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Year 2- CNC exam > Hypertensive disorders > Flashcards

Hypertensive disorders Flashcards

1
Q

Chronic Hypertension or essential hypertension

A

Hypertension identified at booking or before 20 weeks. This includes women who are normotensive because on antihypertensives. Sometimes a complication of renal disease.

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2
Q

PIH

A

New hypertension (> 140/90) presenting after 20 weeks without proteinuria, organ dysfunction or uteroplacental dysfunction.

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3
Q

PET

A

Hypertension developing after 20 weeks with proteinuria, or organ dysfunction (hepatic, renal, neurological, haematological complications) or placental dysfunction.

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4
Q

Eclampsia

A

Onset of convulsions associated with PET.

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5
Q

HELLP

A

Condition often associated to PET, characterised by haemolysis, elevated liver enzymes, low platelets

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6
Q

Labetalol
- dose/route
- side effects
- contraindications
- interactions
- midwifery implications
- difference with other medications

A

max 2.4g/24hrs PO, max 160mg/hr IV infusion
side effects: hypotension, tiredness, weakness

Contraindications: asthma, COPD, Raynaud’s disease, liver problems

Interactions: alcohol, antidepressants, anti diabetics, antihistamines, corticosteroids -> hypotensive effect

Implications: neonatal glycaemia, resp depression, jaundice. Safe during BF

Difference with other meds: 1st line antihypertensive

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7
Q

Nifedipine
- dose/route
- side effects
- contraindications
- interactions
- midwifery implications
- difference with other medications

A

max 90mg/24hrs PO

side effects: headache, flushing, dizziness, oedema, hypotension

contraindications: reduces awareness of hypos in diabetics

Interactions: avoid with grapefruit juice, erythromycin and insulin

Implications: also used for tocolysis (not MR) safe during BF

Difference with other meds: avoid before 20/40 as teterogenic

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8
Q

Methyldopa
- dose/route
- side effects
- contraindications
- interactions
- midwifery implications
- difference with other medications

A

max 3g/24hrs PO

side effects: sedation, depression, fluid retention, headache, GI disturbances, hepatic disorders

contraindications: hx of depression, liver and renal impairment, pheochromocytoma

interactions: alcohol, corticosteroids, iron, salbutamol, anxiolytics

implications: not for postnatal as risk of PND

difference with other meds: safe in asthmatic patients.

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9
Q

Doxazosin
- dose/route
- side effects
- contraindications
- interactions
- midwifery implications
- difference with other medications

A

max 16mg/24hrs PO

side effects: flu like symptoms, vertigo, sleep disturbances

contraindications: cardiac conditions, severe hepatic impairment

interactions: similar to other alpha blockers

implications: avoid if BF

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10
Q

Enalapril
- dose/route
- side effects
- contraindications
- interactions
- midwifery implications
- difference with other medications

A

max 40mg OD PO

side effects: renal impairment, hypotension, nausea, D+V, altered liver function

interactions: calcium channel blocker, beta blockers, methyldopa

implications: can cause skull defects in utero, oligohydramnios, neonatal hypotension

difference with other meds: PN only

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11
Q

Risk factors for CHT

A
  • advanced age
  • FHx
  • Black ethnicity
  • obesity
  • lack of exercise
  • high cholesterol
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12
Q

How many women with CHT develop PET?

A

1 in 4
(superimposed PET)

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13
Q

Severe hypertension is…

A

> 160/110

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14
Q

When does PIH typically go away?

A

within 6 weeks of birth

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15
Q

Differential diagnoses for hypertension (in the absence of proteinuria and organ dysfunction)

A

Pheochromocytoma –> neuroendocrine tumour
Coarctation of the aorta –> narrowing of aorta
Cushing’s syndrome –> excess cortisol
Conn’s syndrome –> excess aldosterone

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16
Q

Symptoms of PET

A
  • nausea and/or vomiting
  • severe pain below ribs
  • severe, persistent headache, not resolved by mild analgesia
  • rapid swelling of face, hands, feet
  • visual disturbances
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17
Q

Signs of PET

A
  • hypertension
  • proteinuria (PCR > 30)
  • oedema
  • raised LFT
  • altered mental status
  • raised creatinine
  • oliguria < 25ml/hr
  • FGR
  • placental abruption
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18
Q

MATERNAL complications of PET

A
  • eclampsia
  • HELLP
  • pulmonary oedema
  • stroke
  • renal/hepatic failure
  • multi-organ failure
  • Disseminated intravascular coagulation (DIC)
  • adult respiratory distress syndrome
  • death
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19
Q

FETAL complications of PET

A
  • IUGR
  • oligohydramnios
  • prematurity
  • placental abruption
  • fetal distress
  • IUD
  • neonatal respiratory distress syndrome
20
Q

What % of women with PET also develop HELLP syndrome?

A

10-20%

21
Q

Signs of HELLP

A
  • hypertension
  • proteinuria
  • epigastric/ right upper quadrant pain
  • generalised oedema
  • gastro-intestinal bleed
  • oliguria
22
Q

Symptoms of HELLP

A
  • malaise
  • fatigue
  • nausea and vomiting
  • headache
23
Q

Bloods used with S+S to diagnose PET + HELLP
FBC

A

Hb < 105 could indicate heamolysis (HELLP)
Platelets < 100 indicates dangerously low platelet count (HELLP)
(normal cut off is 150)

24
Q

Bloods used with S+S to diagnose PET + HELLP
U&Es

A

Creatinine > 73 indicates renal impairment
Uric acid (depends on gestation, normal from 140-380, raised indicates kidney impairment)
eGFR < 90% indicates renal impairment

25
Q

Bloods used with S+S to diagnose PET + HELLP
LFT

A

ALT > 40-70 indicates hepatic impairment (HELLP)
LDH > 600 indicates hemolysis (HELLP)

26
Q

Bloods used with S+S to diagnose PET + HELLP
clotting

A

when abnormal indicates hepatic impairment

27
Q

Bloods used with S+S to diagnose PET + HELLP
sFlt/PIGF ratio
+ when can this test be carried out?

A

> 38 but < 85, 1:5 chances of developing PET in 1 week
85, 1:2 chances of developing PET

singleton pregnancy between 20 - 34+6 weeks

28
Q

Diagnostic tests for HELLP

A
  • feel abdomen for enlarged liver
  • liver USS, CT, MRI
29
Q

When should IV MgSO4 be given?

A
  • eclamptic fit
  • birth is planned < 24hrs with symptomatic severe PET
  • HELLP (LDH> 500)
30
Q

Preconception care

A
  • refer women medicated for CHT to cons Obs/ obstetric physician for pre-pregnancy counselling
  • change medication to Labetalol or Nifedipine, stop statins and other meds contraindicated in pregnancy
  • target BP 135/85
  • support to change lifestyle
31
Q

High risk factors for developing PET

A
  • hypertensive disease in prev. pregnancy
  • chronic hypertension
  • chronic kidney disease
  • autoimmune disease: SLE or APS
  • type 1 or 2 diabetes
32
Q

Moderate risk factors for developing PET

A
  • booking proteinuria 1+ more or PCR > 30
  • 1st pregnancy
  • mat age > 40
  • pregnancy interval of 10+ years
  • BMI > 35
  • FHx in mother/sister
  • multiple pregnancy
33
Q

When is Aspirin pxd?

A

ANY high risk factor
1+ moderate risk factor

150mg every evening from 12-36 weeks

34
Q

Alongside aspirin, what else are high risk women advised to take?

A

800 IU Vit D + Calcium daily

35
Q

AN care in community for CHT and PIH well controlled

A
  • appts every 1-4 weeks initially, then 2 weekly from 32-36 weeks, then weekly or more especially if BP > 135/85
  • routine check: BP, urine, discuss S+S
  • Measure fundal height, metal movements
  • Any concern –> MAU
    PET bloods
    CTG
    USS referral
  • USS for fatal growth, amniotic fluid volume and UAD at 28, 32, 36 weeks
36
Q

AN care in hospital (PET)

A
  • MDT approach (senior ops, neonatologist, senior anaesthetist)
  • Full-PIERS tool to calculate adverse maternal outcomes
  • 4 holy obs (o2 may give warning of pulmonary oedema)
  • fluid balance (min output 100mls/4hrs), daily weights
  • PET bloods (at least 2-3 x week)
  • PCR if clinically indicated
  • Antihypertensives, corticosteroids if birth <34/40
  • daily CTG with Dawes-Redman from 25-26/40
  • daily or weekly USS depending on placental insufficiency
  • TEDs and LMWH
37
Q

Intrapartum care PET

A
  • timing generally from 37/40 to balance risks to baby vs worsening PET
  • IOL not offered before 40-41/40 if CHT or PIH well controlled
  • Decision to deliver once woman stable
  • PET bloods + clotting taken 6hrly in severe PET
  • epidural might help BP control but ensure good level of platelets
  • do not preload before epidural
    -1 hourly obs
  • MgSO4 if fetes < 32/40
  • fluid management –> not necessary if PU > 30ml/hr and stable BP. If necessary, max 80ml/hr intake unless ongoing fluid loss
  • lower threshold for Foley catheter if epidural
  • do not routinely limit duration of 2nd stage, unless severe hypertension when operative birth might become necessary
  • observe for s+s of severe PET and request urgent medical r/w if concerns
  • cEFM to ensure fatal wellbeing
38
Q

Intrapartum care for HELLP

A

similar to PET
- regular PET bloods with clotting and LDH (can even be 2hrly)
- timing of delivery is based on rapid progress of disease
- expedite before platelets < 80 because of risks with regional analgesia

39
Q

Immediate PN care

A
  • 3rd stage Oxytocin –> 5IU + 5IU
  • 4hrly obs unless BP stable for over 24hrs (talk to Dr)
  • continue with antihypertensives except for methyldopa
  • if labetalol use in pregnancy –> hypoglycaemia obs for baby
  • caution with NSAIDS for increased BP effect and for inhibiting platelets aggregation
40
Q

Discharge to community

A
  • plan for follow up care, including frequency of BP checks, treatment
  • GP appt at 2 weeks and 6 weeks
  • women should be aware of increased risk of hypertension and associated cardiovascular morbidity later on in life –> lifestyle changes needed
  • women should be aware of increased risk of recurrent hypertensive disorders in future pregnancies
  • offer appt with obstetrician at 6-8 weeks if severe PET
  • contraceptive advice
41
Q

Small for gestational age (SGA)

A

EFW or AC < 10th centile

42
Q

Fatal growth restriction (FGR)

A

failing to reach genetically predetermined growth potential.
increased risk of adverse perinatal outcome, EFW < 3rd gentile, AC or EFW growth velocity reduction > 50 centiles, abnormal dopplers

43
Q

Why babies are small…

A
  • constitutional
  • placenta-mediated (hypertensive disorders, renal disease, autoimmune disease)
  • non-placenta mediated (chromosomal, fatal infection/CMV, toxoplasmosis, COVID)
44
Q

Uterine artery dopplers

A

PET and FGR associated with inadequate quality and quantity of the maternal vascular response to placentation.
Raised uterine artery dopplers = impedance to flow in uterine arteries is increased
usually assessed at 20/40 USS in Oxford
other places assess between 20-24/40 only if high-risk

45
Q

tools to determine fetal wellbeing biometry

A
  • measure head circumference, abdominal circumference, femur length
  • calculate EFW
  • growth velocity (EFW, AC)
46
Q

umbilical artery dopplers Absent end diastolic flow

A

when the blood flow is absent during diastole. This means that the blood flow to the placenta is markedly decreased.

47
Q

umbilical artery dopplers Reversed end diastolic flow

A

when there is a reversed flow during diastole. This is indicative of an increase in resistance in placental blood flow. it’s the most severe classification of abnormal dopplers and is associated with significant fatal mortality.

Year 2- CNC exam (14 decks)

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