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Midwifery Emergencies > Hypertensive disorders > Flashcards

Hypertensive disorders Flashcards

1
Q

Chronic hypertension

A

Is hypertension that is present at booking or before 20/40, or if the women is already taking antihypertensive medication
(NICE 2011b)

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2
Q

Eclampsia

A

Is a convulsive condition associated with pre-eclamspia

NICE 2011b

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3
Q

HELLP syndrome

A

Haemolysis
Elevated Liver enzymes
Low Platelet count
(NICE 2011b)

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4
Q

Gestational hypertension

A

Is new hypertension presenting after 20 weeks without significant proteinuria
(NICE 2011b)

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5
Q

Pre-eclampsia

A

Is new hypertension presenting after 20 weeks with significant proteinuria
(NICE 2011b)

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6
Q

Severe pre-eclampsia

A

Is pre-eclampsia with severe hypertension and/or with symptoms, and/or biochemical and/or haematological impairment
(NICE 2011b)

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7
Q

Definitions of hypertension

A

Mild hypertension = diastolic 90-99 mmHg + systolic 140-149 mmHg
Moderate hypertension = diastolic 100-109 mmHg + systolic 150-159 mmHg
Severe hypertension = diastolic 110 mmHg or greater + systolic 160 mmHg or greater
(NICE 2011b)

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8
Q

Mean arterial pressure (MAP)

A

Is useful as represents the pressure driving the blood through the arteries
MAP = diastolic pressure + 1/3 systolic pressure - diastolic pressure

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9
Q

Incidence of PIH and pre-eclampsia

A

Pregnancy induced hypertension = 12%
Pre-eclampsia = 3-5%
(Mayes 2012)

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10
Q

How many deaths is pre-eclampsia responsible for?

A

6 maternal deaths between 2014-2016

MBRRACE 2018

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11
Q

When and why is there a normal drop in blood pressure?

A

Physiological dilatation of the spiral arterioles in the placental bed occurs, by stripping away their muscle coating. This allows the pooling of blood in the intervillous spaces of the placental bed, creating a shunt, which lowers the maternal blood pressure. This occurs at 16-18 weeks.
(Mayes 2012)

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12
Q

Risks later in life for women who had pre-eclampsia

A

Increased risk of hypertension and cardiovascular disease

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13
Q

What is the only cure for pre-eclampsia?

A

Delivering the baby

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14
Q

Care for women who are at high risk of pre-eclampsia

A

Advise to take 75mg of aspirin daily from 12 weeks until the birth of the baby

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15
Q

Women who are at high risk are those with any of the following …

A 
- Hypertensive disease during 
  a previous pregnancy 
- Chronic kidney disease 
- Autoimmune disease such as 
  systemic lupus or 
  antiphospholipid syndrome 
- Type 1 or 2 diabetes 
- Chronic hypertension
(NICE 2011b)
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16
Q

Advised to take aspirin if there are 2 or more moderate risk factors:

A
  • First pregnancy
  • Maternal age over 40
  • Pregnancy interval of more
    than 10 years
  • BMI over 35 at booking
  • Family history of pre-
    eclampsia
  • Multiple pregnancy
    (NICE 2011b)
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17
Q

Symptoms of pre-eclampsia to assess antenatally

A
  • Severe headache
  • Problems with vision such
    as blurring or flashing
    before the eyes
  • Severe pain just below the
    ribs (epigastric pain)
  • Vomiting
  • Sudden swelling of the face,
    hands or feet
    (NICE 2011b)
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18
Q

Effects of pre-eclampsia on the central nervous system

A
  • Cerebral haemorrhage
  • Eclampsia (seizures)
  • Cerebral oedema
  • Retinal oedema/retinal
    blindness
    (Mayes 2012)
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19
Q

Effect of pre-eclampsia on the pulmonary system

A
  • Pulmonary oedema
  • Laryngeal oedema
    (Mayes 2012)
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20
Q

Effect of pre-eclampsia on the renal system

A
  • Cortical necrosis
  • Tubular necrosis
    (Mayes 2012)
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21
Q

Effect of pre-eclampsia on the liver

A
  • HELLP syndrome
  • Hepatic rupture
  • Jaundice
    (Mayes 2012)
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22
Q

Effect of pre-eclampsia on the haematological/coagulation system

A 
- Disseminated 
  intravascular coagulation 
  (DIC)
- Haemolysis 
(Mayes 2012)
23
Q

Effect of pre-eclampsia on the placenta

A
  • Placental abruption
  • Placental ischaemia/infarction
    (Mayes 2012)
24
Q

Effect of pre-eclampsia on the fetus/neonate

A
  • IUGR
  • Prematurity
  • Low birth weight
  • Intrauterine hypoxia leading
    to neurological
    complications
  • Perinatal death
    (Mayes 2012)
25
Q

What is DIC?

A

A condition in which blood clots form throughout the body’s small blood vessels. These blood clots can reduce or block blood flow through the blood vessel, which can damage the body’s organs. The increased clotting uses up platelets and clotting factors in the blood. With fewer platelets and clotting factors in the blood, serious bleeding can occur

26
Q

What is pulmonary oedema?

A

Is when there is fluid in the lungs causing shortness of breath. Sit the women right up

27
Q

Assessment of renal functions

A 
- Uric acid levels indicate 
  progress and severity of pre- 
  eclampsia, with increased 
  levels in cases of 
  hypertension, usually before 
  the development of 
  proteinuria
- Blood urea and creatinine 
  levels may be raised, and a 
  high level (>110 micromol/L) 
  indicate a late stage of renal 
  involvement 
- 24 hour urinary protein 
  excretion of  ≥0.3 g/24 hours 
  indicates renal involvement 
(Mayes 2012)
28
Q

Assessment of liver function

A

Serial measurement of liver enzymes, particularly ALT or AST, and where these raise above 70 IU, liver function tests may be carried out
(Mayes 2012)

29
Q

Assessment of coagulation complications

A
  • Blood film
  • Platelet count which often
    decreases below 100 x 10⁶/L
    in pre-eclampsia
  • Coagulation studies
    whereby coagulation levels
    are usually unchanged in
    pre-eclampsia, unless DIC is
    present
    (Mayes 2012)
30
Q

Assessment of fetal wellbeing

A
  • CTG
  • Measure SFH
  • Record fetal movements
  • USS if necessary
    (Mayes 2012)
31
Q

What bloods to be taken 48-72 hours after birth?

A

Platelet count
Transaminases
Serum creatinine
(NICE 2011b)

32
Q

Incidence of pre-eclampsia developing into eclampsia

A

One in 200 women

Mayes 2012

33
Q

What to do during a seizure?

A
  • Remain with the women
  • Call for help
  • Clear the airway of mucus
    and blood and maintain a
    clear airway, using the
    recovery position
  • Turn the women onto her
    left side
  • Protect her from injury
  • Administer oxygen
    Remember ABC
    (Mayes 2012)
34
Q

Observations for eclampsia

A 
- Restlessness or twitching 
  may indicate a seizure 
- Continuous oxygen 
  saturation should be 
  measured. Cyanosis is an 
  important sign of 
  cardiorespiratory failure 
- Temperature recorded 
  hourly. If there is no obvious 
  signs of infection, a rise in 
  temperature could indicate 
  anoxic damage to the 
  temperature-regulating 
  centres in the midbrain 
- Pulse and respirations may 
  be recorded as often as 
  every 5 minutes 
- BP recorded frequently, 
  usually every 15 minutes
- An accurate record of fluid 
  intake and output is 
  essential. A self-retaining 
  catheter is inserted into the 
  bladder and released hourly; 
  thus urinary output can be 
  measured accurately and the 
  women will not have to be 
  distrubed to pass urine.
- Urine is tested for protein
- FH continuously monitored    
- Monitor for signs of labour 
(Mayes 2012)
35
Q

What is the minimum urine output?

A

Less 30ml/hour suggests renal impairment

Mayes 2012

36
Q

What is the only drug to manage eclamptic seizures?

A

Magnesium sulphate

Prompt 2017

37
Q

Loading dose of magnesium sulphate

A

4g magnesium sulphate IV over 5 minutes

Prompt 2017

38
Q

Maintenance dose of magnesium sulphate

A

1g/hour and continue maintenance infusion for 24 hours following birth or the last seizure (whatever is first)
(Prompt 2017)

39
Q

Magnesium toxicity

A

Magnesium sulphate is excreted in the urine by the kidneys. No need to measure magnesium levels as long as there is normal urine output. If women oliguric or has renal impairment, the kidney’s won’t excrete magnesium and the levels are likely to become toxic.
(Prompt 2017)

40
Q

Magnesium sulphate emergency protocol

A 
Stop magnesium sulphate
Basic life support 
Give 1g calcium gluconate IV
Intubate early and ventilate until respiration resumes
(Prompt 2017)
41
Q

Fist line anti-hypertensive drug

A

Labetalol

Mayes 2012

42
Q

Initial dose of labetalol

A

200mg orally

Mayes 2012

43
Q

What does labetalol do?

A

Reduces peripheral resistance and cardiac output, thereby reducing blood pressure
(Mayes 2012)

44
Q

After the initial dose of labetalol, what to do if BP not below threshold after 30 minutes?

A

Repeat 200mg oral dose

Mayes 2012

45
Q

After second dose of labetalol, BP rechecked after 30 minutes and still not below threshold

A 
IV labetalol (5mg/ml)
Loading: 10ml (50mg) over 2 minutes. Repeat after 5 minutes (max 4 doses) until BP controlled
Maintenance: Start infusion at 4ml/hour. Double infusion rate every 30 minutes until BP controlled. Max infusion rate 32 ml/hour 
(Prompt 2017)
46
Q

Who can’t have labetalol?

A

Asthmatic and/or Afro-Caribbean

Prompt 2017

47
Q

What is the second line drug for either women who can’t have labetalol or another option after two doses of labetalol?

A

Nifedipine

Prompt 2017

48
Q

Nifedipine dose

A

10mg orally

Mayes 2012

49
Q

What does nifedipine do?

A

Is a calcium antagonist and lowers blood pressure by inhibiting calcium ion activity in the smooth muscle of the blood vessels, resulting in decreased peripheral vascular resistance
(Mayes 2012)

50
Q

After the first dose of nifedipine, if BP still above threshold after 30 minutes what can be given?

A

Second 10mg oral dose nifedipine

Prompt 2017

51
Q

Third line drug of choice

A

Hydralazine

Mayes 2012

52
Q

Hydralazine loading dose

A

5ml (5mg) over 15 minutes IV

Prompt 2017

53
Q

Hydralazine maintenance dose

A

Start infusion at 5ml/hour. Titrate to systolic BP 140-150 mmHg
Usual rate 2-3 mL/hour
Max infusion rate 18ml/hour
Reduce rate if significant adverse effect or maternal pulse >120 bpm
(Prompt 2017)

54
Q

Offering early birth for women with chronic hypertension

A

Do not offer birth to women with chronic hypertension whose blood pressure is lower than 160/110 mmHg, with or without antihypertensive treatment, before 37 weeks
(NICE 2011b)

Midwifery Emergencies (11 decks)

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