Hypertensive disorders in pregnancy Flashcards
does BP usually go up or down during the 1st trimester? why?
down
- increased maternal blood volume
- decreased colloid oncotic pressure
when is the lowest maternal BP during pregnancy?
13-20 weeks
what are the four types of HTN during pregnancy?
- chronic
- gestational
- preeclampsia
- preeclampsia superimposed on chronic HTN
chronic HTN: definition
- BP 140/90 prior to or during first 20 weeks of pregnancy
- no proteinemia
- BP remains elevated over 12 weeks postpartum
what are the common obstetrical complications to severe chronic HTN?
- superimposed preeclampsia
- premature birth
- intrauterine growth restriction
- fetal demise
- placental abruption
what is the management for chronic HTN?
lifestyle modification
when do you start hypertensive medication for chronic HTN?
when BP is over 160/110 or
continue pre-pregnancy treatment if
- multiple medications were required pre-pregnancy
- evidence of preexisting end organ dysfunction
what are the signs of preeclampsia?
- development of proteinuria
- sudden increase in BP when previously well-controlled
definition: gestational HTN
- nonproteinuric HTN after 20 weeks gestation
provisional diagnosis including
- women who go on to develop preeclampsia
- women with previously undiagnosed chronic HTN
- women who do not develop preeclampsia and whose blood pressures normalize postpartum
mild (under 160/110) or severe (over 160/110)
what is the management for mild gestational HTN?
expectant management
what is the management for severe gestational HTN?
same as for severe preeclampsia
definition: preeclampsia
- new onset HTN and proteiuria after 20 weeks gestation in a previously normotensive woman
- BP over 140 systolic OR over 90 diastolic on 2 separate occasions at least 6 hours apart
definition: mild preeclampsia
- BP 140/90 on 2 separate occasions at least 6 hours apart AND proteinuria over 0.3 g in a 24 hour urine specimen
definition: severe preeclampsia
- systolic over 160 or diastolic over 110 on two occasions at least 4 hours apart while at bedrest
- thrombocytopenia
- impaired liver function
- progressive renal insufficiency
- pulmonary edema
- new onset cerebral or visual disturbances
preeclampsia can mimic what other diseases?
- flu
- gall bladder disease
- migraines
what are the pregnancy associated risk factors for preeclampsia?
- chromosome abnormalities
- hydatidiform mole
- hydrops fetalis
- multifetal pregnancy
- oocyte donation or donor insemination
- structural congenital abnormalities
what are the maternal specific risk factors for preeclampsia?
- age under 20, over 35
- African American
- family history of preeclampsia
- NULLIPARITY**
- preeclampsia in previous pregnancy
- stress
- medical conditions (obesity, thrombophilias, antiphospholipid Ab syndrome)
definition: eclampsia
appearance of seizures in a patient with preeclampsia
definition: HELLP syndrome
a variant of preeclampsia with:
- hemolysis
- elevated liver enzymes
- low platelet count
what are the lab findings for the hemolysis portion of HELLP syndrome?
- abnormal peripheral smear (burr cells, schistocytes, or other abnormal RBC forms)
- LDH over 600
- bilirubin over 1.2
what are the lab findings for the elevated liver enzymes portion of HELLP syndrome?
AST or ALT over 100 IU/L
what are the lab findings for the low platelets portion of HELLP syndrome?
under 100,000 / mm3
what is the ultimate cure for preeclampsia?
delivery
what are the two key management goals for preeclampsia?
- control HTN
- prevent seizures
what is given for seizure control in eclampsia?
magnesium sulfate
what are the maternal indications for delivery?
- over 37 weeks gestation
- worsening labs
- suspected fetal abruption
- persistent headache or vision changes
- persistent severe nausea, vomiting, epigastric pain
- ECLAMPSIA
what are the fetal indications for deliver?
- severe intrauterine growth retardation
- nonreassuring fetal surveillance
- oligohydramnios
when is seizure risk greatest in postpartum management?
first 24 hours
what are the postpartum complications in the presence of preeclampsia and severe chronic HTN?
- pulmonary edema
- heart failure
- hypertensive encephalopathy
- renal failure
definition: intrauterine growth restriction (IUGR)
what is necessary for diagnosis?
- estimated fetal weight under 10th percentile for gestational age (symmetric / assymetric)
- US is necessary for diagnosis
definition: assymetric IUGR?
disproportionately lagging in abdominal growth
- fetal head circumference measurement greater than abdominal circumference
- head sparing
- placental dysfunction
definition: symmetric IUGR?
proportionately small
- a global insult: chromosome abnormality
- may be constitutionally small parents
what is the etiology of IUGR?
end result of numerous pathologies which reduce fetal cell size and, when early and severe enough, fetal cell number
what are the infection related fetal risk factors for IUGR?
- CMV
- toxoplasmosis
- rubella
what are chromosomal risk factors for IUGR?
- trisomies (13, 18, 21)
- trisomy 9 mosaicism
- trisomy 4p
what are the screening tests for IUGR?
- maternal fundal height
- unexplained elevated maternal serum AFP
how is diagnosis of IUGR made?
- obstetric US
- sequential measurement better than single
- definitive diagnosis at delivery
what are special cases of IUGR?
- multiple gestation
- velementous cord insertion, more common in twins
what constitutes a RISK for IUGR?
when AC is less than 10th percentile for gestational age, but EFW is still above 10th percentile for gestational age
