Hypertensive disorders Flashcards
1
Q
Definition
A
BP 140/90 on 2 separate readings 4 h
hours apart or +systolic >30mmHg, diastolic
>15mmHg from booking visit
2
Q
Deadly triad
A
- Hypertension
- Hemorrhage
- Infection
?VTE
3
Q
Classification of hypertension in pregnancy
A
- Gestational hypertension
- Chronic hypertension
- Chronic hypertension superimposed w/ pre-eclampsia
4
Q
Define pre-eclampsia
A
- Pregnancy specific
- Reduced organ perfusion
- Secondary to vasospasm and endothelial activation
- > 140/90 on 2 occasions w/ proteinuria or systemic involvement: renal insufficiency (Cr >80) or liver dysfunction: AST/ALT +, RUQ/epigastric pain due to liver necrosis, ischemia and edema
5
Q
Etiology
A
- Failed invasion of trophoblast cells->maladaption of maternal spiral arterioles
2, Immune intolerance - Maternal maladaption to CV/inflammatory changes of pregnancy
- Dietary deficiencies
- Genetic influences
6
Q
Pathogenesis
A
- Abnormal invasion–> abnormal prostacyclin:thromboxane
ratio–> +thromboxane= vasoconstriction,
PLT aggregation - maladapt arterioles % vasospasm (immune and genetic)–>abnormal villous development=placental insufficiency
- fetal growth restriction,
- ++vascular resistance + HTN
- endothelial cell activation after damage
++coagulation - Inflammatory activation–> +vascular permeability= HTN
and proteinuria - PLTS, fibrinogen deposit subendotheliallum, edema–>
manifest eclampsia (cerebral edema) and HELLP (liver vascular dysreg + edema causing abdominal
pain) pulmonary edema (cap leak)
7
Q
Hematological changes in pre-eclampsia
A
Thrombocytopenia
Hemolysis
DIC
8
Q
Neurological changes in pre-eclampsia
A
Severe headache Visual disturbances Hyperreflexia w/ sustained clonus Convulsions Stroke
9
Q
Risk factors for preeclampsia
A
•Previous history of preeclampsia • Family history of preeclampsia • Inter-pregnancy interval > 10 years • Nulliparity •Pre-existing medical conditions o APLS o Pre-existing diabetes o Renal disease o Chronic hypertension o Chronic autoimmune disease •Age > 40 years •BMI > 35 kg/m2 • Multiple pregnancy •Elevated BP at booking • Gestational trophoblastic disease • Fetal triploidy
10
Q
Evaluation for hypertension at >20 weeks
A
1. History Abdominal pain Blurred vision Edema, rapid weight gain Fetal movements Urine output 2. Examination BP Visual field Hyper-reflexia, clonus Abdominal examination->fetal presentation etc Fetal assessment->CTG, USS 3. Investigations Urine dipstick Spot urine PCR FBC UEC LFTs, LDH Urate 4. Consider initiation of hypertensives Commence= >160 or d>110 Consider= >140/90 5. Consider admission
11
Q
Options for antihypertensives
A
- Methyldopa
- Labetolol
- Nifedipine
- Hydralazine
- Clonidine
12
Q
Outpatient vs inpatient care
A
1. Outpatient if: Mild HTN w/o pre-eclampsia 2. Consider admission Concern for fetal wellbeing SBP >140 or dBP >90 Symptoms of preeclampsia, proteinuria or abnormal bloods
13
Q
Inpatient monitoring
A
- BP 4 hourly if stable
- CTG daily
- Daily ward urinalysis
- Maintain fluid balance
- Daily review
- Normal diet
- Bed rest not usually required
- VTE prophylaxis
14
Q
Indications for birth
A
• Non-reassuring fetal status • Severe fetal growth restriction • ≥ 37 weeks • Eclampsia • Placental abruption • Acute pulmonary oedema • Uncontrollable hypertension • Deteriorating platelet count • Deteriorating liver and/or renal function • Persistent neurological symptoms • Persistent epigastric pain, nausea or vomiting
15
Q
Stabilising prior to birth and postpartum management
A
1. Prior to birth Control HTN Correct coagulopathy Consider eclampsia prophylaxis->Mg Sulphate Attention to fluid status 2. Postpartum Close clinical surveillance VTE prophylaxis Timing of discharge Arrange F/U in 6 weeks to determine if underlying hypertension Maternal screening
