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OBGYN 4MB > Hypertensive Disorders in Pregnancy > Flashcards

Hypertensive Disorders in Pregnancy Flashcards

1
Q

Describe the normal blood pressure changes in pregnancy

A
  • BP falls to a minimum level in 2nd trimester due to reduced vascular resistance (by about 30/15mmHg)
  • By term again rises to pre-pregnant levels
  • Protein excretion increased in normal pregnancy (in absence of renal disease is <0.3g/24hrs)
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2
Q

Define pregnancy induced hypertension

A
  • BP rises above 140/90mmHg after 20wks

- Due to either pre-eclampsia or transient HTN

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3
Q

Define pre-eclampsia

A

New HTN after 20wks with significant proteinuria (>0.3g/24hrs)

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4
Q

Define pre-existing HTN

A

BP>140/90mmHg before pregnancy or before 20wks, or the woman is already on antihypertensives

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5
Q

How is pre-eclampsia caused?

A
  • Blood vessel endothelial cell damage leads to vasospasm, increased capillary permeability and clotting dysfunction
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6
Q

Describe the two phenotypes of pre-eclampsia

A
  1. Early onset:
    - Causes complications before 34wks
    - IUGR
  2. Late onset:
    - Later gestation
    - No IUGR
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7
Q

Describe the pathophysiology of pre-eclampsia

A
  1. Poor placental perfusion:
    - Incomplete trophoblastic invasion of spiral arterioles which causes oxidative stress
    - High resistance to flow in uterine arteries
  2. Oxidatively stressed placenta over-secretes proteins that regulate angiogenic balance:
    - Widespread endothelial cell damage causing vasoconstriction, increased vascular permeability and clotting dysfunction
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8
Q

Define severe pre-eclampsia

A

Pre-eclampsia with severe HTN and/or with symptoms, and/or biochemical and/or haematological impairment

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9
Q

What are the degrees of HTN>

A
  • Mild = 140/90 - 149/99 mmHg
  • Moderate = 150/100 - 159/109mmHg
  • Severe = >160/110mmHg
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10
Q

What are the risk factors that are indicative of high risk and require low dose aspirin from early pregnancy?

A
  1. Hypertensive disease during previous pregnancy
  2. Chronic kidney disease
  3. Autoimmune disease (e.g. SLE, antiphospholipid syndrome)
  4. Type I or II DM
  5. Chronic HTN
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11
Q

What are the risk factors that indicate moderate risk and require lose dose aspirin from early pregnancy if >1 of them is present?

A
  1. Nulliparous
  2. Age >/= 40
  3. Pregnancy interval >10yrs
  4. BMI >35 at booking
  5. Family hx pre-eclampsia
  6. Multiple pregnancy
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12
Q

How is urinary protein assessed?

A
  1. Dipstick - if +1 protein need to quantify amount with further investigations
  2. Protein:Creatinine ratio (PCR) - >30mg/mmol is confirmed significant proteinuria
  3. 24hr collection - >0.3g/24hrs is confirmed significant proteinuria
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13
Q

List the components of HELLP syndrome

A

H - haemolysis (dark urine, raised LDH, anaemia)
EL - elevated liver enzymes (epigastric pain, liver failure, abnormal clotting)
LP - low platelets

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14
Q

List the clinical features of pre-eclampsia

A
  1. Usually asymptomatic
  2. Headache
  3. Drowsiness
  4. Visual disturbances
  5. Nausea/vomiting
  6. Epigastric pain
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15
Q

List the signs of pre-eclampsia on examination

A
  1. HTN (usually 1st sign)
  2. Oedema (not postural or of sudden onset)
  3. Epigastric tenderness (impending complications)
  4. Proteinuria
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16
Q

List the maternal complications of pre-eclampsia

A
  1. Eclampsia
  2. Cerebrovascular haemorrhage
  3. HELLP syndrome
  4. Renal failure
  5. Pulmonary oedema
17
Q

List the fetal complications of pre-eclampsia

A
  1. Increased perinatal morbidity and mortality
  2. IUGR
  3. Preterm delivery
  4. Placental abruption
18
Q

What investigations are done for pre-eclampsia?

A
  • Confirm diagnosis:
    1. Urine PCR
  • Monitor maternal complications:
    1. Blood tests (elevated uric acid)
    2. FBC
    3. LFTs
    4. Renal function
  • Monitor fetal complications:
    1. US
    2. Umbilical artery Doppler
    3. CTG
19
Q

How can pre-eclampsia be prevented?

A
  • Low dose aspirin (75mg) starting before 16wks to decrease risk
  • High-dose vitamin D with calcium supplementation may also be effective
20
Q

List the criteria for admission with a hypertensive disorder

A
  1. Symptoms
  2. Proteinuria with PCR >/= 30
  3. Severe HTN
  4. IUGR with abnormal umbilical artery Doppler or abnormal CTG
  5. Abnormal sFlt-1/PlGF assay
21
Q

What drugs are use in management of pre-eclampsia?

A
  1. Antihypertensives:
    - If BP >/= 150/100mmHg
    - Labetalol for maintenance
    - Target BP <140/90mmHg
  2. Magnesium sulphate:
    - Tx and prevention of eclampsia in severe disease
    - IV loading dose followed by IV infusion
    - Can have magnesium toxicity
    - Dose decreased or stopped if renal impairment or anuria develops
    - If magnesium required delivery is indicated
  3. Steroids:
    - If <34wks for fetal lung maturity
22
Q

Discuss the timing of delivery in pre-eclampsia

A
  • Delivered by 36wks

- Conservative management before 36wks

23
Q

How is the baby delivered in pre-eclampsia?

A
  • C-section before 34wks if IUGR
  • IOL after 34wks
  • Epidural (decreases BP)
  • CTG monitoring
  • BP and fluid balance observed
  • Antihypertensives used in labour
  • Avoid maternal pushing if BP >/= 160/110mmHg
  • Oxytocin used for 3rd stage
24
Q

List the general measures taken in severe pre-eclampsia

A
  1. One to one midwifery care
  2. IMEWS chart commenced
  3. Consultant obstetrician on duty informed
  4. Large bore IV cannula inserted
25
Q

List the basic investigations that need to b performed in cases of severe pre-eclampsia

A
  1. U&E
  2. LFTs
  3. FBC
  4. Clotting screen
  5. Group and save
  • Bloods should be repeated every 12hrs
26
Q

According to Irish guidelines, what monitoring should be done on a woman with severe pre-eclampsia?

A
  1. BP and HR every 15mins; half hourly when stabilised
  2. Catheter inserted and urine output measured hourly
  3. Continuous O2 sats
  4. Fluid balance - total input limited to 80ml/hr
  5. RR hourly
  6. Temp 4hrly
  7. Neurological assessment hourly
  8. Fetal wellbeing assessed
27
Q

What thromboprophylaxis is offered?

A
  • Prior to delivery:
  • TEDS
  • Flowtrons and/or heparin whilst mobile
  • Following delivery:
  • LMWH daily until fully mobile
  • LMWH not given until 4-6hrs after spinal anaesthesia
  • Epidural catheter left in place for at least 12hrs after LMWH and LMWH should not be given for 4-6hrs after removal
28
Q

How is severe HTN managed?

A
  • First choice agent = LABETALOL
  • 200mg initial oral dose; second oral dose after 30mins
  • Can be given IV
  • Can give infusion 20mg/hr via syringe pump
  • CI in asthma, pre-existing cardiac disease
  • If IV labetalol has not decreased BP <160/105 mmHg after 60-90mins consider second line agent
  • Continue labetalol while administering other drugs
  • Second line agents:
  • Hydralazine (CI in hypersensitivity, severe tachycardia, heart failure with high CO)
  • Nifedipine (use this one)
29
Q

How is eclampsia treated and prevented?

A
  • Magnesium sulphate protocol:
  • Loading dose followed by continuous infusion for 24hrs or until 24hrs after delivery (whichever is later)
  • Loading dose 4g IV over 5-10mins
  • Maintenance dose 1g IV per hour
  • SEs - motor paralysis, absent tendon reflexes, respiratory depression, cardiac arrhythmia
30
Q

How are these patients managed postnatally?

A
  • Severe disease monitored in hospital until at least the third postnatal day and have 4hrly BP
  • Betablockers, alpha-adrenergic blockers, ACE inhibitors and calcium antagonists all safe in breastfeeding
  • Avoid diuretics in breastfeeding
  • Methyldopa should not be prescribed postnatally
  • Discharged after day 3-4 when asymptomatic
  • Follow up within 2wks
  • Inform GP
  • All offered hospital appointment within 12wks of delivery
31
Q

List the complications of pre-existing HTN in pregnancy

A
  1. Worsening HTN
  2. Pre-eclampsia
  3. Increased perinatal mortality
32
Q

What investigations should be done in cases of pre-existing HTN?

A
  1. To identify secondary HTN:
    - 2 24hr urine collection for VMA (exclude phaeo)
  2. To look for co-existent disease:
    - Renal function
    - Renal US
  3. To identify pre-eclampsia:
    - Quantification of proteinuria
    - Uric acid level
33
Q

How is pre-existing HTN managed in pregnancy?

A
  1. Ideally medication optimised before pregnancy (ACE inhibitors are teratogenic)
  2. Labetalol normally with nifedipine second line
  3. Treat pregnancy as high risk and start on low dose aspirin
  4. Screen for pre-eclampsia using uterine artery Doppler
  5. Delivery at 38-40wks

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