellular necrosis
Elevated liver enzymes
Rarely - hepatic infarction and rupture of liver capsule

39
Q

Describe what happens to the brain in pre-eclampsia

A 
Cerebral vasoconstriction 
Oedema
Membrane destabalisation 
Focal ischaemia
Seizures
Haemorrhage
40
Q

When can seizures from eclampsia occur

A

Antenatally - 38%
Intrapartum - 18%
Postnatally - 44% usually within the first 24-48hrs post partum

41
Q

What is HELLP syndrome associated with?

A 
Eclampsia
DIC
Placental abruption 
Acute renal failure
Pulmonary oedema
42
Q

What percentage of women with HELLP syndrome will require a blood transfusion or blood products?

A

50%

43
Q

What is used to prevent pre-eclampsia?

A

150mg aspirin daily from 12 weeks in moderate-high risk women

44
Q

How is pre-eclampsia screened for in high risk women?

A

1st and 2nd trimester uterine artery dopplers
Placental growth factor
1st trimester PAPP-A levels

45
Q

What is PAPP-A

A

Pregnancy associated plasma protein

Produced by placenta

46
Q

Describe recommended delivery in women with pre-eclampsia

A

C/S if <34 weeks
MgSO4 if <32 weeks for foetal neuroprotection
Vaginal delivery if >34 weeks, aim for short second stage and IV oxytocin for the 3rd stage

47
Q

Which drugs should be avoided in the 3rd stage of labour with pre-eclampsia and why?

A

Ergometrine or synometrine - increases BP

48
Q

What is the most important/most specific sign of pre-eclampsia to be elicited

A

Brisk tendon reflexes/clonus

49
Q

Which drug is given to reverse the respiratory depressive effect of too much magnesium sulphate in eclampsia?

A

Calcium gluconate

50
Q

How long should magnesium sulphate be continued postpartum?

A

24 hrs after delivery or after last seizure

Obstetrics and gynaecology (67 decks)

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