Hypertensive disorders Flashcards
What is the definition of pre-eclampsia?
Blood pressure above 140/90 Recorded twice over a 4 hour period In the presence of 300mg of protein in urine Occurring after 20th week gestation Resolving after 6th week post partum
What is HELLP syndrome?
A form of severe eclampsia:
Haemolysis
Elevated Liver (enzymes)
Low Platelets
Women typically present with epigastric pain and nausea
Associated with high foetal loss rate
What is eclampsia?
Presence of tonic-clonic seizures in a woman with pre-eclampsia in the absence of other identifiable causes
What are the signs/symptoms of pre-eclampsia?
First sign is hypertension Protein in urine Frontal headaches Epigastric pain Vague "flu-like" symptoms Visual disturbances Rapidly progressive oedema of face and hands
In severe pre-eclampsia: Drowsiness Haemorrhagic stroke Placental abruption HELLP syndrome Pappiloedema Clonus Hyperreflexia
What is the management of mild pre-eclampsia?
BP = 140/90 mmHg
Admit to hospital - For monitoring
Measure blood pressure at least 4 times a day
Twice a week, check kidney function, electrolytes, FBC, transaminases & bilirubin (LFT)
What is the management of moderate pre-eclampsia?
BP = 150/100 mmHg
Admit to hospital for treatment
Oral labetalol aiming to keep BP below 150/100
Measure blood pressure at least 4 times a day
3 times a week: Check kidney function, electrolytes, FBC, transaminases & bilirubin (LFT)
What is the management of severe pre-eclampsia?
BP = 160/110 mmHg
Admit to hospital for treatment
Oral labetalol aiming to keep BP below 150/100
Measure blood pressure more than 4 times a day
3 times a week: Check kidney function, electrolytes, FBC, transaminases & bilirubin (LFT)
What drugs are available for hypertension treatment and what are their contraindications?
Labetalol (CI: Asthma)
Nifedipine (CI: Aortic Stenosis)
Methyldopa (CI: Depression)
Hydralazine (CI: Kidney disease)
When should magnesium sulphate be prescribed?
Patient with severe hypertension
Planning preterm delivery (for neuroprotection)
Patient suffering from eclampsia
How do you treat a patient suffering from eclampsia?
4g IV Magnesium sulphate stat
1g/hour maintenance
How often should blood pressure be measured postnatally in a woman who has had pre-eclampsia/gestational hypertension?
At least 4/day whilst an inpatient
At least once on days 3 and 5
On alternate days thereafter if the results aren’t normal on days 3/5
NOTE: if blood pressure remains > 150/100, start an anti-hypertensive
When should further scans to assess the foetus be carried out in women with hypertensive disease in pregnancy?
28-30 weeks
Repeat at 32-34 weeks if severe pre-eclampsia
What does magnesium sulphate toxicity cause and how is it treated?
Respiratory depression
Treatment: calcium gluconate
How long should magnesium sulphate be continued for in a woman with pre-eclampsia?
For 24 hours after the last seizure or until 24 hours after delivery
What should be monitored whilst giving magnesium sulphate treatment?
Reflexes
Respiratory rate
Oxygen saturation
Urine output
ECG monitoring is required during and for 1 hour after loading dose
When is delivery recommended in women with pre-eclampsia?
If pre-eclampsia develops >37 weeks = Delivery within 24-48 hours
If mild/moderate pre-eclampsia = Offer delivery 34-37 weeks depending on maternal/foetal condition
If severe pre-eclampsia = Offer delivery after 34 weeks following a course of corticosteroids
What groups are at high risk of developing pre-eclampsia? How should they be managed?
Hypertensive disease during previous pregnancy Chronic hypertension CKD Autoimmune disease (SLE) Diabetes Mellitus
75mg OD aspirin from 12 weeks
What is the management of women with chronic hypertension in pregnancy?
Stop taking ACEi, chlorothiazides and Angiotensin-II receptor blockers (ARB) for first half of pregnancy as they are teratogenic
Reduce salt intake
Aim is to keep BP below 150/100
What is the management of women with gestational hypertension?
Mild (>140/90 mmHg) = Measure BP at most once a week, test urine for protein at each antenatal appointment
Moderate (>150/100 mmHg) = Treat with oral labetalol. Measure BP twice a week. Test urine for protein at each antenatal appointment. Blood test for kidney function, liver function, FBC, electrolytes
Severe (>160/110 mmHg) = ADMIT (until BP is less than 160/110). Treat with oral labetalol. Measure BP four times a week. Test urine for protein at each antenatal appointment. Blood test for kidney function, liver function, FBC, electrolytes
What management is required with regards to delivery of a woman with pre-eclampsia?
○ Iatrogenic premature delivery is often required
○ Deliver after 34 weeks
○ Deliver before 34 weeks only if severe hypertension refractory to treatment, or foetal/maternal wellbeing deteriorates
○ Delivery before term is usually by C-section
○ Usually at HIGH RISK of VTE, give prophylactic SC heparin and anti-thromboembolic stockings
○ In spontaneous or induced labour (if clotting studies are normal), epidural anaesthesia is indicated as it helps control blood pressure
○ Ergometrine should be AVOIDED as it significantly increases blood pressure
○ Post-natally, blood pressure and proteinuria should resolve within 6 weeks
○ If it fails to resolve, consider chronic hypertension or renal disease
