Hypertensive disorders Flashcards
Quickly outline the normal mechanism of blood pressure control
Risk factors associated with hypertensive disorders
Gestational HTN
PE
- nulliparous
- multiple gestation
- AMA 35
- past history of HTN
- diabetes
- obesity
- family Hx of PE
- high PAPP A
Describe the pathophysiological changes which occur in women experiencing hypertension in pregnancy
Outline the classification of hypertensive disorders of pregnancy and differentiate between them
Chronic hypertension
- essential hypertension or hypertension secondary to another condition
- BP meeting HT measures before 20 weeks gestaton
- may be diagnosed before pregnancy
Gestational hypertension
- new onset of hypertension after 20 weeks gestation
- no involvement of organ systems and no fetal impact
- typically returns to normal BP by 3 months post party
Preeclampsia
- hypertension diagnosed after 20 weeks
- with the involvement of one or more organ systems or the fetus
- eg. renal, neuro, haematological, liver, pulmonary oedema, FGR
- proteinuria is common but not mandatory for diagnosis
Explain the pathophysiology behind the development of pre-eclampsia/eclampsia
PE
Abnormal placentation is main cause
- spiral artery remodelling is poor (they fail to vasodilator and lose tone)
- trophoblastic invasion is shallow, leading to a poor development of uteroplacental circulation
- this creates a high flow low resistance model - poor perfusion to placenta and foetus
Hypoperfused placenta –> proinflammatory proteins –> mothers circulation –> causes endothelial cell dysfunction = vasospasm and vasoconstriction
result = HYPERTENSION
malperfusion to other parts of body creates other signs
KIDNEY - oliguria and proteinuria
RETINA - blurred vision, flashing lights
LIVER -
Vascular injury makes them more permeable
- generalised oedema
- pulmonary oedema = cough, SOB
- cerebral oedema - headaches, confusion, SEIZURES
Eclampsia
- the development of preeclampsia to seizures
Describe the potential complications to both mother and foetus/neonate
Maternal complications
- eeclampsia
- HELLP
- placental abruption
Fetal
- hypoxia
- FGR
- stillbirth
- preterm birth
Chronic and gestational HT
- superimposed PE
Describe treatment options recommended for women experiencing hypertension in pregnancy
Medications - dose, MOA, side effects
Nifedipine 20-60mg once a day
- CCB
Labetalol 100-400mg TDS
- Beta blocker
Methyldopa - 250-750mg TDS
low dose aspirin - PE prophylaxis
Mag Sulf - prevents seizures CNS depressant
IV loading 4gm over 20 mins
maintenance 1g IV
Describe the type of testing and diagnostic criteria used to identify hypertension in pregnancy
- BP completed within a few hours of each other
- S+S assessment
- urinalysis
- LFT, Renal function test, investigation of other symptoms
Describe the signs and symptoms which may be displayed (maternal and fetal) if a woman is experiencing pre-eclampsia or eclampsia
- RUQ pain
- Blurred vision
- Headache or dizziness
- Proteinuria
- nausea and vomiting
Midwifery assessment of a woman presenting with hypertension
- Urinalysis and send urine off
- FBE
- urea, creatinine, electrolytes, LFT
- abdo palp
- reflexes and clonus
- S+S of PE
- fetal movement and CTG
- Ultrasound and dopplers
What is the minimum requirement for consultation and referral for a woman with a hypertensive disorder
What level hospital can care for these women
Midwifery management of chronic HT across the continuum
Antenatal
- consider taking first line antihypertensives
- obstetric management
- preeclampsia screen with sudden increase in Bp or new proteinuria
- Increased US for growth
- CTG if growth or movement is abnormal
Birth
- similar timing of birth and monitoring for gestational hypertension
Postnatal
Midwifery management of GHTN across the continuum
Antenatal
- continue monitoring for preeclampsia - urgent admission with any S+S
- 28-30 and 30-32 week US for growth
- medication management
- plan timing of birth indicated by blood pressure and gestation
Birth
- severe HT - continuous BP monitoring
- <160/110 - hourly BP
- consider epidural
- plan for instrumental delivery
Postnatal
- continue assessing for PE as can develop postpartum too
Midwifery management of PE across the continuum
Antenatal
- prophylactic low dose aspirin nocte
Birth - CONTROL BP
>37 weeks delivery is indicated
<37 weeks - consider mag sulf and stabilisation first, then delivery
<34 weeks - delay delivery 24-48 hours for corticosteroids, mag sulf
Postnatal
- Hourly obs (if caesar routine post-op obs as usual)
- Urine output
- Strict fluid balance - can ease off once diuresis has occurred and things settle down approx 24 hours
- 1:1 in Bs until diuresis and BP have settled
- Baby Lactates and FGR assessments
-Facilitating normal care
-Skin to skin
-BF or expressing to establish supply
Reflexes and clonus
Deep tendon reflex - tap knee tendon below knee cap on lax leg
- hyperactivity with clonus is a sign of neuromuscular irritability
Clonus - when leg is held in midwives hand and she pushes to hyperextend the foot, the foot beats under the hand
Both indicate severe PE and impending seizure
