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Hypertensive Disorders In Pregnancy Flashcards

1
Q

What are they?

A

A group of conditions in pregnancy characterized by an elevated blood pressure as the cardinal sign and the occurrence of other manifestations in several organ systems (CNS, cardiopulmonary, liver, kidneys, coagulation)

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2
Q

What is Pregnancy induced hypertension

A

Gestational hypertension

Occurs after 20 weeks gestation without proteinuria in a previously normotensive woman

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3
Q

What is Pre-eclampsia?

A

It is hypertension after 20 weeks gestation with proteinuria and /or end organ damage in a previously normotensive, non-proteinuria woman

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4
Q

What is Eclampsia?

A

The occurrence of generalized seizures in a pre-eclamptic patient.

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5
Q

What is Chronic/ Pre-gestational hypertension?

A

Hypertension present before pregnancy, before 20 weeks gestation or which persists for more than 6 weeks postpartum.

Essential/Secondary to a renal disease, endocrine disease or other cause.

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6
Q

FIGO Classification for hypertension

A

Pre-gestational hypertension
Gestational hypertension
Pre-eclampsia
Others: Masked, Transient, White coat

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7
Q

Masked Hypertension

A

BP that is consistently normal in the clinic but elevated in the house

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8
Q

White coat hypertension

A

BP that is found to be elevated in the health facility but is normal outside the facility

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9
Q

Transient Hypertension

A

Elevated BP due to environmental factors or the pain of labour

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10
Q

BP Profile during pregnancy

A

Pre-pregnant BP falls in earl second trimester then gradually increases to term.

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11
Q

What are the figures for Hypertension in pregnancy? How are they measured?

A

Sustained
Systolic BP >/= 140mmHg and/or
Diastolic BP >/= 90mmHg

Two successive readings of BP at least 6 hours apart

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12
Q

Values for severe hypertension

A

Systolic BP >/= 160mmHg

Diastolic BP >/= 110 mmHg

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13
Q

What is significant proteinuria in pregnancy?

A

> /= 300mg in a 24 hour urine collection

Urinary protein : creatinine ratio of >/= 30mg/mmol on a single specimen

Proteinuria of 2+ or more on dipstick

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14
Q

What entails end organ damage in pre-eclampsia?

A 
Severe headaches
Visual symptoms
Epigastric pain
Dyspnea 
Chest pain
Low platelets, low haematocrit and deranged liver enzymes (all deranged lab parameters) - Hellp
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15
Q

Pre-eclampsia in a woman with chronic hypertension (superimposed)

A

After 20 weeks, there is

  1. Resistant hypertension- requires 3 concurrent medications for control
  2. New or worsening proteinuria
  3. One or more features of end organ damage
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16
Q

How is Pre-eclampsia classified?

A

Mild and severe.
Mild: BP is >/= 140/90 and there is proteinuria and/or end organ damage. However, none of the criteria for severe is present

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17
Q

Severe features of pre-eclampsia

A

BP>/= 160/110 on 2 occasions 6 hours apart
Proteinuria > 2g per 24hr urine specimen or 2-4+ on dipstick
Oliguria (<500ml/24 hrs)
HELLP syndrome
Cerebral or visual disturbances
Epigastric pain
Persistent frontal headache
Blurred vision
Retinal changes - hemorrhages, exudates, papilledema

18
Q

What is the etiology of pre-eclampsia?

A

Defective placentation from impaired trophoblastic invasion of maternal spiral arteries during pregnancy. Leads to vasoconstriction instead of dilation of the spiral arteries supplying placental bed. Results in high pressure low volume blood flow instead of vice versa to the placental bed. Systemic hypertension results.

19
Q

Risk factors for Pre-Eclampsia

A 
Nulliparity with a particular father
SLE
Afro-Caribbean ethnicity
Extremes of maternal age: <20, >35
Low socioeconomic status
Large placental mass (in multiple gestation)
Renal disease
Molar pregnancy 
Polyhydramnios
Obesity
Diabetes Mellitus type 1
Chronic hypertension
Mother in law had pre-eclampsia
20
Q

What is the Pathogenesis of Pre-eclampsia?

A

Endothelial cell injury
Fetal rejection phenomenon (following inadequate blocking antibodies)
Compromised placental perfusion
Dietary insufficiency of Calcium, Magnesium, Selenium
Genetic predisposition
Decreased renal glomerular filtration with salt and fluid retention
Decreased intravascular volume

21
Q

Organ specific lesions of pre-eclampsia

A

Glomerulo-endotheliosis - Kidneys
Sub-endothelial fibrin deposition and elevation of AST, ALT - Liver
Vasospasm and Cerebral edema - Brain
Vasospasm, hemolysis & DIC - General vasculature

22
Q

What are the clinical features of pre-eclampsia

A

(Always measure the BP and check proteinuria in every pregnant woman).

Gradual onset hypertension (or sudden/superimposed on chronic one)

Proteinuria - After hypertension(or can rarely be a late finding)

Edema (not important criterion)
IUGR, Placenta abruptio, renal failure, HELLP syndrome

23
Q

What are the Laboratory findings in Pre-eclampsia?

A

Full Blood count - Low platelets (HELLP, DIC, Thrombocytopenia), (Normocytic anemia & schistocytes - Hemolytic anemia/HELLP)
BUN/Cr disturbances
Proteinuria
Haemoconcentration
Thrombocytopenia
Fibrin degradation products
Elevated renal function tests (Uric acid >5.5mg/dl)
Elevated AST/ALT - HELLP syndrome
Prothrombin Time/PTT - If elevated, points to DIC
Decreased Fibrinogen- DIC

24
Q

Maternal complications of Pre-eclampsia

A 
Maternal
Eclampsia
IUGR
Cerebral hemorrhage 
DIC and Thrombocytopenia 
Hepatic Failure
Renal failure
Edema
Pulmonary edema
25
Fetal complications of Pre-eclampsia
``` Prematurity Dysmaturity Uteroplacental insufficiency / Placental infarction Placenta abruptio Intrapartum fetal distress IUGR /SGA from chronic uteroplacental insufficiency Oligohydramnios Still Birth Perinatal morbidity and mortality ```
26
Plausible Pathogenesis
27
Prevention of Pre-eclampsia
Detection of high vascular resistance in uterine artery using USG Use of prophylactic medication with calcium and aspirin supplements ( issa no)
28
Treatment Principles
Specific and Curative - Deliver fetus and placenta. But first, examine the viability of the fetus , severity of the disease and maternal risks. 4 main principles- Stabilize the patient, Control blood pressure with anti hypertensives, Prevent fits by giving MgSo4, Deliver the baby (24-48 hours) - whenever is practical.
29
Treatment of Mild Pre-eclampsia
Bed rest and expectant management Maternal monitoring: 4 hourly BP, daily. Weight measurement, urine testing and monitoring for protein; weekly LFTs, RFTs Anti hypertensive medication are given when the diastolic BP > 100Hg Fetal monitoring: daily kick count, FH; twice weekly non-stress test. Deliver the woman when the gestation reaches 37 weeks even if monitored parameters are good.
30
Mild pre-eclampsia treatment continued
Woman must be delivered earlier than 37 weeks when monitoring parameters reveal signs of worsening disease: Worsening BP and proteinuria Deranged lab parameters - uric acid, LFT, RFT Development of HELLP syndrome Persistent headache, Epigastric pain, visual disturbances Fetal compromise Pre-eclampsia with severe features Eclampsia
31
Pre-eclampsia with severe features
Obstetric emergency - treated as eclampsia * Prevent convulsions by giving MgSO4 * Control BP with anti-hypertensives (Nifedipine, a Methyl Dopa, Hydrallazine) * End pregnancy by delivery of fetus. Assess the woman for induction and vaginal delivery if no contraindication is present and an easy vaginal delivery can be expected- otherwise C/S
32
When does Eclampsia occur
Follows uncontrolled pre-eclampsia and usually occurs after 20 weeks gestation (rarely before). 75% occurs before delivery. Postpartum eclampsia rarely seen after 72 hours
33
How can Eclampsia be prevented?
Adequate treatment of pre-eclampsia and prompt intervention
34
What causes and eclampsia’s seizure?
Cerebral cortical hypoxia due to platelet microthrombi and foci of hemorrhages in the brain
35
Describe the seizure of Eclampsia
Preceded by no aura. Post-seizure duration of unconsciousness lasts for variable amount of time. Seizure induced complications- Tongue biting, fractures, head injury, aspiration of secretions.
36
Principles of Treatment of Eclampsia
* Provision of life support during and after fits - ABC * Control of the seizure and prevention of further seizures using MgSO4 * Control of hypertension (anti hypertensives) * Resuscitation and assessment of the woman for delivery * Special care for the peri-delivery period
37
KATH MgSO4 protocol - Loading dose
Given to all patients with severe pre-eclampsia and those who’ve had eclampsia. Loading dose: 14g 4g (8ml of 50% in 12 ml N/S to make 20 ml 20% MgSO4) slowly Iv over 5 - 10 minutes AND 5g (10ml 50%) into each buttock (total 10g) by deep IM injection. If convulsions occur within 20 minutes of the loading dose, don’t repeat injection. If it occurs after 20 min, another 2g IV MgSO4 can be given.
38
KATH MgSO4 protocol - Maintenance dose
Maintenance dose Give 2.5g (5ml 50%. MgSO4) into each buttock [ie total of 5g (10ml)] every 4hours for 24 hours. The schedule total dose of 5g may be given into alternate buttocks.
39
KATH MgSO4 Clinical Observations
Clinical parameters to monitor each time before the next dose of MgSO4 is given: ``` Patellar reflex (must be present) Respiratory rate (must be >16/min) Hourly urine output (must be >25ml) ``` Do not give next dose of MgSO4 if patellar reflex absent; give 1g Calcium Gluconate slowly IV If urine output <100ml in 4hrs, give half dose of MgSO4.
40
Things to note about MgSO4 protocol
The use of MgSO4 in pre-eclampsia with severe features/eclampsia must be followed with the decision to deliver the woman within 24-48 hours. Treatment with MgSO4 should not exceed 24hrs or 24 hrs after the last convulsion, whichever comes first
41
High yield
Patient counseling before start treatment About condition, treatment, prognosis, and Rick of recurrence in future pregnancies. After delivery, psychological counseling is important especially if she had the pregnancy terminated

Obs & Gynae (6 decks)

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