Hypertensive Disorders in Pregnancy Flashcards
Define hypertension and severe hypertension in pregnancy.
- Hypertension = 140/90 to 159/109mmHg
- Severe = >160/110mmHg
Define pre-eclampsia.
Hypertension present after 20 weeks (>140/90mmHg) and ≥1 of:
- Proteinuria (>0.3g in 24 hours); AND/OR
- Any maternal organ dysfunction:
- Renal - rising creatinine
- Liver - rising AST/ALT ± epigastric/RUQ pain
- Neuro - eclampsia, blind/burred vision, stroke, clonus, severe headache
- Haematological - thrombocytopaenia, DIC, haemolysis
- Uteroplacental - IUGR, abnormal dopplers, stillbirth
Define HELLP.
Haemolysis, Elevated Liver enzymes, and Low Platelets
- Severe form of pre-eclampsia
Define Eclampsia.
≥1 seizure in a patient with pre-eclampsia
What are the risk factors for pre-eclampsia?
- High Risk Factors - ≥1 = Aspirin
- Pre-eclampsia in previous pregnancy
- Chronic kidney diseaseAutoimmune disease (SLE, antiphospholipid syndrome)
- T1DM, T2DM
- Chronic hypertension
- Moderate Risk Factors - ≥2 = Aspirin
- Primigravid
- Age ≥40 years
- Pregnancy interval of >10 years
- BMI ≥35
- FHx of pre-eclampsia
- Multiple pregnancy
What are the signs and symptoms of pre-eclampsia?
- Asymptomatic
- Severe headache
- Visual disturbances (i.e. flashing lights)
- Epigastric/RUQ pain
- Vomiting
- Breathlessness
- Sudden swelling face, feet, hands
What are the investigations for suspected pre-eclampsia?
- Urine dipstick → proteinuria, if ≥1+ or more → PCR quantification = >30mg/mmol is significant
- Do NOT use 24hr urine collection
What is the management of a patient who is at high risk of pre-eclampsia?
- High risk pre-eclampsia
- Aspirin (75mg OD, from 12w until birth)
- Give healthy lifestyle advice
- Dip urine at every appointment
What is the management of pre-eclampsia?
- 1st line: Labetalol (100mg, BD) → contraindicated in asthma
- 2nd line: Nifedipine → causes tocolysis (use methyldopa at term)
- 3rd line: Methyldopa (250mg, BD or TDS)
What is the management of eclampsia?
- IV magnesium sulphate (potent cerebral vasodilator)
- Deliver baby as soon as possible
What monitoring should be carried out in pre-eclamptic patients?
What is the management of pre-eclampsia antepartum?
How should birth be timed in pre-eclampsia?
- Epidural will help to reduce the BP
What is the critical setting management of severe pre-eclampsia/eclampsia?
What is the post-natal monitoring of a patient with pre-eclampsia
- Inpatient for 5 days → highest risk period (deemed at risk for up to 6 weeks)
- Discharge criteria:
- No symptoms of pre-eclampsia
- Blood pressure <150/100mmHg (with or without treatment)
- Blood test results are stable or improving
- BP monitoring:
- Targets achieved (i.e. BP <150/120mmHg) → wean down anti-HTN
- BP <130/80mmHg → stop anti-HTN
What is the advice on breastfeeding for patients with pre-eclampsia/eclampsia?
- Avoid diuretic treatment
- NOT recommended when breastfeeding:
- ARBs
- ACE inhibitors (except enalapril and captopril)
- Amlodipine
- Drugs that are safe: labetalol, nifedipine, enalapril, captopril, atenolol, metoprolol
What counselling should be given to a patient with pre-eclampsia?
- Adapt the counselling based on severity
- Explain that admission may be needed - at least until blood pressure is controlled
- Explain pre-eclampsia and the risks (early delivery, reduced placental function, IUGR, risks to mother)
- Risk of recurrence → 15%
- Explain treatment - labetalol
- Explain that blood pressure will be monitored closely with regular bloods
- Explain that early delivery may be recommended
What is the aetiology of pre-eclampsia?
Impaired trophoblastic invasion of spiral arteries
- (1) Impaired invasion → high resistance flow
- (2) Low flow → poor perfusion of placenta
- (3) Placenta releases factors into circulation
- (4) Factors promote further systemic effects seen:
- Peripheral vasoconstriction
- Increased permeability → oedema
- Glomeruloendotheliosis → proteinuria
- Endothelial damage → platelet consumption
- Elevated liver enzymes (HELLP syndrome)
- Vasospasm, cerebral oedema → eclampsia
