HYPERTENSIVE DISORDERS Flashcards
Deadly Triad
Hypertensive Disorders
Hemorrhage
Infection
4 Types of Hypertensive Disease
Gestational HPN
Preeclampsia and Eclampsia Syndrome
Chronic HPN (any etiology)
Preeclampsia Superimposed on Chronic HPN
BP > 140/90 AFTER 20 weeks in previously NORMOTENSIVE women
GESTATIONAL HPN
Pregnancy specific syndrome that can affect virtually every organ system
PROTEINURIA
> 300 mg/24 h (macroalbuminuria) OR
urine protein:creatinine ratio > 0.3 OR
dipstick 1+ persistent
EVIDENCE IF MULTIORGAN INVOLVEMENT
thrombocytopenia (< 100 000/ul)
renal insufficiency (crea > 1.1 mg/dL or 2x)
liver involvement (AST or ALT 2x)
cerebral symptoms - headache, visual disturbances, convulsions
pulmonary edema
Convulsion that cannot be attributed to another cause in a women with preeclampsia
generalized seizure
ECLAMPSIA
MC at 3rd trimester
1st trimester - ass with molar or hydropic degeneration of placenta
Complications of Eclampsia
abruptio placenta neurologic deficits aspiration pneumonia pulmonary edema cardiorespiratory arrest acute renal failure
BP 140/90 BEFORE pregnancy or diagnosed BEFORE 20 weeks gestations not attributable to gestational trophoblastic disease
OR
HPN persistent AFTER 12 weeks postpartum
Chronic HPN
Gestational HPN disorders are more likely to develop in women who
exposed to chorionic villi for the first time
exposed to superabundance of chorionic villi (twins or H. mole)
preexisting renal or cardiovascular disease
genetically predisposed to HPN developing during pregnancy
Preeclampsia 2 stage disorder
STAGE I - preclinical
faulty trophoblastic vascular remodelling of uterine straight arteries –> placental hypoxia
STAGE II - caused by release of placental factors into the maternal circulation –> systemic inflammatory response and endothelial activation
Pre existing chronic HPN woth NEW ONSET proteinuria and signs/symptoms of various end organ dysfunction
Chronic HPN with Superimposed Preeclampsia
Prevention of Preeclampsia syndrome
High dose calcium
Low dose aspirin
Contraindications to Conservative Management in Severe Preeclampsia
persistent symptoms or severe HPN
eclampsia, pulmonary edema, HELLP syndrome
significant renal dysfunction, coagulopathy
abruption
previable fetus
fetal compromise
Measures the hypertensive response in women at 28-32 weeks AOG who are resting in the L lateral decubitus position and then roll over to assume a supine position
from L lateral decubitus get BP, 5 mins supine position then get BP again
Roll Over Test
(+) role test - increased in 20 mmHg in the diastolic pressure
Done at 24 weeks AOG
increase uterine artery resistance in the 1st or middle trimester
Uterine Artery Doppler Velocimetry
(+) diastolic notch - predictive test for preeclampsia
Earliest laboratory manifestation of preeclampsia
HYPERURICEMIA
d.t. decreased uric acid clearance from decreased glomerular filtration
HELLP syndrome
hemoglobunuria
hyperbilirubinemia
increased LDH, AST, ALT
thrombocytopenia
Methods to Prevent Preeclampsia
Dietary manipulation - low salt diet, calcium or fish oil supplementation
Exercise - physical activity, stretching
Cardiovascular drugs - diuretics, antihypertensive drugs
Antioxidants - ascorbic acid (vitamin C), alpha tocopherol (vitamin E), vitamin D
Antithrombotic drugs - low dose aspirin, aspirin/dipyridamole, aspirin + heparin, aspirin + ketanserin
Diagnosis of HELLP syndrome
HEMOLYTIC ANEMIA
schistocytes on PBS
elevated LDH
elevated total bilirubin
ELEVATED LIVER ENZYMES
increase in AST
increase in ALT
LOW PLATELETS
thrombocytopenia
Urgent control of SEVERE HPN in pregnancy
Labetalol - avoid in women with asthma or CHF
Hyralazine - DOC
Nifedipine - caution with MgSO4
Nicardipine IV - caution with MgSO4
Treatment for Gestational or Chronic HPN in pregnancy
Methyldopa - 1st line DOC
Labetalol - causes fetal growth restriction
Nifedipine - (-) labor
Hydralazine - causes neonatal thrombocytopenia
B-blocker - decrease uteroplacental blood flow; impair fetal response to hypoxic stress
Hydrochlorothiazide - cause volume contraction and electroyte disorders
useful in combi with methyldopa and vasodilator
DOC for prevention of convulsions
Magnesium sulfate (MgSO4)
loading dose of 4 g/slow IV over 5-10 mins and 5 g/deep IM on each buttock then 5 g/IM
loading dose of 4g/slow IV then IV infusion of 2g/hr as ff
*D5w 1 L + 20 MgSO4 (10 ml ampules of 50% MgSO4 x 4) to run at 100 ml/hr (2g/hr) via infusion pump or soluset
Magnesium Sulfate Precautions
U/O of at least 30 mL/hr or 100 mL for 4 hrs
(+) patellar reflex
RR of NOT < 12/minute
CALCIUM GLUCONATE
Serum MgSO4 Levels
4-7 mEq/L (4.8 to 8.4. mg/dL ) - PREVENTS CONVULSION
8 -10 mEq/L - (-) patellar reflex
12 mEq/L - prolonged AV conduction
12-15 mEq/L - respiratory depression
24 mEq/L - cardiac arrest
Other Anti-Seizure Drugs
Diazepam
Phenytoin
MOA of Magnesium Sulfate
decreased presynaptic release of the neurotransmitter glutamate
blockade of glutamatergic N methyl D aspartate
potentiation of adenosine action
Aneurysms in the deep penetrating arteries of the LENTICULOSTRIATE branch of the MCA d.t. long standing HPN
Charcot Bouchard Aneurysms
Long term Consequences in Women with Preeclampsia Syndrome
CARDIO chronic HPN IHD atherosclerosis coronary artery calcification cardiomyopathy thromboembolism
NEUROVASCULAR
stroke
retinal detachment
diabetic retinopathy
METABOLIC type 2 diabetes metabolic syndrome dyslipidemia obesity
RENAL
glomerular dysfunction
proteinuria
CNS
white matter lesions
cognitive dysfunction
retinopathy
