HYPERTENSIVE DISEASES OF PREGNANCY Flashcards
What are the risk factors of HDP according to ISSHP?
CAMP MAP
- chronic HT
- anti-phospholipid syndrome(SLE)
- Multiple pregnancy
- Prior pre-eclampsia
- maternal BMI > 35
- Assisted reproduction
- pre-gestational DM
What is the importance of HDP?
- Leading cause of maternal mortality(MM) globally and 2nd leading in SA(18%)
- eclampsia and pre-eclampsia are the leading HDP that cause death
- since pre-eclampsia affects the endothelium, it is a multi-organ disease
- 60% of HDP deaths due to substandard care
- 75% of these are preventable
What’s the standard protocol of measuring BP?
- use a sphygmomanometer that’s indicated for pregnant women
- Woman must be in sitting position, legs uncrossed, relaxed, arm free of clothes at the level of the heart
- Hypertension>= 140/90mmHg. This should be checked again in 15 minutes if there are slight elevations in BP between 140-150mmHg
- Assess for obesity-BMI>=33 or MUAC >=35
What’s borderline BP/ pre-HT in low risk pregnant women and how is it dealt with and managed?
When systolic BP is 135-139 and diastolic BP is 85-99.
- BP must be repeated within 30mins to 2hrs.
- If still in this range, send home and call after 7 days.
- If lower, pt is low risk and if still between range, pt has pre-HT
Administer 500mg Ca supplements daily for all pregnant woman at any gestational age to reduce pre-eclampsia
How is proteinuria detected and why is this important?
- visual dipstix
- protein:creatinine ratio>0.3 = proteinuria
- 24hr urine>300mg = proteinuria
NB to detect proteinuria as it may indicate pre-eclampsia
When, why and how much aspirin should be given to pregnant women?
- Started from 12-14 weeks and up to 20 weeks
- should be given to prevent pre-eclampsia
- 75-162mg/day aspirin(quarter to half) given daily
How should we examine and take history of a pregnant woman?
- Big 5- CVS, renal, hepatic, GIT, neurological
- Forgotten 4- haematology, endocrine, dermatological, musculoskeletal
- core one- genitourinary
Name the basic HDP tests
- urine-msc, protein:creatinine, 24hr urine test
- blood-FBC for Hb and platelets, creatinine, ALT & LDH
- sonar once mom is stable
How is HDP classified?
Chronic HT- before pregnancy and before 20 weeks gestation
White coat HT- HT at hospital but normal at home
Maternal HT- occurs after 20 weeks gestation
Pre-eclampsia- HT +/- proteinuria or organ dysfunction after 20 weeks of gestation.
HELLP syndrome- Hemolysis, Elevated Liver enzymes, Low Platelets
Eclampsia- more severe than pre-eclampsia and includes coma and seizures
What is the importance of HDP?
- Leading cause of maternal mortality(MM) globally and 2nd leading in SA(18%)
- eclampsia and pre-eclampsia are the leading HDP that cause death
- since pre-eclampsia affects the endothelium, it is a multi-organ disease
- 60% of HDP deaths due to substandard care
- 75% of these are preventable
How is HDP classified?
Chronic HT- before pregnancy and before 20 weeks gestation
White coat HT- HT at hospital but normal at home
Maternal HT- occurs after 20 weeks gestation
Pre-eclampsia- HT +/- proteinuria or organ dysfunction after 20 weeks of gestation.
HELLP syndrome- Hemolysis, Elevated Liver enzymes, Low Platelets
Eclampsia- more severe than pre-eclampsia and includes coma and seizures
Name the basic HDP tests
- urine-msc, protein:creatinine, 24hr urine test
- blood-FBC for Hb and platelets, creatinine, ALT & LDH
- sonar once mom is stable
How should we examine and take history of a pregnant woman?
- Big 5- CVS, renal, hepatic, GIT, neurological
- Forgotten 4- haematology, endocrine, dermatological, musculoskeletal
- core one- genitourinary
When, why and how much aspirin should be given to pregnant women?
- Started from 12-14 weeks and up to 20 weeks
- should be given to prevent pre-eclampsia
- 75-162mg/day aspirin(quarter to half) given daily
How is proteinuria detected and why is this important?
- visual dipstix
- protein:creatinine ratio>0.3 = proteinuria
- 24hr urine>300mg = proteinuria
NB to detect proteinuria as it may indicate pre-eclampsia
What’s borderline BP/ pre-HT in low risk pregnant women and how is it dealt with and managed?
When systolic BP is 135-139 and diastolic BP is 85-89
- BP must be repeated within 30mins to 2hrs.
- If still in this range, send home and call after 7 days.
- If lower, pt is low risk and if still between range, pt has pre-HT
Administer 500mg Ca supplements daily for all pregnant woman at any gestational age to reduce pre-eclampsia
What’s the standard protocol of measuring BP?
- use a sphygmomanometer that’s indicated for pregnant women
- Woman must be in sitting position, legs uncrossed, relaxed, arm free of clothes at the level of the heart
- Hypertension>= 140/90mmHg. This should be checked again in 15 minutes if there are slight elevations in BP between 140-150mmHg
- Assess for obesity-BMI>=33 or MUAC >=35
How is HDP classified?
Chronic HT- before pregnancy and before 20 weeks gestation
White coat HT- HT at hospital but normal at home
Maternal HT- occurs after 20 weeks gestation
Pre-eclampsia- HT +/- proteinuria or organ dysfunction after 20 weeks of gestation.
HELLP syndrome- Hemolysis, Elevated Liver enzymes, Low Platelets
Eclampsia- more severe than pre-eclampsia and includes coma and seizures
Name the basic HDP tests
- urine-msc, protein:creatinine, 24hr urine test
- blood-FBC for Hb and platelets, creatinine, ALT & LDH
- sonar once mom is stable
How should we examine and take history of a pregnant woman?
- Big 5- CVS, renal, hepatic, GIT, neurological
- Forgotten 4- haematology, endocrine, dermatological, musculoskeletal
- core one- genitourinary
When, why and how much aspirin should be given to pregnant women?
- Started from 12-14 weeks and up to 20 weeks
- should be given to prevent pre-eclampsia
- 75-162mg/day aspirin(quarter to half) given daily
How is proteinuria detected and why is this important?
- visual dipstix
- protein:creatinine ratio>0.3 = proteinuria
- 24hr urine>300mg = proteinuria
NB to detect proteinuria as it may indicate pre-eclampsia
What’s borderline BP/ pre-HT in low risk pregnant women and how is it dealt with and managed?
When systolic BP is 135-139 and diastolic BP is 85-99.
- BP must be repeated within 30mins to 2hrs.
- If still in this range, send home and call after 7 days.
- If lower, pt is low risk and if still between range, pt has pre-HT
Administer 500mg Ca supplements daily for all pregnant woman at any gestational age to reduce pre-eclampsia
What’s the standard protocol of measuring BP?
- use a sphygmomanometer that’s indicated for pregnant women
- Woman must be in sitting position, legs uncrossed, relaxed, arm free of clothes at the level of the heart
- Hypertension>= 140/90mmHg. This should be checked again in 15 minutes if there are slight elevations in BP between 140-150mmHg
- Assess for obesity-BMI>=33 or MUAC >=35
What is the importance of HDP?
- Leading cause of maternal mortality(MM) globally and 2nd leading in SA(18%)
- eclampsia and pre-eclampsia are the leading HDP that cause death
- since pre-eclampsia affects the endothelium, it is a multi-organ disease
- 60% of HDP deaths due to substandard care
- 75% of these are preventable
Which features suggest pre-eclampsia?
- HT<32 weeks gestation
- IUGR
- isolated proteinuria
- HT and proteinuria
What are steroids used for after 34 weeks gestation
Stimulate feral lung maturity when pre-eclampsia with severe features is indictated.
What are the steps to stabilise a woman?
- call for help
- ABC
- IV saline(restore fluids and electrolytes) and ringers lactate( restore circulating blood volume in burn and trauma victims)
- MgSO4 to prevent seizures
- BP reduction using 10mg oral nifedipine (every 30 minutes if BP doesn’t drop below 160/110)
- administer oral a-methyldopa
- check if fetus is alive and only monitor(sonar) once mom is stable and she will deliver at a DH
- insert urinary catheter and monitor every hour for urine output until transferred
- monitor vitals every 15 mins until transferred
- during transfer mom accompanied by nurse and SBAR( situation, background, assessment, recommendation) form
- mom must be monitored in the lateral position
What is the immediate assessment during initial stabilisation
- shake and shout
- ABC
- Lateral position
- IV
- MgSo4
- Examine: big 5, forgotten 4, core 1
How is Magnesium sulphate administered?
- loading(14g)
- 4g in 200ml normal saline IV over 20 mins
- 5g in 1ml 2% lignocaine(local anaesthetic and anti-arrhythmic drug) IM in each butt
*maintenance
-5g in 1ml lignocaine IM every 4 hours (until 24hrs after birth or 24hrs after last convulsion)
-1g in 2ml in solution( MgSo4 always 50% solution)
!!!assess urine output, RR and reflexes before re-administration.
!!! If convulsions adminster 2g IV over 10-15 mins
When should the next dose of magnesium not be administered?
- Absent knee jerk
- Urine output< 100mls in last 4 hours
- Respiratory rate < 16BPM( administer calcium gluconate 10% 1g IV over 10 minutes)
What are the indications of MgSO4?
- Pre-eclampsia with severe features
- imminent eclampsia
- eclampsia
- uncontrolled BPs
- concern with transferring
How is BP> 160/110 managed?
1ST LINE - 10mg oral nifedipine repeated every 30 minutes(max 4 times) or until BP<160/110
- Contra- indications
- pulse>120
- cardiac lesion
- unable to swallow
2ND LINE- labetolol(from 20 to 300mg) every 10 mins until BP< 160/110
- Contra-indications
- asthma
- IHD
How is fluid managed?
- catheter and monitor input and output
- IV 200ml NaCl or 80ml/hr RL (loading dose)
- if output<25ml/hr give 200ml RL once
When is delivery indicated for a mom with pre-eclampsia?
MATERNAL COMPLICATIONS at term or preterm: (CHOP CRUE)- recommend termination
- CVA
- HELLP
- Organ dysfunction
- Pulmonary oedema
- Renal dysfunction (crest>120)
- Uncontrolled BP
- coagulaopathy (platelets<100 twice)
- Eclampsia
28-33 WEEKS
- first give corticosteroids
- if unstable or with severe features, deliver after 48hrs if mom STABLE( no eclampsia, HELLP, or severe features ;normal bloods; controlled BP)
- if stable and GA < 34 weeks , council and inform of expected care at the hospitals
> =34 weeks
- inform mom of risks
- neurological impairment
- immature lungs and RDS
- SIDS
- NEC
- ROP
Discuss the induction of labour in hypertension
- with eclampsia
- urgent( 6hrs to get to labour. Delivery 12 hrs after induction)
- favourable cervix
- high care monitoring available
- skilled doctors
- without eclampsia
- induce labour even if cervix is not favourable
What is the proper post-op care in pre-eclampsia?
- monitor chart
- VTE
- don’t discharge before 24hrs and administer MgSO4 for 24hrs
- if eclampsia and organ dysfunction, keep in hospital for at least 3 days
- stop antiHT (CCB and/or diuretics after 48hrs; ACEi and diuretics postpartum) gradually
- provide contraception
- counsel before discharge
List post partum anti-HTs?
ACEi
-oral enalopril 5mg to 20mg/day
CCB
-amlodipine 5mg to 10mg/day
BB
-atenolol 50mg to 100mg/day
List the warning signs of imminent eclampsia
- SP>160mmHg more than 2 times, 6 hours apart
- proteinuria
- oliguria
- cerebral/visual disturbances
- pulmonary oedema or cyanosis
- epigastric, chest pain
- liver dysfunction
- thrombocytopenia and other coagulopathy
