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Obs&Gynae > Hypertensive disorders in pregnancy > Flashcards

Hypertensive disorders in pregnancy Flashcards

1
Q

What is the definition of hypertension in pregnancy?

A

Hypertension in pregnancy is defined as a systolic BP over 140 or diastolic BP over 90 mmHg measured twice at least 4 hours apart; or >160 systolic or >110 diastolic on one occasion

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2
Q

What are some risk factors for hypertensive disorders in pregnancy? (8)

A
  • Extremes of age (<20 >35 years)
  • family history
  • nulliparity
  • multiple pregnancy
  • preexisting diabetes
  • BMI >30
  • previous pre-eclampsia
  • gestational trophoblastic disease.
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3
Q

What are the classifications of hypertensive disorders in pregnancy? (5)

A
  1. Chronic hypertension
  2. Gestational hypertension
  3. Preeclampsia
  4. Preeclampsia superimposed on chronic hypertension
  5. Eclampsia
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4
Q

What is chronic hypertension in pregnancy?

A

Elevated BP of ≥140/90 mmHg occurring before pregnancy or in the first <20 weeks of gestation, with or without organ damage, and persists >12 weeks after delivery.

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5
Q

Define gestational hypertension.

A

New onset of BP ≥140/90 mmHg after 20 weeks gestation without evidence of maternal end organ damage, lasting up to 12 weeks after delivery.

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6
Q

What is preeclampsia?

A

BP ≥140/90 mmHg after 20 weeks gestation with proteinuria (≥0.3g/24hr or protein/creatinine ratio ≥0.3) or, in the absence of proteinuria, new onset of any of the following:

Maternal organ dysfunction:
1. Hematological complications i.e. thrombocytopenia, hemolysis
2. Renal insufficiency
3. Impaired liver function
4. Pulmonary edema
5. Neurological complications ( seizures, altered mental status, blindness, stroke, visual disturbances)
6. uteroplacental dysfunction ( intrauterine fetal growth restriction)

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7
Q

What is eclampsia?

A

Eclampsia is defined as the occurrence of generalized tonic-clonic seizures in a woman with preeclampsia, which cannot be attributed to any cause and no past history of seizure disorder

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8
Q

What is HELLP syndrome?

A

HELLP syndrome is a severe form of preeclampsia involving:
1. Hemolysis
2. Elevated liver enzymes
3. Low platelet count

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9
Q

What is the management of preeclampsia? (8)

A
  1. All women with pre-eclampsia should be hospitalized and placed in Labor Ward or HDU for evaluation.
    - If early onset (<34 weeks), refer to Central Hospital for management.
  2. Blood pressure requires urgent treatment in a monitored setting when ≥ 160/110 mmHg; acceptable agents for
    this include oral nifedipine or intravenous hydralazine
  3. Blood pressures should be consistently maintained below 160 systolic and below 85 mmHg diastolic.
  4. Women with pre-eclampsia who have severe hypertension, or hypertension with neurological signs or symptoms should receive MgSO4 for convulsion prophylaxis.
  5. Where available, fetal monitoring in pre-eclampsia should include assessment of fetal biometry, amniotic fluid
    and umbilical artery Doppler with ultrasound at first diagnosis and thereafter at 2 weekly intervals if the initial assessment was normal and more frequently in the presence of fetal growth restriction.
    - If there is absent end-diastolic flow in the umbilical artery (AEDF) prior to 34 weeks’ gestation,
    the patient should be delivered.
  6. Close monitoring of BP , urine protein, and clinical assessment including reflexes and clonus, FBC, LFTS and Cr at least twice weekly
  7. Delivery at 34 weeks or sooner if severe features develop:
    - repeated episodes of severe HTN despite maintenance rx
    - progressive thrombocytopenia
    - progressively abnormal renal or liver enzymes
    - pulmonary edema
    - abnormal neurological features like a severe intractable headache
    - repeated visual scotoma/ convulsions
    - non reassuring fetal status
  8. Prenatal corticosteroids for fetal lung maturation should be given between 24+0 and 34+0 weeks gestation, but may be given up until 37+0 weeks in cases of elective delivery by Caesarean section
  9. Postpartum hypertension and pre-eclampsia can lead to eclampsia.
    - Patients should be counseled on prodromal warning signs at the time of discharge.
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10
Q

What is the management of eclampsia? (6)

A
  1. stabilization of the patient
  2. prompt delivery.
  3. Put the patient in left lateral position in bed on the floor to protect them from injury.
  4. Give intravenous hydralazine 5mg every 15minutes with titration upto 10mg as needed to a total dose of 40mg in an hr until Bp <160/110mmHg
  5. If fully conscious, Methyldopa 500mg 8hrly or nifedipine 10-20mg q8 hrly with hydralazine regimen if Bp >160/110mmHg
  6. To prevent more seizures: MgSO4 4g(20ml of 20% solution) IV in 500mL NS over 10min and 5g(10ml of 20% solution) IM in each buttock with 1ml of 2% lignocaine loading dose in same the syringe.
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11
Q

What is the postpartum management for women with hypertensive disorders during pregnancy? (3)

A
  1. Monitoring BP
  2. Continuation of antihypertensive therapy as needed
  3. Counseling on the increased risk of future cardiovascular disease
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12
Q

What are the possible maternal complications of hypertensive disorders in pregnancy? (7)

A

Maternal complications:
1. Eclampsia
2. HELLP syndrome
3. Stroke
4. Placental abruption
5. Organ damage (cortical blindness, renal failure, hepatic rupture, transient left ventricular systolic or diastolic dysfunction)
6. Pulmonary edema
7. DIC

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13
Q

What lifestyle modifications are recommended to reduce the risk of hypertensive disorders in pregnancy? (5)

A
  1. Maintaining a healthy weight
  2. Regular physical activity
  3. Balanced diet
  4. Avoiding smoking
  5. Reducing excessive salt intake
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14
Q

What are the antihypertensive medications commonly used in pregnancy? (3)

A
  1. Methyldopa: Typically used for chronic hypertension. Considered safe with a common dose of 250-500 mg orally 2-3 times a day.
  2. Labetalol: A combined alpha and beta-blocker, used for both chronic and acute severe hypertension. Oral dose: 200-400 mg twice a day; IV dose: 20 mg initially, followed by 40-80 mg every 10 minutes, up to a maximum of 300 mg.
  3. Nifedipine: A calcium channel blocker, used for chronic and acute severe hypertension. Extended-release oral dose: 30-120 mg daily.
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15
Q

What medications are contraindicated in hypertensive disorders during pregnancy? (3)

A
  1. ACE inhibitors (e.g., enalapril, lisinopril): Associated with fetal renal dysplasia, oligohydramnios, and fetal/neonatal death. (2nd and 3rd trimester exposure is fetotoxic)
  2. Angiotensin II receptor blockers (ARBs): Similar risks as ACE inhibitors.
  3. Diuretics- may reduce uteroplacental perfusion
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16
Q

What investigations should be done to assess for preeclampsia? (7)

A
  1. Blood pressure measurement: Regular BP checks to detect elevated levels.
  2. Urine analysis: Checking for proteinuria (≥0.3g/24hr).
  3. Complete blood count (CBC): To assess for thrombocytopenia, raised Hb
  4. Liver function tests (LFTs): To detect elevated liver enzymes. especially ALT (to exclude HELLP syndrome)
  5. Renal function tests: To monitor serum creatinine and assess renal function. (uric acid is particularly sensitive)
  6. Coagulation profile: To detect any coagulopathy, especially in severe preeclampsia or HELLP syndrome.
  7. Obstetric USS: To assess fetal growth (EFW) and amniotic fluid index, umbilical artery dopplers ( to evaluate uteroplacental blood flow)
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17
Q

What investigations are recommended for chronic hypertension in pregnancy? (6)

A
  1. Blood pressure monitoring: Regular monitoring to maintain control.
  2. Baseline renal function tests: Serum creatinine, uric acid, and electrolytes and Baseline FBC, LFTs
  3. 24-hour urine collection: To assess for baseline proteinuria.
  4. consider fundoscopic exam Electrocardiogram (ECG): To detect any cardiac changes.
  5. Fetal ultrasound ( from 26 weeks and there after at 2-4 week intervals): Regular monitoring for fetal growth and assessing fetal well being
  6. Consider Echocardiogram (if indicated): To assess for left ventricular hypertrophy or other cardiac abnormalities.
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18
Q

What rapid-acting antihypertensive drugs are used for severe hypertension in pregnancy? BP>160/110 (3)

A
  1. Atenolol(IV)
  2. Hydralazine (IV): 5-10 mg IV slow push (15-20 mins) repeat 4 times every until BP is controlled or a maximum dose of 20-40 mg is reached.
  3. Nifedipine (oral immediate-release): 10-20 mg orally-sublingual , repeated every 30 minutes as needed.
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19
Q

What is the ultimate overall treatment approach for hypertensive disorders in pregnancy?

A

delivery of the baby (termination of the baby)

20
Q

why should women with gestational hypertension be closely monitored

A

because half of them can subsequently develop pre-eclampsia syndrome when gestational hypertension develops before 32 weeks (20-32 weeks)

21
Q

how is pre eclampsia diagnosed (3)

A

by the presence of de novo hypertension accompanied by:
1. proteinuria
2. evidence of other maternal organ dysfunction:
-maternal acute kidney injury Cr>0.9/1 mg/dL
-liver dysfunction( raised AST and ALT) with or without RUQ pain or epigastric abdominal pain
-neurological features ( eclampsia, altered mental status, blindness, stroke, clonus, severe headaches, persistent visual scotoma)
-hematological (thrombocytopenia <150,000/uL, DIC, hemolysis) -and/or fetal growth restriction
3. Uteroplacental dysfunction eg. IUGR, abnormal umbilical artery Doppler, stillbirth

22
Q

what is the normal physiology about maternal blood flow to the placenta (4)

A
  • Maternal blood flow to the placenta increases throughout pregnancy from 50ml/min in the first trimester to 500-750ml/min at term.
  • This increase in perfusion is accomplished by anatomical conversion of maternal spiral arteries by trophoblasts.
  • Trophoblast cells invade the spiral arterioles within the first weeks of pregnancy and replace the smooth muscle of the walls of the vessel, thus converting them into wide bore, low resistance, large capacitance vessels.
  • This process is normally complete by 20 weeks gestation.
23
Q

what is the pathophysiology of pre eclampsia (3)

A
  • There is an impairment of trophoblast to invade the myometrial segments of the spiral arteries.
  • Hence, spiral arteries retain some of their pre-pregnancy characteristics of being relatively narrow bore, of low capacitance and high resistance, and resulting in impaired perfusion of the fetoplacental unit.
  • This leads to the release of proinflammatory proteins that cause endothelial cell dysfunction causing vasoconstriction in different organs, leading to the manifestations of the syndrome
24
Q

what are the fetal complications of pre eclampsia (5)

A
  1. Intrauterine growth restriction
  2. Preterm birth
  3. Stillbirth (intrauterine fetal demise
  4. placenta abruptio
  5. fetal distress
25
Q

what is pre eclampsia with severe features (2)

A
  1. Severe hypertension e.g. a systolic blood pressure over 160 mmHg, or diastolic over 110mmHg with at least 2+ proteinuria.
  2. Moderate hypertension of at least 140mmHg systolic and 90 mmHg diastolic associated with any of:
    -severe headache with visual disturbance
    -epigastric pain
    -signs of clonus
    -liver tenderness
    -platelet count falling to below 100; creatinine >100 mmol/litres
    -alanine amino transferase rising to above 50 IU/litres
26
Q

what is Pre-eclampsia superimposed on chronic hypertension

A

Chronic hypertension with the development of any maternal organ dysfunction consistent with preeclampsia; thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, cerebral or visual symptoms.

27
Q

when do some of the eclamptic seizures occur

A

around 40% of seizures occurring postnatal (usually within 48hrs of delivery)

28
Q

what is the management of chronic HTN (6)

A
  1. Stop contraindicated antihypertensive medications( i.e. diuretics, ACE inhibitors)
  2. Basic labs: FBC, LFT, creatinine and BUN
  3. Urine dipstick for proteinuria and 24hr urine collection if proteinuria is present
  4. Use antihypertensives to maintain blood pressure in the range of 110-140/80-85. Acceptable initial antihypertensives include methyldopa (250mg BD/tds) and nifedipine (10mg tds). Hydralazine should be used as second line agent.
  5. Monitor for development of preeclampsia using urine dipstick at each visit along with clinical assessment and blood tests ( Hb, platelet count, LFTs, Cr and uric acid) at 28 and 34 weeks minimum
  6. Assess fetal wellbeing
29
Q

For a woman with superimposed pre-eclampsia on chronic HTN how do you manage (2)

A
  1. its an indication for delivery.
  2. Administer corticosteroids and MgSO4 as indicated
30
Q

For a woman with chronic HTN and no additional maternal or fetal complications how do you manage

A

deliver at 39 weeks gestation

31
Q

How do you manage gestational hypertension (3)

A
  1. Control of blood pressure with methyldopa or nifedipine to levels of 110-140/80-85mmHg
  2. Monitor for the development of preeclampsia
  3. Monitor fetal growth and wellbeing.
32
Q

what do you do if seizures continue after giving magnesium sulphate in eclampsia (3)

A
  1. If seizures continue after 15min, give another MgSO4 2g(10ml of 20% solution) IV over 5min
  2. If seizures continue or no MgSO4, consider diazepam 10mg IM over 2min - Maintenance dose of diazepam is 40mg in 500ml of NS/ LR
  3. Assess for mode of delivery -assisted vaginal delivery or caesarean section
33
Q

How does magnesium sulphate work

A

as a cerebral vasodilator.

34
Q

what do you do if you suspect magnesium toxicity

A

stop the infusion and administer calcium gluconate 10% in 100ML NS over 10-20mins

35
Q

What are signs of magnesium sulphate toxicity(4)

A
  • RR<16
  • SaO2 <92%
  • absent tendon reflexes
  • muscle paralysis

** if UOP is <30m/hr withhold magnesium sulphate

36
Q

what prophylaxis do you give for preeclampsia (3)

A
  1. Low dose Aspirin at or around 12 weeks gestation(optimal) but before < 16weeks up to 36 weeks GA- (CLASP trial suggest that aspirin may be effective in reducing the risk of early onset preeclampsia by at least 50%)
  2. Vitamin D supplements (any time)
  3. calcium supplements (any time)
36
Q

When do you stop magnesium sulphate

A

24 hours post delivery or last convulsion; whichever comes last

37
Q

who do you give prophylaxis for preeclampsia to (4)

A
  • Previous preeclampsia
  • High Body Mass Index
  • Family history
  • Diabetes
38
Q

What are the preferred drugs for chronic HTN in pregnancy (4)

A

Lower HTN 4 New Moms
-labetalol
-hydralazine
-nifedipine (long acting)
-Methyldopa ( first choice)

39
Q

What are the slow acting antihypertensives in pregnancy (2)

A

when BP 140-159/90-109
1. methyldopa
2. labetalol

40
Q

when can you deliver the baby in gestational HTN

A

Delivery can be made until 39 weeks provided blood pressure can be controlled, fetal monitoring is reassuring and pre-eclampsia has not developed.

41
Q

what are side effects of magnesium sulphate (5)

A
  • blurred vision
  • hypotension
  • headache
  • feeling warm
  • n/v
42
Q

before administering magnesium sulphate in pre eclampsia what should you do

A

check plt count or do a bedside clotting test prior to the IM injections to avoid the development of subcutaneous hematomas at the injection site

43
Q

which women are at increased risk of pre eclampsia and are eligible for use of prophylactic low dose asprin (6)

A
  1. Previous pre-eclampsia
  2. Pre-existing medical conditions (including chronic hypertension, Underlying renal disease, or pre-gestational diabetes mellitus)
  3. Antiphospholipid antibody syndrome,
  4. Multiple pregnancy
  5. Obesity
  6. Assisted reproduction pregnancy
44
Q

if someone is having eclampsia when should you deliver

A

within 12 hours

Obs&Gynae (24 decks)

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