Hypertensive Disorders in Pregnancy Flashcards
what are some fetal complications of chronic hypertension
fetal growth restriction
preterm birth
placental abruptions
still birth
congenital anomalies
what are some maternal risks of chronic HTN
liver failure, kidney failure, preeclampsia/eclampsia
normal blood pressure ranges
less than 120/80
what is elevated blood pressure ranges
120-129/80
what is stage 1 hypertension ranges
130-139/80-89
what is stage 2 hypertesion ranges
> 140/90
what are hypertensive crisis ranges?
180/120
may have signs of end organ damage
what are the parameters for chronic hypertension?
present before or recognized during the first half of pregnancy and persists after 12 week postpartum
what is gestational hypertension
hypertension recognized after 20 weeks gestation
what is pre-eclampsia
gestational HTN with proteinuria and sometimes edema
can be superimposed on chronic HTN
what is ecclampsia?
pre-eclampsia + clonic tonic seizures
what is superimposed pre-eclampsia/eclampsia
pre-clampsia/eclampsia transposed onto chronic HTN
most causes of chronic hypertension are?
idiopathic
(can also be vascular disorders, endocrine disorders, renal disorders, Connective tissue disorders)
how do you take an acurate blood pressure
patient seated after resting for 10 minutes with legs uncrossed and back supported
use appropriate cuff size
appropriate cuff sice for blood pressure
length 1.5 times the upper arm circumfrence
how do you evaluate chronic HTN in pregnancy
rule out underlying disease
assess for end organ damage (CBC, CMP, EKG, 24 hour urine collection)
check for fetal well being
- initial ultrasound for accurate dating
- screening ultrasound
for a mother with chronic HTN when should you do growth ultrasounds ?
monthly after 28 weeks
antepartum fetal testing begins when in a mother with chronic HTN
32-34 weeks gestation
mild chronic HTN in pregnancy. people range, how do you treat
less than 160/110
begin asprin therapy at 81 mg daily at 12 weeks until delivery
initiate antihypertensive medication if the threshold above is met
how frequently are appointments with chronic mild HTN in pregnancy
prenantal visits 2-4 weeks until 34-36 weeks
then weekly
with antepartum fetal testing : NST, Biophysical profile
when do you proceed to delivery in a mother with chronic MILD HTN
38-39 weeks gestation
how do you manage a mom with SEVERE chronic HTN in pregnancy
BP: over 160/110
pharmacetically
start a antihypertensive!
methyldopa
labetolol
nifedipine
what antihypertensives should you avoid in pregnancy and what are their side effects
Ace inhibitors ad angiotensin receptor blockers
they result in fetal growth restrictions, clavarial hypoplasia, malformations
how do you manage a pregnant patient with SERVER HTN (over 160/110)
CLOSE MONITORING
24 hour urine collection every trimester
observe for signs of precclampsia/ecclapmsia
antepartum fetal surveillance with ultrasounds and nonstress tests/biophysical profiles
when do you procceed with delivery of a baby with a mom with chronic SEVERE HTN
37-39 weeks
what is gestational HTN
HTN that occurs after 20 weeks gestation that occurs within 48-72 hours after delivery and resolves by 12 weeks post partum
hypertensive disorders are a _ in pregngnacy
continuum
precclampsia triad***
triad no longer recongized, one feature is common to a lot of pregnancies
Proteinuria
HTN
(edema)
symptoms of preeclampsia
scotoma- blind spot/partial vision loss
blurred vision
epigastric pain/ right upper quadrant pain
headache
risk factors for preecalampsia
nulliparity, african americans, history of preeclampsia, chronic HTN, multifetal gestation, pre-gestational diabetes, collagen vasular disease (SLE) and more!
preeclampsia, what happens and where?
Brain- headache
Heart-edema
Lungs- pulmonary edema
Liver- right upper quadrant pain
Kidneys- Proteinuria/edema
Eyes: vision changes
in preeclampsia the brain is effected and a headacahe occurs, why does a patient get a headache
due to cerebral edema
in preeclampsia why does the heart get edema?
there is an absence of normal intravscular volume expansion (third spacing) and a reduction in circulating blood volume
seen as lower extremity edema
there will be a false increase in hemoglobin and hematocrit
why do the lungs get pulmonary edema in preeclampsia
non cardiogenic pulmonary edema because there is a change in colloid osmotic pressure, capillary endotheelial integrity and intravascular hydrostatic vessels.
ultimately leaky vessels
why does the liver have RUQ pain when there is preeclampsia
sinusoidal fibrin deposition in the periportal areas with hemorrage cause a subscapular hematoma and liver rupture
the stretching of glissons caspule is the pain felt
why do the kidneys have edema/proteinuria in preeclampsia
there is a narrowing of the capilalry lumen and swelling og the glomerular capillary endothelial cells
(leaky vessels and cant filter)
what vision changes are seen in preeclampsia
retinal vasopasm and retinal edema
what is the cause of preeclampsia
the eitiology is unknown
lost of proposed theories: chronic uteroplacental ischemia, LDL toxicity, etc.
what are the parameters for mild precelampsia
greater than 140/90 but less than 160/110
how much protein is in the urine in preeclampsia
24 hour-
protein creatinine ratio-
urine dipstick-
24 hr: greater than 300mg/24 hours
protein: creatinine ratino: 0.3 mg/DL
urine dipstick : +2
what are the parameters for severe preeclampsia with severe features
urine
liver
lung
platelets
cerebral
BP: greater than 160/110 on 2 occasions 4 hours apart
oliguria (less than 500 ml in 24 hours)
liver enzymes twice the upper limit of normal
pulmonary edema
thrombocytopenia
new headache: refractory to medication
preeclampsia evaluation
complete history: past history of HTN, renal disease?
address physical symptoms: headahce, visual changes, vaginal bleeding, epigastric pain
examination findings in preeclampsia
brisk relfexes
clonus - muscle spams, repeated
edema
laboratory findings in preeclampsia
increased: hematocrit, lactate dehydrogenase, AST/ALT, uric acid
low platelets: thrombocytopenia
how do you manage a preeclamptic patient without severe features
less than 37 weeks
between 37-40 weeks
less than 37 weeks: BPP once a week or NST twice a week, fetal growth ultrasound, possible hospitalization
37-40 weeks: begin induction if cervix is favorable if not rippen cervic and then begin induction
how do you manage patients with severe preelampsia with severe features
hospitalize!
deliver if greater than 34 weeks
manage blood pressure
administer corticosteroids if less than 37 weeks and work towards deliver
_ is adminsitered for sezuire prohylaxis ( always in severe ecclampsia)
magnesium sulfate
intrapartum management
vaginal delivery is preferred, mag. sulfate, cervical rippening, pain management
magnesium sulfate is administered via _
IV
seizure prohylaxis
loading dose for magnesium sulfate in preeclampsia
4 gm
maintenance dose of magnesium sulfate for preeclampsia
2gm
theraputic value of mg sulfate
4-6 mg/dl
mag >9
mag > 15
mag>30
symptoms
magenesium sulfate toxicity
> 9= loss of patellar reflexes
> 15= respiratory paralysis
> 30 cardiac arrest
how do you reverse magnesium sulfate overload
calcium gluconate
during magnesium sulfate administration you should have fluid _ (administration/restriction)
restriction
to prevent overload/pulmonary edema
should you continue mag. sulfate after delivery
yes for about 24 hrs after
first thing to do in a eclamptic patient
first line treatment
second line treatment if persistent seizures
protect the airway
magnesium sulfate
lorezepam if persistent
is eclampsia an indication for C-section
no
what is HELLP syndrome
a variant of preeclampsia that stands for Hemolysis, Elevated Liver Enzymes, and low platelets
labs for hellp syndrome
should you deliver them?
LDH greater than 600
AST/ALT elevated twice the upper limit of normal
platelets less than 100,000
deliver immediately
presence of HTN and proteinuria are variable!!!
prevention of preeclampsia
medication
aspirin
