Hypertensive disease Flashcards
What should be taken prophylactically from 12 weeks for people at risk of pre-eclampsia?
low dose aspirin (75mg OD)
For how long in pregnancy does the BP usually drop?
until ~20-24 weeks
Increases to pre-pregnancy BP till term
High risk groups for pre-eclampsia?
Previous HTN disease of pregnancy Chronic HTN (30% --> pre-eclampsia) Chronic kidney disease DM Autoimmune e.g. SLE
Pregnancy induced HTN
After 20 weeks, 5-7% pregnancies
No oedema or proteinuria
Resolves after birth (usually ~1 month)
HELLP syndrome
Haemolysis (will also cause raised LDH)
Elevated Liver enzymes
Low Platelets
Key management:
IV magnesium sulphate to prevent seizures
IV dexamethasone
BP control - labetalol (can use methyl dopa/nifedipine)
Blood transfusions (as needed)
What problems does pre-eclampsia predispose to?
Foetus: prematurity, IUGR
Eclampsia
HELLP syndrome
Haemorrhage: Placental abruption, intra-abdominal, intracerebral
Cardiac / multi-organ failure
Risk factors for pre-eclampsia?
Age >40
BMI>30
Diabetes, obesity
PMH of pre-eclampsia (15% recurrence), HTN and/or renal disease
FH
Nulliparity/new partner (6% nulliparous women)
10 years since last pregnancy
Multi-pregnancy
Features of pre-eclampsia?
HTN (typically 170/110)
Proteinuria (later sign than BP rise)
Red flags: Headache Visual disturbance and papilloedema RUQ/epigastric pain Oedema
Others:
N+V
Drowsiness
Hyperreflexia
Platelet count <100x10^6, abnormal liver enzymes
If treating HTN with methyl-dopa what should be done after birth?
Switch to ACE-i - risk of depression
Anti-HTN used in pregnancy
B-blockers - e.g. labetalol
Methyldopa
Nifedepine
Hydralazine
NB. NOT ACE-i = feto-toxic
Target BP in pregnancy induced HTN?
150/90
After birth when is BP highest?
3-4 days post-partum
Epigastric painm, visual disturbance, proteinuria = postpartum pre-eclampsia
Examination red flags in pre-eclampsia?
Peri-orbital oedema
Clonus >beats
Fits (eclampsia)
Hyper-refelxia
Others: confusion, placental abruption
Classification of pre-eclampsia?
Mild: 140-9/90-9
Moderate: 150-160/100-10
Severe: 160+/110+ or <34 weeks or maternal complications
Maternal complications of pre-eclampsia?
Eclampsia CVA HELLP DIC Liver and renal failure Pulmonary oedema
Foetal complications of pre-eclampsia?
IUGR
Pre-term birth
Placental abruption
Hypoxia
Investigations
PCR = >30mg/l
or
24/hr collection = 0.3g
Monitor maternal complications:
Bloods: U+E, LFT, LDH, FBC, uric acid
Monitor foetal complications:
USS - weight
Umbilical artery doppler
CTG
Management of pre-eclampsia?
Admit if symptomatic, proteinuria, BP>160/110
Drugs: Labetelol, nifedepine, methyl dopa (aim for 140/90) - improves maternal outcomes
Magnesium sulphate in severe disease
Steroids if <34 weeks
Timing of delivery
If mild - before 37 weeks
Moderate-severe: delivery 34-37
If severe with complications then always urgently deliver
<34 weeks:
Conservative management and monitoring in specialist unit + steroids + weight up risk/benefit
CTG
Fluid balance and bloods
Conduct of delivery
<34 weeks: CS
>34 weeks: induction with PGE2
Epidural helps decrease BP Continuous CTG BP and fluid balance Antihypertensives Maternal pushing should be avoided if BP >160/110 in second stage Ocytocin>ergometrine
Post-natal care
Can take 24hrs for severe disease to improve, treatment may be required for several weeks
Monitor bloods - liver enzymes, platelets, renal function
Fluid balance: catheter, caution of pulmonary oedema with fluids
If fluid balance is down –> CVP
Can give furosemide
Eclampsia
1-2% of pre-eclampsia - most common after delivery
Tonic-clonic seizures
Management of eclmapsia?
ABC - may need oxygen/intubation
Turn patient onto side
Magnesiun sulphate:
- controls fits
- IV loading dose 4g over 10 mins
- then 1g/hr for 24 hrs
- if further fits - give 2g bolus
Control HTN:
- IV labetalol (avoid in asthmatics)
- Oral nifedepine
CTG if antepartum
Deliver baby once stable
HELLP syndrome
Haemolysis (microangiopathic)
Elevated liver enzymes
Low platelets
Symptoms:
RUQ/epigastric pain
N+V
